Role of Caregivers in Remote Management of Patients With Type 2 Diabetes Mellitus: Systematic Review of Literature.

BACKGROUND: With the growing use of remote monitoring technologies in the management of patients with type 2 diabetes mellitus (T2DM), caregivers are becoming important resources that can be tapped into to improve patient care. OBJECTIVE: This review aims to summarize the role of caregivers in the remote monitoring of patients with T2DM. METHODS: We performed a systematic review in MEDLINE, Embase, Scopus, PsycINFO, and Web of Science up to 2022. Studies that evaluated the role of caregivers in remote management of adult patients with T2DM were included. Outcomes such as diabetes control, adherence to medication, quality of life, frequency of home glucose monitoring, and health care use were evaluated. RESULTS: Of the 1198 identified citations, 11 articles were included. The majority of studies were conducted in North America (7/11, 64%) and South America (2/11, 18%). The main types of caregivers studied were family or friends (10/11, 91%), while the most common remote monitoring modalities evaluated were interactive voice response (5/11, 45%) and phone consultations (4/11, 36%). With regard to diabetes control, 3 of 6 studies showed improvement in diabetes-related laboratory parameters. A total of 2 studies showed improvements in patients' medication adherence rates and frequency of home glucose monitoring. Studies that evaluated patients' quality of life showed mixed evidence. In 1 study, increased hospitalization rates were noted in the intervention group. CONCLUSIONS: Caregivers may play a role in improving clinical outcomes among patients with T2DM under remote monitoring. Studies on mobile health technologies are lacking to understand their impact on Asian populations and long-term patient outcomes.

Pandemic-related health literacy: a systematic review of literature in COVID-19, SARS and MERS pandemics.

Introduction: Health literacy plays an essential role in one's ability to acquire and understand critical medical information in the coronavirus disease 2019 (COVID-19) infodemic and in other pandemics. We aimed to summarise the assessment, levels and determinants of pandemic-related health literacy and its associated clinical outcomes. Methods: A systematic review was performed in Medline®, Embase®, PsycINFO®, CINAHL® and four major preprint servers. Observational and interventional studies that evaluated health literacy related to the novel COVID-19, severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS) were included. Items used in health literacy instruments were grouped under the themes of knowledge, attitudes and practices. Determinants of health literacy were grouped into five domains: sociodemographic, medical, psychological/psychiatric, health systems-related and others. Results: Of the 2,065 articles screened, 70 articles were included. Of these, 21, 17 and 32 studies evaluated health literacy related to COVID-19, SARS and MERS, respectively. The rates of low pandemic health literacy ranged from 4.3% to 57.9% among medical-related populations and from 4.0% to 82.5% among nonmedical populations. Knowledge about the symptoms and transmission of infection, worry about infection, and practices related to mask usage and hand hygiene were most frequently evaluated. Sociodemographic determinants of health literacy were most frequently studied, among which higher education level, older age and female gender were found to be associated with better health literacy. No studies evaluated the outcomes associated with health literacy. Conclusion: The level of pandemic-related health literacy is suboptimal. Healthcare administrators need to be aware of health literacy determinants when formulating policies in pandemics.

Evaluation of Machine Learning Methods Developed for Prediction of Diabetes Complications: A Systematic Review.

BACKGROUND: With the rising prevalence of diabetes, machine learning (ML) models have been increasingly used for prediction of diabetes and its complications, due to their ability to handle large complex data sets. This study aims to evaluate the quality and performance of ML models developed to predict microvascular and macrovascular diabetes complications in an adult Type 2 diabetes population. METHODS: A systematic review was conducted in MEDLINE®, Embase®, the Cochrane® Library, Web of Science®, and DBLP Computer Science Bibliography databases according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist. Studies that developed or validated ML prediction models for microvascular or macrovascular complications in people with Type 2 diabetes were included. Prediction performance was evaluated using area under the receiver operating characteristic curve (AUC). An AUC >0.75 indicates clearly useful discrimination performance, while a positive mean relative AUC difference indicates better comparative model performance. RESULTS: Of 13 606 articles screened, 32 studies comprising 87 ML models were included. Neural networks (n = 15) were the most frequently utilized. Age, duration of diabetes, and body mass index were common predictors in ML models. Across predicted outcomes, 36% of the models demonstrated clearly useful discrimination. Most ML models reported positive mean relative AUC compared with non-ML methods, with random forest showing the best overall performance for microvascular and macrovascular outcomes. Majority (n = 31) of studies had high risk of bias. CONCLUSIONS: Random forest was found to have the overall best prediction performance. Current ML prediction models remain largely exploratory, and external validation studies are required before their clinical implementation. PROTOCOL REGISTRATION: Open Science Framework (registration number: 10.17605/OSF.IO/UP49X).

