A pilot study to assess the impact of aboriginal and torres strait islander cultural humility webinars on australian medical school students.

BACKGROUND: The Aboriginal and Torres Strait Islander Health Curriculum Framework helps higher education providers to deliver safe and well-informed cultural humility education. However, there is currently a scarcity of evidence surrounding the efficacy and impact of cultural humility education. This study will use qualitative and quantitative research methods to evaluate learning outcomes from an Indigenous health educational webinar aimed at Australian medical students. METHODS: A pilot study was conducted following a group of Australian medical students who attended an educational Indigenous health (IH) culturally responsive webinar. Recruitment was conducted via the webinar hosts' social media pages. Quantitative methods involved sending one pre- and two post-webinar questionnaires to attendees. To assess participants' retention of information, one post-webinar survey was sent out immediately after the webinar and another three months after the webinar. These questionnaires were designed to reflect pre-determined learning objectives for the webinar. Qualitative methods involved a focus group discussion to identify common themes from participant feedback. RESULTS: Twenty-six participants were included in the final quantitative analysis. Most of the participants were clinical students between 18 and 24 years old who did not identify as Aboriginal and/or Torres Strait Islander. There was a significant increase (p = 0.007) between pre-intervention (M = 0.35, SD = 0.26) and post-webinar knowledge for the learning outcome exploring the links between health and education (M = 047, SD = 0.25). No results were obtained from the three months post-intervention questionnaire. The qualitative analysis synthesized feedback from three participants and identified presenter delivery style as an important mediator of webinar effectiveness. CONCLUSIONS: There was a significant increase in knowledge and understanding for the learning outcome that explored the links between health and education. We attribute this partly to the engaging and conversational delivery style of the webinar presenters. The importance of Indigenous facilitators that encourage reflective teaching should not be understated. Our results suggest that cultural humility webinars can have a positive impact on medical students' understanding of the Aboriginal and/or Torres Strait Islander health landscape. This pilot study warrants further research on a larger population.

Interethnic differences in dementia epidemiology: global and Asia-Pacific perspectives.

The burden of dementia will continue to rise globally, particularly in developing countries, many of which lie in the Asia-Pacific region. It was initially thought that both prevalence and incidence of dementia showed little geographic variation. More recent work has suggested differences: migrant populations attain rates between their homelands and adopted countries, and higher rates have been found in African Americans and Hispanics compared to Caucasian Whites, and also among native Australians. The only interethnic studies in the Asia-Pacific region were performed in Singapore, which showed lower standardized prevalence among ethnic Chinese compared to ethnic Malays and Indians, independent of vascular risk factors. There was conflicting information about the relative frequencies of Alzheimer's disease and vascular dementia between ethnic groups in Singapore. More research, with careful attention to potential cultural confounders, is needed to further explore and better understand interethnic differences in dementia epidemiology.

Factors associated with functional decline of hospitalised older persons following discharge from an acute geriatric unit.

INTRODUCTION: Older persons are likely to develop functional impairment following hospitalisation. Several studies in the West have examined the factors associated with functional decline following the older person's discharge from hospital but there are little data on Asian populations. This study aims to look at the associated risk factors in our local population, following admission to an acute geriatric unit. MATERIALS AND METHODS: This is a retrospective, cohort study. Patients who were discharged from an inpatient geriatric unit over a 3-month period were recruited. Data including their demographic information, functional status prior to admission and at the time of discharge, and medical conditions were obtained from the inpatient medical notes. A follow-up telephone interview was conducted at 3 months to determine the functional status of these patients at that point in time. RESULTS: Following hospitalisation, 40.4% of patients developed functional decline. Of those discharged, 29.6% showed functional decline at 3 months. The principal diagnosis, hypoalbuminaemia, tendency to fall, premorbid functional independence and the length of hospitalisation were associated with functional decline during hospitalisation, while hypoalbuminaemia, the presence of bedsores, institutionalisation, the length of hospitalisation and premorbid functional dependence were important factors associated with functional decline between the time of discharge and 3 months after. In the multivariable predictive model, independent predictors of functional decline at the time of discharge included patient's tendency to fall, premorbid functional independence and the length of hospitalisation, while the presence of bedsores was the only significant predictor of functional decline 3 months post-discharge. CONCLUSIONS: Many elderly patients developed new functional impairment following hospitalisation. Several factors were found to be associated with this functional decline, though no single predictive model similar to the other published studies was identified.

