Validation and use of the Second Victim Experience and Support Tool questionnaire: a scoping review.

OBJECTIVES: Patient safety incidents can impact not only patients and families but also healthcare providers, who may experience negative emotions and symptoms, such as anxiety, guilt, stress, and loss of confidence. To identify and support these "second victims," a screening tool called the Second Victim Experience and Support Tool (SVEST) has been developed. This scoping review aims to map our current knowledge of the SVEST in terms of its scope of use, validation and limitations. STUDY DESIGN: Scoping review. METHODS: In accordance with the framework outlined by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews, we conducted a literature search in MEDLINE, CINAHL, Cochrane Library, SCOPUS, Embase and PsycINFO databases from database inception up till 1 March 2023. RESULTS: A total of 31 studies were reviewed. The SVEST has been cross-culturally adapted from English into other languages. The SVEST has been successfully used in different contexts and with various healthcare professionals, including doctors, nurses, allied health professionals, midwives and pharmacists. The tool has been used to assess the impact of second victim experiences and the effectiveness of support interventions in addressing the phenomenon. Validity assessment of translated versions of SVEST in the reviewed studies revealed good content validity in most cases, although some studies did not report clear values for scale-level Content Validity Index. On the whole, SVEST is generally a reliable and valid tool, although further refinements and modifications may improve its validity and reliability. CONCLUSIONS: The review highlights the significance of SVEST as a crucial resource for healthcare providers and organisations that prioritise well-being and safety in health care. It also underscores the importance of recognising the needs of second victims and offering them appropriate interventions to manage the aftermath of adverse events.

A musculoskeletal ultrasound program as an intervention to improve disease modifying anti-rheumatic drugs adherence in rheumatoid arthritis: a randomized controlled trial.

Objectives: To evaluate the effect of a musculoskeletal ultrasound programme (MUSP) applying real-time ultrasonography with reinforcement of findings by a rheumatologist on improving disease-modifying anti-rheumatic drugs (DMARDs) adherence in rheumatoid arthritis (RA).Method: Eligible RA patients with low adherence score (< 6) on the 8-item Morisky Medication Adherence Scale (MMAS-8) were randomized to either an intervention group (receiving MUSP at baseline) or a control group (no MUSP), and followed up for 6 months. Adherence measures (patient-reported and pharmacy dispensing records) and clinical efficacy data were collected. The MUSP's feasibility and acceptability were assessed.Results: Among 132 recruited RA patients, six without baseline visits were excluded; therefore, 126 patients were analysed (62 intervention and 64 control). The primary outcome (proportion of patients with 1 month MMAS-8 score < 6) was significantly smaller (p = 0.019) in the intervention (35.48%) than the control group (56.25%). However, 3 and 6 month adherence and clinical efficacy outcomes were not significantly different between the two groups (all p > 0.05). All 62 patients completed the MUSP (mean time taken, 9.2 min), with the majority reporting moderately/very much improved understanding of their joint condition (71%) and the importance of regularly taking their RA medication(s) (79%). Most patients (90.3%) would recommend the MUSP to another RA patient.Conclusions: The MUSP improved RA patients' DMARDs adherence in the short term and was feasible and well accepted by patients. Future studies could evaluate whether repeated feedback using MUSP could help to sustain the improvement in DMARD adherence in RA patients, and whether this may be clinically impactful and cost-effective.

Thermography in rheumatoid arthritis: a comparison with ultrasonography and clinical joint assessment.

