Historical database cohort study addressing the clinical patterns prior to idiopathic pulmonary fibrosis (IPF) diagnosis in UK primary care.

OBJECTIVE: To explore the clinical pathways, including signs and symptoms, and symptom progression patterns preceding idiopathic pulmonary fibrosis (IPF) diagnosis. DESIGN AND SETTING: A historical cohort study was conducted using primary care patient records from the Optimum Patient Care Research Database. PARTICIPANTS: Patients included were at least 30 years, had IPF diagnosis, identified via clinical-coding and free-text records and had a consultation with a chest specialist prior to IPF diagnosis. OUTCOME MEASURES: The signs and symptoms in the year prior to IPF diagnosis from clinical codes and free-text in primary care electronic records included: cough, dyspnoea, dry cough, weight loss, fatigue/malaise, loss of appetite, crackles and clubbed fingers. The time course of presentations of clinical features and investigations in the years prior to IPF diagnosis were mapped. RESULTS: Within 462 patients identified, the majority (77.9%) had a respiratory consultation within 365 days prior to the chest specialist visit preceding the IPF diagnosis recorded in their primary care records. The most common symptoms recorded in the 1 year prior to IPF diagnosis were dyspnoea (48.7%) and cough (40.9%); other signs and symptoms were rarely recorded (<5%). The majority of patients with cough (58.0%) and dyspnoea (55.0%) in the 1 year before IPF diagnosis had multiple recordings of the respective symptoms. Both cough and dyspnoea were recorded in 23.4% of patients in the year prior to diagnosis. Consultation rates for cough, dyspnoea and both, but not other signs or symptoms, began to increase 4 to 5 years prior diagnosis, with the sharpest increase in the last year. Cough and dyspnoea were often preceded by a reduction in measured weight over 5 years leading to IPF diagnosis. CONCLUSION: Prolonged cough and/or progressive dyspnoea, especially if accompanied with weight loss, should signal for a referral to specialist assessment at the earliest opportunity.

Hydrolyzed Chicken Extract (ProBeptigen®) on Cognitive Function in Healthy Middle-Aged People: A Randomized Double-Blind Trial.

Cognitive decline is an important issue of global public health. Cognitive aging might begin at middle adulthood, the period particularly vulnerable to stress in lifespan. Essence of chicken (EOC) has consistently demonstrated its beneficial effects on various cognitive domains as nutritional supplementation. This study primarily aimed to examine the cognitive enhancement effects of ProBeptigen® (previously named CMI-168), hydrolyzed peptides extracted from EOC, in healthy middle-aged people under mild stress. Ninety healthy subjects were randomly assigned into the ProBeptigen® or placebo group for eight weeks. Neurocognitive assessment, event-related potentials (ERPs), and blood tests were conducted before, during, and after the treatment. The ProBeptigen® group outperformed placebo group on Logical Memory subtests of Wechsler Memory Scale-third edition (WMS-III) and Spatial Working Memory task in the Cambridge Neuropsychological Test Automated Battery (CANTAB). The anti-inflammatory effects of ProBeptigen® in humans were also confirmed, with progressively declining high-sensitivity C-reactive protein (hs-CRP) levels. Regular dietary supplementation of ProBeptigen® is suggested to improve verbal short- and long-term memory as well as spatial working memory, and reduce inflammation in middle-aged healthy individuals with stress. The effects of ProBeptigen® on cognition warrant further investigation. (NCT03612752).

Healthcare resource utilization and costs associated with incremental systemic corticosteroid exposure in asthma.

BACKGROUND: Although systemic corticosteroid (SCS) treatment, irrespective of duration or dosage, is associated with adverse outcomes for patients with asthma, the longitudinal effects of this treatment on adverse outcomes, healthcare resource utilization (HCRU), and healthcare costs are unknown. METHODS: We identified patients initiating intermittent or long-term SCS who were diagnosed with active asthma from UK general practice with linked secondary care data. Control (non-SCS) patients were matched by sex and index date with those initiating SCS. Minimum baseline period was 1 year prior to index date; minimum follow-up duration was 2 years post-index date. Cumulative incidence of SCS-associated adverse outcomes and associated HCRU and costs were compared between SCS and non-SCS patient groups and among average SCS daily exposure categories. Associations between exposure and annualized HCRU and costs were assessed, adjusted for confounders. RESULTS: Analyses included 9413 matched pairs. Median (interquartile range) follow up was as follows: SCS group: 7.1 (4.1-11.8) years; control group: 6.4 (3.8-10.0) years. Greater SCS dosages were correlated with greater cumulative incidence. For example, patients with type 2 diabetes receiving an average daily dosage of ≥7.5 mg had a 15-year cumulative incidence (37.5%) that was 1.5-5 times greater than those receiving lower dosages. HCRU and costs increased annually for SCS patients but not for non-SCS patients. Increases in all-cause adverse outcome (excluding asthma)-associated HCRU and costs were dose-dependent. CONCLUSIONS: Over the long term, adverse outcomes associated with SCS initiation were relatively frequent and costly, with a positive dosage-response relationship with SCS exposure.

