Association between sleep quality and quality of life in Singapore.

PURPOSE: Several studies have examined the relationship between sleep quality and health-related quality of life (HRQOL). However, there are a lack of generalizable data on this association in Singapore. Our study aimed to (1) investigate the association between sleep quality and HRQOL and (2) examine whether age moderated these associations. METHODS: Data were obtained from nationwide Singapore Mental Health Study 2016 (n = 6126, response rate = 69.5%). Sleep quality was assessed using Pittsburgh Sleep Quality Index (PSQI) where higher scores indicate poorer sleep quality. HRQOL [Physical component summary (PCS) and Mental component summary (MCS)] were measured using 12-item Short-Form Survey. Associations were investigated using multivariable linear regression models, adjusted for sociodemographic, physical, and mental comorbidities. Interactions between age and sleep quality were examined by including interaction terms individually. RESULTS: Poorer PSQI score was significantly associated with lower PCS (ß = - 0.44) and lower MCS (ß = - 0.73). Among PSQI components, lower PCS was significantly associated with subjective sleep quality (ß = - 1.06), sleep duration (ß = - 0.30), sleep disturbance (ß = - 0.33), and daytime dysfunction (ß = - 0.75). Lower MCS was significantly associated with subjective sleep quality (ß = - 1.36), sleep latency (ß = - 0.24), sleep disturbance (ß = - 0.16), using of sleeping medication (ß = - 1.12), and daytime dysfunction (ß = - 2.08). Age moderated the association between PSQI score with PCS and MCS. Stronger association between PSQI score and MCS was observed in younger individuals (ß = - 0.90) than older adults (ß = - 0.45). CONCLUSION: Our study found that poor sleep quality was associated with HRQOL of certain age groups more than others. Future studies may identify potential mediators to help people with chronic sleep problems.

Treatment delays for mental disorders in Singapore: results from the Singapore Mental Health Study 2016.

PURPOSE: Although the trajectory of mental disorders can be improved with timely treatment, many people defer treatment-seeking. This study aimed to examine the prevalence and correlates of treatment delays for mental disorders in Singapore, as well as perceived effectiveness of treatment received. METHODS: A total of 6126 respondents, aged 18 and above, participated in the Singapore Mental Health Study 2016-a cross-sectional, nationwide study conducted in Singapore from 2016 to 2018. Lifetime treatment contact for mood, anxiety, and alcohol use disorders (AUD) was assessed using the World Mental Health-Composite International Diagnostic Interview (Version 3.0). Multivariable logistic regression was conducted to examine correlates of delayed treatment. RESULTS: A total of 137 participants had made lifetime treatment contact for a mental disorder. The proportion of respondents who received delayed treatment (i.e., at least one year after onset of disorder) was 60.8% for any disorder, 59.5% for mood disorders, 56.3% for anxiety disorders, and 92.7% for AUD. The median delay was 5 years for mood disorders, one year for anxiety disorders, and 4 years for AUD. Treatment delay was significantly associated with older age, higher educational qualification, lifetime AUD, and earlier age of onset of disorder. 58.4% of respondents with lifetime treatment contact had received treatment that they considered effective. CONCLUSION: The high prevalence and long durations of treatment delay underscore the need to encourage help-seeking for mental disorders, especially since treatment is generally perceived to be helpful. Our findings also highlight several population groups more susceptible to receiving delayed treatment.

Mediating effect of symptom severity on the relationship between aggression, impulsivity and quality of life outcomes among patients with schizophrenia and related psychoses.

Aims: Aggression and impulsivity among individuals with schizophrenia have been associated with poor clinical outcomes including worsening of symptoms and substance abuse which have been linked to a lower quality of life (QoL). The current study aimed to look at the mediating effect of symptom severity on the relationship between aggression, impulsivity and QoL among outpatients with schizophrenia and related psychoses in a multi-ethnic Asian population. Methods: Data (n = 397) were collected from outpatients seeking treatment at the Institute of Mental Health. The World Health Organization quality of life-BREF (WHOQOL-BREF) scale, the symptoms checklist-90 revised (SCL-90-R), Buss Perry aggression questionnaire (BPAQ), and the Barratt impulsiveness scales (BIS) were used to assess subjective well-being, symptom severity, aggression, and impulsivity, respectively. Mediation analysis was performed using the PROCESS macro to understand the mediating effect of symptom severity. Results: Motor impulsivity (MI) was indirectly associated with both the physical and psychological health domains of QoL while self-control was indirectly associated with the physical, psychological, and environmental health QoL domains through increased symptom severity. Conclusion: The significant indirect effect of symptom severity in our study highlights one potential pathway through which impulsivity impacts the QoL of individuals with schizophrenia and related psychoses. Elucidating other factors besides symptom severity that have an indirect effect on the QoL of individuals provides alternative approaches for treatment through which better clinical outcomes can be achieved.