AIM: To compare thermography with ultrasonography and clinical joint assessment in patients with rheumatoid arthritis (RA). MATERIALS AND METHODS: Thermography and ultrasonography (power Doppler (PD) and grey-scale (GS) joint inflammation scored semi-quantitatively 0-3) were performed sequentially on both hands of 37 RA patients. Using generalised estimating equations analysis, (a) thermographic parameters (TP) were compared between joints based on their PD and GS joint inflammation positivity/negativity status, while (b) TP and ultrasound-detected joint inflammation were compared between joints categorised by their clinical swelling/tenderness status. RESULTS: Comparing PD positive versus negative joints, the differences in mean values (95% CI) for TP including maximum (Tmax), minimum (Tmin), average (Tavg), and Tmax minus Tmin (Tmax-min) temperatures (in °C) were 1.37 (0.86, 1.87), 0.91 (0.46, 1.36), 1.16 (0.67, 1.64), and 0.46 (0.28, 0.64), respectively. Comparing GS positive versus negative joints, the corresponding results for thermography were 1.09 (0.67, 1.52), 0.66 (0.32, 1.00), 0.86 (0.47, 1.26), and 0.45 (0.28, 0.62), respectively. p-Values were all <0.001. The differences in mean values (95% CI) for ultrasound scores, but not for TP, were statistically significant for (a) swollen tender joints (PD: 0.67 [0.39, 0.96], p<0.001; GS: 0.86 [0.54, 1.18], p<0.001) and (b) swollen non-tender joints (PD: 0.46 [0.07, 0.84], p=0.021; GS: 0.83 [0.37, 1.29], p<0.001) when compared to non-swollen non-tender joints. CONCLUSION: Joints in RA patients have significantly higher temperature readings when ultrasound-detected joint inflammation is present. Swollen tender/non-tender joints exhibited a greater degree of ultrasound-detected joint inflammation than non-swollen non-tender joints, although their temperature readings were not significantly higher.

Pre-operative pressure pain thresholds do not meaningfully explain satisfaction or improvement in pain after knee replacement: a cohort study.

OBJECTIVES: Pain sensitization could be a risk factor for poor outcomes after knee replacement surgery (KR) for knee osteoarthritis (KOA). We aimed to evaluate the association between pre-operative central and peripheral pain sensitization measured using a digital pressure algometer and KR outcomes. METHODS: Consecutive patients with severe KOA listed for KR were recruited. Sociodemographic and symptoms data were collected prior to surgery. Pre-operative pressure pain thresholds (PPTs) were measured using a digital pressure algometer at the index knee and forearm. Patient satisfaction at 6 and 12 months after KR was assessed using a 4-point Likert scale, and dichotomized to satisfied and dissatisfied to KR. Western Ontario and McMaster Universities Index (WOMAC) Pain and function was assessed. The associations between pre-operative PPTs with KR outcomes at 6 and 12 months were evaluated. RESULTS: Of the 243 patients recruited, response rate at 6 and 12 months were 95.5% and 96.7%. The dissatisfaction rates were 8.2% and 5.1% at 6 and 12 months. There was no statistically significant association between pre-operative index knee or forearm PPTs and patient satisfaction. PPTs measured at the knee, but not the forearm, were weakly associated with change in the WOMAC pain score at 12 months, after adjustment for confounding factors. CONCLUSION: Pre-operative central sensitization, measured by handheld digital algometry, was not statistically significantly associated with satisfaction or change in pain after KR. Pre-operative peripheral sensitization was associated with change in pain symptoms after KR; however, this association was weak and unlikely to be a meaningful predictor of KR outcome in clinical practice.

Comparing the 1997 update of the 1982 American College of Rheumatology (ACR-97) and the 2012 Systemic Lupus International Collaborating Clinics (SLICC-12) criteria for systemic lupus erythematosus (SLE) classification: which enables earlier classification of SLE in an urban Asian population?

