Achieving satisfactory functional outcomes in conservatively treated proximal humerus fractures: relationship between shoulder range of motion and patient-reported clinical outcome scores.

Background: Proximal humerus fractures are common osteoporotic fractures. Postinjury outcome measures include objective clinician-measured range of motion (ROM) and subjective patient-reported outcome measures (PROMs), but the relationship between both has not been established. This study aimed to determine the relationship between shoulder ROM and PROMs and establish which ROMs correlated most with PROMs. Methods: A prospective cohort study was conducted on patients with acute proximal humerus fractures. Surgical intervention, open or pathological fractures, neurovascular compromise, polytrauma, or delayed presentations were excluded. Correlation and regression analyses between active ROM and PROMs (Quick Disabilities of Arm, Shoulder and Hand [QuickDASH] and Oxford Shoulder Score [OSS]) at 1-year postinjury were explored. ROM cutoffs predicting satisfactory PROM scores were established. Results: Fifty-five patients were recruited. Moderate correlations were observed between PROMs and flexion, extension, and abduction, but not internal and external rotation. Multivariate analysis showed significant relationships between PROMs and flexion [QuickDASH: adjusted coefficient (AC): -0.135, P = .013, OSS: AC: 0.072, P = .002], abduction [QuickDASH: AC: -0.115, P = .021, OSS: AC: 0.059, P = .005], and extension [QuickDASH: AC: -0.304, P = .020] adjusting for age, gender, Neer classification, injury on dominant side, and employment. Achieving 130° flexion, 59° extension, and 124° abduction were correlated with satisfactory OSS/QuickDASH scores, respectively. Conclusion: Overall, holistic assessment of outcomes with both subjective and objective outcomes are necessary, as shoulder flexion, extension, and abduction are only moderately correlated with PROMs. Attaining 130° flexion, 59° extension, and 124° abduction corresponded with satisfactory functional outcomes measured by OSS/QuickDASH and can guide rehabilitation.

Collaborative model of care between orthopaedics and allied healthcare professionals (CONNACT) in knee osteoarthritis: Effectiveness-implementation hybrid randomized controlled trial of a community-based, multidisciplinary, stratified intervention.

OBJECTIVE: To compare the clinical and cost effectiveness of the Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT), a community-based, stratified, multidisciplinary intervention consisting of exercise, education, psychological and nutrition delivered through a chronic care model to usual hospital care in adults with knee osteoarthritis (OA). METHODS: Pragmatic, parallel-arm, single-blinded superiority RCT trial. Community-dwelling, ambulant adults with knee OA (Kellgren-Lawrence grade > 1; Knee Injury and OA Outcome Score (KOOS4) ≤75) were enrolled. Primary outcome was KOOS4 at 12-months; secondary outcomes included: quality of life, physical performance measures, symptom satisfaction, psychological outcomes, dietary habits, and global perceived effect. Intention-to-treat analysis using generalized linear model (GLM) and regression modeling were conducted. Economic evaluation through a societal approach was embedded. RESULTS: 110 participants (55 control, 55 intervention) were randomized. No between-group difference found for the primary outcome (MD [95%CI]: -1.86 [-9.11. 5.38]), although both groups demonstrated within-group improvement over 12-months. Among the secondary outcomes, the CONNACT group demonstrated superior dietary change (12 months) and physical performance measures (3 months), and global perceived effect (6 months). While there was no between-group difference in total cost, significant productivity gains (reduced indirect cost) were seen in the CONNACT group. CONCLUSION: CONNACT was not superior to usual care at 1 year. Further efforts are needed to understand the underlying contextual and implementation factors in order to further improve and refine such community-based, stratified care models moving forward. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT03809975. Registered January 18, 2019. https://clinicaltrials.gov/ct2/show/NCT03809975.

A cross sectional study exploring the relationship of self-reported physical activity with function, kinesiophobia, self-efficacy and quality of life in an Asian population seeking care for knee osteoarthritis.