Prevalence and correlates of suicide planning and attempt among individuals with suicidal ideation: Results from a nationwide cross-sectional survey.

BACKGROUND: Suicidality spans from having suicidal ideation to planning and making an attempt. However, not all individuals with suicidal thoughts will proceed to plan or attempt suicide. Our study investigated (i) the prevalence of suicide planning and attempt among those with suicidal ideation and (ii) their associations with sociodemographic characteristics, mental disorders, adverse childhood events and prior suicidal behaviour. METHOD: This cross-sectional analysis utilised data from Singapore Mental Health Study 2016. Only respondents with suicidal ideation were included. A total of 411 and 365 individuals were examined to establish the prevalence of suicide planning and attempt respectively. Multivariable logistic regressions were performed to determine associations. RESULTS: The prevalence of suicide planning and attempt were 17.7 % and 10.6 % respectively, with >80.0 % occurring within a year of suicidal ideation. Suicide planning was more likely among those who had mood disorders. Suicide attempt was more likely for those were currently married, had lower educational qualifications, history of anxiety disorders, history of emotional neglect and parental separation. LIMITATIONS: Recall bias may be present because the age of onset for various mental disorders and suicidal behaviours were self-reported. As suicide was criminalised when the study was conducted, the prevalence of suicidal behaviours may have been underestimated. CONCLUSION: Individuals at risk of suicide planning and attempt should be identified early since most of them progressed within a year. Findings suggest the importance of including prior suicide behaviour and history of dysfunctional family and emotional abuse in suicide risk assessment and intervention.

Food insufficiency, adverse childhood experiences and mental health: results of the Singapore Mental Health Study 2016.

OBJECTIVE: This study aimed to investigate the prevalence and correlates of food insufficiency and its association with mental disorders and adverse childhood experiences (ACE) in Singapore. DESIGN: This analysis utilised data from the Singapore Mental Health Study (SMHS 2016). SETTING: SMHS 2016 was a population-based, psychiatric epidemiological study conducted among Singapore residents. PARTICIPANTS: Interviews were conducted with 6126 respondents. Respondents were included if they were aged 18 years and above, Singapore citizens or permanent residents and able to speak in English, Chinese or Malay. RESULTS: The prevalence of food insufficiency was 2·0 % (95 % CI (1·6, 2·5)) among adult Singapore residents. Relative to respondents who did not endorse any ACE, those with ACE (OR: 2·9, 95 % CI (1·2, 6·6)) had higher odds of food insufficiency. In addition, there were significant associations between lifetime mental disorders and food insufficiency. Bipolar disorder (OR: 2·7, 95 % CI (1·2, 6·0)), generalised anxiety disorder (OR: 4·5, 95 % CI (1·5, 13·5)) and suicidal behaviour (OR: 2·37, 95 % CI (1·04, 5·41)) were shown to be significantly associated with higher odds of food insufficiency. CONCLUSIONS: The prevalence of food insufficiency is low in Singapore. However, this study identifies a vulnerable group of food-insufficient adults that is significantly associated with mental disorders, including suicidality. Government-funded food assistance programmes and multi-agency efforts to deal with the social determinants of food insufficiency, such as income sufficiency and early detection and intervention of mental distress, are key to ensuring a sustainable and equitable food system.

Depression and Suicidality: The Roles of Social Support and Positive Mental Health.