OBJECTIVE: We compared the 1997 update of the 1982 American College of Rheumatology (ACR-97) and the 2012 Systemic Lupus International Collaborating Clinics (SLICC-12) criteria, for earlier classification of systemic lupus erythematosus (SLE) in a multiethnic urban Asian SLE population. METHODS: Patients from a retrospective, nested case-control study of the influence of lupus nephritis on mortality in SLE were studied. For each patient, dates of first manifestations of each criteria (both ACR-97 and SLICC-12) were recorded, and the date of disease classification using ACR-97 or SLICC-12 criteria was compared to determine which criteria resulted in earlier classification. RESULTS: Among 182 SLE patients (74.2% Chinese, 18.1% Malay, 4.4% Indian and 3.3% Other ethnicities), 10 (5.5%) did not fulfill the ACR-97 criteria and 2 (1.1%) did not fulfill the SLICC-12 criteria. Using the SLICC-12 criteria, 18% of subjects showed earlier classification, whereas 7% of subjects showed earlier classification using the ACR-97 criteria. The SLICC hematologic criteria of "Leukopenia or lymphopenia" contributed most significantly to earlier diagnosis by SLICC-12. "Leukopenia or lymphopenia'' was present in 59% (19/32) of patients where SLICC-12 criteria allowed for earlier classification than ACR-97, compared with 15.4% (2/13) of patients where ACR-97 allowed earlier classification than SLICC-12 ( p = 0.02). The immunologic criterion that is considered a strength of the SLICC-12 criteria did not appear to contribute significantly to earlier diagnosis in this study. CONCLUSION: SLICC-12 criteria allow for earlier classification of SLE in a multiethnic cohort of Asian patients, supporting the validity of the SLICC-12 criteria and its use in clinical care and research.

Colchicine lack of effectiveness in symptom and inflammation modification in knee osteoarthritis (COLKOA): a randomized controlled trial.

OBJECTIVES: Uric acid may activate an innate immune response in osteoarthritis (OA), contributing to disease pathology and progression. We evaluated the effectiveness of colchicine on pain and function in symptomatic knee OA (KOA) and the underlying mechanism of action. METHODS: Colchicine effectiveness in symptoms and inflammation modification in knee osteoarthritis (COLKOA) was a double-blind, placebo-controlled, randomized trial comparing 16 weeks of treatment with 0.5 mg twice-daily oral colchicine to placebo for knee osteoarthritis (KOA). The primary endpoint was ≥30% improvement in total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score at week 16. Secondary endpoints included improvement in pain (0-10 Likert scales); WOMAC pain; patient global assessment (0-100); physical function; the OARSI-OMERACT response; quality of life; and change in serum, urine, synovial fluid (SF) biomarkers of cartilage metabolism and inflammation, and plasma/SF colchicine concentrations. RESULTS: Of 109 randomly assigned participants, 39% (95% confidence interval (CI) 27-52%) and 49% (95% CI 36-62%) in the colchicine and placebo arms respectively met the primary endpoint at study end (P = 0.284, odds ratio 0.66, 95% CI 0.31-1.41). No strong evidence of treatment differences was identified on clinical secondary endpoints. Treatment significantly reduced mean serum hs-CRP (P = 0.008) and SF CTXI (P = 0.002); treatment tended to reduce inflammatory markers (SF IL-6, IL8, TNFα, CD14 and IL-18), but these differences were not statistically significant. CONCLUSION: Colchicine (0.5 mg twice-daily orally) reduced inflammation and high bone turnover biomarkers known to be associated with OA severity and progression risk, but did not reduce KOA symptoms over a 16-week study period. A longer-term study to evaluate for slow-acting disease modifying effects is warranted. TRIAL REGISTRATION: The trial has been registered at clinicaltrials.gov as NCT02176460. Date of registration: June 26, 2014.

Cross-cultural measurement equivalence of the EQ-5D-5L items for English-speaking Asians in Singapore.

