The Art of Remediating Age-Related Cognitive Decline: Art Therapy Enhances Cognition and Increases Cortical Thickness in Mild Cognitive Impairment.

OBJECTIVE: Previous research on art therapy (AT) in cognitive aging has been lacking. AT can potentially engender significant cognitive gains, due to its rigorous cognitive involvement, making it useful to tackle age-related cognitive decline. Along with these cognitive gains, associated neuroplastic changes are hypothesized to arise from AT as well. The current intervention examined the effects of an AT intervention on cognitive outcomes and cortical thickness (CT) among participants with mild cognitive impairment. METHOD: Participants were assigned to AT (n = 22) and an active control group (n = 27). In both, weekly 45-min sessions were carried out across 3 months. Cognitive assessments and structural magnetic resonance imaging scans were carried out at baseline and 3-month follow-up. Whole brain analyses on CT were carried out. Cognitive outcomes were analyzed using hierarchical linear models. RESULTS: Significant gains in immediate memory and working memory span were observed in the AT group, relative to the control group. Significantly increased CT in the AT group, relative to controls, was observed in a right middle frontal gyrus (MFG) cluster. Furthermore, CT changes in this cluster were significantly and positively correlated with changes in immediate memory. CONCLUSION: These findings highlighted the role of MFG neuroplasticity in enhancing certain cognitive functions in AT. AT is a neuroplastic intervention capable of engendering significant cognitive gains and associated cortical changes in the context of age-related cognitive decline, even when executed as a low-intensity intervention across 3 months. Given the preliminary nature of these findings, future larger sampled studies are needed.

Family-based therapy for anorexia nervosa: results from a 7-year longitudinal Singapore study.

PURPOSE: To determine the effectiveness of Family-Based Therapy (FBT) as a treatment for Anorexia Nervosa (AN) in adolescents in a Singaporean cohort. FBT has proven effective in studies in the West, but no such study has been done in Asia. METHODS: This is a retrospective analysis of a hospital-based cohort, which included all paediatric patients (≤ 18-years) with AN treated at a tertiary hospital in Singapore between 2011 and 2017 (n = 119). The patients either received manualised FBT (n = 42) or individualized adolescent focussed therapy (non-FBT) (n = 77). Patient characteristics and time to remission were abstracted from patient records. Survival analysis was used to determine median time to remission and remission-free survival rates. Hazard ratios for remission were obtained by cox regression. RESULTS: Patients in the non-FBT group had a significantly longer time to remission compared with the FBT group after adjustment for age, gender, BMI, psychiatric comorbidity, and ethnicity (p = 0.003, HR = 2.523, 95% CI 1.37-4.64). In the FBT group, the median time to remission was 5.0 months (95% CI 3.4-6.6 months); 11 months shorter than the non-FBT group (p < 0.001, 95% CI 7.9-14.1 months). FBT group remission rates were 69% and 90% at 1 and 2 years, respectively. Non-FBT group remission rates were 30% and 57% at 1 and 2 years, respectively. CONCLUSIONS: This study confirms that FBT is an effective treatment strategy for AN in adolescents in the Asian context. FBT can shorten the illness duration, which reduces disruption to schooling and family life at this critical life stage. LEVEL OF EVIDENCE: Level IV, evidence obtained from retrospective review of data before and after the introduction of new intervention.

Multisystem inflammatory syndrome in children (MIS-C) of a toddler initially presenting with fever and pyuria.

We report a case of multisystem inflammatory syndrome in children (MIS-C) in an East Asian toddler. He presented with a 2-day history of fever and pyuria, 5 weeks before that he had recovered from COVID-19. He was initially treated as urinary tract infection. On day 5 of fever, he was noted to have bilateral non-suppurative limbus-sparing conjunctivitis, red and cracked lips and erythematous extremities. Investigations showed raised inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), thrombocytopenia and a markedly elevated NT-proBNP. He received prompt and appropriate treatment inpatient; however, he still had mild coronary abnormalities at 9 months postdischarge. The aim of this paper is to describe the initial presentation and progress of a case of MIS-C. The unique features of this case are his initial presentation of pyuria and notably, his demography (young age, East Asian) which is more typical of Kawasaki disease than MIS-C.