Manipulative and body-based methods in chronic kidney disease patients: A systematic review of randomized controlled trials.

BACKGROUND: and purpose: Among chronic kidney disease (CKD) patients, manipulative and body-based methods (MBM) have demonstrated efficacy in improving symptoms such as fatigue. This review aims to summarize the efficacy and safety of MBM among CKD patients. METHODS: A systematic review was performed in PubMed, Embase, Scopus, CINAHL, CENTRAL and PsycInfo. Randomised controlled trials (RCTs) which evaluated the use of MBM among adult CKD patients were included. The grading of recommendations, assessment, development, and evaluation (GRADE) approach was used to determine the risk of bias and certainty of evidence. The efficacy of each MBM was determined by reduction in symptom severity scores. All adverse reactions were documented. RESULTS: Of 8529 articles screened, 55 RCTs were included. Acupressure (n = 23), massage therapy (n = 17), reflexology (n = 6) and acupuncture (n = 5) were the most studied MBMs. Acupressure and reflexology were shown to reduce sleep disturbance and fatigue by 6.2-50.0% and 9.1-37.7% respectively. For uremic pruritus, acupressure and acupuncture reduced symptoms by 34.5-77.7% and 56.5-60.2% respectively. Common adverse reactions associated with acupressure included intradialytic hypotension (20.4%) and dizziness (11.1%) while that of acupuncture included elbow soreness (7.5%) and bleeding (7.5%). No adverse effects were reported for massage therapy, moxibustion, reflexology and yoga therapy. CONCLUSION: Acupressure, reflexology and massage therapies were the most well-studied MBMs which have demonstrated efficacy in alleviating sleep disturbance, fatigue and uremic pruritus symptoms in CKD patients.

Role of Alternative Medical Systems in Adult Chronic Kidney Disease Patients: A Systematic Review of Literature.

There is a growing interest in the use of alternative medical systems (AMS), such as traditional Chinese medicine (TCM), ayurveda, homeopathy, and naturopathy, among chronic kidney disease patients. This review summarizes the efficacy and safety of AMS interventions in chronic kidney disease (CKD) patients. A systematic review was conducted in MEDLINE, Embase, Scopus, CINAHL, CENTRAL, and PsycINFO in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Synthesis without meta-analysis (SWiM) guidelines. Randomized controlled trials (RCTs) which evaluated the use of AMS among adult CKD patients were included. The efficacy of each AMS was assessed based on improvement in biochemical markers or reduction in symptom severity scores. All adverse reactions were recorded. Of the 14,583 articles retrieved, 33 RCTs were included. TCM (n=20) and ayurveda (n=6) were the most well-studied. Majority of studies (66.7%) had a sample size <100. Common indications evaluated included improvement in renal function (n=12), proteinuria (n=5), and uremic pruritus (n=5). Among TCM, acupuncture and syndromes-based TCM granules formulation were shown to improve estimated glomerular filtration rate (eGFR) by 5.1-15.5% and 7.07-8.12% respectively. Acupuncture reduced uremic pruritus symptoms by 54.7-60.2% while Huangkui, Shenqi granules, and Tripterygium wilfordii Hook F reduced proteinuria by 18.6-50.7%, 61.8%, and 32.1% respectively. For Ayurveda, camel milk and Nigella sativa oil improved eGFR by 16.9% and 86.8%, respectively, while capsaicin reduced pruritus scores by 84.3%. Homeopathic verum medication reduced pruritus scores by 29.2-41.5%. Nausea was the most common adverse effect reported with alpha-keto amino acids (0.07%), Nigella sativa oil (7.04%), and silymarin (10%). TCM and ayurveda were more well-studied AMS therapies that demonstrated efficacy in CKD patients. RCTs with larger sample sizes are needed to ascertain the efficacy and safety of promising AMS.