PURPOSE: To investigate how the response labels of the 5-level EQ-5D (EQ-5D-5L) items are interpreted and used by English-speaking Chinese and non-Chinese Singaporeans, as a means to assessing whether those items are cross-culturally equivalent health-status measures in this Asian population. METHODS: In face-to-face interviews, Chinese, Malay and Indian visitors to a primary care institution in Singapore were asked to rate the relative severity conveyed by EQ-5D-5L response labels, each containing the keyword of 'no(t),' 'slight(ly),' 'moderate(ly),' 'severe(ly),' or 'unable'/'extreme(ly),' using a 0-100 numerical rating scale. Participants were also asked to describe 25 hypothetical health states using the EQ-5D-5L response labels. Differences between Chinese and Malay/Indian participants in label interpretation and selection were examined using multivariate regression analysis to adjust for participant characteristics. RESULTS: The differences in adjusted mean severity scores for individual EQ-5D-5L labels between Chinese (n = 148) and non-Chinese (Malay: n = 53; Indian: n = 56) participants ranged from 0.0 to 9.0. The relative severity of the labels to the participants supported the ordinality of the EQ-5D-5L response labels and was similar across ethnic groups. Chinese and non-Chinese participants selected similar response labels to describe each hypothetical health state, with the adjusted odds ratios of selecting any type of the five response labels for non-Chinese versus Chinese participants ranging from 0.92 to 1.15 (p > 0.05 for all). CONCLUSIONS: The EQ-5D-5L items are likely to generate equivalent health outcomes between English-speaking Chinese and non-Chinese Singaporeans.

Cigarette smoking and risk of total knee replacement for severe osteoarthritis among Chinese in Singapore--the Singapore Chinese health study.

PURPOSE: Data on the effects of cigarette smoking with osteoarthritis (OA) are inconsistent and no study has examined the effect of smoking cessation. We examined smoking status, duration, dosage and cessation in association with risk of total knee replacement (TKR) for severe knee OA among elderly Chinese in Singapore. METHODS: We used data from the Singapore Chinese Health Study, a population-based prospective cohort of 63,257 Chinese men and women aged 45-74 years during enrollment between 1993 and 1998. Detailed information on smoking, current diet and lifestyle factors were obtained through in person interviews. As of 31 December 2011, 1,973 incident TKR cases for severe knee OA had been identified via linkage with nationwide hospital discharge database. We used Cox regression methods to examine smoking in relation to TKR risk with adjustment for age, gender, education, body mass index (BMI), comorbidities and physical activity level. RESULTS: Compared to never smokers, current smokers had a 51% decrease in risk of TKR [Hazards ratio (HR) = 0.49; 95% confidence interval (CI) = 0.40-0.60]. Among current smokers, there was a very strong dose-dependent association between increasing duration and dosage of smoking with decreasing risk of TKR (P for trend <0.0001). Among former smokers, there was a dose-dependent response between decrease in duration of smoking cessation and reduction in TKR risk (P for trend = 0.034). CONCLUSION: Our findings strongly implicate smoking as a protective factor for TKR indicated for severe knee OA. This concurs with experimental data that nicotine promotes proliferation and collagen synthesis in chondrocytes.

The effect of comorbidity on hospital mortality in patients with SLE from an Asian tertiary hospital.

OBJECTIVES: The objective of the study was to assess the disease burden of systemic lupus erythematosus (SLE) and the usefulness of the Charlson Comorbidity Index (CCI) as risk-adjusted hospital mortality predictors in patients with SLE using a hospital administrative database. METHODS: A historical cohort study of a hospital discharge database from 2004 to 2011 was used to identify cases with SLE and comorbidity using the International Statistical Classification of Diseases and Related Health Problems, ninth revision, Australian modification (ICD-9-AM) codes. RESULTS: Over the eight years, 841 patients met the criteria of SLE with a hospital mortality rate of 9.2%. The hospital mortality rates (2.4%, 15.7%, 25.0%, and 30.4%, respectively, p < 0.001) and hospital length of stay (geometric mean, 3.5, 5.6, 8.8, and 7.5 days, respectively, p < 0.001) were consistently increased for patients with CCI ranging from none, low, moderate to high grade, respectively. Cox proportional hazards model analysis showed that CCI (hazard ratio (HR) 7.8 high vs. none, p < 0.001) and infectious disease (HR 2.0, p = 0.016) were significant and independent predictors of hospital mortality. Similar results were also seen with hospital length of stay by zero-truncated negative binomial regression model analysis. CONCLUSION: The SLE burden is high in this population. Comorbidities and infectious disease were some of the most important contributors to hospital mortality and resource utilization.