Developing a comprehensive, culturally sensitive conceptual framework of health domains in Singapore.

The increasing focus of healthcare systems worldwide on long-term care highlights the need for culturally sensitive Health-Related Quality of Life instruments to accurately capture perceived health of various populations. Such instruments require a contextualized conceptual framework of health domains, which is lacking in some socio-cultural contexts. We developed a comprehensive and culturally sensitive conceptual framework of health domains relevant to the Singaporean population. We recruited Singaporeans/ permanent residents, English/ Chinese-speaking, with/ without chronic illnesses to participate in focus group discussions (FGDs) and in-depth interviews (IDIs). We elicited health areas participants perceived to be important for them to be happy and satisfied with life. To encourage spontaneous emergence of themes, we did not specify any aspect beyond the broad domains of Physical, Mental, and Social health so as not to limit the emergence of new themes. Themes from the transcripts were distilled through open coding (two independent coders), then classified into more abstract domains (each transcript coded independently by two coders from a pool of six coders). From October 2013 to August 2014, 121 members of the general public participated in 18 FGDs and 13 IDIs (44.6% males, mean age: 53.3 years 77% Chinese, 9% Malay, 12% Indian, 63% with chronic illness) while 13 healthcare workers participated as patient-proxies in three FGDs. Thematic analysis identified 27 domains. The 15 physical domains included physical appearance, energy, physical fitness, and health and resistance to illness. The nine mental domains included emotions, self-esteem, and personal freedom. The three social domains were social contact, social relationships, and social roles. This conceptual framework reflected physical, mental, and social dimensions of well-being, suggesting that the Singapore population's views on health support the World Health Organization's definition of health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity".

Understanding Medical Students' Experience with Stress and Its Related Constructs: A Focus Group Study from Singapore.

OBJECTIVE: In order to protect medical students from burnout and its untoward psychiatric effects, it is imperative to understand their stress, burnout, coping, and resilience experiences. This study aimed to derive collective definitions from the medical student perspective, to identify common themes of students' experiences, and to distinguish pre-clinical and clinical year students' experiences relating to these four constructs. METHODS: The authors conducted focus groups of medical students in Singapore across 4 years using a semi-structured question guide. Participants shared their understanding, experiences, and the relationships between stress, burnout, coping, and resilience. Coders independently evaluated construct definitions and derived common themes through an iterative process, and compared transcripts of pre-clinical and clinical year students to determine differences in experience over time. RESULTS: Nine focus groups (54 students, 28 females, mean age 24.3) were conducted. Students identified common definitions for each construct. Nine themes emerged within three domains: (1) relating constructs to personal experience, (2) interrelating stress, burnout, coping, and resilience, and (3) understanding the necessity of stress. Compared to clinical students, pre-clinical students reported theory-based rather than reality-based experiences and exam-induced stress, defined constructs using present rather than future situations, and described constructs as independent rather than interrelated. CONCLUSIONS: This sample of medical students in Singapore shares a common understanding of stress, burnout, coping, and resilience, but experiences these uniquely. They perceive a positive role for stress. These findings build upon prior literature, suggesting an interrelationship between stress and its related constructs and adding the novel perspective of students from an Asian country.

Barriers and facilitators for clinical trial participation among diverse Asian patients with breast cancer: a qualitative study.