Do-not-resuscitate orders: towards a policy in Singapore.

Despite the fact that the pioneers of cardio-pulmonary resuscitation (CPR) designed the techniques for victims who were meant to be "salvable", currently CPR is largely applied to anyone who collapses, regardless of their underlying illness. However, the central fact is that CPR (and all its related complex and expensive technology) has a very low success rate (in terms of eventual hospital discharge) and the most important determinant of survival has always been the nature and stage of the underlying illnesses. All these bespeak of a need to have do-not-resuscitate (DNR) orders which will incorporate the pertinent medical, ethical, socio-cultural and legal components. In this discussion paper some guidelines for DNR orders relevant to Singapore are proposed, the main rationale of the guidelines are explained and some challenges and needed changes associated with its implementation are addressed.

Anaemia in the hospitalised elderly.

A retrospective study was done to look at the various features of our elderly anaemic patients and to determine the usefulness of evaluating anaemia in this age group. Of the 151 patients admitted to one of the acute admission and rehabilitation wards of our Department from January 1990 to June 1990, 54 were anaemic. The prevalence of anaemia was significantly higher in the old old age group (> or = 75 years) compared to the young old, and those from an institutional background had a significantly higher prevalence of more severe anaemia (Hb < 8g/dl). The majority of causes (66%) could be easily established with a simple work-up and deficiency-related anaemias comprised 44% of the total causes. The clinical usefulness of this work-up may also extend to the mildly anaemic group (Hb > or = 10g/dl) though further studies are needed to determine the level of haemoglobin when the evaluation becomes cost-effective.

Health care services for the elderly--a Singapore perspective.

Singapore is greying at a phenomenal pace as well as in a markedly disproportionate manner. By the year 2030, the elderly will comprise around 25% of the total population; at the same time the numbers of younger and economically active persons will decline. The reasons for this process are varied and its implications disturbing. An important consequences is the urgent need for careful and comprehensive planning to meet the elderly's needs. The needs are best addressed when the elderly are looked at as either being well or frail. A guiding principle is that most of them prefer and should remain within community (and not be institutionalised). Efficient and appropriate community services must be developed so as to support the elderly's stay in the community.

Clinical utility of a portable ultrasound scanner in the measurement of residual urine volume.

BACKGROUND: Post-voiding residual urine volume is an important investigation in the management of voiding dysfunction. Catheterisation is widely regarded as the "gold" standard method of measurement. We investigated the performance of a portable ultrasound scanner (Bladder Scan BVI-2500), as an alternative method of measurement. METHODS: This study was prospective in nature. One hundred measurements of post-voiding residual urine volume by ultrasound were compared with measurements by catheterisation. RESULTS: The mean absolute error of the scanner was 52 mL. For volumes below 200 mL and 100 mL, this was 36 mL and 24 mL respectively. A decision regarding whether to decompress the bladder by catheterisation would have also been correct in 86% to 89% of instances, depending on the cut-off value of the residual volume used. In other words, the ultrasound measurement would have been correct in 9 out of 10 clinical cases. CONCLUSION: We recommend the routine use of portable ultrasound scanners of similar accuracy in the measurement of post-voiding residual urine volume.

Neuroimaging guidelines in cognitive impairment: lessons from 3 cases of meningiomas presenting as isolated dementia.

We report three cases of large intracranial meningiomas who presented with dementia alone and no accompanying focal neurological deficits. The meningiomas were detected solely as a result of a policy of routinely scanning the brains of patients presenting with early dementia. Dramatic improvements in the cognitive functions were noted following the excision of the tumours in two of the patients (the third passed away in the perioperative period). The implications of these cases with regard to deciding when to order a brain scan for patients presenting with isolated dementia are discussed in this article and a brief review of the relevant medical literature on this topic is also presented.

An evidence-based clinical approach to the diagnosis of dementia.

With the rapidly ageing population in Singapore, dementia prevalence is on the rise. Early diagnosis is important as dementia impacts not only on patients and their families, but also on the community and healthcare system as a whole; with early treatment plans drawn up, the suffering associated with this illness can be more effectively and efficiently managed. In this paper, we present a 4-step, evidence-based assessment strategy for primary care physicians, which cover the essential objectives of the dementia evaluation, incorporating local data where possible. The first step requires the important exclusion of delirium as the cause of forgetfulness or confusion. The second step involves clinically establishing that the patient's chronic confusional state is due to dementia. The third step looks at the behavioural, functional and social dimensions of dementia. The final step determines the aetiology of dementia with the use of a focused history, physical examination, a predefined battery of haematological tests and, in selected cases, structural neuroimaging.