OBJECTIVE: Despite being preventable, suicide remains a leading cause of death globally, with depression being one of the more prominent risk factors. This study examines the roles of social support and positive mental health in the depression-suicidality pathway. METHODS: We utilized data from the Singapore Mental Health Study 2016. Social support and positive mental health were examined as mediators in the relationship between 12-month depression and 12-month suicidality using survey-weighted generalized structural equation modeling. RESULTS: Overall positive mental health was found to partially mediate the relationship between depression and suicide. Of the discrete positive mental health domains, the depression-suicidality relationship was partially mediated by general coping and fully mediated by personal growth and autonomy. CONCLUSION: While findings regarding social support were inconclusive, positive mental health may play a significant role in alleviating the effects of depression on suicidality. This highlights the multifaceted nature of suicidality and reveals positive mental health as a new area in assessing and treating at-risk people, to improve clinical outcomes.HIGHLIGHTSThe effect of depression on suicidality was partially mediated by overall positive mental health.General coping partially mediated the relationship between depression and suicidality.Personal growth and autonomy fully mediated the relationship between depression and suicidality.

A cross-sectional study on the perceived barriers to physical activity and their associations with domain-specific physical activity and sedentary behaviour.

BACKGROUND: Physical inactivity and sedentary behaviour have detrimental consequences to the individual and the economy. Our study examined the prevalence of perceived barriers to physical activity in Singapore's adult population and their associations with physical activity and sedentary behaviour. METHODS: This cross-sectional analysis utilised data from a nationwide survey in Singapore. Participants (n = 2867) were recruited from February 2019 to March 2020. The independent variables were internal (e.g. fatigue, age) and external (e.g. weather, cost) perceived barriers to physical activity. The outcomes were domain-specific physical activity (work, transport and leisure) and sedentary behaviour, all of which were assessed using the Global Physical Activity Questionnaire. The associations were examined using zero-inflated negative binomial regressions for physical activity and linear regression for sedentary behaviour. RESULTS: The median (Interquartile range) for work-related, transport-related and leisure-related physical activity were 0 (0 - 1440), 600 (160 - 1120) and 360 (0 - 1080) MET (metabolic equivalent)-minutes per week. The median sedentary behaviour (IQR) was 360 (240 - 540) minutes per day. The top three barriers were lack of time (65.3%), fatigue (64.7%) and pollution (56.1%). After adjustment, the level of transport-related physical activity was lower for respondents who cited lacking pavement or parks as a barrier, but higher for those who indicated cost and safety concerns. Respondents who reported pollution as a barrier were more likely to engage in transport-related physical activity. The level of leisure-related physical activity was lower for respondents indicating weather, lack of time and age as barriers, but higher for those reporting safety concerns. The odds of engaging in leisure-related physical activity was lower for those citing age, cost and fatigue as barriers, but higher for those indicating the weather. Sedentary behaviour was positively associated with work and limited accessibility to exercise facilities, but negatively with safety concerns. CONCLUSION: Individuals can be motivated to overcome internal barriers (fatigue, lack of time, cost and age) through social support and emphasis on exercise benefits. External barriers (weather and lack of pavements or parks) can be reduced by raising awareness of existing infrastructure. Sedentary behaviour can be improved by implementing workplace measures, such as reducing the time spent sitting.

The associations between caregivers' psychosocial characteristics and caregivers' depressive symptoms in stroke settings: a cohort study.

BACKGROUND: Studies have found that caregivers can influence stroke survivors' outcomes, such as mortality. It is thus pertinent to identify significant factors associated with caregivers' outcomes. The study objective was to examine the associations between caregivers' psychosocial characteristics and caregivers' depressive symptoms. METHODS: The analysis obtained three-month and one-year post-stroke data from the Singapore Stroke Study, which was collected from hospital settings. Caregivers' depressive symptoms were assessed via the Center for Epidemiologic Studies Depression instrument. Psychosocial characteristics of caregivers included subjective burden (Zarit Burden Interview), quality of care-relationship (a modified 3-item scale from the University of Southern California Longitudinal Study of Three-Generation Families) and expressive social support (an 8-item scale from Pearlin et al.). Mixed effect Tobit regressions were used to examine the associations between these study variables. RESULTS: A total of 214 caregivers of stroke patients hospitalized were included in the final analysis. Most caregivers were Chinese women with secondary school education, unemployed and married to the patients. Caregivers' subjective burden was positively associated with their depressive symptoms (Partial regression coefficient: 0.18, 95% CI 0.11-0.24). Quality of care-relationship (Partial regression coefficient: - 0.35, 95% CI - 0.63 to - 0.06) and expressive social support (partial regression coefficient: - 0.28, 95% CI - 0.37 to - 0.19) were negatively associated with caregivers' depressive symptoms. Caregivers' depressive symptoms were higher at three-month post-stroke than one-year post-stroke (Partial regression coefficient: - 1.00, 95% CI - 1.80 to - 0.20). CONCLUSION: The study identified subjective burden, quality of care-relationship and expressive social support as significantly associated with caregivers' depressive symptoms. Caregivers' communication skills may also play a role in reducing caregivers' depressive symptoms.