OARSI recommended performance-based tests to assess physical function in people diagnosed with hip or knee osteoarthritis.

OBJECTIVES: To recommend a consensus-derived set of performance-based tests of physical function for use in people diagnosed with hip or knee osteoarthritis (OA) or following joint replacement. METHODS: An international, multidisciplinary expert advisory group was established to guide the study. Potential tests for consideration in the recommended set were identified via a survey of selected experts and through a systematic review of the measurement properties for performance-based tests. A multi-phase, consensus-based approach was used to prioritize and select performance-based tests by applying decision analysis methodology (1000Minds software) via online decision surveys. The recommended tests were chosen based on available measurement-property evidence, feasibility of the tests, scoring methods and expert consensus. RESULTS: Consensus incorporated the opinions of 138 experienced clinicians and researchers from 16 countries. The five tests recommended by the advisory group and endorsed by Osteoarthritis Research Society International (OARSI) were the 30-s chair-stand test, 40 m fast-paced walk test, a stair-climb test, timed up-and-go test and 6-min walk test. The first three were recommended as the minimal core set of performance-based tests for hip or knee OA. CONCLUSION: The OARSI recommended set of performance-based tests of physical function represents the tests of typical activities relevant to individuals diagnosed with hip or knee OA and following joint replacements. These tests are complementary to patient-reported measures and are recommended as prospective outcome measures in future OA research and to assist decision-making in clinical practice. Further research should be directed to expanding the measurement-property evidence of the recommended tests.

Associations between complications and health-related quality of life in individuals with diabetes.

OBJECTIVE: Type 2 diabetes and associated complications adversely affect health-related quality of life (HRQoL). However, it is unclear whether different complications have the same or different associations with HRQoL. We examined associations between retinopathy, nephropathy, peripheral neuropathy (microvascular), coronary heart disease, stroke and peripheral arterial disease (macrovascular) in diabetes and HRQoL. DESIGN: This study was a follow-up examination between 2004 and 2007 of participants from four previous cross-sectional population-based studies in Singapore. METHODS: Health-related quality of life was assessed through self-administered SF-36 health survey version 2. Diabetes and complications status were assessed through self-report, clinical and laboratory examinations. About 2601 individuals, 2205 healthy and 396 with diabetes, were studied. RESULTS: Lower physical component scores (PCS) were associated with microvascular (2.96 points, P < 0.001) and both macro- and microvascular complications (4.67 points, P < 0.001), but not diabetes alone. Coronary heart disease (3.86 points, P = 0.007), peripheral neuropathy (11.46 points, P < 0.001) and severe retinopathy (4.46 points, P < 0.001) were associated with lower PCS. The greatest reduction in scores was seen in peripheral neuropathy. CONCLUSIONS: Quality of life in patients with diabetes is affected mainly by presence of complications, and not diabetes per se. Peripheral neuropathy was associated with the greatest reduction in quality of life. Improved management to prevent or delay onset of complications may reduce the effect on quality of life in patients with diabetes.

Predicting preference-based SF-6D index scores from the SF-8 health survey.

PURPOSE: To develop and test functions for predicting the preference-based SF-6D index scores from the SF-8 health survey. METHODS: This study was a secondary analysis of data collected in a population health survey in which respondents (n = 7,529) completed both the SF-36 and the SF-8 questionnaires. We examined seven ordinary least-square estimators for their performance in predicting SF-6D scores from the SF-8 at both the individual and the group levels. RESULTS: In general, all functions performed similarly well in predicting SF-6D scores, and the predictions at the group level were better than predictions at the individual level. At the individual level, 42.5-51.5% of prediction errors were smaller than the minimally important difference (MID) of the SF-6D scores, depending on the function specifications, while almost all prediction errors of the tested functions were smaller than the MID of SF-6D at the group level. At both individual and group levels, the tested functions predicted lower than actual scores at the higher end of the SF-6D scale. CONCLUSIONS: Our study developed functions to generate preference-based SF-6D index scores from the SF-8 health survey, the first of its kind. Further research is needed to evaluate the performance and validity of the prediction functions.