BACKGROUND: Physical activity is a guideline-recommended first-line intervention for people with knee osteoarthritis. Physical activity levels, and its potential correlates, is underexplored in Asian populations with knee osteoarthritis. METHODS: Participants enrolled in a longitudinal study in Singapore self-reported physical activity (UCLA activity score), function (Knee Osteoarthritis Outcome Score [KOOS-12]), kinesiophobia (Brief fear of movement [BFOM]), self-efficacy (ASES-8), and quality of life (EQ-5D-5 L). One-Way ANOVA was used to test the difference in outcomes between UCLA categories, while ordinal logistic regression was used to identify the associated factors to physical activity level. RESULTS: Seventy-three percent of all enrolled participants (n = 311/425) reported either inactivity or low physical activity (median 4, IQR 3-5). Significant, weak, positive correlations were observed be-tween UCLA activity score and either KOOS-12 (Spearman's rho: 0.1961; p < 0.001), ASES-8 (0.1983; p = 0.004), or EQ-5D-5 L (0.2078; p < 0.001). A significant, weak, negative correlation was observed between physical activity and BFOM (-0.2183; p < 0.001). Significant differences in function between groups (moderate vs. inactive or low physical activity) were not clinically important. Participants with obesity, from the eldest age category (i.e. ≥75), or who identified as Malay or female, were less physically active than those with a healthy BMI, below the age of 54, or who identified as Chinese or male, respectively. CONCLUSION: Healthcare professionals in Asia should be aware of the large proportion of people with knee osteoarthritis who are either inactive or have low physical activity levels. Screening for, and offering interventions to promote, physical activity and its correlates should be prioritised.

Comparing Consistency and Usability of Common Bowel Function Scoring Systems in Anorectal Malformation Patients.

BACKGROUND: Assessment of postoperative bowel function in anorectal malformation (ARM) patients is crucial for benchmarking outcomes. We compared existing bowel function scoring systems in various aspects in patients with ARM. METHODS: With ethical approval, this was a cross-sectional study involving 5 paediatric surgery referral centres in Malaysia, comparing the Kelly, Japanese Study Group of Anorectal Anomalies (JSGA), Holschneider and Krickenbeck bowel function questionnaires. We recruited patients aged 4-17 years, who had completed definitive surgery & stoma closure (where relevant) > 12 months prior to participation. We standardised outcomes of each scoring system into categories ('good', 'fair', 'poor' and 'very poor') to facilitate comparison. Parents & patients were surveyed and asked to rate the ease of understanding of each questionnaire. The difference in protocol scores rated between parents and patients were compared. Association of each bowel function scoring protocol with type of anomaly was assessed. Statistical significance was p < 0.05. RESULTS: Thirty-nine parents (21 mothers, 18 fathers) and 23 patients were included in this study. Fair agreement was found between Kelly and Krickenbeck protocols (κ = 0.343; p < 0.001), between JSGA constipation and Holschneider protocols (κ = 0.276; p = 0.002); JSGA constipation and Krickenbeck protocols (κ = 0.256; p = 0.004); and between Holschneider and Krickenbeck protocols (κ = 0.273; p = 0.003). Only the Kelly protocol showed significant correlation between parents and patients' answers (ρ = 0.459, p = 0.028). Krickenbeck demonstrated the best negative correlation of patients' scores with ARM types (ρ = -0.401, p = 0.001). The Kelly protocol ranked highest when comparing ease of understanding. CONCLUSION: All the questionnaires appeared comparable in assessing postoperative faecal continence in ARM patients. The Kelly questionnaire performed best in 3 key areas of assessment. LEVEL OF EVIDENCE: Level III Cross-Sectional Study.

Study on proximal humerus evaluation of effective treatment (SPHEER) - what is the effect of rehabilitation compliance on clinical outcomes of proximal humerus fractures.