Osteoporosis awareness among patients in Singapore (OASIS)-a community hospital perspective.

This study examines factors associated with osteoporosis awareness and knowledge using Osteoporosis Prevention and Awareness Tool (OPAAT). Of 410 patients, majority of patients had a OPAAT score < 24 (n = 362, 88.3%). Lower education level (odds ratio (OR) (primary education): 3.63; OR (no formal education): 111.5; p < 0.001) and diabetic patients (OR: 1.67; p = 0.003) were associated with lower OPAAT scores. INTRODUCTION: Lack of osteoporosis awareness forms a critical barrier to osteoporosis care and has been linked with increased institutionalization, healthcare expenditures, and decreased quality of life. This study aims to identify factors associated with osteoporosis awareness and knowledge among female Singaporeans. METHODOLOGY: A cross-sectional study was conducted among adult female patients (aged 40 to 90 years old) who were admitted into Outram Community Hospital from April to October 2020. Osteoporosis awareness and knowledge were assessed using interviewer-administered Osteoporosis Prevention and Awareness Tool (OPAAT). High knowledge was defined as a OPAAT score ≥ 24. Multivariate logistical regression analyses were used to identify predictors of low OPAAT scores. RESULTS: Of 410 patients recruited, their mean age was 71.9 ± 9.5 years old and majority of patients had a OPAAT score < 24 (n = 362, 88.3%). Patients with lower OPAAT scores tended to be older (72.5 ± 9.2 vs 67.5 ± 10.1, p < 0.001), attained lower education level (p < 0.001), and were more likely to live in public housing (92.5% vs 81.5%, p = 0.009). The prevalence of diabetes mellitus was higher in patients with low OPAAT scores (39.2% vs 18.8%, p = 0.006). After adjustment for covariates, lower education level (odds ratio (OR) (primary education): 3.63; OR (no formal education): 11.5; p < 0.05) and patients with diabetes mellitus (OR: 1.67; p = 0.03) were associated with lower OPAAT knowledge scores. CONCLUSION: Elderly female patients in community hospital have inadequate osteoporosis awareness despite being at risk of fractures. There is a need to address the knowledge gap in osteoporosis, especially among diabetic patients or patients with lower education.

COVID-19 Vaccine Hesitancy-A Scoping Review of Literature in High-Income Countries.

Vaccine hesitancy forms a critical barrier to the uptake of COVID-19 vaccine in high-income countries or regions. This review aims to summarize rates of COVID-19 hesitancy and its determinants in high-income countries or regions. A scoping review was conducted in Medline®, Embase®, CINAHL®, and Scopus® and was reported in accordance with the PRISMA-SCr checklist. The search was current as of March 2021. Studies which evaluated COVID-19 vaccine hesitancy and its determinants in high-income countries (US$12,536 or more GNI per capita in 2019) were included. Studies conducted in low, lower-middle, and upper-middle income countries or regions were excluded. Factors associated with vaccine hesitancy were grouped into four themes (vaccine specific, individual, group, or contextual related factors). Of 2237 articles retrieved, 97 articles were included in this review. Most studies were conducted in U.S. (n = 39) and Italy (n = 9). The rates of vaccine hesitancy across high-income countries or regions ranged from 7-77.9%. 46 studies (47.4%) had rates of 30% and more. Younger age, females, not being of white ethnicity and lower education were common contextual factors associated with increased vaccine hesitancy. Lack of recent history of influenza vaccination, lower self-perceived risk of contracting COVID-19, lesser fear of COVID-19, believing that COVID-19 is not severe and not having chronic medical conditions were most frequently studied individual/group factors associated with increased vaccine hesitancy. Common vaccine-specific factors associated with increased vaccine hesitancy included beliefs that vaccine are not safe/effective and increased concerns about rapid development of COVID-19 vaccines. Given the heterogeneity in vaccine hesitancy definitions used across studies, there is a need for standardization in its assessment. This review has summarized COVID-19 vaccine hesitancy determinants that national policymakers can use when formulating health policies related to COVID-19 vaccination.

