Telemedical Interventions for Chronic Obstructive Pulmonary Disease Management: Umbrella Review.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a growing epidemic, with a heavy associated economic burden. Education, physical activity, and pulmonary rehabilitation programs are important aspects of the management of COPD. These interventions are commonly delivered remotely as part of telemedicine interventions. Several systematic reviews and meta-analyses have been conducted to assess the effectiveness of these interventions. However, these reviews often have conflicting conclusions. OBJECTIVE: We aim to conduct an umbrella review to critically appraise and summarize the available evidence on telemedicine interventions for the management of COPD. METHODS: In this umbrella review, the MEDLINE, Embase, PsycINFO, and Cochrane databases were searched from inception to May 2022 for systematic reviews and meta-analyses relating to telemedicine interventions for the management of COPD. We compared odds ratios, measures of quality, and heterogeneity across different outcomes. RESULTS: We identified 7 systematic reviews that met the inclusion criteria. Telemedicine interventions used in these reviews were teletreatment, telemonitoring, and telesupport. Telesupport interventions significantly reduced the number of inpatient days and quality of life. Telemonitoring interventions were associated with significant reductions in respiratory exacerbations and hospitalization rates. Teletreatment showed significant effectiveness in reducing respiratory exacerbations, hospitalization rate, compliance (acceptance and dropout rate), and physical activity. Among studies that used integrated telemedicine interventions, there was a significant improvement in physical activity. CONCLUSIONS: Telemedicine interventions showed noninferiority or superiority over the standard of care for the management of COPD. Telemedicine interventions should be considered as a supplement to usual methods of care for the outpatient management of COPD, with the aim of reducing the burden on health care systems.

A prospective observational study exploring the association of comorbid chronic health conditions with total healthcare expenditure in people with mental health conditions in an Asian setting.

BACKGROUND: It is pertinent to focus on chronic medical condition (CMC) comorbidity with mental health conditions (MHC) as their co-occurrence has significant cost and health implications. However, current evidence on co-occurrence of MHC with CMC is mixed and mostly from Western settings. Therefore, our study aimed to (i) describe the association between MHC and total healthcare expenditure, (ii) examine the association between CMC and total healthcare expenditure and (iii) examine determinants of total and different types of healthcare expenditure in respondents with and without MHC in an Asian setting. METHODS: The data from Singapore Mental Health Study (SMHS) 2016, a nationwide epidemiological survey, were linked with the National claims record (from 2017 to 2019). Multivariable Generalized Linear Models (GLM) were used to examine the association between MHC and total and different types of healthcare expenditure. RESULTS: A total of 3077 survey respondents were included in current analysis. Respondents with MHC had a lower mean age of 38.6 years as compared to those without MHC (47.1 years). MHC was associated with increased total healthcare expenditure after adjusting for covariates (b = 0.508, p < 0.05). In respondents with MHC, presence of CMC increased the total healthcare expenditure by 35% as compared to 40% increase in those without MHC. Interestingly, 35-49 years age group with MHC had almost 3 times higher total healthcare expenditure and 7.5 times higher inpatient expenditure as compared to the 18-34 years age group. CONCLUSION: Our study highlights variations in association of CMC and age with total healthcare expenditure in those with versus without MHC in an Asian setting. Practical recommendations include appropriate planning and resource allocation for early diagnosis and management of MHC, proactive screening for CMC in those with MHC and addressing the dual issues of treatment gap and stigma to facilitate early help seeking and prevent episodic, costly healthcare utilization.

The Willingness to Pay for Telemedicine Among Patients With Chronic Diseases: Systematic Review.