INTRODUCTION: Proximal humeral fractures (PHFs) are 3rd commonest fragility fractures and cause significant functional impairment. This paper sought to determine impact of rehabilitation compliance on the clinical outcomes for non-surgically managed PHFs, while ascertaining reasons for non-compliance which can be addressed to improve compliance. METHODS: Prospective cohort study of patients undergoing non-surgical treatment for PHFs from August 2017 to April 2020 in a tertiary trauma centre was performed. Data was collected via questionnaire: patient demographic data, PHF injury details, clinical outcome measures, therapist-reported (Sport Injury Rehabilitation Adherence Scale [SIRAS]) and patient-reported (subjective compliance, frequency of exercise) rehabilitation compliance measures. Data was analysed using multiple linear regression model to account for confounding variables. RESULTS: 107 participants attended physical therapy follow-up for mean 137.8 days. 6-week SIRAS strongly predicted 3-month Constant score (p = 0.023; 95%CI = 0.265,3.423), OSS (p = 0.038; 95%CI = 0.049,1.634), flexion ROM (p < 0.001; 95%CI = 2.872,8.982), extension ROM (p = 0.035; 95%CI = 0.097,2.614), abduction ROM (p = 0.002;95%CI = 1.995,8.466) and achievement of functional active ROM at 3-months (p = 0.049; 95%CI = 1.001,1.638). Pain was the top reason impairing rehabilitation compliance from therapist (43.9% at 6-weeks and 20.6% at 3-months) and patient-perspective (33.6% at 6-weeks, 24.3% at 3-months). Author-developed patient-reported compliance measures had good correlation with validated SIRAS score (subjective compliance: p < 0.001 frequency of exercise: p = 0.001). CONCLUSION: Rehabilitation compliance predicts short-term clinical outcomes up to 3-months and potentially 1-year outcomes. Pain control should be optimised to maximise rehabilitation compliance and improve PHF outcomes. There is lack of consensus definition for rehabilitation compliance measures; patient-reported measures used have good correlation to existing validated measures and could serve as a steppingstone for further research. LEVEL OF EVIDENCE: II, cohort study.

Rehabilitation of Older Asian Traumatic Brain Injury Inpatients: A Retrospective Study Comparing Functional Independence between Age Groups.

Across traumatic brain injury (TBI) severities, a geriatric TBI tsunami has emerged. Mixed outcomes are reported for elderly TBI with positive functional improvements with acute inpatient rehabilitation. We studied the effect of age at TBI on discharge functional outcomes, levels of independence and length of stay. A retrospective analysis of Asian TBI patients during inpatient rehabilitation over a 4-year period was conducted. Independent variables included admission GCS, post-traumatic amnesia (PTA) duration and injury subtypes. Primary outcomes were discharge Functional Independence Measure (Td-FIM) and FIM gain. In total, 203 datasets were analysed; 60.1% (122) were aged ≥65 years (older), while 39.9% (81) were <65 years (younger). At discharge, older TBI had a significantly lower Td-FIM by 15 points compared to younger (older 90/126 vs. younger 105/126, p < 0.001). Median FIM gains (younger 27 vs. older 23, p = 0.83) and rehabilitation LOS (older 29.5 days vs. younger 27.5 days, p = 0.79) were similar for both age groups. Older TBIs had significantly lower independence (Td-FIM category ≥ 91) levels (49.4% older vs. 63.9% younger, p = 0.04), higher institutionalisation rates (23.5% older vs. 10.7% younger, p = 0.014) and need for carers (81.5% older vs. 66.4% younger, p = 0.019) on discharge. Although 77% of older TBI patients returned home, a significantly higher proportion needed care. This study supports the functional benefits of TBI rehabilitation in increasing independence regardless of age without incurring longer inpatient rehabilitation days.

Social determinants of outcomes in nonoperatively treated proximal humerus fractures.

Background: Proximal humerus fractures (PHFs) are common fractures especially in the elderly, with most fractures being managed nonoperatively. Traditional biomedical factors such as radiological alignment have not been able to meaningfully predict comfort and capability after PHFs. Conversely, recent literature has increasingly recognized the role of psychological factors in determining comfort and capability after PHFs. Nonetheless, less is known about the impact of social factors. Additional study of these potentially modifiable social factors as targets for enhancing recovery from injury is merited. Among people recovering from a nonoperatively- treated proximal humerus fracture (PHF) we studied the social factors associated with patient-reported outcomes at 6 months and 1 year. Methods: One hundred seventy-one patients who received nonoperative management of a PHF completed baseline measures of sociodemographic characteristics (age, gender, race, employment status, household income, educational level, presence of domestic workers, housing type, and smoking status). Six and 12 months after fracture, participants completed the Oxford Shoulder Score (OSS), Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) and EuroQol-5-Dimensions (EQ5D) measures of comfort and capability. The relationship between capability and social factors was assessed using linear regression modelling, accounting for potential confounding from age, fracture severity assessed using Neer classification, premorbid comorbidities measured by Charlson Comorbidity Index, and premorbid functional status measured by Parker Mobility Index and Barthel Index. Results: Lower capability (higher QuickDASH scores) 6 months and 1 year after fracture were associated with being unemployed (coef: -5.02 [95% CI: -9.96 to -0.07]; P = .047) and having domestic workers at home (coef: 8.63 [95% CI: 1.39 to 15.86]; P = .020), but not with Neer classification. Both greater shoulder discomfort and magnitude of incapability (lower OSS scores) and worse general quality of life (lower EQ5D scores) were associated with having domestic workers (coef: -4.07 [95% CI: -6.62 to -1.53]; P = .002 and coef: -0.18 [95% CI: -0.29 to -0.07]; P = .001 respectively) or living in an assisted care facility (coef: -14.82 [95% CI: -22.24 to -7.39]; P < .001 and coef: -0.59 [95% CI: -0.90 to -0.29] P < .001). Conclusions: The finding that people recovering from PHF experience less incapability in proportion to their social independence (employment, absence of a caregiver such as domestic workers at home and living outside care facilities) emphasizes the important associations of social factors to musculoskeletal health, and the utility of accounting for social factors in the development and assessment of care strategies.