Characteristics and Outcomes of Locally Recurrent Retroperitoneal Sarcoma After First Relapse in a Single Tertiary Asian Centre and Applicability of the Sarculator.

OBJECTIVE: Retroperitoneal sarcomas (RPS) comprise of 15% of soft tissue sarcomas where five-year overall survival rate is about 50%. Locoregional recurrences are observed in up to 50% of patients within the first five years following resection. Various factors have been shown to influence survival outcomes, such as histological subtype and tumour size. A nomogram for first relapse locally recurrent RPS was developed using 602 patients from 22 centres. The recurrent RPS Sarculator is available in an electronic interface and includes variables of age, size, margins of re-resection, radiotherapy, chemotherapy and histology to predict for 6-year disease-free survival (DFS) and overall survival (OS). It has not been validated externally. This study aims to validate the Sarculator recurrence nomogram in predicting the survival outcomes of recurrent RPS in an Asian population as well as examine relapse patterns. METHODS: Patients diagnosed with first recurrent RPS from 1 January 2000 to 31 December 2017 with first local relapse and eligible for curative re-resection were retrospectively analysed. The type of surgery was unique for individual patients and suggestions of adjuvant therapy were based on globally recognised standards. Patients were followed up every 3 to 4 months post-operatively for the first 2 to 3 years and 6-monthly to a year thereafter. A R0 or R1 margin is deemed as complete resection, including a microscopically negative margin (R0) and microscopically positive but macroscopically clear margin (R1). R2 is classified as an incomplete resection with tumour rupture or remaining disease. Harrell's C concordance index was used to determine the nomogram's discriminative ability and calibration plots were used to assess accuracy. For the calibration, the patients were divided into 3 groups. Death data was retrieved from the National Birth and Death registry for accuracy. RESULTS: There were 53 patients included in this study. Patient and tumour characteristics have been summarised in Table 1. All patients had their second resection at a single centre. 66.0% had their first resection at the same centre. The median age was 53 (range 21- 79) at diagnosis, median tumour size was 17cm (12cm to 28cm) and median follow-up duration was 44.1 months. The most commonly encountered subtypes were de-differentiated liposarcoma (DDLPS) (56.6%), well-differentiated liposarcoma (WDLPS) (20.8%) and leiomyosarcoma (LMS) (11.3%) with a majority being high-grade (75.5%). The median disease-free interval was 2.9 years (2- 5.3 years) from the first surgery. The median age at second surgery was 56 (21- 79) and all patients had a complete resection (R0/R1). Recurrence patterns differed with subtypes where 90.9% and 9.1% of WDLS, 76.7% and 16.7% of DDLPS and 83.3% and 16.7% of LMS had local and distant relapses respectively from the second surgery. 62.5% of distant relapses was in the lung followed by nodes (18.8%) and liver (12.5%). The 5-year OS from the second surgery was 66.2% (95% CI: 54.3%- 80.8%). The 1-year, 3 years and 6 years DFS were 50.2% (95% CI: 38.2% - 65.9%), 10.4% (4.26% - 25.5%) and 3.91% (0.684% - 22.4%) respectively. Overall, 32 patients (60.4%) had passed away from sarcoma. The concordance indices for 6-year OS and DFS were 0.7 and 0.65 (Figure 1) respectively which represents a fairly accurate prediction by Sarculator. CONCLUSION: Our study has shown the Sarculator nomogram for primary recurrent was applicable in our cohort and its potential application in an Asian setting. The Sarculator nomogram will be a useful tool in clinical practice to improve risk stratification and facilitate prognosis-based decision-making. Moving forward, novel therapeutic strategies are required to enhance the prognosis of patients with recurrent RPS.