Teacher led school-based surveillance can allow accurate tracking of emerging infectious diseases - evidence from serial cross-sectional surveys of febrile respiratory illness during the H1N1 2009 influenza pandemic in Singapore.

BACKGROUND: Schools are important foci of influenza transmission and potential targets for surveillance and interventions. We compared several school-based influenza monitoring systems with clinic-based influenza-like illness (ILI) surveillance, and assessed the variation in illness rates between and within schools. METHODS: During the initial wave of pandemic H1N1 (pdmH1N1) infections from June to Sept 2009 in Singapore, we collected data on nation-wide laboratory confirmed cases (Sch-LCC) and daily temperature monitoring (Sch-DTM), and teacher-led febrile respiratory illness reporting in 6 sentinel schools (Sch-FRI). Comparisons were made against age-stratified clinic-based influenza-like illness (ILI) data from 23 primary care clinics (GP-ILI) and proportions of ILI testing positive for pdmH1N1 (Lab-ILI) by computing the fraction of cumulative incidence occurring by epidemiological week 30 (when GP-ILI incidence peaked); and cumulative incidence rates between school-based indicators and sero-epidemiological pdmH1N1 incidence (estimated from changes in prevalence of A/California/7/2009 H1N1 hemagglutination inhibition titers ≥ 40 between pre-epidemic and post-epidemic sera). Variation in Sch-FRI rates in the 6 schools was also investigated through a Bayesian hierarchical model. RESULTS: By week 30, for primary and secondary school children respectively, 63% and 79% of incidence for Sch-LCC had occurred, compared with 50% and 52% for GP-ILI data, and 48% and 53% for Sch-FRI. There were 1,187 notified cases and 7,588 episodes in the Sch-LCC and Sch-DTM systems; given school enrollment of 485,723 children, this represented 0.24 cases and 1.6 episodes per 100 children respectively. Mean Sch-FRI rate was 28.8 per 100 children (95% CI: 27.7 to 29.9) in the 6 schools. We estimate from serology that 41.8% (95% CI: 30.2% to 55.9%) of primary and 43.2% (95% CI: 28.2% to 60.8%) of secondary school-aged children were infected. Sch-FRI rates were similar across the 6 schools (23 to 34 episodes per 100 children), but there was widespread variation by classrooms; in the hierarchical model, omitting age and school effects was inconsequential but neglecting classroom level effects led to highly significant reductions in goodness of fit. CONCLUSIONS: Epidemic curves from Sch-FRI were comparable to GP-ILI data, and Sch-FRI detected substantially more infections than Sch-LCC and Sch-DTM. Variability in classroom attack rates suggests localized class-room transmission.

Evolution of paediatric eating disorders in Singapore: a historical cohort study.

OBJECTIVE: Most eating disorders (EDs) develop during adolescence, impacting a critical period of development. There is limited research on EDs in children in Singapore or the rest of South-East (SE) Asia. DESIGN: We analysed a hospital-based cohort of paediatric patients (≤18 years) with EDs (n=177) in Singapore between 2011 and 2021. Historical trends, over three decades, were obtained by comparison with two previously published Singapore studies. RESULTS: Of the 177 patients, the majority 158 (89%) were females, with anorexia nervosa (AN) 151 (85%). The mean age at diagnosis was 14.6 (SD 1.8) years. For AN, the mean duration of illness before diagnosis was 8.3 (SD 6.3) months and this has decreased by 8.4 months (95% CI 4.5 to 12.3 months, p=<0.0001) from the 2003 to 2010 cohort, and 17.7 months (95% CI 12.6 to 22.8 months, p=<0.0001) from the 1994 to 2002 cohort. Avoidant/restrictive food intake disorder (ARFID) cases are increasing, and the clinical profile differs from other EDs. Since family-based therapy (FBT) was introduced for patients with AN, the remission rate at 1 year improved from 30% to 79%, and time to remission has decreased from 16 to 7.5 months. CONCLUSIONS: AN is the most common ED in paediatric patients in Singapore. Over the past three decades, EDs are being diagnosed earlier. FBT has emerged as the most effective treatment for AN. ARFID is being diagnosed more frequently. Data suggest that EDs are prevalent and increasing among adolescents in SE Asia. Singapore is a good test case for SE Asia, but research and attention to the problem in the region is needed.

