Prediction of drug permeation through microneedled skin by machine learning.

Stratum corneum is the outermost layer of the skin preventing external substances from entering human body. Microneedles (MNs) are sharp protrusions of a few hundred microns in length, which can penetrate the stratum corneum to facilitate drug permeation through skin. To determine the amount of drug delivered through skin, in vitro drug permeation testing is commonly used, but the testing is costly and time-consuming. To address this issue, machine learning methods were employed to predict drug permeation through the skin, circumventing the need of conducting skin permeation experiments. By comparing the experimental data and simulated results, it was found extreme gradient boosting (XGBoost) was the best among the four simulation methods. It was also found that drug loading, permeation time, and MN surface area were critical parameters in the models. In conclusion, machine learning is useful to predict drug permeation profiles for MN-facilitated transdermal drug delivery.

Understanding reasons and determinants of medication non-adherence in community-dwelling adults: a cross-sectional study comparing young and older age groups.

BACKGROUND: Medication non-adherence has become a striking problem among patients with chronic diseases worldwide. However, literature on prevalence, reasons and factors associated with medication non-adherence in Singapore general population is still lacking. This study aimed to (1) estimate the prevalence of intentional and unintentional medication non-adherence in young (aged 21-64 years) and older adults (aged ≥ 65 years), respectively; (2) identify and compare the main reasons for non-adherence; and (3) examine the association between potential factors and non-adherence in each group. METHODS: This study sampled 1,528 community-dwelling adults on medications (young adults:766, older adults: 762) from a cross-sectional population health survey conducted in the northern and central regions of Singapore in 2018/2019. Self-reported medication non-adherence and its reasons were collected using a modified questionnaire and compared between the two groups. Multiple logistic regressions were conducted to examine the association between potential factors (e.g., social-demographic factors, smoking and drinking status, presence of diabetes, hypertension, or dyslipidaemia, and presence of depressive symptoms) and medication non-adherence in each group. RESULTS: The prevalence of non-adherence was 38.4% and 22.3% in young and older adults, respectively, with young adults reporting higher unintentional and intentional non-adherence rates than older adults. "Afraid of developing drug dependence" was the most common reason in both groups (young:74.8% vs. old:73.5%). Compared to young adults (3.7%), "Not understanding medication labels" was more prevalent in older adults (8.8%). Presence of depressive symptoms was associated with non-adherence in both young (odds ratio [95% confidence interval]: 3.00 [1.79, 5.05]) and older adults (4.16 [2.31, 7.51]). Being employed (2.92 [1.76, 4.84]) and taking ≥ 2 medications (1.42 [1.04, 1.95]) had positive association while personal income of SGD1,000-4,000 (0.53 [0.36, 0.77]) and current smoking (0.61 [0.39, 0.95]) had inverse association with non-compliance in young adults. Diagnosis of diabetes, hypertension, or dyslipidaemia (2.63 [1.25, 5.53]) was associated with higher odds of non-compliance in older adults. CONCLUSIONS: Young adults had higher prevalence of medication non-adherence than older adults. The main reasons for non-adherence reported by young and older adults were generally comparable. Presence of depressive symptoms was a risk factor of medication non-adherence in both groups.

Chronic low back pain and its impact on physical function, mental health, and health-related quality of life: a cross-sectional study in Singapore.