Adaptation and validation of the chronic illness-related shame scale among patients with knee osteoarthritis in Singapore.

BACKGROUND: Osteoarthritis (OA) of the knee is one of the most common and disabling conditions worldwide. A neglected aspect of knee OA is its psychosocial impact, such as shame. However, assessment tools to measure shame among patients diagnosed with knee OA are lacking. In this study, the psychometric properties of the Chronic Illness-related Shame Scale (CISS) were evaluated among knee OA patients in Singapore. METHODS: Adaptations were made to CISS for use among the knee OA population. An exploratory factor analysis (EFA) was performed to analyze the factor structure. Cronbach's Alpha and corrected item-total correlations were used to evaluate the internal consistency. Spearman correlation coefficient was used to test the correlation between CISS and Patient Health Questionnaire-4 (PHQ-4) to determine the validity of the instrument. RESULTS: The EFA yielded a one-factor structure, with an eigenvalue of 4.78 explaining 68.25% of variance. Cronbach Alpha was 0.92, which indicated good internal consistency. The Spearman correlation revealed a significant correlation between CISS and PHQ-4. CONCLUSIONS: The adapted CISS is a valid and reliable instrument to measure shame for knee OA patients. Both research and clinical settings can benefit from the use of the adapted CISS for assessing shame among knee OA patients.

Singapore KneE osTeoarthritis CoHort (SKETCH): protocol for a multi-centre prospective cohort study.

BACKGROUND: Knee osteoarthritis (OA) is a leading cause of global disability. The understanding of the role of psychosocial factors in knee OA outcomes is still evolving particularly in an Asian context. The primary aim of this study is to explore psychosocial factors that prognosticate short and long-term clinical outcomes, productivity, and healthcare utilization in patients with knee OA. Secondary aims are to explore the mediation and directional relationships and the role it plays in predicting the discordance between self-reported measures (SRM), physical-performance measures (PPMs) and objective clinical parameters. METHODS: A multi-centre prospective cohort study of community ambulant knee OA patients seeking treatment in the tertiary healthcare institutions in Singapore will be conducted. Patients with secondary arthritis, significant cognitive impairment, severe medical comorbidities or previous knee arthroplasty will be excluded. Primary clinical outcome measure is the Knee injury and OA Outcome Score-12 (KOOS-12). Baseline characteristics include sociodemographic status, arthritis status including symptom duration and radiographic severity, comorbidities and functional status through Charlson Comorbidities Index (CCI), Barthel Index (BI) and Parker Mobility Score (PMS). Psychosocial variables include social support, kinesiophobia, negative affect, self-efficacy, injustice, chronic illness shame and the built environment. Clinical outcomes include quality of life, physical performance, global assessment, satisfaction and physical activity levels. Productivity and healthcare utilization will be assessed by a modified OA Cost and Consequences Questionnaire (OCC-Q) and the Work Productivity and Activity Impairment Questionnaire (WPAI). Variables will be collected at baseline, 4, 12 months and yearly thereafter. Regression, mediation and structural equation modelling will be used for analysis. DISCUSSION: Results will allow contextualization, identification, and phenotyping of the critical (and potentially modifiable) psychosocial parameters that predict positive clinical outcomes in the OA population to guide optimization and refinement of healthcare and community. This will facilitate: 1. identification of high-risk knee OA subpopulations that will likely experience poor outcomes and 2. formulation of targeted multidisciplinary comprehensive approaches to address these psychosocial factors to optimize non-surgical treatment care, maximize functional outcomes and create more value-based care model for knee OA. ETHICS AND DISSEMINATION: The study has been registered under clinicaltrials.gov registry (Identifier: NCT04942236).