A 5-year community program in Singapore to prevent cognitive decline.

INTRODUCTION: There is a scarcity of naturalistic follow-up studies on cognitive stimulating activities (CSAs), particularly in a real-world setting and over long-term. We thus investigated a pooled novel CSA intervention to prevent cognitive decline amongst community-dwelling older adults without dementia. METHODS: Nested within a community-based longitudinal follow-up cohort study of community-dwelling and multi-ethnic older adults (N = 991), a subset of the cohort (n = 264) underwent four single-blinded randomized controlled trials involving four novel CSAs, including mindfulness, horticulture, art therapy, and choral singing. At the cohort's 5-year follow-up, we examined if involvements in the CSAs improved cognition, compared to controls (n = 727). The primary outcomes were changes in global cognition and specific cognitive domain scores measured by the mini-mental state examination (MMSE). Exploratory subgroup analyses stratified by baseline cognitive status and the number of CSAs were also conducted. RESULTS: Compared to the control group, there was a small improvement in the CSA group on the total MMSE score (d = 0.108) and MMSE-immediate recall score (d = 0.199). Furthermore, subgroup analyses revealed medium effect sizes of improvements (d = 0.420) in cognitive domains in mild cognitive impairment (MCI) (vs. cognitively healthy) and those involved in two CSAs (vs. one CSA). DISCUSSION: In summary, a CSA intervention improved cognition. MCI and those involved in two CSAs gained greater benefits from the CSAs. These sustained improvements in cognitive functions could have a significant impact on delaying or preventing dementia.

Comparability of different methods for estimating influenza infection rates over a single epidemic wave.

Estimation of influenza infection rates is important for determination of the extent of epidemic spread and for calculation of severity indicators. The authors compared estimated infection rates from paired and cross-sectional serologic surveys, rates of influenza like illness (ILI) obtained from sentinel general practitioners (GPs), and ILI samples that tested positive for influenza using data from similar periods collected during the 2009 H1N1 epidemic in Singapore. The authors performed sensitivity analyses to assess the robustness of estimates to input parameter uncertainties, and they determined sample sizes required for differing levels of precision. Estimates from paired seroconversion were 17% (95% Bayesian credible interval (BCI): 14, 20), higher than those from cross-sectional serology (12%, 95% BCI: 9, 17). Adjusted ILI estimates were 15% (95% BCI: 10, 25), and estimates computed from ILI and laboratory data were 12% (95% BCI: 8, 18). Serologic estimates were least sensitive to the risk of input parameter misspecification. ILI-based estimates were more sensitive to parameter misspecification, though this was lessened by incorporation of laboratory data. Obtaining a 5-percentage-point spread for the 95% confidence interval in infection rates would require more than 1,000 participants per serologic study, a sentinel network of 90 GPs, or 50 GPs when combined with laboratory samples. The various types of estimates will provide comparable findings if accurate input parameters can be obtained.

Qualities of a psychiatric mentor: a quantitative Singaporean survey.

OBJECTIVE: Psychiatric mentors are an important part of the new, seamless training program in Singapore. There is a need to assess the qualities of a good psychiatric mentor vis-à-vis those of a good psychiatrist. METHOD: An anonymous survey was sent out to all psychiatry trainees and psychiatrists in Singapore to assess quantitatively the relative importance of 40 qualities for a good psychiatrist and a good mentor. RESULTS: The response rate was 48.7% (74/152). Factor analysis showed four themes among the qualities assessed (professional, personal values, relationship, academic-executive). A good mentor is defined by professional, relationship, and personal-values qualities. Mentors have significantly higher scores than psychiatrists for two themes (relationship and academic-executive). CONCLUSION: Being a good mentor, in Asia, means being a good psychiatrist first and foremost but also requires additional relationship and academic-executive skills. Mentors should be formally trained in these additional skills that were not part of the psychiatric curriculum.

Ageing in Asia: Beyond the Astana Declaration Towards Financing Long-term Care for All Comment on "Financing Long-term Care: Lessons From Japan".

