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.

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.

Association of Pain Catastrophizing and Depressive States with Multidimensional Early Labor Pain Assessment in Nulliparous Women Having Epidural Analgesia - A Secondary Analysis.

BACKGROUND: Labor pain is a variable and complex experience with both sensory and affective components. Pain catastrophizing tendencies are predictive of increased distress during labor. Likewise, pain severity has important associations with increased depressive symptoms in mothers, with consequences on perinatal and infant outcomes. Hence, we investigated the association between increased early labor pain with both pre-delivery pain catastrophizing and depressive states. METHODS: We recruited nulliparous women who had requested labor epidural analgesia. Pre-delivery questionnaires including short-form McGill pain questionnaire-2 (SF-MPQ-2), pain catastrophizing scale (PCS), and Edinburgh postnatal depression score (EPDS) were administered. RESULTS: A total of 712 women completed the pre-delivery questionnaires. There was a significant association between SF-MPQ-2 neuropathic subscale and EPDS ≥ 10 (unadjusted OR 1.74, 95% CI 1.11-2.73, p = 0.0161), as well as PCS ≥ 25 (unadjusted OR 1.55, 95% CI 1.06-2.26, p = 0.0244). SF-MPQ-2 sensory intermittent subscale and EPDS ≥ 10 (unadjusted OR 2.02, 95% CI 1.34-3.03, p = 0.0007), and PCS ≥ 25 (unadjusted OR 1.59, 95% CI 1.14-2.23, p = 0.0069) also showed significant association. CONCLUSION: Increased sensory intermittent and neuropathic subsets of early labor pain are significantly correlated with increased pre-delivery pain catastrophizing and depressive states in nulliparous women. This positive association may be useful for pre-delivery risk stratification for early interventions towards a more holistic care management.

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.

Healthcare at the time of COVID-19: A review of the current situation with emphasis on anesthesia providers.

Coronavirus disease 2019 (COVID-19) is spreading rapidly around the world with devastating consequences on patients, healthcare workers, health systems, as well as economies. While, healthcare systems are globally operating at maximum capacity, healthcare workers and especially anesthesia providers are facing extreme pressures, something that is also leading to declining availability and increasing stress. In this regard, it is extremely concerning the fact that some regions worldwide have reported up to 20% of their cases to be healthcare workers. When considering that the global case fatality rate may be as much as 5.4%, these numbers are concerning and unacceptable. As this pandemic accelerates, access to personal protective equipment for health workers is a key concern since at present, healthcare workers are every country's most valuable resource in the fight against COVID-19. Governments and heath organizations should take care of their staff and support them in any way possible. This review aims to describe the current situation anesthesia providers are facing in the setting of COVID-19 and provide solutions and evidence on important concerns, including which guidance to follow, the level of equipment that is adequate, and the level of protection they need for every patient being administered an anesthetic.

Best practice in cardiac anesthesia during the COVID-19 pandemic: Practical recommendations.

The COVID-19 outbreak has influenced the entire health care system, including cardiac surgery. In this review, the authors reveal practical aspects that are important during the COVID-19 pandemic with regards to the safe delivery of cardiac anesthesia. Timing for operations of the cardio-vascular system may be well programmed in most cases. Hence, the level of priorities must be defined for any single patient. The postponement of surgery may be convenient for most cases, if it is made in the best interest of the patient. The preanesthetic evaluation should be attentive of the respiratory history of the patient. Cardiac anesthesia always implies some respiratory monitoring; hence the existing clinical situation of the patient's respiratory system should be clear. In case of emergency surgery, the patient should be treated as if they potentially have or are at risk for the virus. In the case of a COVID-19 confirmed or suspected patient, attention must be made to preserve operating room and team integrity. The machineries are to be draped with plastic to simplify the disinfection after the operation. Perioperative management of suspected or confirmed COVID-19 patients must strictly follow the most relevant international guidelines. This review article has synthesized the common aspects present in the most important of these.

The use of pre-operative virtual reality to reduce anxiety in women undergoing gynecological surgeries: a prospective cohort study.

