Cardiovascular disease risk in people of African ancestry with HIV in the United Kingdom.

OBJECTIVES: Our objective was to describe the prevalence of cardiovascular disease (CVD) risk factors in people of African ancestry with HIV in the UK. METHODS: We conducted a cross-sectional analysis of CVD risk factors in Black people with HIV aged ≥40 years and estimated the 10-year CVD risk using QRISK®3-2018. Correlations between body mass index (BMI) and CVD risk factors were described using Pearson correlation coefficients, and factors associated with 10-year CVD risk ≥5% were described using logistic regression. RESULTS: We included 833 Black people with HIV and a median age of 54 years; 54% were female, 50% were living with obesity (BMI ≥30 kg/m2), 61% had hypertension, and 19% had diabetes mellitus. CVD risk >5% ranged from 2% in female participants aged 40-49 years to 99% in men aged ≥60 years, and use of statins ranged from 7% in those with CVD risk <2.5% to 64% in those with CVD risk ≥20%. BMI was correlated (R2 0.1-0.2) with triglycerides and diastolic blood pressure in women and with glycated haemoglobin, systolic and diastolic blood pressure, and total:high-density lipoprotein (HDL) cholesterol ratio in men. In both female and male participants, older age, blood pressure, diabetes mellitus, and kidney disease were strongly associated with CVD risk ≥5%, whereas obesity, total:HDL cholesterol, triglycerides, and smoking status were variably associated with CVD risk ≥5%. CONCLUSIONS: We report a high burden of CVD risk factors, including obesity, hypertension, and diabetes mellitus, in people of African ancestry with HIV in the UK. BMI-focused interventions in these populations may improve CVD risk while also addressing other important health issues.

Knowledge, attitudes, and perceptions of residents towards Hospital-at-Home (HaH) and its role in residency training.

BACKGROUND: With the proliferation of Hospital at Home (HaH) programmes globally, there is a need to equip junior doctors with the skills necessary for provision of HaH care. The ideal training structure and clinical requirements for junior doctors to be considered competent in providing HaH care is still poorly understood. This study examines the perceptions of junior doctors towards HaH, and aims to determine the learning needs that might be helpful for future curriculum planning. METHODS: We conducted a cross-sectional study of residents at the National University Health System (NUHS) Singapore. Using a 45-item questionnaire, we explored the knowledge, attitudes and perceptions of residents towards HaH, and their interest in participating in HaH as part of residency training. RESULTS: One hundred six residents responded. Overall knowledge and attitudes were mostly average. Perceptions were neutral but comparatively lower in the domains of safety, efficiency and equity. 69% of residents showed a positive attitude and interest to participate in HaH as part of residency rotations. 80% of respondents were keen to have a 2-4 week rotation incorporated into routine training. Demographic factors that influenced higher scores in various domains included type of residency programme and years of work experience. CONCLUSION: Our findings suggest that residents are interested in participating in HaH. Incorporation of HaH rotations in residency training will allow juniors doctors to receive greater exposure and training in the skills specific to provision of HaH care. Further studies on the introduction of a HaH curriculum and Entrustable Professional Activities (EPAs) specific for HaH in residency training may be useful to to ensure that we have a competent HaH workforce that can support and keep up with the growth of HaH globally.

Experiences of Patients and Their Caregivers Admitted to a Hospital-at-Home Program in Singapore: a Descriptive Qualitative Study.