Neurofibrillary and ethico-legal tangles: in search of surrogates for dementia patients lacking decision-making capacity and relatives.

Singapore's greying population has led to an alarming increase in the prevalence of dementia, and inevitably to a rising number of dementia patients who lack competence and relatives. Although legislative provisions exist in the current Mental Disorders and Treatment Act (MDTA) for the appointment of committees of person and estate for incompetent patients, healthcare professionals continue to face challenging obstacles in their attempts to search for appropriate surrogate decision-makers for such patients. We illustrate, with 2 cases from our clinical experience, the ethical, legal and administrative tangles faced in our search for appropriate surrogate decision-makers. Specific problems, such as administrative ambiguities in applying the MDTA and the impracticalities of a rigorous judicial process in appointing surrogates, are discussed. We propose possible solutions how these obstacles can be effectively tackled, in particular adopting a radical shift from the present judiciary model to a clinical-based model of appointing surrogates for healthcare decisions. This clinical model is based on best interests considerations and emphasies peer review and a multidisciplinary consultative approach in determining the clinical merits of proposed treatment and its impact on quality of life. The ultimate aim of such a change is to facilitate timely medical care while ensuring ethical practices that respect the patient's dignity.

Assessing decision-making capacity in dementia patients: a semi-structured approach.

One of the consequences of the rapidly increasing numbers of dementia patients in Singapore will be the need for all clinicians (including non-psychiatrists) to be familiar with the fundamentals of how decision-making capacity should be assessed. The clinical settings when the need for such evaluations arise, often involve cognitively or emotionally impaired patients who are required to make treatment, placement, financial or testamentary decisions. The clinician must first diagnose the patient's psychopathology and then go onto testing the functional abilities involved in decision-making. These comprise (1) making and expressing a choice, (2) understanding the relevant information, (3) appreciating the relevance of the information to oneself and (4) reasoning with the given information. The eventual judgement of the patient's decision-making capacity involves the weighing of impairment noted in any of the four decisional abilities against the potential adverse consequences of abiding by the patient's decision. The ethical impulse underlying this manner of judgement balances the respecting of patient's autonomy with protecting the patient from harm. Given the relative complexity of the assessment process, there is merit in developing a semi-structured approach to the evaluation of patients' decision-making capabilities; such an approach can guide a wider group of clinicians and psychologists through the essential steps of the process and thus enable the assessment to be more thorough, as well as fairer, to the patient.

Cognitive testing of elderly Chinese from selected community clubs in Singapore.

The aim of this study was to describe the psychometric performance of cognitively normal elderly Chinese on selected psychological tests. One hundred and fifty-five community-living, cognitively intact elderly Chinese, stratified according to age and gender were administered a selected neuropsychological assessment battery which comprised the Abbreviated Mental Test (AMT), the Chinese Mini-Mental Status (CMMS), the Short Blessed Test (SBT), the Word-List Immediate Memory (WL-i), the Word-List Delayed Memory (WL-d), the Word-List Recognition Memory (WL-r), the Set Test (ST), the modified Boston Naming Test (BNT), the Constructional Praxis Test (CPT), the Block Design Test (BDT) and the Object Assembly Test (OAT). The local median scores (ranges) of the above tests were as follows-AMT: 9 (6-10); CMMS: 25 (16-28); SBT: 2 (0-10); WL-i: 17 (8-27); WL-d: 5 (0-10); WL-r: 9 (1-10); ST: 13 (6-25); BNT: 14 (10-15); CPT: 1 (0-3); BDT: 19 (0-42); OAT: 20 (3-33). These results can assist in the clinical identification of cognitive abnormalities amongst the elderly Chinese in Singapore. Future work will attempt to adjust these overall scores for variables such as the subjects' education and age.

Improving the diagnosis related grouping model's ability to explain length of stay of elderly medical inpatients by incorporating function-linked variables.