Impact of COVID-19 on environmental services workers in healthcare settings: a scoping review.

BACKGROUND: In the wake of the coronavirus disease 2019 (COVID-19) pandemic, demand for deep cleaning and environmental services workers grew exponentially. Although there is extant literature examining the impact of the COVID-19 pandemic on healthcare workers, less emphasis has been placed on environmental services workers, who play an equally important front-line role. AIM: To examine the impact of the COVID-19 pandemic on environmental services workers employed in healthcare settings. METHODS: Scoping review methodology. A search strategy was developed, in consultation with a medical information specialist, employing various combinations of the keywords [(environmental services worker OR health attendant OR housekeeping) AND (COVID OR coronavirus OR pandemic OR epidemic)]. Four bibliographical databases were searched from inception to 5th July 2022: OVID Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Cochrane Database. RESULTS: In total, 24 studies were included in this review. The studies were generally cross-sectional in design. Seroprevalence studies highlighted significantly higher rates of COVID-19 among environmental services workers (housekeeping, cleaning and janitorial staff) compared with other clinical and non-clinical staff in the same institutions. In addition, based on qualitative interviews, environmental services workers experienced greater psychological stress working during the pandemic. CONCLUSIONS: Environmental services workers were particularly vulnerable to increased work stress and COVID-19 during the pandemic. Health systems need to do more to support these workers. Further research could investigate specific policy and procedural changes to benefit this under-recognized group in the greater healthcare workforce.

Impact of the COVID-19 pandemic on a tertiary care public hospital in Singapore: resources and economic costs.

BACKGROUND: The COVID-19 pandemic has prompted hospitals to respond with stringent measures. Accurate estimates of costs and resources used in outbreaks can guide evaluations of responses. We report on the financial expenditure associated with COVID-19, the bed-days used for COVID-19 patients and hospital services displaced due to COVID-19 in a Singapore tertiary hospital. METHODS: We conducted a retrospective cost analysis from January to December 2020 in the largest public hospital in Singapore. Costs were estimated from the hospital perspective. We examined financial expenditures made in direct response to COVID-19; hospital admissions data related to COVID-19 inpatients; and the number of outpatient and emergency department visits, non-emergency surgeries, inpatient days in 2020, compared with preceding years of 2018 and 2019. Bayesian time-series was used to estimate the magnitude of displaced services. RESULTS: USD $41.96 million was incurred in the hospital for COVID-19-related expenses. Facilities set-up and capital assets accounted for 51.6% of the expenditure; patient-care supplies comprised 35.1%. Of the 19,611 inpatients tested for COVID-19 in 2020, 727 (3.7%) had COVID-19. The total inpatient- and intensive care unit (ICU)-days for COVID-19 patients in 2020 were 8009 and 8 days, respectively. A decline in all hospital services was observed from February following a raised disease outbreak alert level; most services quickly resumed when the lockdown was lifted in June. CONCLUSION: COVID-19 led to an increase in healthcare expenses and a displacement in hospital services. Our findings are useful for informing economic evaluations of COVID-19 response and provide some information about the expected costs of future outbreaks.

Association of body mass index with Short-Form 36 physical and mental component summary scores in a multiethnic Asian population.