BACKGROUND: Hospital at Home (HaH) programs have been shown to improve clinical outcomes, quality of care, and patient satisfaction. However, how Asian patients experience HaH remained underexplored. OBJECTIVE: To explore the perceptions and experiences of patients and caregivers admitted to a hospital-at-home program in Singapore. DESIGN: Descriptive qualitative study design. PARTICIPANTS: Purposive sampling was used to conduct 36 interviews with 13 patients, nine Legally Acceptable Representatives (LARs), and 14 caregivers until data saturation was achieved. INTERVENTIONS: NUHS@Home is a HaH program providing care through a multi-disciplinary team, enabled by remote vital signs monitoring through a tablet and wireless blood pressure and oxygen meters. APPROACH: This study used in-depth semi-structured individual interviews. Interviews were transcribed and thematically analyzed using Braun and Clark's six-step inductive approach. KEY RESULTS: The overarching theme identified was "Enablers, difficulties, and improvements to the HaH experiences" which was supported by three key themes: (1) Perceived better care at home, (2) Importance of social support, and (3) Organizational structures required to support HaH. Participants described overall HaH experiences around factors contributing to their impeding engagement, overall satisfaction, and quality of care. CONCLUSIONS: Although HaH is unfamiliar to the Singapore population, most of the participants in this study had an overall positive experience. The key challenges found in this paper were the stress and inconvenience caused to caregivers. The enablers for positive HaH experiences were (1) consideration of patient's family members as key participants in the patients' therapeutic alliance; (2) the HaH care team must be accessible, approachable, and reassuring, and communicate frequently and timely with patients and their families; and (3) financing strategies to ensure HaH out-of-pockets costs remain affordable which are critical to keeping HaH as an option for patients and families.

Technology-enabled virtual ward for COVID management of the elderly and immunocompromised in Singapore: a descriptive cohort.

BACKGROUND: To address the hospital bed demand for Delta and Omicron surges in Singapore, the National University Health System (NUHS) developed a COVID Virtual Ward to relieve bed pressures on its three acute hospitals-National University Hospital, Ng Teng Fong General Hospital, Alexandra Hospital. To serve a multilingual population, the COVID Virtual Ward featuring protocolized teleconsultation of high-risk patients, use of a vital signs chatbot, supplemented by home visits where necessary. This study aims to evaluate the safety, outcomes and utilisation of the Virtual Ward as a scalable response to COVID-19 surges. METHODS: This is a retrospective cohort study of all patients admitted to the COVID Virtual Ward between 23 September to 9 November 2021. Patients were defined as "early discharge" if they were referred from inpatient COVID-19 wards and "admission avoidance" if they were referred directly from primary care or emergency services. Patient demographics, utilisation measures and clinical outcomes were extracted from the electronic health record system. The primary outcomes were escalation to hospital and mortality. Use of the vital signs chatbot was evaluated by examining compliance levels, need for automated reminders and alerts triggered. Patient experience was evaluated using data extracted from a quality improvement feedback form. RESULTS: 238 patients were admitted to the COVID Virtual Ward from 23 September to 9 November, of whom 42% were male, 67.6% of Chinese ethnicity. 43.7% were over the age of 70, 20.5% were immunocompromised, and 36.6% were not fully vaccinated. 17.2% of patients were escalated to hospital and 2.1% of patients died. Patients who were escalated to hospital were more likely to be immunocompromised or to have a higher ISARIC 4C-Mortality Score. There were no missed deteriorations. All patients received teleconsults (median of 5 teleconsults per patient, IQR 3-7). 21.4% of patients received home visits. 77.7% of patients engaged with the vital signs chatbot, with a compliance rate of 84%. All patients would recommend the programme to others in their situation. CONCLUSIONS: Virtual Wards are a scalable, safe and patient-centered strategy to care for high risk COVID-19 patients at home. TRIAL REGISTRATION: NA.

Perceptions of Hospital-at-Home Among Stakeholders: a Meta-synthesis.

BACKGROUND: Hospital-at-home (HaH) provides acute healthcare in patients' homes as an alternative to traditional hospital inpatient care. HaH has been shown to improve clinical outcomes, increase patient satisfaction, and reduce hospitalization costs. Despite its effectiveness, the uptake of HaH remains slow and little is known about factors that impact the quality and transferability of HaH. This review aimed to qualitatively synthesize existing literature to examine the perspectives of stakeholders to identify areas of improvement in this model of care. METHODOLOGY: Six electronic databases (Cumulative Index of Nursing and Allied Health Literature, PubMed, Embase, PsychINFO, Scopus, and Mednar) were searched from inception date until 3 February 2021. The included studies were assessed for quality using the Critical Appraisal Skills Program tool. This review was registered on the International Prospective Register of Systematic Reviews. The meta-synthesis was completed according to Sandelowski and Barroso's guidelines. RESULTS: Sixteen articles met the inclusion criteria. The overarching synthesized theme was "the intricacies of developing HaH," and the four main themes were (1) factors influencing patient selection, (2) advantages of HaH, (3) challenges of HaH, and (4) enablers for HaH development. CONCLUSION: Overall, high levels of satisfaction were expressed by various stakeholders. Continuity of care remains an important factor for patient-centeredness in HaH. Caregivers should be involved in the decision-making process and supported throughout the HaH duration to prevent caregiver burnout. Collaboration and coordination among healthcare professionals are vital and can be strengthened through training and technological advancements of remote patient monitoring. Institutional and organizational support for stakeholders may make HaH a viable solution to modern healthcare challenges.