The Impact of Stroke Subtype on Recovery and Functional Outcome after Inpatient Rehabilitation: A Retrospective Analysis of Factors.

The aims of this study were to compare inpatient rehabilitation outcomes between acute stroke subtypes of Cerebral Infarction (CI) and Intracerebral Hemorrhage (ICH), and to determine the predictors of discharge outcomes. A retrospective study of stroke inpatients was carried out using the discharge Functional Independence Measure (FIM) as the primary outcome measure. Relationships between stroke subtype, rehabilitation impairments, and medical complications on FIM -gain were analyzed. Altogether, 280 datasets including 211 (75.4%) CI and 69 (24.6%) ICH were analyzed. ICH patients were significantly younger than CI patients (55 years ICH vs. 64.0 years CI years, p < 0.001), had a 10-fold higher proportion needing ICU admission (ICH 82.6% vs. CI 7.6%, p < 0.001), and had significantly lower total admission FIM scores (67 points ICH vs. 74 CI points, p = 0.006), with lower motor-FIM scores in particular (38 points ICH vs. 48 points CI, p = 0.003). Significant functional improvements after inpatient rehabilitation, i.e., FIM gain, occurred regardless of stroke subtype (FIM-ICH Δ 27 vs. FIM-CI Δ 21, p = 0.05). Despite significantly worse initial stroke severity, ICH patients achieved similar functional gains, independence levels, and return-home rates compared with their CI counterparts after inpatient rehabilitation.

Acute Kidney Injury within an Enhanced Recovery after Surgery (ERAS) Program for Colorectal Surgery.

BACKGROUND: We aimed to determine the prevalence, risk factors, and outcomes of acute kidney injury (AKI) within an ERAS program for colorectal surgery (CRS). METHODS: This is a retrospective case-control study conducted from March 2016 to September 2018 at a single tertiary hospital in Singapore. All adult patients requiring CRS within our ERAS program were considered eligible. Exclusions were stage 5 chronic kidney disease or patients requiring a synchronous liver resection. The primary outcome was AKI as defined by the Kidney Disease Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. Secondary outcomes included mortality, major complications, and hospital length of stay. Patient, surgical, and anaesthesia-related data were analysed to determine factors associated with AKI. RESULTS: A total of 575 patients were eligible for the study. Twenty patients were excluded from the study leaving 555 patients for analysis. Mean age was 67.8 (SD 11.4) years. Seventy-four patients met the criteria for AKI (13.4%: stage 1-11.2%, stage 2-2.0%, stage 3-0.2%). One patient required renal replacement therapy (RRT). Patients with AKI had a longer length of stay (median [IQR], 11.0 [5.0-17.0] days vs 6.0 [4.0-8.0] days; P < .001), more major complications (OR, 6.55; 95% CI, 3.00-14.35, P < .001), and a trend towards higher mortality at one year (OR, 1.44; 95% CI 0.48-4.30; p = 0.511. After multivariable regression analysis, factors associated with AKI were preoperative creatinine (OR, 1.01 per 10 µmol/l; 95% CI, 1.03-1.22; P = 0.01), robotic surgery vs open surgery (OR, 0.15; 95% CI, 0.06-0.39; P < 0.001), anaesthesia duration (OR, 1.38 per hour; 95% CI, 1.22-1.55; P < 0.001), and major complications (OR, 5.55; 95% CI, 2.63-11.70; P < 0.001). CONCLUSIONS: Within the present cohort, the implementation of an ERAS program for CRS was associated with a low prevalence of moderate to severe AKI despite a balanced intravenous fluid regimen. Patients having open surgery, longer procedures, and major complications are at increased risk of AKI.

The effect of body mass index on inpatient rehabilitation outcome after stroke in an East-Asian cohort: a prospective study.