BACKGROUND: Telemedicine is increasingly being leveraged, as the need for remote access to health care has been driven by the rising chronic disease incidence and the COVID-19 pandemic. It is also important to understand patients' willingness to pay (WTP) for telemedicine and the factors contributing toward it, as this knowledge may inform health policy planning processes, such as resource allocation or the development of a pricing strategy for telemedicine services. Currently, most of the published literature is focused on cost-effectiveness analysis findings, which guide health care financing from the health system's perspective. However, there is limited exploration of the WTP from a patient's perspective, despite it being pertinent to the sustainability of telemedicine interventions. OBJECTIVE: To address this gap in research, this study aims to conduct a systematic review to describe the WTP for telemedicine interventions and to identify the factors influencing WTP among patients with chronic diseases in high-income settings. METHODS: We systematically searched 4 databases (PubMed, PsycINFO, Embase, and EconLit). A total of 2 authors were involved in the appraisal. Studies were included if they reported the WTP amounts or identified the factors associated with patients' WTP, involved patients aged ≥18 years who were diagnosed with chronic diseases, and were from high-income settings. RESULTS: A total of 11 studies from 7 countries met this study's inclusion criteria. The proportion of people willing to pay for telemedicine ranged from 19% to 70% across the studies, whereas the values for WTP amounts ranged from US $0.89 to US $821.25. We found a statistically significant correlation of age and distance to a preferred health facility with the WTP for telemedicine. Higher age was associated with a lower WTP, whereas longer travel distance was associated with a higher WTP. CONCLUSIONS: On the basis of our findings, the following are recommendations that may enhance the WTP: exposure to the telemedicine intervention before assessing the WTP, the lowering of telemedicine costs, and the provision of patient education to raise awareness on telemedicine's benefits and address patients' concerns. In addition, we recommend that future research be directed at standardizing the reporting of WTP studies with the adoption of a common metric for WTP amounts, which may facilitate the generalization of findings and effect estimates.

Seeking healthcare services post-stroke: a qualitative descriptive study exploring family caregiver and stroke survivor perspectives in an asian setting.

AIM: Exploration of the healthcare journey post-stroke is incomplete without acknowledging the crucial role of family caregivers. With limited literature documenting the role of caregivers in the healthcare journey post-stroke, we aimed to describe the healthcare experiences of family caregivers and stroke survivors across different caregiver identities in Singapore. METHODS: We conducted a qualitative descriptive study involving semi-structured interviews with transcripts analysed using thematic analysis. 26 stroke survivors and 35 family caregivers purposively sampled from multiple settings. RESULTS: Findings were summarized into seeking care and experience of healthcare encounters. Seeking care comprised of the following themes: factors influencing seeking care, decision to seek care and role of caregiver in seeking care. Experience of healthcare encounters comprised of the following themes: service around the patient, service with care and role of caregiver in healthcare encounters. CONCLUSION: Multi-dimensional role of caregivers in healthcare experience emerged as a major finding. Unique to our Asian context, as per the participants' accounts, family caregivers seemed to be central in healthcare decision-making for stroke survivors, with adult-child caregivers commonly reported being engaged in collaborative decision-making. While spousal caregivers preferred a relational healthcare experience, adult-child caregivers preferred a transactional one. Practical implications include equipping caregivers with skillset to make healthcare decisions, provision of supportive decision-making environment for caregivers and reinforcing communication aspects in the medical, nursing and allied healthcare curriculum to improve healthcare experience.

Support system diversity among family caregivers of stroke survivors: a qualitative study exploring Asian perspectives.

BACKGROUND: Caregiving is a global phenomenon which is bound to increase in tandem with the aging population worldwide. Stroke is a condition common in older people that requires complex caregiving necessitating provision of adequate support to the caregivers. Past literature consists of limited accounts of types and organization of support arrangements needed by different caregivers. We aimed to describe the support system of caregivers of stroke survivors in Singapore, highlighting differences across the different caregiver identities (i.e. spouse, adult-child, etc.). METHODS: We conducted a qualitative descriptive study in the community setting involving 61 purposively sampled and recruited stroke survivors and caregivers. Semi-structured interviews were conducted, and transcripts were analysed using thematic analysis. RESULTS: Our findings were summarized across the following 4 themes: 1) cultural influence and caregiving; 2) caregiver support system with the following sub-themes: 2.1) dyadic caregiver support type, 2.2) extended caregiver support type, 2.3.) distributed caregiver support type and 2.4) empowering caregiver support type; 3) breaks in care of stroke survivor and 4) complex relationship dynamics. We operationalized the caregiver support system as comprising of type, people and activities that enable the caregiver to participate in caregiving activities sustainably. While spouse caregivers preferred dyadic and extended support systems positioning themselves in a more central caregiving role, adult-child caregivers preferred distributed support system involving family members with paid caregivers playing a more central role. CONCLUSIONS: Our findings highlight caregiver identity as a surrogate for the differences in the caregiver support systems. Practical implications include imparting relationship-building skills to the stroke survivor-caregiver dyads to sustain dyadic support system and educating clinicians to include differences in caregiving arrangements of stroke survivors in practising family-centred care.