Telling the difference and the telling differences between hospital in the home and outpatient parenteral antibiotic therapy.

Doctors, authors, funders and hospital managers should take care to distinguish the important differences between hospital in the home (HIH) and outpatient parenteral antimicrobial therapy (OPAT) services. HIH is an inpatient service delivered at home usually by (or on behalf of) hospitals, which aims to substitute for a traditional inpatient stay. It does so by delivering a wide range of hospital treatments to patients at home, or residential aged care, using hospital medical and nursing staff, delivery technologies and venous access, pharmacy, radiology and pathology, and a structured system of on call and governance. OPAT is an outpatient service, usually run through infectious diseases physicians' offices or departments. Most care is delivered in infusion centres and requires patients to travel for their care. Generally, there is no after-hours support. HIH has supplanted the role of OPAT due to improved governance and a wider clinical and severity scope. HIH is accessible from hospital emergency departments or directly from residential aged care facilities. Inpatient capacity has been expanded during the COVID-19 pandemic. There is evidence that both HIH and OPAT can successfully treat their selected patient groups. There are no head-to-head studies, but in observational comparisons there might be more adverse drug events in OPAT. OPAT places a greater onus of care, supervision and travel needs on the patient and family. Where HIH is not available, OPAT may remain an alternative for some patients. However, HIH seeks to redefine the delivery of inpatient care away from the location of care.

An Evaluation of the Influence of Body Mass Index on Severity Scoring.

OBJECTIVES: Although one third or more of critically ill patients in the United States are obese, obesity is not incorporated as a contributing factor in any of the commonly used severity of illness scores. We hypothesize that selected severity of illness scores would perform differently if body mass index categorization was incorporated and that the performance of these score models would improve after consideration of body mass index as an additional model feature. DESIGN: Retrospective cohort analysis from a multicenter ICU database which contains deidentified data for more than 200,000 ICU admissions from 208 distinct ICUs across the United States between 2014 and 2015. SETTING: First ICU admission of patients with documented height and weight. PATIENTS: One-hundred eight-thousand four-hundred two patients from 189 different ICUs across United States were included in the analyses, of whom 4,661 (4%) were classified as underweight, 32,134 (30%) as normal weight, 32,278 (30%) as overweight, 30,259 (28%) as obese, and 9,070 (8%) as morbidly obese. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: To assess the effect of adding body mass index as a risk adjustment element to the Acute Physiology and Chronic Health Evaluation IV and Oxford Acute Severity of Illness scoring systems, we examined the impact of this addition on both discrimination and calibration. We performed three assessments based upon 1) the original scoring systems, 2) a recalibrated version of the systems, and 3) a recalibrated version incorporating body mass index as a covariate. We also performed a subgroup analysis in groups defined using World Health Organization guidelines for obesity. Incorporating body mass index into the models provided a minor improvement in both discrimination and calibration. In a subgroup analysis, model discrimination was higher in groups with higher body mass index, but calibration worsened. CONCLUSIONS: The performance of ICU prognostic models utilizing body mass index category as a scoring element was inconsistent across body mass index categories. Overall, adding body mass index as a risk adjustment variable led only to a minor improvement in scoring system performance.

The cost of repetitive laboratory testing for chronic disease.

Interval laboratory investigations are necessary for monitoring chronic diseases. However, testing too frequently may not be beneficial clinically and can be considered low-value care. We examined the frequency of glycosylated haemoglobin, lipids, iron panels (serum iron, ferritin, transferrin, iron binding) thyroid function (free T4 and thyroid stimulating hormone) and 25-OH vitamin D tests in a 1290-bed tertiary hospital in Singapore. All tests done over a 20-month period (January 2016 to August 2017) were retrieved from the laboratory database. Of the 275 565 tests done for 115 971 patients, 5.2% were repeat tests done at intervals shorter than the minimum retesting interval, as defined by the Royal College of Pathologist and Irish Guidelines on the Use of the Laboratory. Using the Centers for Medicare and Medicaid Services Clinical Laboratory Fee Schedule, we estimated a cost burden of US$222 096 per year. Strategies to reduce unnecessary repetitive testing can result in significant cost savings.