Chronic low back pain, defined as low back pain lasting more than 3 months, is a globally prevalent health problem with significantly high medical and economic burden on individuals and the society. This study aimed to estimate the prevalence of chronic low back pain and examine its association with health outcomes including physical function, mental health, and quality of life among adult population in Singapore. Cross-sectional secondary data analysis was performed using baseline data of the 1941 adults (mean age: 52.6 years, range: 21-97 years) from a representative population health survey conducted in the Central region of Singapore. Those with self-reported chronic low back pain in past six months were identified. The Late-Life Function and Disability Instrument, Patient Health Questionnaire-9, and EQ-5D-5L were used to measure physical function and limitation, mental health, and health-related quality of life, respectively. Generalized Linear Regressions were used to examine the association of chronic low back pain with physical function, limitation, depressive symptoms, and health-related quality of life. There were 8.1% (n = 180) participants reporting having chronic low back pain in past six months, among whom 80.5% sought treatments at either primary care, specialist outpatient, or Traditional Chinese Medicine clinics. Individuals with chronic low back pain reported poorer physical function, more limitations in performing major life tasks and social activities, more depressive symptoms, and lower health-related quality of life (all p < 0.01), even after adjusting for socio-demographics, lifestyle factors, and number of morbidities. The prevalence of chronic low back pain was 8.1% among the study population. Chronic low back pain was associated with poorer physical function, more limitations and depressive symptoms, and lower health-related quality of life. The findings highlight the significant impact of chronic low back pain on physical function and limitation, mental health, and health-related quality of life in a general population. Increased awareness on prevention, early and proper management of low back pain, and rehabilitation policies are required to better tackle the burden of low back pain at the population level.

Psychometric Properties of the Patient Activation Measure in Community-Dwelling Adults in Singapore.

INTRODUCTION: Measuring health activation in general population using valid instruments is needed to facilitate the evaluation of health education and behavioral programs in community. The 13-item Patient Activation Measure was well validated in patients with different chronic diseases but rarely validated in general population. The objective of this study was to assess the psychometric properties of the Patient Activation Measure among community-dwelling adults in Singapore. METHODS: Data of participants having valid responses to the English-version measure (N = 824) were analyzed. The psychometric properties were assessed by demonstrating evidence for uni-dimensionality using Rasch Principal Component Analysis of Residuals, known-group validity, convergent and divergent validity, and internal consistency reliability using Cronbach's alpha. RESULTS: The uni-dimensionality of the Patient Activation Measure was supported by the Rasch Principal Component Analysis of Residuals results. Participants having multimorbidity or polypharmacy and being inactive in physical activity had significantly lower activation scores. The activation score was positively and moderately correlated with health confidence measured by the Health Confidence Measure (r = .38, P < .001), and negatively and weakly correlated with depressive symptoms measured by the Patient Health Questionnaire (r = - .13, P < .001). The internal reliability was good with a Cronbach's alpha of .82. CONCLUSION: The 13-item Patient Activation Measure has acceptable construct validity and good internal consistency among community-dwelling adults. It is a potential instrument to measure health activation in this population. Further research is required to investigate the expansion of response options, validate the cut-off scores for the activation levels and examine the test-retest reliability and responsiveness.

Associations of social isolation, social participation, and loneliness with frailty in older adults in Singapore: a panel data analysis.

BACKGROUND: There is a shortage of research evidence about how social isolation, social participation, and loneliness were longitudinally associated with frailty. This study was to 1) examine the associations of social isolation, social participation, and loneliness with level of frailty among community-dwelling older adults using panel data, and 2) explore the moderating effect of gender on the association of social isolation, social participation and loneliness with frailty. METHODS: The study included 606 participants aged 60 years and above from the longitudinal Population Health Index Survey conducted in Singapore. At each timepoint, level of frailty was determined using the Clinical Frailty Scale. Social isolation was assessed by the Lubben Social Network Scale-6, and loneliness was assessed using the three-item UCLA Loneliness Scale. Fixed-effects ordinal logistic regressions were conducted with level of frailty as the dependent variable and social isolation and loneliness as the independent variables, adjusting for time-varying socio-demographic, lifestyle, and health-related factors. RESULTS: Increase in social participation was associated with lower level of frailty (odds ratio: 0.96, 95% confidence interval: 0.93-0.99) and feeling lonely was associated with higher level of frailty (odds ratio: 2.90, 95% confidence interval: 1.44-5.84). Social isolation was not associated with frailty. Gender did not have moderating effect on these associations. CONCLUSIONS: This study observed that social isolation and loneliness had differential longitudinal association with level of frailty among community-dwelling older adults and suggested that loneliness and frailty should be measured and addressed concurrently among community-dwelling older adults.

Psychometric evaluation of the 8-item Altarum Consumer Engagement (ACE) Measure™ in community-dwelling adults in Singapore.