INTRODUCTION: We examined the association between admission body mass index (BMI) and discharge rehabilitation functional outcome using the Functional Independence Measure (FIM) in an East-Asian cohort of stroke patients during inpatient rehabilitation. METHODS: A prospective observational cohort study of stroke patients admitted to a single inpatient rehabilitation unit was conducted. Using the World Health Organisation Asian standards, BMI was classified as underweight (< 18.5 kg/m2), normal (18.5-22.9 kg/m2) and overweight (≥ 23 kg/m2). The primary outcome measure was discharge FIM, and secondary outcomes included FIM gain, FIM efficiency and FIM effectiveness. RESULTS: 247 stroke subjects were enrolled (mean age 59.48 [SD 12.35] years, 64.4% [159] male, 52.6% [130] ischaemic stroke). The distributions of underweight, normal and overweight BMI were 10.9% (27), 33.2% (82), and 55.9% (138) respectively on admission and 11.7% (29), 38.1% (94), and 50.2% (124) respectively on discharge. Significant small decreases in BMI from admission (median [IQR]: 23.58 [23.40, 24.70]) to discharge (median [IQR]: 23.12 [22.99, 24.21]) (p < 0.001) were found. Similarly, clinically significant FIM gains (mean FIM 26.71 [95% CI: 24.73, 28.69], p < 0.001) were noted after 36 days of median length of stay. No significant relationships were found between BMI and discharge FIM (p = 0.600), FIM gain (p = 0.254), FIM efficiency (p = 0.412) nor FIM effectiveness (p = 0.796). CONCLUSION: Findings from this study unequivocally support the benefits of acute inpatient stroke rehabilitation. Patients in the obese BMI range tended to normalise during rehabilitation. BMI, whether underweight, normal, or overweight was not correlated with discharge FIM.

3D-printed external cranial protection following decompressive craniectomy after brain injury: A pilot feasibility cohort study.

OBJECTIVES: 3D-printed (3DP) customized temporary cranial protection solutions following decompressive craniectomy (DC) are currently not widely practiced. A pilot trial of a 3DP customized head protection prototype device (HPPD) on 10 subjects was conducted during the subacute rehabilitation phase. MATERIALS AND METHODS: Subjects > 30 days post-DC with stable cranial flaps and healed wounds were enrolled. HPPD were uniquely designed based on individuals' CT scan, where the base conformed to the surface of the individual's skin covering the cranial defect, and the lateral surface three-dimensionally mirrored, the contralateral healthy head. Each HPPD was fabricated using the fused deposition modeling method. These HPPD were then fitted on subjects using a progressive wearing schedule and monitored over 1, 2, 4, 6 and 8 follow-up (FU) weeks. Outcomes during FU included; reported wearing time/day (hours), subjective pain, discomfort, pruritus, dislodgment, cosmesis ratings; and observed wound changes. The primary outcome was safety and tolerability without pain or wound changes within 30 minutes of HPPD fitting. RESULTS: In all, 10 enrolled subjects received 12 HPPDs [5/10 male, mean (SD) age 46 (14) years, mean (SD) duration post-DC 110 days (76)] and all subjects tolerated 30 minutes of initial HPPD fitting without wound changes. The mean (SD) HPPD mass was 61.2 g (SD 19.88). During 8 weeks of FU, no HPPD-related skin dehiscence was observed, while 20% (2/10) had transient skin imprints, and 80% (8/10) reported self-limiting pressure and pruritis. DISCUSSION: Findings from this exploratory study demonstrated preliminary feasibility and safety for a customized 3DP HPPD for temporary post-DC head protection over 8 weeks of follow-up. Monitoring and regular rest breaks during HPPD wear were important to prevent skin complications. CONCLUSION: This study suggests the potential for wider 3DP technology applications to provide cranial protection for this vulnerable population.

Factors Associated with Intention to Donate Hematopoietic Stem Cells among Blood Donors.

INTRODUCTION: Past studies pay little attention to the intention to donate hematopoietic stem cells (HSC) among blood donors. This study investigated the level of and the influence of socio-demographic characteristics, knowledge, attitude, subjective norm and self-efficacy on the intention to donate HSC among blood donors. METHODS: This cross-sectional study recruited blood donors at selected public hospitals in the Malaysian State of Sarawak in 2019. A structured questionnaire was developed based on the review of relevant literature. It gathered information on socio-demographic characteristics, knowledge, attitude, subjective norm and self-efficacy on the intention to donate HSC. Variables with a p value <0.200 in bivariate analysis were included in the variable selection for regression modeling to examine their associations with the intention to donate HSC. RESULTS: A total of 569 blood donors participated (94.5% response rate). Overall, 87.1% reported a positive intention to donate HSC. In the regression model, the factor with the greatest association with intention to donate HSC was subjective norms about HSC donation (ß = 0.35, 95% CI 0.27-0.42), followed by attitude about regulations of HSC donation (ß= 0.21, 95% CI 0.13-0.35), self-efficacy on HSC donation (ß = 0.15, 95% CI 0.09-0.32), attitude about the potential side effects of HSC donation (ß = 0.14, 95% CI 0.02-0.10) and highest education level (ß = 0.10, 95% CI 0.03-0.44). CONCLUSIONS: The findings can be used to formulate a better strategy in promoting HSC donation among blood donors in the region.