Population segmentation of type 2 diabetes mellitus patients and its clinical applications - a scoping review.

BACKGROUND: Population segmentation permits the division of a heterogeneous population into relatively homogenous subgroups. This scoping review aims to summarize the clinical applications of data driven and expert driven population segmentation among Type 2 diabetes mellitus (T2DM) patients. METHODS: The literature search was conducted in Medline®, Embase®, Scopus® and PsycInfo®. Articles which utilized expert-based or data-driven population segmentation methodologies for evaluation of outcomes among T2DM patients were included. Population segmentation variables were grouped into five domains (socio-demographic, diabetes related, non-diabetes medical related, psychiatric / psychological and health system related variables). A framework for PopulAtion Segmentation Study design for T2DM patients (PASS-T2DM) was proposed. RESULTS: Of 155,124 articles screened, 148 articles were included. Expert driven population segmentation approach was most commonly used, of which judgemental splitting was the main strategy employed (n = 111, 75.0%). Cluster based analyses (n = 37, 25.0%) was the main data driven population segmentation strategies utilized. Socio-demographic (n = 66, 44.6%), diabetes related (n = 54, 36.5%) and non-diabetes medical related (n = 18, 12.2%) were the most used domains. Specifically, patients' race, age, Hba1c related parameters and depression / anxiety related variables were most frequently used. Health grouping/profiling (n = 71, 48%), assessment of diabetes related complications (n = 57, 38.5%) and non-diabetes metabolic derangements (n = 42, 28.4%) were the most frequent population segmentation objectives of the studies. CONCLUSIONS: Population segmentation has a wide range of clinical applications for evaluating clinical outcomes among T2DM patients. More studies are required to identify the optimal set of population segmentation framework for T2DM patients.

Prevalence and risk factors for elevated anxiety symptoms and anxiety disorders in chronic kidney disease: A systematic review and meta-analysis.

BACKGROUND: Anxiety is associated with poor health outcomes among chronic kidney disease (CKD) patients. This review summarizes the prevalence and risk factors associated with elevated anxiety symptoms and disorders among CKD patients. METHODS: Articles evaluating the prevalence and risk factors associated with elevated anxiety symptoms and disorders among CKD patients, as diagnosed via DSM 4th or 5th edition criteria, clinical interviews or validated questionnaires, were searched in Medline®, Embase®, PsychINFO® and CINAHL®. Using random-effects meta-analyses, the prevalence of elevated anxiety symptoms and disorders were estimated. A narrative review on the risk factors associated with elevated anxiety symptoms and disorders was presented. RESULTS: From 4941 articles, 61 studies were included. The pooled prevalence of anxiety disorders (9 studies, n = 1071) among CKD patients across studies was 19% while that of elevated anxiety symptoms (52 studies, n = 10,739) was 43%. Across continents, prevalence of elevated anxiety symptoms was highest in Europe and Asia. Between pre-dialysis and dialysis patients, the prevalence of elevated anxiety symptoms was not statistically different at 31% and 42% respectively. Common risk factors associated with elevated anxiety symptoms included concomitant depression, lower parathyroid hormone levels, increased comorbidities, increased duration of hospitalization, reduced perceived quality of life, and decreased vitality levels. CONCLUSION: Given the high prevalence of anxiety disorders and elevated anxiety symptoms, more studies are required to assess the role and outcomes of anxiety screening among CKD patients. This could facilitate early identification of at-risk patients and potentially improve their clinical outcomes.

Complementary and alternative medicine therapies for uremic pruritus - A systematic review of randomized controlled trials.