Severity of Illness Scores May Misclassify Critically Ill Obese Patients.

OBJECTIVE: Severity of illness scores rest on the assumption that patients have normal physiologic values at baseline and that patients with similar severity of illness scores have the same degree of deviation from their usual state. Prior studies have reported differences in baseline physiology, including laboratory markers, between obese and normal weight individuals, but these differences have not been analyzed in the ICU. We compared deviation from baseline of pertinent ICU laboratory test results between obese and normal weight patients, adjusted for the severity of illness. DESIGN: Retrospective cohort study in a large ICU database. SETTING: Tertiary teaching hospital. PATIENTS: Obese and normal weight patients who had laboratory results documented between 3 days and 1 year prior to hospital admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seven hundred sixty-nine normal weight patients were compared with 1,258 obese patients. After adjusting for the severity of illness score, age, comorbidity index, baseline laboratory result, and ICU type, the following deviations were found to be statistically significant: WBC 0.80 (95% CI, 0.27-1.33) × 10/L; p = 0.003; log (blood urea nitrogen) 0.01 (95% CI, 0.00-0.02); p = 0.014; log (creatinine) 0.03 (95% CI, 0.02-0.05), p < 0.001; with all deviations higher in obese patients. A logistic regression analysis suggested that after adjusting for age and severity of illness at least one of these deviations had a statistically significant effect on hospital mortality (p = 0.009). CONCLUSIONS: Among patients with the same severity of illness score, we detected clinically small but significant deviations in WBC, creatinine, and blood urea nitrogen from baseline in obese compared with normal weight patients. These small deviations are likely to be increasingly important as bigger data are analyzed in increasingly precise ways. Recognition of the extent to which all critically ill patients may deviate from their own baseline may improve the objectivity, precision, and generalizability of ICU mortality prediction and severity adjustment models.

Home-First or Hospital-First? A Propensity Score-Weighted Retrospective Cohort Study.

OBJECTIVES: This study aimed to compare clinical and utilization outcomes between home-first and hospital-first models of care in the operation of a hospital-at-home (HaH) program. DESIGN: This is a retrospective cohort study in which the primary outcome was a composite of oxygenation, intensive care unit admission, and all-cause mortality and the primary utilization outcome was length of stay (hospital and home bed days). SETTINGS AND PARTICIPANTS: The study sample included 1025 patients with COVID-19 admitted to an HaH program in Singapore from September 23, 2021, to February 29, 2022. METHODS: Propensity score weighting and regression analysis were used to adjust for confounding between both groups. RESULTS: There was no significant difference in the odds of occurrence of the primary outcome between the home-first and hospital-first groups (OR, 1.17; 95% CI, 0.44-3.10). Home-first patients had a shorter length of stay by an average of 2.02 (95% CI, 1.10-2.93) days with no statistically significant difference in clinical outcomes compared with hospital-first patients. CONCLUSIONS AND IMPLICATIONS: Patients with COVID-19 suitable for HaH should be considered for direct admission to HaH without need for an initial hospital stay.

Risk Factors Associated with Chemotherapy-Induced Nausea and Vomiting Among Women with Breast Cancer Receiving Highly Emetogenic Chemotherapy: Individual Patient-Based Analysis of Three Prospective Antiemetic Trials.