BACKGROUND: A valid and reliable measure is essential to assess patient engagement and its impact on health outcomes. This study aimed to examine the psychometric properties of the 8-item Altarum Consumer Engagement Measure™ (ACE Measure) among English-speaking community-dwelling adults in Singapore. METHODS: This cross-sectional study involved 400 randomly selected community-dwelling adults (mean age: 49.7 years, 50.0% were female, 72.3% were Chinese) who completed the English version of the 8-item ACE Measure independently. The item-level statistics were described. The internal consistency of the measure was measured by Cronbach alpha and item-rest correlations. Validity of the tool was assessed by 1) factorial validity using confirmatory factor analysis (CFA), 2) hypothesis-testing validity by correlating ACE subscales (Commitment and Navigation) with health-related outcomes, and 3) criterion validity against the Patient Activation Measure and Health Confidence Measure. RESULTS: There was no floor or ceiling effect for Commitment and Navigation subscales, and the Cronbach alpha for each subscale was 0.76 and 0.54, respectively. The two-factor structure was confirmed by CFA. In general, Commitment and Navigation subscales were positively correlated with frequency of activity participation (rho = 0.30 - 0.33) and EQ-5D visual analog scale (rho = 0.15 - 0.30). Individuals who perceived better health than peers had higher subscale scores (p < 0.01). Each subscale score had moderate and positive correlations with activation score (rho = 0.48 - 0.55) and health confidence score (rho = 0.35 - 0.47). CONCLUSIONS: The two-subscale ACE Measure demonstrated good construct validity in English-speaking Singapore community-dwelling adults. Evidence in internal consistency was mixed, indicating further investigation.

End-stage organ disease-Healthcare utilisation: Impact of palliative medicine.

OBJECTIVES: Although patients living with end-stage organ disease (ESOD) suffer unmet needs from the physical and emotional burdens of living with chronic illness, they are less likely to receive palliative care.The aims of the study were to determine if palliative care referrals reduced healthcare utilisation and if impact on healthcare utilisation was dependent on the timing of the referral. METHODS: Patients with ESOD who received palliative care support were matched with those who did not using coarsened exact matching and propensity score matching, and compared in this retrospective cohort study. Primary outcomes of interests were reduction in all-cause emergency department (ED) visits and costs, reduction in all-cause tertiary hospital admissions, length of hospital stay and inpatient hospital costs. RESULTS: Patients with ESOD referred to palliative care experienced a reduction in the frequency of all cause ED visits and inpatient hospital admissions. Significant impact of a palliative care referral was at 3 months, rather than 1 month prior to death with a greater reduction in the frequency of ED visits, inpatient hospital admissions, length of stay and charges (p all <0.05). The most common ESOD referred to palliative care for 1110 matched patients was end-stage renal failure (57.7%), and least commonly for respiratory failure (7.6%). CONCLUSION: Palliative care can reduce healthcare utilisation, with reduction greatest when the referral is timed earlier in the disease trajectory. Cost savings can be judiciously redirected to the development of palliative care resources for integrated support of patients and caregivers.

Palliative Rehabilitation Improves Health Care Utilization and Function in Frail Older Adults with Chronic Lung Diseases.