INTRODUCTION: Uremic pruritus (UP) is one of the most bothersome symptoms among chronic kidney disease (CKD) patients. The pathophysiology of UP remains elusive, resulting in limited treatment options. The inability of standard medical treatments to provide effective relief has piqued interest in complementary and alternative medicine (CAM). METHODOLOGY: A systematic review of randomized controlled trials (RCTs) summarizing the efficacy and safety profile of CAM used for UP in CKD patients was performed. CAM interventions were classified using categories proposed by the National Center for Complementary and Integrative Health. The efficacy of each CAM was determined from changes in UP severity and all reported adverse effects were extracted. RESULTS: Of 5242 articles screened, 34 RCTs were included, with 15 (44.1 %) studies having a sample size greater than 50. The studies considered 21 treatments including omega-3 fatty acid supplementation (n=5), acupuncture (n=5), topical capsaicin (n=4) and acupressure (n=3). Acupuncture, acupressure and topical capsaicin were shown to be effective in improving uremic pruritus. Interventions which include oral omega-3 fatty acid and zinc supplementation demonstrated mixed efficacy. Other therapies such as evening primrose oil, turmeric, vitamin B3, vitamin D and thermal therapy were not effective for treatment of UP. Common adverse effects reported with topical capsaicin included mild burning sensations (50.0-88.2 %) or erythema (6.7-22.7%) while that of acupuncture included soreness (7.5 %), bleeding (6.0-7.5%) and hematoma (1.9 %). CONCLUSIONS: Acupuncture, acupressure and topical capsaicin have the largest body of evidence for efficacy in the treatment of UP. Larger and higher quality RCTs are required to examine the efficacy and safety of promising CAM.

The role of mind-body interventions in pre-dialysis chronic kidney disease and dialysis patients - A systematic review of literature.

INTRODUCTION: With the rise in complementary medicine usage, mind-body interventions (MBI), encompassing therapies like yoga and music therapy, have been gaining interest. The use of MBI in non-chronic kidney disease (CKD) patients have demonstrated efficacy for ameliorating pain, stress and anxiety symptoms. As CKD patients often suffer from these symptoms, MBI may serve as potential adjunctive therapies. This review aimed to summarize the studied indications of MBI among CKD patients. METHODS: A systematic review was performed in Medline®, Embase®, Scopus®, CINAHL®, CENTRAL® and PsycInfo® in accordance to the PRISMA and SWiM checklists. Randomised controlled trials (RCTs) which evaluated the use of MBI among adult CKD patients were included. The efficacy of each MBI was determined by reduction in symptoms severity scores. All adverse reactions were documented. RESULTS: Of the 7,417 articles screened, 32 RCTs were included. Music therapy (n = 11), relaxation therapy (n = 9) and spiritual therapy (n = 6) were the most well studied MBIs. Frequently studied indications for MBIs were anxiety symptoms (n = 12), pain (n = 7) and depressive symptoms (n = 5). Music and spiritual therapies were shown to reduce 8.06-43.5 % and 36.1-41.1 % of anxiety symptoms respectively. For pain relief, music (41.8 %-61.5 %) and yoga therapies (36.7 %) were shown to be effective for reduction of pain. Lastly, spiritual therapy was shown to reduce depressive symptoms by 56.8 %. No adverse effects were reported for any MBI. CONCLUSION: Music therapy, relaxation and spiritual therapies are more well-studied MBIs which were shown to reduce anxiety, depressive symptoms and pain in CKD patients. Larger RCTs are required to confirm the efficacy and safety of promising MBIs.

Validity and reliability of EQ-5D-5L among patients with axial spondyloarthritis in Singapore.

OBJECTIVE: This study aims to evaluate the reliability and validity of EuroQOL-5 Dimensions-5 Levels (EQ-5D-5L) among patients with axial spondyloarthritis (SpA) in Singapore. METHODS: A cross-sectional study was conducted involving patients with axial SpA in an Asian tertiary hospital from 2017 to 2018. This study followed the COnsensus-based Standards for selection of health Measurement Instruments framework. Construct validity was evaluated by testing 22 a priori hypotheses with other patient-reported outcomes measures. Cronbach's alpha was used to estimate the internal consistency of the EQ-5D-5L, while its test-retest reliability was assessed using weighted kappa and the intraclass correlation coefficient (ICC). The measurement error was assessed by analyzing minimal detectable change (MDC). RESULTS: The median age of included patients (n=118) was 35 years (interquartile range: 28, 49). Ninety-six (81.4%) patients were male, while 112 (94.9%) patients were of Chinese ethnicity. The EQ-5D-5L demonstrated good internal consistency with a Cronbach's alpha of 0.79. The test-retest reliability of the EQ-5D-5L was good with a weighted kappa of ≥0.61 for mobility, self-care, usual activities, and anxiety/depression; the ICC was 0.92 and 0.99 for the EQ-5D-5L index and visual analog scale (VAS) scores, respectively. The weighted kappa for the EQ-5D-5L pain/discomfort was moderate [0.53, 95% confidence interval: 0.41-0.60]. The MDC for EQ-5D-5L index and VAS scores was 0.06 and 4.5, respectively. Convergent validity was supported as all hypotheses were confirmed in the results. CONCLUSION: This study supports EQ-5D-5L as a valid and reliable instrument for assessing health-related quality of life among patients with axial SpA in Singapore.