BACKGROUND: Recruitment rates for cancer trials are low for racial/ethnic minorities. Little is known about factors influencing trial recruitment in Asian patients. Our aim is to examine the barriers and facilitators for participation in trials among multi-ethnic Asian women with breast cancer. METHODS: We recruited a convenience sample from consecutive women seen at the National Cancer Centre. Two experienced bilingual (English and Chinese) moderators conducted focus groups to theme saturation. The question guide incorporated open-ended questions soliciting opinions about trial participation and knowledge. Women were first asked if they were willing, unwilling, or still open to participate in future trials. Sessions were audiotaped and transcribed. Transcripts were independently coded for emergent themes. RESULTS: Sixteen of 103 women approached participated in five focus groups. Chinese, Malay, and Indian participants aged 29 to 69 represented different cancer stages. Five had no prior knowledge of trials. We identified three major themes comprising of 22 minor themes for barriers and facilitators. The major themes were: 1) patient-related, 2) trial-related, and 3) sociocultural factors. Women willing to join trials expressed themes representing facilitators (better test therapy, cost-effective profile, or trust in doctors and local healthcare systems). Women unwilling to participate expressed themes associated with barriers, while women still open to participation expressed themes representing both facilitators and barriers. Malay women were more likely to express themes related to 'fatalism' as a barrier. DISCUSSION/CONCLUSION: We found that facilitators and barriers to trial participation among Asian women were similar to those previously reported in Western women. Knowledge of trials is limited among women receiving breast cancer treatment. Unique sociocultural factors suggest that approaches customised to local and community beliefs are needed to improve trial participation in minority groups.

Quality of life domains important and relevant to family caregivers of advanced cancer patients in an Asian population: a qualitative study.

PURPOSE: This study aims to identify domains of quality of life (QoL) that are culturally relevant to Chinese caregivers of advanced cancer patients in Singapore and to evaluate content adequacy of currently available instruments for use in the target population. METHODS: English- and Chinese-speaking caregivers of advanced cancer patients receiving care under a tertiary cancer center and/or a community hospice home care/day care provider were recruited for in-depth interviews. The interviews were analyzed using thematic analysis. The identified domains, themes and sub-themes were compared to concepts addressed by items from five existing cancer-specific caregiver QoL instruments. RESULTS: Eighteen female and eight male caregivers aged 28-74 years participated in the study. Twenty-nine QoL themes and 59 sub-themes were identified in six domains, namely physical health, mental health, social health, spiritual health, financial health and daily life. Collectively, but not individually, the content of the five existing instruments adequately cover the physical health domain, social health domain and some themes on mental health domain for the study population. Content gaps were identified in the domains of mental health, spiritual health, daily life and financial health. CONCLUSIONS: The present study found culturally and contextually specific themes and sub-themes about positive emotional health, spiritual health and financial health.

A systematic review and meta-analysis comparing pancreaticoduodenectomy versus limited resection for duodenal gastrointestinal stromal tumors.

PURPOSE: This study was designed to compare the clinical outcomes of patients who underwent limited resection (LR) versus pancreaticoduodenectomy (PD) for duodenal gastrointestinal stromal tumors (GISTs). METHODS: A systematic review of the literature was performed to identify studies analyzing the clinical outcomes of LR and PD for duodenal GISTs. RESULTS: Eleven studies were included, of which 7 that compared 162 patients who underwent LR versus 98 patients who underwent PD were suitable for meta-analysis. Patients who underwent PD were more likely to have tumors which were large (≥ 5 cm) [76.0 vs. 36.6 %, odds ratio (OR) 5.49, 95 % confidence interval (CI) 1.8-16.76], with high mitotic count ≥5/50 high-power field (HPF) (33.7 vs. 18.5 %, OR 2.23, 95 % CI 1.22-4.08), classified as high risk (60.3 vs. 32.0 %, OR 3.23, 95 % CI 1.65-6.34), and which were located at D2 (80.5 vs. 28.6 %, OR 10.33, 95 % CI 5.22-20.47) compared with LR. PD was associated with a higher postoperative morbidity rate than LR [48.3 vs. 20.7 %, relative risk (RR) 2.34, 95 % CI 1.61-3.42]. LR was not associated with an increased local recurrence rate, had a better DFS [hazard ratio (HR) 2.07, 95 % CI 1.07-4.01], and lower rate of distant metastasis (8.9 vs. 25.8 %, OR 0.28, 95 % CI 0.13-0.59) compared with PD. CONCLUSIONS: LR should be the procedure of choice for duodenal GIST whenever technically feasible, because it is associated with good oncologic outcomes and lower morbidity compared with PD. The oncologic outcome of GIST is more likely to be dependent on tumor biology rather that the type of surgical resection. The use of Imatinib in patients with duodenal GIST may potentially allow a proportion of patients who would otherwise require a PD to undergo LR instead.