The Prevalence and Correlates of Disability in Singapore: Results from a Nationwide Cross-Sectional Survey.

OBJECTIVE: The study aims to estimate the prevalence of disability and the association of disability with socio-demographic correlates and health outcomes among the Singapore population. METHODS: Face-to-face interviews were conducted with a representative sample of Singapore's population. Using the Washington Group's questionnaire, disability was defined using both the 'standard' (a lot of difficulty or higher in one or more domains) and the 'wider' threshold (of 'some' or greater difficulty). Data on socio-demographic correlates, self-reported lifestyle, physical activity, chronic conditions, and health-related quality of life were also collected. RESULTS: The prevalence of any disability using the standard threshold was 3.1% (95% CI: 2.4-4.1). When separated by disability type, mobility (1.8%) was the most prevalent, followed by vision (0.8%), cognition (0.5%), hearing (0.3%), and self-care (0.2). In the adjusted regression analysis, lower education and unemployed and economically inactive status (versus employed) were significantly associated with disability. CONCLUSIONS: Although this prevalence is lower than other countries, it is a significant finding in terms of actual numbers and impact at both the individual and the societal levels. Our findings also highlight the need to strengthen health services and preventive interventions targeting older adults and those who are physically inactive to reduce the burden of disability in these groups.

Examining the Influence of Social Interactions and Community Resources on Caregivers' Burden in Stroke Settings: A Prospective Cohort Study.

Since the introduction of the integrated care model, understanding how social interactions and community resources can alleviate caregivers' burden is vital to minimizing negative patients' outcomes. This study (n = 214) examined the associations between these factors and caregivers' burden in stroke settings. It used 3-month and 1-year post-stroke data collected from five tertiary hospitals. Subjective and objective caregivers' burdens were measured using Zarit burden interview and Oberst caregiving burden scale respectively. The independent variables examined were quality of care relationship, care management strategies for managing patients' behaviour, family caregiving conflict, formal service usage and assistance to the caregiver. Significant associations were determined using mixed effect modified Poisson regressions. For both types of burden, the scores were slightly higher at 3 months as compared to 1 year. Poorer care-relationship (relative risk: 0.81, 95% confidence interval (CI): 0.70-0.94) and adopting positive care management strategies (relative risk: 1.05, 95% CI: 1.02-1.07) were independently associated with a high subjective burden. Providing assistance to caregivers (relative risk: 2.45, 95% CI: 1.72-3.29) and adopting positive care management strategies (relative risk: 1.03, 95% CI: 1.02-1.04) were independently associated with a high objective burden. Adopting positive care management strategies at 3 months had a significant indirect effect (standardised ß: 0.11, 95% CI: 0.01 to 0.20) on high objective burden at one year. Healthcare providers should be aware that excessive care management strategies and assistance from family members may add to caregivers' burden.

Exploration and Development of a Simpler Respiratory Distress Observation Scale (modRDOS-4) as a Dyspnea Screening Tool: A Prospective Bedside Study.

Introduction: End-of-life patients face difficulties in reporting respiratory distress. The Respiratory Distress Observation Scale (RDOS) is a well-known tool; however, field implementation has been challenging from ground feedback. We sought to develop a simpler scale. Setting: Patients referred for palliative consult in a tertiary hospital in Singapore were recruited. Methods: A priori, we identified 18 dyspnea physical signs and documented their presence through bedside observation. Dyspnea severity was self-reported. The cohort was randomly split into training and test sets. Partial least square regression with leave-one-out cross-validation was used to develop a four-point model from the training set. Using the test set, data fit was compared using Akaike and Bayesian Information Criterion. Discrimination was assessed using receiver operating characteristics. Results: Of 122 patients, mean age was 67.9 years (range 23-93, standard deviation 12.9), 71.3% had a primary cancer diagnosis, and 58.1% were chair/bedbound with a Palliative Performance Scale of ≤50. Median reported dyspnea scale was 5 (interquartile range 3-7). Our model (modRDOS-4) consisted of four predictors (grunting, respiratory rate, accessory muscle use, paradoxical breathing). A modRDOS-4 of ≥6 identified moderate-to-severe dyspnea with a sensitivity of 0.78 and specificity of 0.90. Using the test set, with the modRDOS-4, the Akaike Information Criterion (AIC) is 149.8, Bayesian Information Criteria (BIC) is 154.1, and the receiver operating characteristics (ROC) is 0.74. With the original RDOS, the AIC is 145.2, BIC is 149.5, and ROC is 0.76. Conclusion: For a quick assessment of dyspnea, we developed a four-item tool with a pilot web-based nomogram. External validation is needed.