OBJECTIVES: The Integrated Care for Advanced REspiratory Disorders (ICARE) service is a stay-in, post-acute care program for hospitalized patients with chronic, nonmalignant lung diseases. It provides palliative rehabilitation-a novel model integrating functional rehabilitation with early palliative care. We compare reduction of health care utilization among ICARE participants vs matched controls receiving usual care. DESIGN: This is a prospective, propensity score-matched study. Primary outcomes were reduction in hospital readmissions and length of stay and emergency department (ED) visits, comparing the period 6 months before and after ICARE, or 6 months before and after hospital discharge (for controls). Secondary outcomes included 6-minute walking distance (6MWD) and Modified Barthel Index (MBI). SETTING: Participants were matched 1:1 to controls by age, respiratory diagnosis, socioeconomic strata, index hospitalization length of stay, frailty, and recent admissions into intensive care unit or noninvasive ventilation units. METHODS: Multidisciplinary interventions focused on symptom relief, functional rehabilitation, targeted comorbidity management, and postdischarge care coordination. RESULTS: One hundred pairs of patients were matched. Participants were older adults (mean age 73.9 ± 8.2 years) with prolonged index hospitalization (median 12.0 days; interquartile range 7-18). Overall, 57% had high Hospital Frailty Risk Scores and 71% had overlapping respiratory diagnoses, the most common commonest being COPD (89%), followed by interstitial lung disease (54%) and bronchiectasis (28%). Small reductions in health care utilization were observed among controls. ICARE was associated with a further 9.1 ± 19.9 days' reduction in hospitalization length of stay (P < .001), 0.8 ± 1.9 lesser admission (P < .001), and 0.6 ± 2.2 fewer ED visits (P < .02). Participants with longest index hospitalization were observed to have greatest reduction in length of stay. 6MWD and MBI scores improved by 41.0 ± 60.2 m and 12.3 ± 11.6 points, respectively (both P < .001). Greater improvement was observed in patients with lower baseline 6MWD and MBI scores. Prescription of slow-release opioids rose from 9% to 49%. Treatment for anxiety and depression rose from 5% to 19%. CONCLUSIONS AND IMPLICATIONS: Integrating palliative care with postexacerbation functional rehabilitation was associated with short-term reduction in health care utilization, improved functional capacity, and increased treatment of dyspnea, anxiety, and depression.

Psychosocial impact of skin diseases: A population-based study.

BACKGROUND: While it is well established that skin disease places significant psychosocial burden on a patient's wellbeing, its effects have rarely been examined in Asian populations. OBJECTIVE: Evaluate the psychosocial burden of skin disease among community-dwelling adults in Singapore. METHODS: This cross-sectional study included 1510 participants interviewed on their history of thirteen skin diseases. The Patient Health Questionnaire (PHQ-9), Lubben Social Network Scale-6 (LSNS-6), University of California Los Angeles (UCLA) Loneliness Scale, and European Quality of Life-5 Dimensions- 5 Level (EQ-5D-5L) were used as measures for depressive symptoms, social isolation, loneliness and quality of life respectively. Multiple linear regression analysis was used to examine the association of skin diseases with each of the four measured outcomes. RESULTS: Participants with skin diseases reported significantly higher PHQ-9 and UCLA Loneliness scale scores, and lower LSNS-6 and EQ-5D-5L scores when compared to their healthy counterparts. The presence of skin disease was positively associated with depressive symptoms (B = 0.40, SE = 0.11), and negatively associated with quality of life (B = -0.03, SE = 0.01). As disease severity was not evaluated in this study, we were unable to ascertain the associations between disease severity and measured outcomes. CONCLUSION: Participants with skin diseases were more likely to have depressive symptoms, social isolation, loneliness and lower quality of life. Unemployed, single and elderly patients were at higher risk of developing depressive symptoms. More emphasis should be placed on the psychosocial aspect of care to reduce the burden of skin disease. Some considerations include monitoring patients for mood-related changes and implementing early psychosocial interventions.

Frailty and healthcare utilisation across care settings among community-dwelling older adults in Singapore.