Burden of informal care in stroke survivors and its determinants: a prospective observational study in an Asian setting.

BACKGROUND: Informal caregiving is an integral part of post-stroke recovery with strenuous caregiving demands often resulting in caregiving burden, threatening sustainability of caregiving and potentially impacting stroke survivor's outcomes. Our study aimed to examine and quantify objective and subjective informal care burden after stroke; and to explore the factors associated with informal care burden in Singapore. METHODS: Stroke patients and their informal caregivers were recruited from all five tertiary hospitals in Singapore from December 2010 to September 2013. Informal care comprised of assistance provided by informal caregivers with any of the activities of daily living. Informal care burden was measured by patients' likelihood of requiring informal care, hours of informal care required, and informal caregivers' Zarit's Burden Score. We examined informal care burden at 3-months and 12-months post-stroke. Generalized linear regressions were applied with control variables including patients' and informal caregivers' demographic characteristics, arrangement of informal care, and patients' health status including stroke severity (measured using National Institute of Health Stroke Scale), functional status (measured using Modified Rankin Scale), self-reported depression, and common comorbidities. RESULTS: Three hundred and five patients and 263 patients were examined at 3-months and 12-months. Around 35% were female and 60% were Chinese. Sixty three percent and 49% of the patients required informal care at 3-months and 12-months point, respectively. Among those who required informal care, average hours required per week were 64.3 h at 3-months and 76.6 h at 12-months point. Patients with higher functional dependency were more likely to require informal care at both time points, and required more hours of informal care at 3-months point. Female informal caregivers and those caring for patients with higher functional dependency reported higher Zarit's Burden. While informal caregivers who worked full-time reported higher burden, those caring for married stroke patients reported lower burden at 3-months point. Informal caregivers who co-cared with foreign domestic workers, i.e.: stay-in migrant female waged domestic workers, reported lower burden. CONCLUSIONS: Informal care burden remains high up to 12-months post-stroke. Factors such as functional dependency, stroke severity, informal caregiver gender and co-caring with foreign domestic workers were associated with informal care burden.

Role of caregiver factors in outpatient medical follow-up post-stroke: observational study in Singapore.

BACKGROUND: Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke. METHOD: Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0-3 months (early) and 4-12 months (late) post-stroke. RESULTS: For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits. CONCLUSION: We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.

Improving the Primary Care Consultation for Diabetes and Depression Through Digital Medical Interview Assistant Systems: Narrative Review.