The Astana Declaration on primary healthcare in 2018 was the attempt to revive the ideals of the World Health Organization (WHO) Alma-Ata Declaration 40 years later, together with a call for the political will to provide adequate financing at acceptable quality of care. This approach is taken to achieve the past ideals of Health for All, given the new challenges of universal health coverage. The economic case for primary healthcare is justified against the growing demand due in part to the growing costs of chronic conditions and the rise of ageing population, other than the supply-side factors of the healthcare industry. Past healthcare systems have evolved greater roles of the state versus the market, but few have involved the Third Sector or civil society in more integrated ways to provide and finance long-term care (LTC) with population ageing. From the extremes of the communist state to capitalist free markets, an optimal public-private system has to reach a balance in access, cost and quality for health and LTC. Recent studies of health and LTC have distilled newer developments in public-private mixes of provision, financing and regulation, in response to the needs of fast-ageing Asian societies. While Japan was the oldest country in the world, other countries in Asia have caught up and are now acknowledged where innovative models of integrated eldercare under economic limits, hold great promise of their transferability to the rest of ageing societies. Besides other forms of integrated LTC delivery with traditional systems, newer forms of financing like savings funds and superannuation have been developed, with participation from government, industry and civil society. There is much to learn from the new Asian models of financing, using appropriate technology and social innovations, and integrating health and social systems for LTC.

Experience from a Multi-Disciplinary Team Against COVID-19: A Healthcare Perspective.

Globally, the capacity of healthcare systems across continents has been strained and put to the test with the emergence of the Coronavirus disease 2019 (COVID-19) pandemic. The timely need to ensure the availability of healthcare facilities to isolate and manage the surge in COVID-19 cases without overwhelming existing hospital capacity has posed challenges in many countries. In this paper, we discuss the conceptualisation, preparations and operationalisation of a community healthcare facility that was set up within a short time frame to attend to the convalescent needs of a large number of COVID-19 patients in the early phase of handling the pandemic. In the first month of operations, we monitored a total of 2129 clinical encounters, with the majority of patients between 17-35 years of age and between day 2 to day 6 of illness upon admission. Overall, there was a good outcome for the patients, with only 2.3% requiring transfer back to restructured hospitals. There was also no mortality. We hope that the sharing of our experiences of the challenges and learning lessons gleaned may be useful to guide individuals in planning for the future preparedness of healthcare systems in managing pandemics.

Mindfulness Awareness Practice (MAP) to Prevent Dementia in Older Adults with Mild Cognitive Impairment: Protocol of a Randomized Controlled Trial and Implementation Outcomes.

BACKGROUND: With an aging population, developing non-pharmacological interventions (NPIs) to delay dementia has become critical. Apart from cognitive decline, dementia is associated with multiple pathophysiology, including increased oxidative stress, dysregulated gene expressions, cytokine, neurotrophin, and stress markers, telomere shortening, and deteriorations in brain connectivity. Although mindfulness practices have been proposed to ameliorate these biological changes, no empirical studies were conducted. We thus aimed to investigate the effects of mindfulness awareness practice (MAP) to prevent cognitive decline and improve peripheral biomarkers in community-dwelling older adults diagnosed with mild cognitive impairment (MCI). METHODS/DESIGN: This was a single-blinded and parallel-group randomized controlled trial with two arms (intervention and active control arms), conducted over nine months. A total of 60 consenting community-dwelling older adults diagnosed with MCI were planned to be randomized in a 1:1 ratio to either the MAP or the Health Education Program (HEP). Interventions were performed weekly for the initial 12 weeks, and monthly for the subsequent six months. Outcome measures were assessed at baseline, 3-month, and 9-month post-intervention by blinded assessors. Primary outcomes were neurocognitive tests, comprehensive peripheral biomarkers, and brain imaging scans. Secondary outcomes included basic health screening measures, affective symptoms, and measures of physical functions. Linear-mixed models were used to examine the effects of MAP on these outcome measures. SIGNIFICANCE: This is the first randomized controlled trial to systematically investigate the effects of a mindfulness intervention in improving cognitive functions and various biomarkers in community-dwelling older adults diagnosed with MCI. Our findings have the potential to inform mindfulness intervention as a novel approach to delay dementia.

Mindfulness improves inflammatory biomarker levels in older adults with mild cognitive impairment: a randomized controlled trial.