BACKGROUND: Frailty is frequently found to be associated with increased healthcare utilisation in western countries, but little is known in Asian population. This study was conducted to investigate the association between frailty and healthcare utilisation in different care settings among community-dwelling older adults in Singapore. METHODS: Data from a population health survey among community-dwelling adults were linked with an administrative database to retrieve data of healthcare utilisation (including government primary care clinic visits, specialised outpatient clinic visits, emergency department visits, day surgery and hospitalisations) occurred during a six-month look-back period and six-month post-baseline respectively. Baseline frailty status was measured using the five-item FRAIL scale, which was categorised into three groups: robust (0), pre-frail (1-2), and frail (3-5). Negative binomial regression was applied to examine the association between frailty with respective healthcare utilisation (dependent variables), controlling for other confounding variables. RESULTS: In our sample of 701 older adults, 64.8% were of robust health, 27.7% were pre-frail, and 7.6% were frail. Compared to the robust group, frail individuals had a higher rate of specialised outpatient clinic visits (incidence rate ratio (IRR): 2.8, 95% confidence interval (CI): 1.2-6.5), emergency department visits (IRR: 3.1, 95%CI: 1.1-8.1), day surgery attendances (IRR: 6.4, 95%CI: 1.3-30.9), and hospitalisations (IRR: 6.7, 95%CI: 2.1-21.1) in the six-month period prior to the baseline and in subsequent 6 months (IRR: 3.3, 95%CI: 1.6-7.1; 6.4, 2.4-17.2; 5.8, 1.3-25.8; 13.1, 4.9-35.0; respectively), controlling for covariates. CONCLUSIONS: Frailty was positively associated with the number of specialised outpatient clinic visits, emergency department visits, day surgeries and hospitalisations occurred during 6 months prior to and after the baseline. As frailty is a potentially reversible health state with early screening and intervention, providing preventive activities that delay the onset or progression of frailty should have potential effect on delaying secondary and tertiary care utilisation.

Development of a scalable and extendable multi-dimensional health index to measure the health of individuals.

BACKGROUND: For population health management, it is important to have health indices that can monitor prevailing health trends in the population. Traditional health indices are generally measurable at different geographical levels with varied number of health dimensions. The aim of this work was to develop and validate a scalable and extendable multi-dimensional health index based on individual data. METHODS: We defined health to be made up of five different domains: Physical, Mental, Social, Risk, and Healthcare utilization. Item response theory was used to develop models to compute domain scores and a health index. These were normalized to represent an individual's health percentile relative to the population (0 = worst health, 100 = best health). Data for the models came from a longitudinal health survey on 1,942 participants. The health index was validated using age, frailty, post-survey one-year healthcare utilization and one-year mortality. RESULTS: The Spearman rho between the health index and age, frailty and post-survey one-year healthcare utilization were -0.571, -0.561 and -0.435, respectively, with all p<0.001. The area under the Receiver Operating Characteristic curve (AUROC) for post-survey one-year mortality was 0.930. An advantage of the health index is that it can be calculated using different sets of questions and the number of questions can be easily expanded. CONCLUSION: The health index can be used at the individual, program, local, regional or national level to track the state of health of the population. When used together with the domain scores, it can identify regions with poor health and deficiencies within each of the five health domains.

Association of Nutritional Status with Physical Function and Disability in Community-Dwelling Older Adults: A Longitudinal Data Analysis.

Objective: To investigate how change in nutritional status is associated with physical function and disability among community-dwelling older adults. Methods: Baseline and 1-year follow-up data of 593 community-dwelling older adults were obtained from the Population Health Index survey in Singapore. The Mini Nutritional Assessment was used to assess nutritional status; the Late-Life Function and Disability Instrument was used to measure physical function and disability. Multivariate linear regression was applied to examine the association of change in nutritional status with physical function and disability. Results: Compared to older adults with normal nutritional status at both baseline and 1-year follow-up, those who became undernourished or remained undernourished reported poorer physical function (B = -6.36 and -5.96, respectively; both P < 0.01), and had less frequent involvement (B = -3.95 and -2.84, respectively; both P < 0.01) and more limitation in performing life tasks (B = -13.24 and -16.02, respectively; both P < 0.01) at 1-year follow-up. However, older adults with improved nutritional status did not differ in physical function and frequency of involvement in life tasks compared to those with normal nutrition. Conclusion: Undernutrition is associated with poorer physical function and disability in community-dwelling older adults regardless of whether it developed or was persistent over one year. Improving nutritional status could be an effective strategy to improve physical function in older adults.

Optimizing Vancomycin Dosing in Chronic Kidney Disease by Deriving and Implementing a Web-Based Tool Using a Population Pharmacokinetics Analysis.