BACKGROUND: Digital medical interview assistant (DMIA) systems, also known as computer-assisted history taking (CAHT) systems, have the potential to improve the quality of care and the medical consultation by exploring more patient-related aspects without time constraints and, therefore, acquiring more and better-quality information prior to the face-to-face consultation. The consultation in primary care is the broadest in terms of the amount of topics to be covered and, at the same time, the shortest in terms of time spent with the patient. OBJECTIVE: Our aim is to explore how DMIA systems may be used specifically in the context of primary care, to improve the consultations for diabetes and depression, as exemplars of chronic conditions. METHODS: A narrative review was conducted focusing on (1) the characteristics of the primary care consultation in general, and for diabetes and depression specifically, and (2) the impact of DMIA and CAHT systems on the medical consultation. Through thematic analysis, we identified the characteristics of the primary care consultation that a DMIA system would be able to improve. Based on the identified primary care consultation tasks and the potential benefits of DMIA systems, we developed a sample questionnaire for diabetes and depression to illustrate how such a system may work. RESULTS: A DMIA system, prior to the first consultation, could aid in the essential primary care tasks of case finding and screening, diagnosing, and, if needed, timely referral to specialists or urgent care. Similarly, for follow-up consultations, this system could aid with the control and monitoring of these conditions, help check for additional health issues, and update the primary care provider about visits to other providers or further testing. Successfully implementing a DMIA system for these tasks would improve the quality of the data obtained, which means earlier diagnosis and treatment. Such a system would improve the use of face-to-face consultation time, thereby streamlining the interaction and allowing the focus to be the patient's needs, which ultimately would lead to better health outcomes and patient satisfaction. However, for such a system to be successfully incorporated, there are important considerations to be taken into account, such as the language to be used and the challenges for implementing eHealth innovations in primary care and health care in general. CONCLUSIONS: Given the benefits explored here, we foresee that DMIA systems could have an important impact in the primary care consultation for diabetes and depression and, potentially, for other chronic conditions. Earlier case finding and a more accurate diagnosis, due to more and better-quality data, paired with improved monitoring of disease progress should improve the quality of care and keep the management of chronic conditions at the primary care level. A somewhat simple, easily scalable technology could go a long way to improve the health of the millions of people affected with chronic conditions, especially if working in conjunction with already-established health technologies such as electronic medical records and clinical decision support systems.

Correction to: Inhibitory effects of tea polyphenols by targeting cyclooxygenase-2 through regulation of nuclear factor kappa B, Akt and p53 in rat mammary tumors.

The authors regret to inform that there were unknowing errors in figures. The corrected images are given below. These figures are not affecting the results and conclusion of the manuscript. Hence, the text in original paper remains unchanged.

Dyadic approach to post-stroke hospitalizations: role of caregiver and patient characteristics.

AIM: To study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3-12 months post-stroke in Singapore. METHODS: Patients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome. RESULTS: Two hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3-12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization. CONCLUSION: Recommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.

Acceptance of Tele-Rehabilitation by Stroke Patients: Perceived Barriers and Facilitators.

OBJECTIVE: To explore the perceived barriers and facilitators of tele-rehabilitation (TR) by stroke patients, caregivers and rehabilitation therapists in an Asian setting. DESIGN: Qualitative study involving semi-structured in-depth interviews and focus group discussions. SETTING: General community. PARTICIPANTS: Participants (N=37) including stroke patients, their caregivers, and tele-therapists selected by purposive sampling. INTERVENTIONS: Singapore Tele-technology Aided Rehabilitation in Stroke trial. MAIN OUTCOME MEASURES: Perceived barriers and facilitators for TR uptake, as reported by patients, their caregivers, and tele-therapists. RESULTS: Thematic analysis was used to inductively identify the following themes: facilitators identified by patients were affordability and accessibility; by tele-therapists, was filling a service gap and common to both was unexpected benefits such as detection of uncontrolled hypertension. Barriers identified by patients were equipment setup-related difficulties and limited scope of exercises; barriers identified by tele-therapists were patient assessments, interface problems and limited scope of exercises; and common to both were connectivity barriers. Patient characteristics like age, stroke severity, caregiver support, and cultural influence modified patient perceptions and choice of rehabilitation. CONCLUSIONS: Patient attributes and context are significant determinants in adoption and compliance of stroke patients to technology driven interventions like TR. Policy recommendations from our work are inclusion of introductory videos in TR programs, provision of technical support to older patients, longer FaceTime sessions as re-enforcement for severely disabled stroke patients, and training of tele-therapists in assessment methods suitable for virtual platforms.

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors.

BACKGROUND: It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors. METHODS: Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke. RESULTS: Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter. CONCLUSION: Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Can caregivers report their care recipients' post-stroke hospitalizations and outpatient visits accurately? Findings of an Asian prospective stroke cohort.