Few randomized controlled trials investigated the effects of mindfulness intervention on older adults diagnosed with mild cognitive impairment (MCI). Furthermore, there have been hypotheses and theoretical mechanisms on the benefits of mindfulness intervention on biomarkers of stress, inflammation, and neuroplasticity implicated in MCI that warrant empirical evidence. We conducted a pilot randomized controlled trial to examine whether Mindful Awareness Practice (MAP) improved biomarker levels in older adults with MCI. Fifty-five community-dwelling older adults aged 60 and above were randomized into either the treatment arm, MAP, or the active control arm, the health education program (HEP). Researchers who were blinded to treatment allocation assessed the outcomes at baseline, 3-month, and 9-month follow-ups. Linear-mixed models were used to examine the effect of MAP on biomarker levels. MAP participants had significantly decreased high-sensitivity c-reactive protein (hs-CRP) levels at 9-month (ß = -0.307, 95% CI = -0.559 to -0.054 P = 0.018). Exploratory sub-group analyses by sex showed significantly decreased hs-CRP in females only (ß = -0.445, 95% CI = -0.700 to -0.189, P = 0.001), while stratification by MCI subtype showed hs-CRP decreased only in amnestic-MCI (aMCI) (ß = -0.569, 95% CI = -1.000 to -0.133, P = 0.012). Although total sample analyses were not significant, males had significantly decreased interleukin (IL)-6 (ß = -1.001, 95% CI = -1.761 to -0253, P = 0.011) and IL-1ß (ß = -0.607, 95% CI = -1.116 to -0.100, P = 0.021) levels at 3-month and non-significant improvements at 9-month time-point. MAP improved inflammatory biomarkers in sex- and MCI subtype-specific manners. These preliminary findings suggest the potential of mindfulness intervention as a self-directed and low-cost preventive intervention in improving pathophysiology implicated in MCI.

Effects of choral singing versus health education on cognitive decline and aging: a randomized controlled trial.

We conducted a randomized controlled trial to examine choral singing's effect on cognitive decline in aging. Older Singaporeans who were at high risk of future dementia were recruited: 47 were assigned to choral singing intervention (CSI) and 46 were assigned to health education program (HEP). Participants attended weekly one-hour choral singing or weekly one-hour health education for two years. Change in cognitive function was measured by a composite cognitive test score (CCTS) derived from raw scores of neuropsychological tests; biomarkers included brain magnetic resonance imaging, oxidative damage and immunosenescence. The average age of the participants were 70 years and 73/93 (78.5%) were female. The change of CCTS from baseline to 24 months was 0.05 among participants in the CSI group and -0.1 among participants in the HEP group. The between-group difference (0.15, p=0.042) became smaller (0.12, p=0.09) after adjusting for baseline CCTS. No between-group differences on biomarkers were observed. Our data support the role of choral singing in improving cognitive health in aging. The beneficial effect is at least comparable than that of health education in preventing cognitive decline in a community of elderly people. Biological mechanisms underlying the observed efficacy should be further studied.

Barriers to smoking cessation: a qualitative study from the perspective of primary care in Malaysia.

OBJECTIVES: This qualitative study aims to construct a model of the barriers to smoking cessation in the primary care setting. DESIGN: Individual in-depth, semistructured interviews were audio-taped, then verbatim transcribed and translated when necessary. The data were first independently coded and then collectively discussed for emergent themes using the Straussian grounded theory method. PARTICIPANTS AND SETTING: Fifty-seven current smokers were recruited from a previous smoking related study carried out in a primary care setting in Malaysia. Current smokers with at least one failed quit attempts were included. RESULTS: A five-theme model emerged from this grounded theory method. (1) Personal and lifestyle factors: participants were unable to resist the temptation to smoke; (2) Nicotine addiction: withdrawal symptoms could not be overcome; (3) Social cultural norms: participants identified accepting cigarettes from friends as a token of friendship to be problematic; (4) Misconception: perception among smokers that ability to quit was solely based on one's ability to achieve mind control, and perception that stopping smoking will harm the body and (5) Failed assisted smoking cessation: smoking cessation services were not felt to be user-friendly and were poorly understood. The themes were organised into five concentric circles based on time frame: those actionable in the short term (themes 1 and 2) and the long term (themes 3, 4, 5). CONCLUSIONS: Five themes of specific beliefs and practices prevented smokers from quitting. Clinicians need to work on these barriers, which can be guided by the recommended time frames to help patients to succeed in smoking cessation.