Background: Chronic kidney disease (CKD) patients requiring intravenous vancomycin bear considerable risks of adverse outcomes both from the infection and vancomycin therapy itself, necessitating especially precise dosing to avoid sub- and supratherapeutic vancomycin exposure. Methods: In this retrospective study, we performed a population pharmacokinetic analysis to construct a vancomycin dose prediction model for CKD patients who do not require renal replacement therapy. The model was externally validated on an independent cohort of patients to assess its prediction accuracy. The pharmacokinetic parameter estimates and the equations were productized into a Web application (VancApp) subsequently implemented in routine care. The association between VancApp-based dosing and time-to-target concentration attainment, 30-day mortality, and nephrotoxicity were assessed postimplementation. Results: The model constructed from an initial cohort (n = 80) revealed a population clearance and volume of distribution of 1.30 L/h and 1.23 L/kg, respectively. External model validation (n = 112) demonstrated a mean absolute prediction error of 1.25 mg/L. Following 4 months of clinical implementation of VancApp as an optional alternative to usual care [VancApp (n = 22) vs. usual care (n = 21)], patients who had received VancApp-based dosing took a shorter time to reach target concentrations (median: 66 vs. 102 h, p = 0.187) and had fewer 30-day mortalities (14% vs. 24%, p = 0.457) compared to usual care. While statistical significance was not achieved, the clinical significance of these findings appear promising. Conclusion: Clinical implementation of a population pharmacokinetic model for vancomycin in CKD can potentially improve dosing precision in CKD and could serve as a practical means to improve vital clinical outcomes.

Prevalence of frailty and its association with depressive symptoms among older adults in Singapore.

OBJECTIVES: The aims of the study were to (1) estimate the prevalence of frailty among community-dwelling older adults , and (2) investigate the independent association between level of frailty and depressive symptoms. METHODS: A total of 721 older adults (aged 60 and above ) were included in this study. Severity of frailty was determined using the Clinical Frailty Scale and further classified into four levels (CFS1-3: F1, CFS4: F2, CFS5: F3, and CFS6-7: F4). The depressive symptoms were assessed using the Patient Health Questionnaire-9. The prevalence of frailty by four levels was described and the association between level of frailty and depressive symptoms was assessed using multiple linear regression. RESULTS: The prevalence of frailty among the study population was 24.5% (F2: 14.4%, F3:3.7%, F4: 6.4%). There was no significant difference in level of frailty between male and female. With the increase in severity level of frailty, older adults reported substantially higher depressive symptom scores (p < .001), even after controlling for socio-demographics, number of non-mental chronic conditions, and number of medications taken regularly. CONCLUSIONS: Level of frailty is independently associated with depressive symptoms among community-dwelling older population, which is not fully explained by symptom overlap, socio-demographic, and comorbidity covariates.

Effects of chronic diseases on health-related quality of life and self-rated health among three adult age groups.

Little is known about whether there is any difference in associations of chronic diseases with health-related quality of life and self-rated health across age groups. The purpose of the present study was to examine the associations of one specific and multiple chronic diseases with health-related quality of life and self-rated health (measured using the 5-level EQ-5D version) in three age groups: young (21-44 years), middle-aged (45-64 years), and older adults (≥65 years). Secondary data analysis of 1932 participants in the Population Health Index Survey was performed. Linear regression results showed that different chronic diseases had a characteristic effect on health-related quality of life and self-rated health among different age groups. The presence of a single chronic disease was associated with lower health-related quality of life and self-rated health in young adults. Multi-morbidity was consistently associated with decreased health-related quality of life and self-rated health in all age groups. Our findings suggest that although young adults have a lower prevalence of chronic diseases, their impacts on health-related quality of life and self-rated health can be as significant as that in middle-aged and older adults.

Sex differences in associations between multimorbidity and physical function domains among community-dwelling adults in Singapore.