The Impact of Radiotherapy and Histological Risk Factors on Outcomes in Malignant Phyllodes Tumors.

PURPOSE: Breast phyllodes tumors (PT) are classified into benign, borderline, and malignant grades based on histopathologic characteristics. Specific to malignant PT (MPT), surgery is the mainstay yet relapse rates are high and knowledge gaps in the literature exist regarding adjuvant radiotherapy (RT). We aimed to investigate the outcomes of patients with MPT treated in a tertiary Asian institution. METHODS AND MATERIALS: Patients with nonmetastatic MPT treated from February 1992 to June 2019 were analyzed retrospectively. RT details and relapse fields were studied. Outcomes of patients with and without RT were compared and hazard ratios were calculated using Cox proportional hazard test. Multivariable analysis was performed. RESULTS: Twenty-two of 89 patients received adjuvant RT and the median dose was 60 Gy. In the no-RT group, 4 patients received RT on relapse and had no further recurrences; a further 2 received RT for fungating relapses with good symptomatic relief. RT was only increasingly prescribed after 2004. Median follow-up in the RT group was 3.31 years, compared with 6.17 years in the no-RT group. In the RT group, 15 patients (68.2%) underwent mastectomy, versus 39 (58.2%) in the no-RT group. One patient in the RT group developed an infield local relapse, compared with 21 of 67 patients in the no-RT group. Multivariate model showed that RT decreased risk of locoregional failure (hazard ratio 0.12, 95% confidence interval [CI] 0.02-0.92, P = .04). Three-year locoregional recurrence-free survival was higher in the RT group, 92.3% (95% CI, 78.9-100) versus 73.3% (95% CI, 63.1-85.1) in the no-RT group (P = .03). There were no differences in 3-year survival. CONCLUSIONS: We recommend that adjuvant radiotherapy be discussed for malignant PT for local control, even after mastectomy.

Applicability of the Sarculator and MSKCC nomograms to retroperitoneal sarcoma prognostication in an Asian tertiary center.

AIM: To study the applicability of 2 common nomograms in retroperitoneal sarcoma patients treated in an Asian tertiary hospital, and to study relapse patterns. METHODS: Patients from 1st January 2000 to 31st December 2017 were retrospectively analysed. R2 resection from an external institution were ineligible. Harrel's C concordance index and calibration plots were used to assess nomograms' accuracy. RESULTS: 109 patients were eligible, with a median age of 56, median tumour size of 16 cm and median follow up of 44.1 months. Most common subtypes were DDLPS (46.8%), LMS (19.3%) and WDLPS (13.8%). Overall, 81.1% had passed away from sarcoma. Recurrence patterns differed with subtypes; 6.7% of WDLPS and 66.7% of LMS had distant relapses. WDLPS patients had a median sarcoma specific survival of 139 months (122-NA), while the rest had a median SSS of 72.3 months (59.7-NA). The 5-years and 7-year OS were 63.0% (95% CI: 53.6%-74.0%) and 51.6% (41.1%-64.8%) respectively. The 5-years and 7-year DFS were 22.4% (15.5%-32.3%) and 17.5% (11%-27.8%) respectively. The 4-years, 8-years and 12-year SSS were 71.3% (62.7%-81.0%), 51.8% (40.8%-65.8%) and 32.2% (19.7%-52.6%) respectively. The concordance indices for 7-year DFS and OS (Sarculator) were 0.63 and 0.73. The concordance indices for 4-, 8- and 12-year SSS (MSKCC) were 0.64, 0.72 and 0.72. CONCLUSION: Both nomograms were effective in our cohort. Both nomograms can be further improved by specifying the type of relapse and including a longer-term endpoint for the Sarculator.

68Gallium-labelled PSMA-PET/CT as a diagnostic and clinical decision-making tool in Asian prostate cancer patients following prostatectomy.