OBJECTIVES: To investigate the association between body mass index (BMI) and physical and mental health-related quality of life (HRQoL) in a multiethnic Asian population in Singapore, and explore whether there were gender and ethnic differences in this association. METHODS: We conducted cross-sectional analyses using data from 5027 Chinese, Malay and Indian participants (2403 men and 2624 women) aged 24-95 years. These subjects were from four previous cross-sectional surveys carried out in Singapore (from 1982 to 1998) who attended a follow-up examination (including both a questionnaire and a clinic examination) between 2004 and 2007, during which HRQoL was assessed. Participants were classified as underweight (<18.5 kg m(-2)), normal weight (18.5 to <23 kg m(-2)), overweight (23 to <25 kg m(-2)), moderate obese (25 to <30 kg m(-2)) and severe obese (>or=30 kg m(-2)). HRQoL was measured using the Short-Form 36-item questionnaire (SF-36) physical component summary score (PCS) and mental component summary score (MCS). Linear regressions with and without adjusting for other covariates were used to evaluate the association between BMI and SF-36 PCS and MCS. RESULTS: Compared with participants with normal weight, moderate or severe obesity was associated with 0.8 points (95% confidence interval (CI): -1.5 to -0.1, P=0.03) and 2.1 points lower PCS (95% CI: -3.1 to -0.1, P<0.001), respectively, after adjustment for sociodemographic variables, family functioning measure scores and the presence of chronic diseases. These associations were greater in women than in men. In contrast, being underweight was associated with 1.3 points lower MCS (95% CI: -2.3 to -0.3, P=0.014). CONCLUSIONS: In this study (one of few studies in the Asia-Pacific region), obesity was associated with lower PCS and the effect was modified by gender but not ethnicity, such that the association was greater in women than in men. However, obesity was not associated with MCS. Underweight was associated with reduced MCS but not PCS.

Neuropsychiatric lupus: clinical challenges, brain-reactive autoantibodies and treatment strategies.

Neurological manifestations in lupus can be due to active lupus disease affecting the brain or to other reasons. Reversible posterior leucoencephalopathy syndrome, primary lymphoma of the central nervous system, cerebral infections by bacteria (e.g. mycobacteria), viruses (e.g. JC virus), fungi (e.g. Cryptococcus) and parasites (e.g. Acanthamoeba), steroid-induced psychosis and reactive depression need to be excluded. Brain-reactive autoantibodies have been described as associating with neuropsychiatric lupus. The strongest associations described to date are with antiribosomal P protein and antiphospholipid antibodies. However these autoantibodies have not been shown to play significant roles in the pathogenesis. Treatment strategy for severe neuropsychiatric lupus include establishing definitive diagnosis, early identification and treatment of aggravating factors, appropriate symptomatic treatment, adequate immunosuppression, selective B-cell depletion and autologous haematopoietic stem cell transplant. Systematic reviews have shown that cyclophosphamide administration is superior to pulse methylprednisolone as a maintenance therapy. Mycophenolate mofetil has been shown to have modest effect and should only be considered if cyclophosphamide cannot be administered.

Health-related quality of life of patients with systemic lupus erythematosus in Asia: how can this be improved?

The multicultural and multilinguistic landscape in Asia poses interesting challenges in the assessment and improvement of Health-Related Quality of Life (HRQoL) in Asian patients with systemic lupus erythematosus (SLE). This article highlights some of these challenges and addresses the issue of how to improve HRQoL of these patients by: (1) framing important concepts in HRQoL in relation to the chronic relapsing nature and multisystem involvement in this condition; (2) discussing ways to improve measurement of HRQoL of SLE patients in Asia by reviewing existing HRQoL instruments (both generic (i.e. the SF-36) and disease-specific (i.e. the L-QoL, LupusQoL, SLEQoL and SLE Symptom Checklist)) and item banking; and (3) discussing approaches to improving HRQoL in SLE.

Factors associated with health services utilization in patients with systemic lupus erythematosus: a systematic review.