Factors affecting medication adherence among pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis of literature.

BACKGROUND: Medication adherence plays an essential role in slowing the progression of chronic kidney disease (CKD). This review aims to summarise factors affecting medication adherence among these pre-dialysis CKD patients. METHODS: A systematic review of the literature was performed in Medline®, Embase®, SCOPUS® and CINAHL®. Peer-reviewed, English language articles which evaluated factors associated with medication adherence among pre-dialysis CKD patients were included. Meta-analysis was performed to assess the pooled medication adherence rates across studies. Factors identified were categorised using the World Health Organization's five dimensions of medication adherence (condition, patient, therapy, health-system, and socio-economic domains). RESULTS: Of the 3727 articles reviewed, 18 articles were included. The pooled adherence rate across studies was 67.4% (95% CI 61.4-73.3%). The most studied medication class was anti-hypertensives (55.6%). A total of 19 factors and 95 sub-factors related to medication adherence were identified. Among condition-related factors, advanced CKD was associated with poorer medication adherence. Patient-related factors that were associated with lower medication adherence included misconceptions about medication and lack of perceived self-efficacy in medication use. Therapy-related factors which were associated with poorer medication adherence included polypharmacy while health system-based factors included loss of confidence in the physician. Socioeconomic factors such as poor social support and lower education levels were associated with poorer medication adherence. CONCLUSION: Factors associated with poor medication adherence among pre-dialysis CKD patients were highlighted in this review. This will aid clinicians in designing interventions to optimise medication adherence among pre-dialysis CKD patients.

Differential Health Care Use, Diabetes-Related Complications, and Mortality Among Five Unique Classes of Patients With Type 2 Diabetes in Singapore: A Latent Class Analysis of 71,125 Patients.

OBJECTIVE: With rising health care costs and finite health care resources, understanding the population needs of different type 2 diabetes mellitus (T2DM) patient subgroups is important. Sparse data exist for the application of population segmentation on health care needs among Asian T2DM patients. We aimed to segment T2DM patients into distinct classes and evaluate their differential health care use, diabetes-related complications, and mortality patterns. RESEARCH DESIGN AND METHODS: Latent class analysis was conducted on a retrospective cohort of 71,125 T2DM patients. Latent class indicators included patient's age, ethnicity, comorbidities, and duration of T2DM. Outcomes evaluated included health care use, diabetes-related complications, and 4-year all-cause mortality. The relationship between class membership and outcomes was evaluated with the appropriate regression models. RESULTS: Five classes of T2DM patients were identified. The prevalence of depression was high among patients in class 3 (younger females with short-to-moderate T2DM duration and high psychiatric and neurological disease burden) and class 5 (older patients with moderate-to-long T2DM duration and high disease burden with end-organ complications). They were the highest tertiary health care users. Class 5 patients had the highest risk of myocardial infarction (hazard ratio [HR] 12.05, 95% CI 10.82-13.42]), end-stage renal disease requiring dialysis initiation (HR 25.81, 95% CI 21.75-30.63), stroke (HR 19.37, 95% CI 16.92-22.17), lower-extremity amputation (HR 12.94, 95% CI 10.90-15.36), and mortality (HR 3.47, 95% CI 3.17-3.80). CONCLUSIONS: T2DM patients can be segmented into classes with differential health care use and outcomes. Depression screening should be considered for the two identified classes of patients.

Outpatient primary and tertiary healthcare utilisation among public rental housing residents in Singapore.