OBJECTIVE: Prostate cancers (PCa) in Asian individuals are molecularly distinct from those found in their Caucasian counterparts. There is no risk stratification tool for Asian men with rapid biochemical recurrence (BCR) following radical prostatectomy (RadP). This study aims to assess the detection rate of 68Ga-prostate-specific membrane antigen-positron emission tomography/computed tomography (PSMA-PET/CT) for diagnosis of clinical recurrence and as a treatment decision making tool in Asian patients with BCR post-RadP. METHODS: 68Ga PSMA-PET and CT body with/without bone scan [conventional workup (CWU)] were performed in 55 Asian patients with BCR within 36 months post-RadP. Two blinded reviewers assessed the images. Detection rates of 68Ga PSMA-PET/CT were evaluated, and impact on management was reviewed by comparison with CWU. RESULTS: Median time to BCR post-RadP was 8.1 months. Detection rate for 68Ga PSMA-PET/CT was 80% (44/55). A positive scan was significantly associated with increasing prostate-specific antigen (PSA) level [odds ratio (OR) = 1.13 (95% CI 1.05-1.30), P = 0.017], but not with higher Gleason grade or shorter PSA doubling time. Compared to CWU, 68Ga PSMA-PET/CT detected an additional 106 lesions in 33/44 patients with a positive scan, resulting in a change in management in 25/44 (56.8%) patients: 10 to hormonal therapy (HT) and whole pelvis radiotherapy (RT) in addition to bed RT, and 15 to palliative HT alone. CONCLUSIONS: In the present report, we demonstrated the diagnostic and treatment decision utility of 68Ga PSMA-PET/CT in Asian men with rapid BCR. Detection of small volume nodal and systemic recurrences at low PSA levels (< 1.0 ng/mL) highlights the role of the tool in assigning patients to treatment intensification with HT-RT or palliative HT in polymetastatic disease.

Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) trial: protocol of a randomized clinical trial on tele-rehabilitation for stroke patients.

BACKGROUND: Most acute stroke patients with disabilities do not receive recommended rehabilitation following discharge to the community. Functional and social barriers are common reasons for non-adherence to post-discharge rehabilitation. Home rehabilitation is an alternative to centre-based rehabilitation but is costlier. Tele-rehabilitation is a possible solution, allowing for remote supervision of rehabilitation and eliminating access barriers. The objective of the Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) trial is to determine if a novel tele-rehabilitation intervention for the first three months after stroke admission improves functional recovery compared to usual care. METHODS/DESIGN: This is a single blind (evaluator blinded), parallel, two-arm randomised controlled trial study design involving 100 recent stroke patients. The inclusion criteria are age ≥40 years, having caregiver support and recent stroke defined as stroke diagnosis within 4 weeks. Consenting participants will be randomized with varying block size of 4 or 6 assuming a 1:1 treatment allocation with the participating centre as the stratification factor. The baseline assessment will be done within 4 weeks of stroke onset, followed by follow-up assessments at 3 and 6 months. The tele-rehabilitation intervention lasts for 3 months and includes exercise 5-days-a-week using an iPad-based system that allows recording of daily exercise with video and sensor data and weekly video-conferencing with tele-therapists after data review. Those allocated to the control group will receive usual care. The primary outcome measure is improvement in life task's social activity participation at three months as measured by the disability component of the Jette Late Life Functional and Disability Instrument (LLFDI). Secondary outcome variables consist of gait speed (Timed 5-Meter Walk Test) and endurance (Two-Minute Walk test), performance of basic activities of daily living (Shah-modified Barthel Index), balance confidence (Activities-Specific Balance Confidence Scale), patient self-reported health-related quality-of-life [Euro-QOL (EQ-5D)], health service utilization (Singapore Stroke Study Health Service Utilization Form) and caregiver reported stress (Zarit Caregiver Burden Inventory). DISCUSSION: The goal of this trial is to provide evidence on the potential benefit and cost-effectiveness of this novel tele-rehabilitation programme which will guide health care decision-making and potentially improve performance of post-stroke community-based rehabilitation. TRIAL REGISTRATION: This trial protocol was registered under ClinicalTrials.gov on 18 July 2013 as study title "The Singapore Tele-technology Aided Rehabilitation in Stroke (STARS) Study" (ID: The STARS Study, ClinicalTrials.gov Identifier: NCT01905917 ).