INTRODUCTION: This study first aimed to determine the adequacy of the Diagnosis Related Grouping (DRG) model's ability to explain (1) the variance in the actual length of stay (LOS) of elderly medical inpatients and (2) the LOS difference in the same cohort between the departments of Geriatric Medicine (GRM) and General Medicine (GM). We then looked at how these explanatory abilities of the DRG changed when patients' function-linked variables (ignored by DRG) were incorporated into the model. MATERIALS AND METHODS: Basic demographic data of a consecutively hospitalised cohort of elderly medical inpatients from GRM and GM, as well as their actual LOS, discharge DRG codes [with their corresponding trimmed average length of stay (ALOS)] and selected function-linked variables (including premorbid functional status, change in functional profile during hospitalisation and number of therapists seen) were recorded. Beginning with ALOS, function-linked variables that were significantly associated with LOS were then added into two multiple liner regression models so as to quantify how the functional dimension improved the DRGs' abilities to explain LOS variances and interdepartmental LOS differences. Forward selection procedure was employed to determine the final models. For the interdepartmental analysis, the study sample was restricted to patients who shared common DRG codes. RESULTS: 114 GRM and 118 GM patients were studied. Trimmed ALOS alone explained 8% of the actual LOS variance. With the addition of function-linked variables, the adjusted R2 of the final model increased to 28%. Due to common code restrictions, the data of 79 GRM and 78 GM patients were available for the analysis of interdepartmental LOS differences. At the unadjusted stage, the median stay of GRM patients was 4.3 days longer than GM's and with adjustments made for the DRGs, this difference was reduced to 3.9 days. Additionally adjusting for the patients' functional features diminished the interdepartmental LOS discrepancy even further, to 2.1 days. CONCLUSION: This study demonstrates that for elderly medical inpatients, the incorporation of patients' functional status significantly improves the DRG model's ability to predict the patients' actual LOS as well as to explain interdepartmental LOS differences between GRM and GM.

Critical role of functional decline in delayed discharge from an acute geriatric unit.

INTRODUCTION: Delayed hospital discharge of elderly patients after an acute illness poses significant problems, including bed-blockade, iatrogenesis, and increase in morbidity, dependency and social isolation. The aim of this study was to determine the factors associated with delayed discharge from an acute geriatric unit. MATERIALS AND METHODS: This was a prospective cohort study involving 172 consecutive non-institutionalised patients, 65 years and older, admitted to an acute geriatric unit. The medical, functional, psychological and social variables of each subject were documented and any decline in functional status recorded. Based on the discharge status, patients were dichotomised into the "delayed" and "non-delayed" groups. Initial bivariate analyses of the variables were performed to select those associated with the "delayed discharge" group at the P < 0.05 levels. These variables were in turn entered into a multivariate logistic regression model to identify factors significantly associated with delayed discharge. RESULTS: Forty-eight patients (27.9%) had their discharge from the acute geriatric care unit delayed despite clinically fit to be so. Variables significantly associated with delayed discharge in the multivariate model were: 1) decline in basic activities of daily living (ADL) status [P < 0.001; adjusted odds ratio (AOR), 3.63; 95% confidence interval (CI), 1.33 to 9.86] and 2) need for skilled nursing [P = 0.012; AOR, 4.57; 95% CI, 1.88 to 11.14]. CONCLUSIONS: The study demonstrates the central importance of effectively identifying elderly patients who are at risk of delayed discharge after acute hospitalisation through a multidisciplinary focus on illness-induced functional decline. It is likely therefore that proactive approaches to rehabilitation and caregiver training, and adequate community-based services, may facilitate early and effective return of these patients to their homes, thereby reducing inappropriate use of acute beds.

Text mining in livestock animal science: introducing the potential of text mining to animal sciences.

In biological research, establishing the prior art by searching and collecting information already present in the domain has equal importance as the experiments done. To obtain a complete overview about the relevant knowledge, researchers mainly rely on 2 major information sources: i) various biological databases and ii) scientific publications in the field. The major difference between the 2 information sources is that information from databases is available, typically well structured and condensed. The information content in scientific literature is vastly unstructured; that is, dispersed among the many different sections of scientific text. The traditional method of information extraction from scientific literature occurs by generating a list of relevant publications in the field of interest and manually scanning these texts for relevant information, which is very time consuming. It is more than likely that in using this "classical" approach the researcher misses some relevant information mentioned in the literature or has to go through biological databases to extract further information. Text mining and named entity recognition methods have already been used in human genomics and related fields as a solution to this problem. These methods can process and extract information from large volumes of scientific text. Text mining is defined as the automatic extraction of previously unknown and potentially useful information from text. Named entity recognition (NER) is defined as the method of identifying named entities (names of real world objects; for example, gene/protein names, drugs, enzymes) in text. In animal sciences, text mining and related methods have been briefly used in murine genomics and associated fields, leaving behind other fields of animal sciences, such as livestock genomics. The aim of this work was to develop an information retrieval platform in the livestock domain focusing on livestock publications and the recognition of relevant data from cattle and pigs. For this purpose, the rather noncomprehensive resources of pig and cattle gene and protein terminologies were enriched with orthologue synonyms, integrated in the NER platform, ProMiner, which is successfully used in human genomics domain. Based on the performance tests done, the present system achieved a fair performance with precision 0.64, recall 0.74, and F(1) measure of 0.69 in a test scenario based on cattle literature.