Purpose: Although risk factors related to chemotherapy-induced nausea and vomiting (CINV) have been identified in previous studies, only a few studies have evaluated the risk factors associated with contemporary antiemetic prophylaxis, including olanzapine/aprepitant- or NEPA-containing regimens. This study aimed to identify the risk factors associated with CINV development in Chinese breast cancer patients receiving doxorubicin and cyclophosphamide chemotherapy. Methods: Data from 304 patients enrolled in 3 previously reported prospective antiemetic studies were included. Multivariate logistic regression models were used to predict risk factors associated with CINV occurrence. Additionally, the likelihood of treatment failure in relation to the number of risk factors in individual patients was evaluated. Results: Multivariate analysis of the entire study group revealed that obesity status (defined as body mass index/= 25.0 kg/m2) and the use of olanzapine/aprepitant- or NEPA-containing anti-emetic regimens were associated with a high likelihood, while a history of motion sickness was associated with a lower likelihood, complete response (CR), and "no nausea" in the overall phase. A history of vomiting during pregnancy was also associated with a lower likelihood of an overall CR. Patients with an increasing number of risk factors had a higher likelihood of treatment failure and shorter time to first vomiting. Those who did not achieve CR and "no nausea" in the first cycle were less likely to achieve these parameters in the subsequent cycle of chemotherapy. Conclusion: The present study confirmed previously reported risk factors for CINV in Chinese breast cancer patients receiving doxorubicin and cyclophosphamide. Further optimization of CINV control is required for patients with identifiable risk factors; olanzapine/aprepitant- or NEPA- containing prophylaxis are the preferred contemporary anti-emetics regimens for Chinese breast cancer patients undergoing doxorubicin and cyclophosphamide chemotherapy.

Experiences of patients and their caregivers in a Virtual Ward in Singapore: A descriptive qualitative study.

BACKGROUND: The experiences of COVID-19 patients admitted to Virtual Wards and their caregivers are underexplored in Asian communities. A COVID-19 Virtual Ward (CVW) was recently established in Singapore. AIM: This study aims to describe the experiences of high-risk COVID-19 patients admitted to a Virtual Ward and their caregivers in a multi-racial Asian community. METHODS: A descriptive qualitative study was conducted from November 2021 to March 22 among high-risk COVID-19 patients and their caregivers who had been admitted to a CVW. The CVW involved teleconsultation whereby patients submitted their vital signs via a chatbot on their mobile phone and were supported remotely by a team of allied health professionals. In-depth interviews were conducted with patients and their caregivers and analyzed thematically. Findings The findings were supported by three themes. First, CVW admissions were perceived to be safe and effective. The second emerging theme related to the benefits and burdens of receiving care at home. The benefits of CVW were perceived comfort and familiarity with the home environment, while burdens included ensuring discipline in submitting health data and self-isolating from other household members. Last, the role of external factors such as informal support, paid domestic workers, and work arrangements was highlighted by the participants. Overall, key enablers for a successful CVW experience were the availability of social support, timely care from the care team, and 24/7 access to the team. CONCLUSION: In conclusion, CVW was perceived as a safe and effective strategy to manage high-risk patients at home. We recommend that Virtual Wards should be further developed to expand bed capacity in both pandemic and non-pandemic settings.

Proportion of medical admissions that may be hospitalised at home and their service utilisation patterns: a single-centre, descriptive retrospective cohort study in Singapore.

OBJECTIVES: For eligible patient groups, hospital-at-home (HaH) programmes have been shown to deliver equivalent patient outcomes with cost reduction compared with standard care. This study aims to establish a benchmark of inpatient admissions that could potentially be substituted by HaH services. DESIGN: Descriptive retrospective cohort study. SETTING: Academic tertiary hospital in Singapore. PARTICIPANTS: 124 253 medical admissions over 20 months (January 2016 to August 2017). PRIMARY AND SECONDARY OUTCOME MEASURES: The primary measure was the proportion of hospitalised patients who may be eligible for HaH, based on eligibility criteria adapted for the Singapore context. The secondary measures were the utilisation patterns and outcomes of these patients. RESULTS: Applying generalised eligibility criteria to the retrospective dataset showed that 53.0% of 124 253 medical admissions fitted the eligibility criteria for HaH based on administrative data. 46.8% of such patients had a length of stay <48 hours ('short-stay') and 53.1% had a length of stay ≥48 hours ('medium-stay'). The mortality rate and the 30-day readmission rate were lower in the 'short-stay' cohort (0.6%, 12.8%) compared with the 'medium-stay' cohort (0.7%, 20.3%). The key services used by both groups were: parenteral drug administration, blood investigations, imaging procedures and consultations with allied health professionals. CONCLUSIONS: Up to 53.0% of medical admissions receive care elements that HaH programmes could provide. Applying estimates of functional limitations and patient preferences, we propose a target of ~18% of inpatient medical admissions to be substituted by HaH services. The methodology adopted in this paper is a reproducible approach to characterise potential patients and service utilisation requirements when developing such programmes.