OBJECTIVES: SLE patients require varying levels of health services since disease severity and activity differ among individuals. Understanding the factors associated with health service utilisation would be useful in improving equitable access. It would also help to identify modifiable factors and current good practices so as to improve quality of care and thus reduce utilisation. Thus, the objective of this review is to identify factors associated with health services utilisation. METHODS: Five electronic databases (PubMed, PsycINFO, EMBASE, International Pharmaceutical Abstract, Web of Science) and bibliographies of short-listed articles were searched. All indicators of health service utilisation (physician and specialist visits, hospitalisations, direct costs) and alternative medicine utilisation were accepted as outcomes in primary studies. Two authors independently selected the studies based on pre-specified inclusion and exclusion criteria. RESULTS: Of 1,276 papers retrieved from electronic and hand searches, 25 were finally selected and reviewed in totality, of which 13 were cross-sectional, 5 were prospective, and 7 were retrospective studies. A variety of service types (e.g. outpatient visits, hospitalisations, etc.) and factors (e.g. demographic, socioeconomic, laboratory indices, etc.) were evaluated. Type of health insurance, poorer physical functioning and greater disease severity were found to be associated with higher utilisation across several studies. CONCLUSION: Modifying the choice or coverage of health insurance plans of SLE patients is a possible option in improving equitable access. Better management of patient reported outcomes such as physical functioning and timely management of SLE to reduce disease severity may reduce health services utilisation in the long term.

A systematic review of nudge theories and strategies used to influence adult health behaviour and outcome in diabetes management.

BACKGROUND: Diabetes is a chronic disease associated with a variety of complications, and nudging may be a potential solution to improve diabetes control. Since nudging is a new concept, no review of literature on nudging diabetic patients into improving their health behaviour has been done. Therefore, we aim to collate a list of nudge intervention and determine the context in which nudging is successful. METHODS: We adopted a two-arm search strategy comprising the search of literature databases and snowballing using relevant search terms. We summarized patient characteristics, the nudge intervention, according to nudging strategies, delivery mode and their outcomes. The conditions present in effective nudge interventions were assessed and reported. RESULTS: We retrieved 11,494 studies from our searches and included 33. An additional five studies were added through snowballing. Studies included utilized framing (n=5), reminders (n=10), gamification (n=2), social modelling (n=5) and social influence (n=16). Studies on reminders and gamification were more likely to have a statistically significant outcome. The targeted health behaviours identified were medication adherence, physical activity, diet, blood glucose monitoring, foot care, self-efficacy, HbA1c and quality of life. Of these, studies with adherence to medication, foot care practice and quality of life as targeted health behaviours were more likely to show a statistically significant outcome. CONCLUSION: Nudging has shown potential in changing health behaviour of patients with diabetes in specific context. We identified two possible factors (delivery mode and patient characteristics) that may affect the effectiveness of nudge intervention.

Rasch analysis of the Oxford Knee Score.

OBJECTIVES: Use Rasch analysis to examine the psychometric properties of the Oxford Knee Score (OKS), particularly in respect to unidimensionality, and consistency of item functioning before and after total knee replacement and across age and gender groups. METHODS: The 12-item OKS was administered to 1,712 patients before the surgery, and 1,322 and 855 patients were administered the instrument repeatedly at the 6-month and 2-year postoperative assessments, respectively. Data were fitted to the Rasch partial credit model with the Winsteps program. Differential item functioning (DIF) analysis was performed, and fit statistics in combination with principal components analysis of the residuals were used to test the unidimensionality assumption. The fit criteria were set at 1.5 and 2.0 for infit mean-square (MNSQ) and outfit MNSQ, respectively. RESULTS: At baseline, item difficulty ranged from -1.86 to 1.78 logits, and person measures had a mean+/-SD of -0.01+/-0.89. Misfit items were "limping" and "night pain" in preoperative data and "limping" and "kneeling" in postoperative data. After removing items limping and kneeling and recoding item night pain, none of the items misfit at each of the time points and there was stability of item difficulty ordering across time. In the modified OKS set, five items displayed DIF by age and three by gender. CONCLUSION: The original OKS had adequate targeting and good coverage of knee severity levels in preoperative patients. The modified 10-item OKS data fit the Rasch model and had stable item difficulty ordering over time.