BACKGROUND: Health services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors' HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients. METHODS: A prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types. RESULTS: We observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%. CONCLUSIONS: The accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.

Primary Technology Enhanced Care Home HbA1c Testing (PTEC HAT) programme: a feasibility pilot study in Singapore.

BACKGROUND: Considering time-consuming, cost-related limitations of laboratory-based HbA1c testing and follow-up clinic visits for diabetes management, it is important to explore alternative care models which incorporate point-of-care testing for HbA1c to monitor glycaemic control and related management. METHODS: Therefore, we adopted an implementation perspective to conduct one group pre- and post-intervention feasibility pilot assessing feasibility, acceptability and satisfaction with conducting home HbA1c test by patients with type 2 diabetes coupled with telemonitoring and teleconsultations (i.e., the Primary Technology Enhanced Care (PTEC) Home HbA1c Testing (HAT) Programme) in Singaporean primary care setting. The secondary objective was to compare the HbA1c, blood pressure and primary care visits at the end or during intervention, vs. 6 months before. Adult patients with type 2 diabetes with HbA1c ≤ 8% without any diabetes complications and having phone compatibility were recruited. Data was collected via patient self-reports and electronic medical records extraction. While summary statistics and paired t-test were computed for quantitative data, open-ended feedback was analysed using content analysis. RESULTS: A total of 33 participants completed the intervention out of 37 (33/37 = 89%) recruited from 73 eligible (37/73 = 51%). Most were either 51 to 60 years old (46.9%) or more than 60 years (37.5%), with more males (53.1%) and majority Chinese (93.8%). Majority (81.3%) felt that home HbA1c testing was beneficial with most commonly reported benefit of not having a clinic visit. A key finding was the average of diabetes-related visits being significantly lower post-intervention with comparable HbA1c values pre- and post-intervention. The most commonly reported challenge was using Bluetooth to transmit the reading (43.7%), followed by having too many steps to remember (28.1%). While participants reported being overall satisfied with the intervention, only 22% were willing to pay for it. CONCLUSION: Our findings support home HbA1c testing by patients coupled with telemonitoring and teleconsultations. Following are practical recommendations for the implementation scaling phase: offering PTEC HAT Programme to suitable patients who are self-motivated and have adequate digital literacy, provision of adequate educational and training support, sending reminders and exploring enabling manual submission of HbA1c readings considering Bluetooth-related challenges.

Preferences and willingness-to-pay for a blood pressure telemonitoring program using a discrete choice experiment.

This study aimed to elicit the preferences and willingness-to-pay for blood pressure (BP) telemonitoring programs. This study also investigated the different factors or participant characteristics that could influence preferences and choice behaviors. Participants with hypertension were identified from an online survey panel demographically representative of Singapore's general population. Participants completed a discrete choice experiment (DCE) with 12 choice sets, selecting their preferred BP monitoring program differing on five attributes: mode of consultation, BP machine type (with Bluetooth or not), BP machine price, monthly fee, and program duration. The base reference population (male, married, higher income, more formal education years, full-time worker, aged 55 to <65 years, and digital skills score of 36) preferred teleconsultation over in-person consultation, Bluetooth feature, lower machine price, lower monthly fee, and shorter program duration. A subgroup of participants can be considered teleconsultation-resistant, and three demographic factors were associated with lower preference for teleconsultation: female, fewer formal education years, and lower income. Considering the reference population and Bluetooth attribute, participants were willing to pay 66 SGD (~49 USD) additional for the machine to obtain the Bluetooth feature. Considering the reference population and teleconsultation attribute, participants were willing to pay 6.80 SGD (~5.10 USD) extra monthly fee for a program using teleconsultation. Here we report that amongst participants with hypertension, there is strong preference for the use of teleconsultation and a BP machine with Bluetooth feature in a BP monitoring program. However, a subgroup of participants are teleconsultation-resistant and would prefer in-person consultation.

Effectiveness of an algorithm-driven home telemonitoring system on the metabolic control and self-care behaviour of Asian adults with type-2 diabetes mellitus: A randomised controlled trial.