Prehospital portable ultrasound for safe and accurate prehospital needle thoracostomy: a pilot educational study.

BACKGROUND: Simulated needle thoracostomy (NT) using ultrasound may reduce potential injury, increase accuracy, and be as rapid to perform as the traditional landmark technique following a brief educational session. Our objective was to determine if the use of an educational session demonstrating the use of handheld ultrasound to Emergency Medical Services (EMS) staff to facilitate NT was both feasible, and an effective way of increasing the safety and efficacy of this procedure for rural EMS providers. METHODS: A pre/post-educational intervention on a convenience sample of rural North American EMS paramedics and nurses. Measurement of location and estimated depth of placement of needle thoracostomy with traditional landmark technique was completed and then repeated using handheld ultrasound following a training session on thoracic ultrasound and correct placement of NT. RESULTS: A total of 30 EMS practitioners participated. Seven were female (23.3%). There was a higher frequency of dangerous structures underlying the chosen location with the landmark technique 9/60 (15%) compared to the ultrasound technique 1/60 (1.7%) (p = 0.08). Mean time-to-site-selection for the landmark technique was shorter than the ultrasound technique at 10.7 s (range 3.35-45 s) vs. 19.9 s (range 7.8-50 s), respectively (p < 0.001). There was a lower proportion of correct location selection for the landmark technique 40/60 (66.7%) when compared to the ultrasound technique 51/60 (85%) (p = 0.019). With ultrasound, there was less variance between the estimated and measured depth of the pleural space with a mean difference of 0.033 cm (range 0-0.5 cm) when ultrasound was used as compared to a mean difference of 1.0375 cm (range 0-6 cm) for the landmark technique (95% CI for the difference 0.73-1.27 cm; p < 0.001). CONCLUSIONS: Teaching ultrasound NT was feasible in our cohort. While time-to-site-selection for ultrasound-guided NT took longer than the landmark technique, it increased safe and accurate simulated NT placement with fewer identified potential iatrogenic injuries.

Perceptions of Stakeholders Toward "Hospital at Home" Program in Singapore: A Descriptive Qualitative Study.

OBJECTIVE: Hospital at Home (HaH) programs have been shown to improve quality of care and patient satisfaction, and reduce bed occupancy rate in hospitals. Despite the prevalence of HaH in Western countries, studies in Asia are limited and the perception of HaH remains underexplored in Asian context. Understanding the perceptions of stakeholders is vital before implementing HaH in any new settings. Thus, the aim of this study is to explore the perceptions of referring physicians, care providers, patients, and caregivers on HaH programs in a multiracial country such as in Singapore. METHODS: This study used a descriptive qualitative design. Participants from 2 tertiary hospitals in Singapore, including 13 referring physicians, 10 care providers, 15 patients, and 3 caregivers, were interviewed between June 2020 and September 2020. Data were analyzed using inductive thematic analysis. RESULTS: The overarching theme titled "The stakeholders' perception on HaH" was pillared by 4 main themes: (1) patients suitable for HaH; (2) perceived advantages and benefits of HaH; (3) perceived risks, anxiety, and concerns about HaH; and (4) potential enablers of HaH. Overall, the findings reported that most of the stakeholders embraced HaH. Timely medical interventions and support from care providers were reportedly important factors to maintain patient safety and quality of care. The importance of having adequate resources and sound financing mechanisms to develop a successful HaH program was also highlighted. CONCLUSIONS: This study offered insights into HaH from the perspectives of stakeholders in Singapore and facilitate the planning of future HaH pilot programs in multiracial Singapore and other Asian countries.

Treating acutely ill patients at home: Data from Singapore.