BACKGROUND: Globally, public housing is utilized to provide affordable housing for low-income households. Studies have shown an association between public housing and negative health outcomes. There is paucity of data pertaining to outpatient primary and tertiary healthcare resources utilization among public rental housing residents in Singapore. METHODS: A retrospective cohort study was performed, involving patients under the care of SingHealth Regional Health System (SHRS) in Year 2012. Healthcare utilization outcomes evaluated included number of outpatient primary and specialist care clinic visits, emergency department visits and hospitalization in Year 2011. Multivariate logistical analyses were used to examine the association between public rental housing and healthcare utilization. RESULTS: Of 147,105 patients, 10,400 (7.1%) patients stayed in public rental housing. There were more elderly (54.8 ± 18.0 vs 49.8 ± 17.1, p < 0.001) and male patients [5279 (50.8%) vs 56,892 (41.6%), p < 0.001] residing in public rental housing. Co-morbidities such as hypertension and hyperlipidemia were more prevalent among public rental housing patients. (p < 0.05). After adjustment for covariates, public rental housing was not associated with frequent outpatient primary care clinic or specialist outpatient clinic attendances (p > 0.05). However, it was associated with increased number of emergency department visits (OR: 2.41, 95% CI: 2.12-2.74) and frequent hospitalization (OR: 1.56, 95% CI: 1.33-1.83). CONCLUSION: Residing in public rental housing was not associated with increased utilization of outpatient healthcare resources despite patients' higher disease burden and frequency of emergency department visits and hospitalizations. Further research is required to elucidate their health seeking behaviours.

Comparison of Clinical Presentation and Outcomes of Peritonitis in the Elderly and Younger Peritoneal Dialysis Patients.

BACKGROUND: The incidence of elderly patients receiving peritoneal dialysis (PD) has increased. This study aimed to examine the clinical presentation and outcomes of peritonitis in elderly PD patients compared with younger PD patients. METHODS: This single-center, retrospective, observational cohort study included all adult PD patients who developed peritonitis between January 2011 and December 2014. Elderly was defined as ≥ 65 years old at PD initiation. The primary outcome was medical cure, defined as a peritonitis episode cured by antibiotics without being complicated by catheter removal, transfer to hemodialysis (HD), relapsing peritonitis,or death. The secondary outcomes were clinical manifestations (fever, cloudy dialysate) and complications (catheter removal, transfer to HD, relapse, hospitalization, and mortality). Peritonitis outcomes were compared using multivariable logistic regression. RESULTS: Overall, 377 peritonitis episodes occurred in 247 patients. Of these, 126 episodes occurred in 79 elderly patients and 251 episodes occurred in 168 younger patients. Baseline demographic data were comparable between the 2 groups, except that elderly patients were significantly more likely to have diabetes mellitus (66% vs 46%), diabetic nephropathy (55% vs 39%), and a lower serum albumin than younger patients. Medical cure was comparable between the 2 groups (71% vs 72%, respectively, p = 0.67, adjusted odds ratio [AOR] 0.89, 95% confidence interval [CI]: 0.52 - 1.53). Compared with younger patients, elderly patients experiencing peritonitis had lower odds of fever (OR 0.53, 95% CI: 0.30 - 0.94), cloudy dialysate (OR 0.45, 95% CI: 0.23 - 0.88), and catheter removal (AOR 0.50, 95% CI: 0.26 - 0.98), but similar odds of transfer to HD (AOR 0.70, 95% CI: 0.32 - 1.51), relapse (AOR 1.57, 95% CI: 0.46 - 5.40), hospitalization (AOR 1.55, 95% CI: 0.52 - 4.56), and all-cause mortality (AOR 1.88, 95% CI: 0.83 - 4.26). CONCLUSIONS: Compared with younger patients, elderly PD patients with peritonitis achieved similar medical cure rates, a lower catheter removal rate, and comparable rates of HD transfer, relapse, hospitalization, and death. Elderly PD patients experiencing peritonitis were less likely to present with fever or cloudy dialysate.

Prevalence and risk factors for hypercalcemia among non-dialysis patients with chronic kidney disease-mineral and bone disorder.