AIM: Healthcare professionals are leveraging on telehealth to manage patients with type-2 diabetes mellitus (T2DM). This study aimed to determine the clinical outcomes of patients using a novel tele-monitoring system (OPTIMUM) as compared to the standard of care. METHODS: An open-labelled randomised controlled trial involving 330 Asian patients with T2DM, aged 26-65 years, and suboptimal glycaemic control (HbA1c = 7.5-10%) was conducted in a Singapore public primary care clinic. The patients were assigned in a 1:1 ratio by block randomization to the intervention group to receive: in-app video-based tele-education, tele-monitoring of the blood pressure (BP), capillary glucose and weight via Bluetooth devices and mobile application, followed by algorithm-based tele-management by the OPTIMUM telehealth care team for abnormal parameters. Patients received usual care in the control group. Clinical assessments and self-care-related questionnaires were administered for both groups at baseline and 6 months. RESULTS: Complete data of 159 (intervention) and 160 (control) patients with comparable demographic profiles were analysed. Those in the intervention group showed significantly lower HbA1c by 0.34% (95%CI = -0.57 to -0.11; p = 0.004); first measurement of systolic BP decreased by 2.98 mmHg (95%CI:-5.8 to -0.08; p = 0.044) and diastolic BP by 4.24 mmHg (95%CI = -6.0 to -2.47; p = 0.001); and total cholesterol by 0.18 mmol/L (95%CI: -0.34 to -0.01; p = 0.040) compared to the control group, after adjusting for baseline variables. Questionnaire scores showed significant improvements in medication adherence and self-care behaviour in the intervention group. No significant weight change was noted between groups. CONCLUSION: The OPTIMUM tele-monitoring system improved the glycaemic, BP and total cholesterol control in patients with suboptimal T2DM control by enhancing their medication adherence and self-care over 6 months.

Qualitative study exploring heterogeneity in caregiving experiences post-stroke in Singapore.

OBJECTIVE: Stroke, a common illness in older adults, accounts for up to 4% of direct medical costs in developed nations. Informal caregiving contributing a significant proportion of economic burden post-stroke warrants a deeper understanding of the caregiving context to sustain caregiving arrangement. While literature exists describing differences in motivation and preferences of caregivers, limited literature explores differences in caregiving experiences of different types of caregivers (ie, spouse, adult-child, sibling or others). Addressing this gap, our study aimed to explore the caregiving experience of stroke survivors and their family caregivers across different caregiver identities in an Asian setting. DESIGN: Qualitative descriptive study. SETTING: Community setting. PARTICIPANTS: We conducted semi-structured interviews with 26 stroke survivors and 35 caregivers purposively sampled from an outpatient rehabilitation setting, an outpatient clinic and a support organisation. Data were analysed using thematic analysis. OUTCOME MEASURES: Themes including caregiving experience of stroke survivors and their family caregivers across different caregiver identities. RESULTS: Following five themes were reported: caregiver reserve, coping strategies, caregiver burden, competing commitments and role of foreign domestic worker (FDW) in family caregiving. Spouse caregivers were less willing to ask for help, commonly adopted faith-based, and spacing or recharging types of coping, reported emotional strain and shared limited accounts of FDWs. Adult-child caregivers were more willing to ask for help, engaged in alternative care arrangements involving FDWs, commonly adopted action-focussed coping and reported multidimensional caregiver burden. CONCLUSION: Our findings illustrated the heterogeneity in factors affecting caregiving experience across spouse and adult-child caregivers. Practical implications include conducting a needs assessment for caregiver-stroke survivor dyads and providing tailored support, training and information to help caregivers cope better.

Bromelain inhibits nuclear factor kappa-B translocation, driving human epidermoid carcinoma A431 and melanoma A375 cells through G(2)/M arrest to apoptosis.