Sex Modifies the Association of Fibroblast Growth Factor 21 With Subclinical Carotid Atherosclerosis.

Background and Aims: Fibroblast growth factor 21 (FGF21), an emerging metabolic hepatokine, is associated with atherosclerosis. An interaction with sex has been described in various populations. We aimed to study whether sex modulates the relationship between FGF21 and subclinical carotid atherosclerosis in a diabetes-enriched multiethnic population of Singapore. We explore differences in intermediary mechanisms, in terms of hypertension, lipids, and inflammation, between FGF21 and atherosclerosis. Methods: We recruited 425 individuals from a single diabetes center in Singapore, and demographics, anthropometry, metabolic profile, FGF21, and carotid ultrasonography were performed. Multivariable logistic regression models were used to study the association between subclinical atherosclerosis and FGF21 adjusting for age, ethnicity, body mass index (BMI), hemoglobin A1c (HbA1c), systolic and diastolic blood pressures, and low-density lipoprotein (LDL)-cholesterol separately for males and females as two groups after an interaction test. Results: An interaction test assessing interaction by sex on the relationship between subclinical atherosclerosis and FGF21 showed a significant interaction with sex (Pinteraction = 0.033). In the female subgroup, significant independent associations of standardized lnFGF21 with subclinical atherosclerosis were seen, with 1 SD increment in lnFGF21 being associated with 1.48-fold (95% CI: 1.03, 2.12; p = 0.036) increase in risk. In the male subgroup, the association of subclinical atherosclerosis with standardized lnFGF21 was not significant [odds ratio (OR) (95% CI): 0.90 (0.63, 1.28); p = 0.553]. We found sex interactions with pulse pressure being significantly associated in females only and triglycerides and C-reactive protein being associated with males only. Conclusion: FGF21 is positively associated with subclinical carotid atherosclerosis in women, but not in men. The sex-racial patterns in the mechanisms by which FGF21 causes subclinical atherosclerosis needs to be explored in larger population-based studies and mechanistically studied in greater detail.

Effectiveness of a pharmacist-led structured group-based intervention in improving medication adherence and glycaemic control among type 2 diabetes mellitus patients: A randomized controlled trial.

BACKGROUND: A pharmacist-led structured group-based intervention (MEDIHEALTH) was formulated to improve medication adherence among Malay type 2 diabetes mellitus (T2DM) patients in the Malaysian state of Sarawak. OBJECTIVES: The objective of this study was to examine the effectiveness of MEDIHEALTH and its mechanism of impact for improving medication adherence and the glycated haemoglobin (HbA1c) level. METHODS: A two group and parallel randomised controlled trial with a twelve months follow-up period was conducted at two primary health clinics in Malaysia that were surrounded by Malay communities. Malay T2DM patients whose HbA1c was >7% and total score on the Self-Efficacy for Appropriate Medication Use Scale (SEAMS) was <26 were recruited and parallelly randomised to the MEDIHEALTH or usual care (control) groups. The extended theory of planned behaviour was employed to test the mechanism of impact. Repeated measure analysis of variance was used to assess the difference in the estimated marginal mean of the SEAMS scores and HbA1c level between the intervention and control groups at different times. RESULTS: A total of 142 participants were recruited and randomised; three from the intervention group and eight from the control group withdrew before receiving any treatment. Hence, 68 participants in the intervention group and 63 in the control group were included for analyses. The MEDIHEALTH group had a significantly greater increase in the SEAMS score compared to the control group (p < 0.001) at one, three, six and twelve months post-intervention. There was also a significantly greater reduction in HbA1c in the MEDIHEALTH compared to the control group at one, three, six and twelve months post-intervention (p < 0.001). These improvements were mediated by enhancements in perceived behavioural control and knowledge about medications. CONCLUSIONS: The MEDIHEALTH may improve medication adherence and glycaemic control among Malay T2DM patients.