BACKGROUND: Pre-operative anxiety is common and is associated with negative surgical outcomes. Virtual reality (VR) is a promising new technology that offers opportunities to modulate patient experience and cognition and has been shown to be associated with lower levels of anxiety. In this study, we investigated changes in pre-operative anxiety levels before and after using VR in patients undergoing minor gynecological surgery. METHODS: Patients who underwent elective minor gynecological surgeries in KK Women's and Children's hospital, Singapore were recruited. The VR intervention consisted of 10-min exposure via a headset loaded with sceneries, background meditation music and breathing exercises. For the primary outcome of pre-operative anxiety, patients were assessed at pre- and post-intervention using the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes of self-reported satisfaction scores and EuroQol 5-dimension 3-level (EQ-5D-3L) were also collected. RESULTS: Data analysis from 108 patients revealed that HADS anxiety scores were significantly reduced from 7.2 ± 3.3 pre-intervention to 4.6 ± 3.0 post-intervention (p < 0.0001). Furthermore, HADS depression scores were significantly reduced from 4.7 ± 3.3 pre-intervention to 2.9 ± 2.5 post-intervention (p < 0.0001). Eighty-two percent of the patients self-reported VR intervention as 'Good' or 'Excellent'. EQ-5D-3L showed significant changes in dimensions of 'usual activities' (p = 0.025), 'pain/discomfort' (p = 0.008) and 'anxiety/ depression' (p < 0.0001). CONCLUSIONS: For patients undergoing minor gynecological procedures, the VR intervention brought about a significant reduction in pre-operative anxiety. This finding may be clinically important to benefit patients with high pre-operative anxiety without the use of anxiolytics. TRIAL REGISTRATION: This study was registered on clinicaltrials.gov registry ( NCT03685422 ) on 26 Sep 2018.

Risk Factors Associated with Development of Acute and Sub-Acute Post-Cesarean Pain: A Prospective Cohort Study.

BACKGROUND: Although cesarean delivery is one of the most commonly performed surgical procedures, robust data regarding post-cesarean pain is still lacking. Recent studies showed an association between pain upon local anesthetic (LA) injection for spinal anesthesia, or the use of a "three simple questions", and acute post-cesarean pain. Nevertheless, these assessments have yet to be validated further, despite their relative ease of use. We aimed to assess the association between pain score upon LA injection with acute post-cesarean pain after 24 hours at rest (primary outcome) and sub-acute post-cesarean pain lasting for 4 weeks or more (secondary outcome). METHODS: Women undergoing cesarean delivery under spinal anesthesia were given pre-operative questionnaires on pain and psychological vulnerability. We also assessed the pain score upon LA injection and mechanical temporal summation. Univariate and multivariable logistic regressions were performed. RESULTS: The incidence of moderate-to-severe acute post-cesarean pain at 24 hours was 21.0% (95% CI=16.6-27.6%) (48 of 217 patients). Pain score upon LA injection was not significantly associated with acute post-cesarean pain after 24 hours at rest (unadjusted OR=1.10, 95% CI=0.95-1.27, P=0.21). However, pain score upon LA injection was significantly associated with sub-acute post-cesarean pain (adjusted OR=1.29, 95% CI=1.07-1.55, P=0.0089) with significant covariate of increased pre-operative central sensitization inventory (CSI) scores (adjusted OR=1.05, 95% CI=1.01-1.09, P=0.0111; area under the curve (AUC)=0.691). CONCLUSION: There was no association between increased pain score upon LA injection and acute post-cesarean pain, but it was associated with sub-acute post-cesarean pain. Further work is needed to define pain score upon LA injection as a convenient pragmatic measure of risk stratifying patients predisposed to sub-acute post-cesarean pain.

The Current Clinically Relevant Findings on COVID-19 Pandemic.

The emergence of a novel coronavirus and coronavirus disease 2019 (COVID-19) represents a challenge to global healthcare. In the past 20 years, this is the third coronavirus that jumped the species barrier and infected humans. It is highly contagious but associated with low pathogenicity. First identified in Wuhan, China, a city of over 11 million, the disease has since spread to every continent except Antarctica. About 15% to 20% of all cases may be called severe, and it is believed many cases are asymptomatic. The average age of a person with COVID has been reported as 49 years. Worse outcomes are associated with geriatric populations and those with underlying diseases such as cardiovascular, respiratory disorders, and/or diabetes. The coronavirus, like other coronaviruses, is highly contagious and has a latency period of about 14 days. Most patients present with fever and a dry cough, but fever may be absent. Differential diagnosis can be challenging since influenza may present with similar symptoms. Chest radiography or computed tomography may be used to find evidence of secondary pneumonia. Nosocomial infection is of concern, and it has been reported that 3.8% of all cases with COVID-19 in that country involve healthcare workers in China. Most patients have mild disease, and supportive care suffices. A variety of repurposed and investigational drugs are being evaluated. There are currently no antiviral therapies or vaccines, even if many therapies are proposed. Hand hygiene, social distancing, and scientifically sound information are the best strategies at the moment to combat this epidemic.

The Expanding Role of the COX Inhibitor/Opioid Receptor Agonist Combination in the Management of Pain.