PURPOSE: To examine the prevalence and risk factors for hypercalcemia among non-dialysis chronic kidney disease (CKD) patients with mineral and bone disorder (MBD). METHODS: A retrospective cohort study was conducted in Singapore General Hospital, involving all CKD stage 4 and 5 pre-dialysis patients who were on treatment for MBD in June 2016. Each patient was followed up for 1 year and screened for hypercalcemia episodes. Mild, moderate and severe hypercalcemia were defined as corrected calcium of 2.47-3.00, 3.01-3.50 and ≥ 3.51 mmol/l respectively. Patients who were on dialysis, post-renal transplant, post-parathyroidectomy or had no calcium levels taken during the study period were excluded. Details related to patients' clinical information and hypercalcemia episodes were collected. Multivariate logistic regression analysis was performed to evaluate risk factors for hypercalcemia. RESULTS: Of 557 patients, 75 (13.4%) patients developed hypercalcemia. There were 120 (97.6%) mild and 3 (2.4%) moderate hypercalcemia episodes. The daily elemental calcium intake from phosphate binders and usage of vitamin D analogues did not differ between patients with and without hypercalcemia (p > 0.05). After adjusting for covariates, lower baseline iPTH level [odds ratio (OR) 0.96, 95% CI 0.93-0.99], history of hypercalcemia in past 1 year (OR 11.11, 95% CI 3.36-36.75) and immobility (OR 3.34, 95% CI 1.34-8.40) were associated with increased hypercalcemia risk. CONCLUSION: Hypercalcemia affects a significant proportion of pre-dialysis patients with MBD. More studies should be undertaken to evaluate other risk factors associated with hypercalcemia.

Appropriateness of vancomycin therapeutic drug monitoring and its outcomes among non-dialysis patients in a tertiary hospital in Singapore.

Background Vancomycin therapeutic drug monitoring (TDM) is commonly performed to ensure safe and effective use of the antibiotic. Aim of Study To evaluate appropriateness of vancomycin TDM and its outcomes in Singapore General Hospital. Method A retrospective, cross-sectional study was conducted between 1 January 2014 and 28 February 2014 involving patients who received ≥ 1 dose of intravenous vancomycin with TDM. Patient demographics and relevant vancomycin TDM data were collected from medical records. Results Of 746 vancomycin troughs measured among 234 patients, 459 troughs (61.5%) were taken inappropriately, with a median time of 2.6 h (interquartile range 1.1-4.3) before the next scheduled dose. Inappropriate interpretation of vancomycin troughs resulted in 41 unnecessary dose suspensions, 24 dose changes, and 102 unchanged vancomycin doses. The cost incurred due to inappropriate interpretation and measurement after discontinuation of treatment was US$7286. No differences in rates of vancomycin related nephrotoxicity, ototoxicity, recurrent infection, development of infection secondary to vancomycin resistant microorganism and mortality were observed (p > 0.05). Conclusion This study highlighted a high incidence of inappropriate vancomycin TDM which has led to increased healthcare cost.

Public rental housing and its association with mortality - a retrospective, cohort study.

BACKGROUND: Socioeconomic status (SES) is a well-established determinant of health status and home ownership is a commonly used composite indicator of SES. Patients in low-income households often stay in public rental housing. The association between public rental housing and mortality has not been examined in Singapore. METHODS: A retrospective, cohort study was conducted involving all patients who utilized the healthcare facilities under SingHealth Regional Health (SHRS) Services in Year 2012. Each patient was followed up for 5 years. Patients who were non-citizens or residing in a non-SHRS area were excluded from the study. RESULTS: A total of 147,004 patients were included in the study, of which 7252 (4.9%) patients died during the study period. The mean age of patients was 50.2 ± 17.2 years old and 7.1% (n = 10,400) of patients stayed in public rental housing. Patients who passed away had higher utilization of healthcare resources in the past 1 year and a higher proportion stayed in public rental housing (p < 0.001). They also had higher rates of co-morbidities such as hypertension, hyperlipidaemia and diabetes. (p < 0.001) After adjustment for demographic and clinical covariates, residence in public rental housing was associated with increased risk of all-cause mortality (Adjusted hazard ratio: 1.568, 95% CI: 1.469-1.673). CONCLUSION: Public rental housing was an independent risk factor for all-cause mortality. More studies should be conducted to understand health-seeking behavior and needs of public rental housing patients, to aid policymakers in formulating better plans for improving their health outcomes.