Clinical Outcome of Tuberculous Meningitis with Hydrocephalus - A Retrospective Study.

BACKGROUND: To study the clinical outcome of tuberculous meningitis with hydrocephalus (TBMH) and the factors contributing to its poor clinical outcome. METHODS: Clinical data of 143 adult patients diagnosed with TBM over a 6-year period in two tertiary hospitals in Malaysia were retrospectively reviewed. Relevant clinical and radiological data were studied. Patients with TBMH were further analysed based on their clinical grade and rendered treatment to identify associated factors and outcome of this subgroup of patients. The functional outcome of patients was assessed at 12 months from treatment. RESULTS: The mean age of patients was 35.6 (12.4) years old, with a male gender predominance of 67.1%. Forty-four percent had TBMH, of which 42.9% had surgical intervention. In the good modified Vellore grade, 76.5% was managed medically with concurrent anti-tuberculosis treatment (ATT), steroids and osmotic agents. Four patients had surgery early in the disease as they did not respond to medical therapy and reported a good outcome subsequently. Poor outcome (65.2%) was seen in the poor modified Vellore grade despite medical and surgical intervention. Multivariate model multiple Cox regression showed significant results for seizure (adjusted hazard ratio [aHR]: 15.05; 95% CI: 3.73, 60.78), Glasgow coma scale (GCS) (aHR: 0.79; 95% CI: 0.70, 0.89) and cerebrospinal fluid (CSF) cell count (aHR: 1.11; 95% CI: 1.05, 1.17). CONCLUSION: Hydrocephalus was seen in 44% of patients in this study. GCS score, seizure and high CSF cell count were factors associated with a poor prognosis in TBM. Patients with TBMH treated medically (TBMHM) had better survival function compared to TBMH patients undergoing surgical intervention (TBMHS) (P-value < 0.001). This retrospective study emphasises that TBMH is still a serious illness as 47.6% of the patients had poor outcome despite adequate treatment.

An Exploratory Clinical Study on an Automated, Speed-Sensing Treadmill Prototype With Partial Body Weight Support for Hemiparetic Gait Rehabilitation in Subacute and Chronic Stroke Patients.

Impairments in walking speed, capacity, and endurance are commonly seen after stroke. Treadmill training improves endurance and gait speed. However, the lack of variable training speed and automated speed progression increases the risk of backward displacement and falling. An automated, speed-sensing treadmill prototype with partial body weight support, the Variable Automated Speed and Sensing Treadmill II (VASST II), was tested in an outpatient rehabilitation setting. Eleven subacute or chronic hemiplegics who could ambulate at > 0.2 m/s for >50 m participated in the study. All subjects underwent physiotherapist-supervised training on VASST II for 60 min daily, 3 times per week, for 5 weeks (total 15 h). Outcome measures at Week 3 (mid-VASST II training), Week 6 (post-VASST II training), Week 12 (first follow-up), and Week 24 (second follow-up) included the 6 minute walk test (6 MWT), 10 meter walk test (10 MWT), Berg Balance Scale (BBS) score, and Functional Ambulation category (FAC) score. User acceptability of VASST II for both study subjects and physiotherapists were also assessed. All subjects [median (IQR) age: 53.0 (22) years; median (IQR) duration post-stroke: 524 (811) days] completed VASST II training. At baseline, mean ± SD 6 MWT was 114 ± 50.9 m; mean ± SD 10 MWT was 0.37 ± 0.18 m/s; mean ± SD BBS score was 40 ± 10; and, mean ± SD FAC score was 4 ± 1. At Week 6, there were significant improvements in the 6 MWT [158.91 ± 88.69 m; P = 0.003], 10 MWT [0.49 ± 0.30 m/s; P = 0.016], and BBS score [42 ± 10; P = 0.003]. Improvements in 6 MWT and BBS scores were sustained at Week 24, but not in the 10 MWT. No VASST II-training related falls were reported. All subjects rated their VASST II training positively and indicated that it improved their current walking ability. VASST II training was effective, feasible, and safe in patients with subacute or chronic post-stroke hemiparetic gait, with sustained gains in distance walked (6 MWT) and functional balance (BBS score) up to 19 weeks post-intervention.