Translating the family medicine vision into educational programmes in Singapore.

The core of the Family Medicine (FM) vision is patient-centred care, requiring specific education and vocational training. We traced how FM education started and what have been achieved. FM training began in 1971 with the formation of the College of General Practitioners Singapore. Previously, training consisted of self-directed learning, lunchtime talks and examination preparation courses run by hospital specialists. Formal FM vocational training programmes in the United Kingdom and Australia provided the model for a 3-year programme in 1988. The tripartite relationship between the local university, College of Family Physicians and Ministry of Health, together with a structured training programme, contributed to its success. To date, more than 240 Family Physicians in Singapore have been awarded the Masters in Medicine (FM) degree. The Graduate Diploma in Family Medicine programme (GDFM) was introduced in 2000 for Family Physicians who wished to practice at an enhanced level. This programme has trained 194 doctors since then. Behind the scenes, the following were important developments: counterculture with a difference, tripartite stake-holding, training the trainers and learning from others. For the FM undergraduate programme, our aim is to develop the knowledge base, core values and roles of the Family Physician. Sustaining the value of Family Medicine as a career choice is the enduring vision.

Family medicine education in Singapore: a long-standing collaboration between specialists and family physicians.

In many countries, family medicine (FM) training has been conducted mainly by senior family physicians alone. However, FM training in Singapore in the last 30 years has involved specialists working in close collaboration with family physicians. The areas in which specialists are currently involved include the training of FM trainees in tertiary hospitals, the Master of Medicine in Family Medicine [MMed (FM)] and Graduate Diploma in Family Medicine (GDFM) programmes. This close relationship has been crucial in the continuing vocational and professional development of family physicians and in fostering closer collaboration between family physicians and specialists, thus ultimately benefiting patient care.

Outcome predictors in elderly head and neck free flap reconstruction: A retrospective study and systematic review of the current evidence.

Free flap tissue transfer has become the gold standard for reconstruction of composite head and neck defects. We sought to investigate the efficacy and morbidity of these procedures in the elderly. We retrospectively reviewed 245 head and neck free flap procedures (234 patients). Patients were stratified by age group (≥ or <65 years). Univariate and multivariate analyses were used to evaluate the following primary outcomes - free flap survival, postoperative medical and surgical complications and 30-day mortality. We found that free flap success and surgical complication rates were similar between the two age groups. Overall flap success and perioperative mortality rates were 94.3% and 2.1% respectively. Medical complications were significantly more common in the elderly group (p <0.001) and this correlated with comorbidity (OR = 2.81, p = 0.044) and advanced tumour stage (OR = 10.20, p= 0.029). Age was not independently associated with poor outcomes in our cohort. We then performed a systematic review of similar case-control studies worldwide and compared their findings with our results. We conclude that advanced age does not preclude free flap success in head and neck reconstruction. Rather, the presence of comorbidity appears to predict the development of medical complications postoperatively. Elderly patients with low comorbidity scores may be offered free flap reconstruction with less reservation.

Study Protocol for a Randomized Controlled Trial of Choral Singing Intervention to Prevent Cognitive Decline in At-Risk Older Adults Living in the Community.

Introduction: This study is a parallel-arm randomized controlled trial evaluating choral singing's efficacy and underlying mechanisms in preventing cognitive decline in at-risk older participants. Methods: Three-hundred and sixty community-dwelling, non-demented older participants are recruited for a 2-year intervention. Inclusion criteria are self-reported cognitive complaints, early cognitive impairment based on neuropsychological test scores or multiple risk factors of dementia. Participants are randomized to either weekly choral singing sessions or general health education. The primary outcome is cognitive performance, measured by a composite cognitive test score (CCTS). Secondary outcomes include depression, anxiety and neuropsychiatric symptoms; perceived stress; sleep quality and severity of dementia symptoms. Underlying mechanisms are examined using blood- and urine-based biomarkers and neuroimaging. Results: Screening began in July 2016. The first group of participants (n = 93) have been recruited. Intervention and control treatments are ongoing and will end in December 2019. Discussion: An evidence-based singing intervention for dementia prevention holds potential for healthcare savings and societal welfare. Trial Registration: NCT02919748, IRB Approval Number: NUS 2508.