OBJECTIVES: The aims of the study were to identify the associations between multimorbidity and specific physical function domains among community-dwelling adults in Singapore, and to examine sex differences in the associations. METHODS: This study was conducted using baseline data of 1,940 participants in the Population Health Index Survey conducted in the Central Region of Singapore from November 2015 to November 2016. Physical function was assessed using the Function Component of the Late-life Function and Disability Instrument and compared between men and women. Multiple linear regressions were conducted to examine associations between multimorbidity and different physical function domains for all participants, and in men and women separately. RESULTS: The prevalence of multimorbidity in the study population was 35.0% for adults aged 21 years and above, with no differences between men and women. Multimorbidity was associated with reduced upper extremity function, basic and advanced lower extremity function, and overall function in men and women after adjusting for demographic factors. Multimorbidity had a stronger association with advanced lower extremity function and overall physical function in women than in men. CONCLUSIONS: The findings of this study indicate that multimorbidity is associated with physical function domains in men and women, and in particular advanced lower extremity for women. Effective community-based interventions need to be implemented to preserve physical function in individuals with multimorbidity to keep them functionally independent and physically active in the community. Additional focus on advanced lower extremity function for women is needed.

Incidence of thromboembolic and bleeding events in patients with newly diagnosed nonvalvular atrial fibrillation: An Asian multicenter retrospective cohort study in Singapore.

BACKGROUND: Real-world effectiveness and safety of antithrombotics in nonvalvular atrial fibrillation (NVAF) patients in Singapore has not been thoroughly studied. HYPOTHESIS: Users of various antithrombotics experience a significantly different risk of stroke and major bleed compared with warfarin users. METHODS: This multicenter retrospective cohort study included patients age ≥ 21 years newly diagnosed with NVAF between July 2012 and September 2015. Using electronic medical records, data on patients' demographics, antithrombotics prescribed, and CHA2 DS2 -VASc and HAS-BLED risk factors were collected. Patients were followed for 1 year from diagnosis for the primary effectiveness and safety endpoints of incident stroke or systemic embolism and major bleed, respectively. The secondary safety endpoint was overall bleed. Hazard ratios (HR) were determined from Cox regression. RESULTS: Of 743 patients included, 224 were on warfarin, 156 on direct oral anticoagulants (DOACs), 277 on single antiplatelet therapy (SAPT), 28 on dual antiplatelet therapy (DAPT), and 58 on no therapy. Mean age (±SD) was 68.7 ± 13.0 years. Compared with warfarin users, SAPT (adjusted [adj.] HR: 3.70, 95% confidence interval [CI]: 1.21-11.3) and DAPT users (adj. HR: 10.1, 95% CI: 1.51-67.2) were more likely to develop thromboembolic outcomes. Also, DOAC users (adj. HR: 0.304, 95% CI: 0.158-0.585), SAPT users (adj. HR: 0.142, 95% CI: 0.0680-0.295), and DAPT users (adj. HR: 0.112, 95% CI: 0.0146-0.857) were less likely to experience any bleed compared with warfarin users. CONCLUSIONS: SAPT and DAPT are less effective than warfarin in NVAF patients. DOACs may be considered in view of lower risk of overall bleed.

Effectiveness of Diabetes Foot Screening in Primary Care in Preventing Lower Extremity Amputations.

INTRODUCTION: The risk of lower extremity amputations (LEAs) in diabetics is 20 times higher than in non-diabetics. Clinical practice guidelines recommend that all diabetics should receive an annual foot examination to identify high-risk foot conditions. Despite this recommendation, there is little evidence in the literature to show its effectiveness in preventing LEA. This study aims to evaluate the effectiveness of diabetes foot screening in primary care in preventing LEA and to identify LEA risk factors. MATERIALS AND METHODS: This is a retrospective cohort study of diabetic patients who visited the National Healthcare Group Polyclinics for the first time from 1 January 2008 to 31 December 2012. The intervention of interest was foot screening performed at least once during 2 years of follow-up, and the outcome of interest was LEA (major and/or minor) performed during 2 years of follow-up. Patients who did foot screening (n=8150) were compared to a propensity score matched control group (n=8150) who did not do foot screening. Logistics regression was done to identify factors associated with LEA. RESULTS: Among those who underwent foot screening, there were 2 (0.02%) major amputations and 15 (0.18%) minor amputations compared with 42 (0.52%) and 52 (0.64%) among those who did not (P<0.001). CONCLUSION: Lack of diabetes foot screening, lower socioeconomic status, hip fracture, Malay ethnicity, chronic kidney disease, poorer glycaemic control, longer diabetes duration and male gender have been found to be associated with a higher risk of LEA.