Cognitive testing of elderly Chinese people in Singapore: influence of education and age on normative scores.

AIM: to establish age- and education-adjusted mean psychometric test scores of cognitively normal elderly Chinese people in Singapore. METHOD: 155 community-living, cognitively intact elderly Chinese subjects, stratified according to age and education, were selected from the membership lists of senior citizens' clubs and were administered a neuropsychological assessment battery. The mean test scores were then analysed for correlations with demographic characteristics. RESULTS: only education and age were independent variables; gender and language spoken were strongly correlated with education by the chi2 method (P < 10[-5]). Subsequent statistical analysis of education and age on the psychological test scores by the general linear model procedure enabled the formulation of a table of age- and education-adjusted normative cognitive scores. CONCLUSION: the derivation of age- and education-adjusted normative scores of a selected neuropsychological assessment battery on elderly Chinese people enables a more accurate diagnosis of dementia to be made and may facilitate better international comparisons of this condition. As our subjects are representative of many others from China, these results may serve not only as a local, but also as a regional, reference source.

Dementia in the hospitalized elderly--a study of 100 consecutive cases in Singapore.

AIM: This survey aims to study the medical, functional and social aspects of hospitalized elderly patients with dementia. METHODS: The case records of 100 patients with dementia admitted consecutively to our department were systematically reviewed to extract the patients' demographic data, presenting features, underlying cause(s) of dementia, functional disabilities and carers' difficulties. RESULTS: Eighty per cent of the patients were 75 years of age and above and 44% were males. In this cohort 55% had vascular dementia, with Alzheimer's disease being the next most common (40%). The overwhelming majority had marked cognitive impairment as assessed by the Abbreviated Mental Test and worsening degrees of dementia were significantly associated with increasing disabilities in both mobility and activities of daily living (ADL). Fifty-seven families reported coping difficulties and this group had significant correlations with the respective patients' bladder and bowel incontinence as well as worsening states of ambulatory and ADL function. CONCLUSION: Patients with dementia present with complex problems and management requires attention not only to patients' medical problems and rehabilitation strategies but also to education, emotional support and help for their frequently stressed out carers.

Diagnostic performance of two mental status tests in the older chinese: influence of education and age on cut-off values.

AIMS: To (1) establish the clinical usefulness of the 10-item Abbreviated Mental Test (AMT) and the 18-item Chinese Mini-Mental Status Examination (CMMSE) for detecting cognitive impairment associated with dementia in the elderly Chinese; (2) determine how the tests' optimal cut-off scores varied with the patients' educational level and age; and (3) evaluate which was the more accurate test. METHODS: 151 cognitively-healthy, community dwelling elderly Chinese subjects and 95 elderly Chinese outpatients with dementia were administered the AMT and CMMSE. Receiver-Operating Characteristic (ROC) analysis was used to determine the tests' optimal cut-off scores for each of the education-by-age subgroups and their areas-under-the-curve were compared non-parametrically to evaluate which test was more accurate. RESULTS: Both the AMT and CMMSE could identify cognitive impairment accurately, but higher cut-off values were necessary for the younger and more educated cohort, while lower values were adequate for the older and less educated subgroup. The AMT appeared to reach a ceiling effect in the more educated categories. The diagnostic accuracies of the two instruments were statistically equivalent; there was a trend, however, for the CMMSE to be performing better in the more educated subgroups. CONCLUSIONS: To maximise the diagnostic efficiency of these two clinically useful mental status tests, it is important to adjust their cut-off scores for the patients' education and age. Though no clear superiority of either instrument was established in this study, we recommend the AMT for patients with 0-6 years of education, whereas for those with greater levels of literacy, we think it better to administer the CMMSE.