Pain management in both outpatient and inpatient settings demands a multidisciplinary approach entailing medical, physical and psychological therapies. Among these, multimodal analgesic regimens stand out as a promising treatment options. Cyclo-oxygenase (COX) inhibitor/opioid receptor agonist combinations hold great potential as effective pillars in the multimodal pain management by providing adequate analgesia with fewer safety risks due to COX inhibitors' opioid-sparing effect. Thus, these combinations, either freely or in fixed-dose formulation, offer a feasible option for the prescribing clinicians who seek to maximise therapeutic effect while simultaneously minimise adverse effects. The selection of the appropriate non-steroidal anti-inflammatory drug (NSAID) and opioid agent at optimal doses is essential. It should be tailored to the patients' analgesic necessities, and his/her gastrointestinal and cardiovascular risk, and potential concurrent aspirin use. Moreover, it should allow for addiction risk and the potential opioid-induced bowel dysfunction and constipation. To ensure an optimal match between the characteristics of the patient and the properties of the chosen medication, and to guide adequate and well-tolerated treatment decisions, it is of paramount importance to expand clinicians' knowledge of the currently available COX inhibitor/opioid receptor agonist combinations. This invited narrative review deals with the literature evidence covering the components of multimodal opioid-sparing analgesic regimens. Also, it provides insights into the clinically relevant choice criteria to ensure a patient-tailored analgesia.

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.

Epidemiologic Characteristics of Multimorbidity and Sociodemographic Factors Associated With Multimorbidity in a Rapidly Aging Asian Country.

Importance: Multimorbidity is a growing health care problem in aging societies and is strongly associated with epidemiologic characteristics and sociodemographic factors. Knowledge of these associations is important for the design of effective preventive and management strategies. Objectives: To determine the association between multimorbidity and sociodemographic factors (age, socioeconomic status [SES], sex, and race/ethnicity) and the association between mental health diseases and physical diseases, as well as their implications for the types and costs of health care use. Design, Setting, and Participants: This population-based cross-sectional study used deidentified Singapore Eastern Regional Health System data collected between January 1, 2012, and December 31, 2016. Patients who were alive as of January 1, 2016, and residing in the Regional Health System region in 2016 (N = 1 181 024) were included. Patients who had no year of birth records (n = 573), were born in 2017 (n = 93), or died before January 1, 2016 (n = 47 322), were excluded. Main Outcomes and Measures: Multimorbidity, age, sex, SES, mental health, race/ethnicity, and health care use. Results: In the study population of 1 181 024 individuals, the mean (SD) age was 39.6 (22.1) years, 51.2% were women, 70.1% were Chinese, 7.1% were Indian, 13.5% were Malayan, and 9.3% were other races/ethnicities. Multimorbidity, present in 26.2% of the population, was more prevalent in female (26.8%; 95% CI, 26.7%-26.9%) than in male (25.6%; 95% CI, 25.5%-25.7%) patients and among patients with low SES (41.6%) than those with high SES (20.1%). Mental health diseases were significantly more prevalent among individuals with low SES (5.2%; 95% CI, 5.1%-5.2%) than high SES (2.1%; 95% CI, 2.0%-2.1%; P < .001). The 3 most prevalent disease combinations were chronic kidney disease and hypertension, chronic kidney disease and lipid disorders, and hypertension and lipid disorders. Although chronic kidney disease, hypertension, lipid disorders, and type 1 and/or type 2 diabetes-related diseases had a low cost per capita, the large number of patients with these conditions caused the overall proportion of the cost incurred by health care use to be more than twice that incurred in other diseases. Conclusions and Relevance: These findings emphasize the association between multimorbidity and sociodemographic factors such as increasing age, lower SES, female sex, and increasing number of mental disorders. Health care policies need to take sociodemographic factors into account when tackling multimorbidity in a population.

Developing population health research priorities in Asian city state: Results from a multi-step participatory community engagement.

OBJECTIVES: To identify a broad range of research priorities to inform the studies seeking to improve population health outcomes based on the engagement of diverse stakeholders. METHODS: A multi-step, participatory and mixed-methods approach was adopted to solicit and structure the investigative themes from diverse stakeholders. The priority setting exercise involved four key phases: (1) feedback from community leadership; (2) interim ranking survey and focus group discussions during the population health symposium; (3) individual in-depth interviews with stakeholders in the community; and (4) synthesis of the research priorities from the multistep process. RESULTS: Diverse stakeholders in Singapore, comprising community partnership leaders, health care and social service providers, users of population health services, patients and caregivers, participated in the research priority setting exercise. Initial 14 priorities were identified from six community leadership feedback, 42 survey responses, two focus groups (n = 16) and 95 in-depth interviews. The final integrated research agenda identified six priorities: empower residents and patients to take charge of their health; improve care transition and management through relationship building and communication; enhance health-social care interface; improve respite care services for long-term caregivers; develop primary care as a driving force for care integration; and capacity building for service providers. Selected research questions in each priority area were also generated to develop novel models of care, foster collaboration, implement optimal services and enhance understanding of the end users' care needs. CONCLUSIONS: This study illuminates that greater community engagement in research priority setting for population health can facilitate the formulation of evidence-based research agendas that matter to the care providers and service users in the community. The outcomes derived from this exercise will help focus researchers' efforts through which meaningful gains can be made for population health.