INTRODUCTION: Hospital-at-home programmes are well described in the literature but not in Asia. We describe a home-based inpatient substitutive care programme in Singapore, with clinical and patient-reported outcomes. METHODS: We conducted a retrospective cohort study of patients admitted to a hospital-at-home programme from September 2020 to September 2021. Suitable patients, who otherwise required hospitalisation, were admitted to the programme. They were from inpatient wards, emergency department and community nursing teams in the western part of Singapore, where a multidisciplinary team provided hospital-level care at home. Electronic health record data were extracted from all patients admitted to the programme. Patient satisfaction surveys were conducted post-discharge. RESULTS: A total of 108 patients enrolled. Mean age was 67.9 (standard deviation 16.7) years, and 46% were male. The main diagnoses were skin and soft tissue infections (35%), urinary tract infections (29%) and fluid overload (18%). Median length of stay was 4 (interquartile range 3-7) days. Seven patients were escalated back to the hospital, of whom 2 died after escalation. One patient died at home. There was 1 case of adverse drug reaction and 1 fall at home, and no cases of hospital-acquired infections. Patient satisfaction rates were high and 94% of contactable patients would choose to participate again. CONCLUSION: Hospital-at-home programmes appear to be safe and feasible alternatives to inpatient care in Singapore. Further studies are warranted to compare clinical outcomes and cost to conventional inpatient care.

Sunitinib-associated hyperammonemic encephalopathy successfully managed with higher intensity conventional hemodialysis: A case report.

RATIONALE: Hyperammonemia encephalopathy is a rare but severe complication that has been reported in association with the use of sunitinib, a tyrosine kinase inhibitor. We report here a unique case of a patient with end stage renal disease that was initiated on sunitinib for metastatic renal cell carcinoma. PATIENT CONCERNS: A 65-year-old man with end stage renal disease on maintenance conventional hemodialysis and had concomitant stable Child-Pugh class B liver cirrhosis consequent of hepatitis C infection was started on sunitinib for metastatic renal cell carcinoma. He developed confusion few weeks after starting therapy with no other indication of worsening liver dysfunction otherwise. DIAGNOSIS: He was later diagnosed with hyperammonemia encephalopathy. INTERVENTIONS: His treatment was discontinued and reinitiated at a lower dose after recovery and titrated according to tolerance. As ammonia is a very low molecular weight molecule and is cleared well with diffusive clearance, we intensified his dialysis regimen by increasing intensity for each session and frequency per week. OUTCOMES: With this change in dialysis regimen, patient was able to continue treatment with sunitinib. LESSONS: Clinicians prescribing sunitinib should be vigilant to monitor for this complication in patients receiving sunitinib, apart from the more usual presentation of hepatotoxicity. We found that a more intensive hemodialysis regimen consisting of 4× a week conventional high-flux hemodialysis (HD) can permit the continuation of treatment with sunitinib in an end stage renal disease (ESRD) patient with Child-Pugh class B liver cirrhosis.

Asian Attitudes and Perceptions Toward Hospital-At-Home: A Cross-Sectional Study.

Introduction: Hospital-at-Home (HaH) programmes are well-established in Australia, Europe, and the United States. However, there is limited experience in Asia, where the hospital is traditionally seen as a safe and trusted space for healing. This cross-sectional study aimed to explore attitudes and perceptions among patients and caregivers in Singapore toward this care model. Methods: A quantitative study design was adopted to collect data among patients and their caregivers from medical wards within two acute hospitals in Singapore. Using a series of closed-ended and open-ended questions, the investigator-administered survey aimed to explore barriers and facilitators determining patients' and caregivers' responses. The study questionnaire was pretested and validated. Data were summarised using descriptive statistics, and logistic regression was performed to determine key factors influencing patients' decisions to enrol in such programmes. Results: Survey responses were collected from 120 participants (101 patients, 19 caregivers; response rate: 76%), of which 87 respondents (72.5%) expressed willingness to try HaH if offered. Many respondents valued non-quantifiable programme benefits, including perceived gains in quality of life. Among them, reasons cited for acceptance included preference for the comfort of their home environment, presence of family members, and confidence toward remote monitoring modalities. Among respondents who were unwilling to accept HaH, a common reason indicated was stronger confidence toward hospital care. Discussion: Most patients surveyed were open to having acute care delivered in their home environment, and concerns expressed may largely be addressed by operational considerations. The findings provide useful insights toward the planning of HaH programmes in Singapore.