Bromelain, obtained from pineapple, is already in use clinically as adjunct in chemotherapy. Our objective was to test its ability to act as a sole anti-cancer agent. Therefore, we describe its anti-proliferative, anti-inflammatory and subsequent anti-cancer effects in vitro, against human epidermoid carcinoma-A431 and melanoma-A375 cells. Bromelain exhibited reduction in proliferation of both these cell-lines and suppressed their potential for anchorage-independent growth. Further, suppression of inflammatory signaling by bromelain was evident by inhibition of Akt regulated-nuclear factor-kappaB activation via suppression of inhibitory-kappaBα phosphorylation and concomitant reduction in cyclooxygenase-2. Since, the inflammatory cascade is well-known to be closely allied to cancer; we studied the effect of bromelain on events/molecules central to it. Bromelain caused depletion of intracellular glutathione and generation of reactive oxygen-species followed by mitochondrial membrane depolarization. This led to bromelain-induced cell-cycle arrest at G(2)/M phase which was mediated by modulation of cyclin B1, phospho-cdc25C, Plk1, phospho-cdc2, and myt1. This was subsequently followed by induction of apoptosis, indicated by membrane-blebbing, modulation of Bax-Bcl-2 ratio, Apaf-1, caspase-9, and caspase-3; chromatin-condensation, increase in caspase-activity and DNA-fragmentation. Bromelain afforded substantial anti-cancer potential in these settings; hence we suggest it as a potential prospect for anti-cancer agent besides only an additive in chemotherapy.

Linear PEI nanoparticles: efficient pDNA/siRNA carriers in vitro and in vivo.

Linear polyethylenimine (lPEI, 25 kDa) nanoparticles' (LPN) series was synthesized by varying percentage of cross-linking with 1,4-butanediol diglycidyl ether (BDE) and their size, surface charge, morphology, pDNA protection/release, cytotoxicity and transfection efficiency were evaluated. Synthesized nanoparticles (NPs) were spherical in shape (size: ∼109 - 235 nm; zeta potential: +38 to +16 mV). These NPs showed increased buffering capacity with increasing percent cross-linking and also exhibited excellent transfection efficiency (i.e., ∼1.3 - 14.7 folds in case of LPN-5) in comparison with lPEI and the commercial transfection agents used in this study. LPN-5 based GFP-specific siRNA delivery resulted in ∼86% suppression of targeted gene expression. These particles were relatively nontoxic in vitro (in cell lines) and in vivo (in Drosophila). In vivo gene expression studies using LPN-5 in Balb/c mice through intravenous injection showed maximum expression of the reporter gene in the spleen. These results together demonstrate the potential of these particles as efficient transfection reagents. FROM THE CLINICAL EDITOR: The authors demonstrate a novel method of synthesizing linear PEI nanoparticles to utilize these as transfection agents.

Defining and measuring multimorbidity in primary care in Singapore: Results of an online Delphi study.

Multimorbidity, common in the primary care setting, has diverse implications for both the patient and the healthcare system. However, there is no consensus on the definition of multimorbidity globally. Thus, we aimed to conduct a Delphi study to gain consensus on the definition of multimorbidity, the list and number of chronic conditions used for defining multimorbidity in the Singapore primary care setting. Our Delphi study comprised three rounds of online voting from purposively sampled family physicians in public and private settings. Delphi round 1 included open-ended questions for idea generation. The subsequent two rounds used questions with pre-selected options. Consensus was achieved based on a pre-defined criteria following an iterative process. The response rates for the three rounds were 61.7% (37/60), 86.5% (32/37) and 93.8% (30/32), respectively. Among 40 panellists who responded, 46.0% were 31-40 years old, 64.9% were male and 73.0% were from the public primary healthcare setting. Based on the findings of rounds 1, 2 and 3, consensus on the definition of a chronic condition, multimorbidity and finalised list of chronic conditions were achieved. For a condition to be chronic, it should last for six months or more, be recurrent or persistent, impact patients across multiple domains and require long-term management. The consensus-derived definition of multimorbidity is the presence of three or more chronic conditions from a finalised list of 23 chronic conditions. We anticipate that our findings will inform multimorbidity conceptualisation at the national level, standardise multimorbidity measurement in primary care and facilitate resource allocation for patients with multimorbidity.