Meta-DHGNN: method for CRS-related cytokines analysis in CAR-T therapy based on meta-learning directed heterogeneous graph neural network.

Chimeric antigen receptor T-cell (CAR-T) immunotherapy, a novel approach for treating blood cancer, is associated with the production of cytokine release syndrome (CRS), which poses significant safety concerns for patients. Currently, there is limited knowledge regarding CRS-related cytokines and the intricate relationship between cytokines and cells. Therefore, it is imperative to explore a reliable and efficient computational method to identify cytokines associated with CRS. In this study, we propose Meta-DHGNN, a directed and heterogeneous graph neural network analysis method based on meta-learning. The proposed method integrates both directed and heterogeneous algorithms, while the meta-learning module effectively addresses the issue of limited data availability. This approach enables comprehensive analysis of the cytokine network and accurate prediction of CRS-related cytokines. Firstly, to tackle the challenge posed by small datasets, a pre-training phase is conducted using the meta-learning module. Consequently, the directed algorithm constructs an adjacency matrix that accurately captures potential relationships in a more realistic manner. Ultimately, the heterogeneous algorithm employs meta-photographs and multi-head attention mechanisms to enhance the realism and accuracy of predicting cytokine information associated with positive labels. Our experimental verification on the dataset demonstrates that Meta-DHGNN achieves favorable outcomes. Furthermore, based on the predicted results, we have explored the multifaceted formation mechanism of CRS in CAR-T therapy from various perspectives and identified several cytokines, such as IFNG (IFN-γ), IFNA1, IFNB1, IFNA13, IFNA2, IFNAR1, IFNAR2, IFNGR1 and IFNGR2 that have been relatively overlooked in previous studies but potentially play pivotal roles. The significance of Meta-DHGNN lies in its ability to analyze directed and heterogeneous networks in biology effectively while also facilitating CRS risk prediction in CAR-T therapy.

PrCRS: a prediction model of severe CRS in CAR-T therapy based on transfer learning.

BACKGROUND: CAR-T cell therapy represents a novel approach for the treatment of hematologic malignancies and solid tumors. However, its implementation is accompanied by the emergence of potentially life-threatening adverse events known as cytokine release syndrome (CRS). Given the escalating number of patients undergoing CAR-T therapy, there is an urgent need to develop predictive models for severe CRS occurrence to prevent it in advance. Currently, all existing models are based on decision trees whose accuracy is far from meeting our expectations, and there is a lack of deep learning models to predict the occurrence of severe CRS more accurately. RESULTS: We propose PrCRS, a deep learning prediction model based on U-net and Transformer. Given the limited data available for CAR-T patients, we employ transfer learning using data from COVID-19 patients. The comprehensive evaluation demonstrates the superiority of the PrCRS model over other state-of-the-art methods for predicting CRS occurrence. We propose six models to forecast the probability of severe CRS for patients with one, two, and three days in advance. Additionally, we present a strategy to convert the model's output into actual probabilities of severe CRS and provide corresponding predictions. CONCLUSIONS: Based on our findings, PrCRS effectively predicts both the likelihood and timing of severe CRS in patients, thereby facilitating expedited and precise patient assessment, thus making a significant contribution to medical research. There is little research on applying deep learning algorithms to predict CRS, and our study fills this gap. This makes our research more novel and significant. Our code is publicly available at https://github.com/wzy38828201/PrCRS . The website of our prediction platform is: http://prediction.unicar-therapy.com/index-en.html .

What is said about #donateliver or #liverdonor? Reflexive thematic analysis of Twitter (X) posts from 2012 to 2022.

BACKGROUND: There is sustained interest in understanding the perspectives of liver transplant recipients and living donors, with several qualitative studies shedding light on this emotionally charged subject. However, these studies have relied primarily on traditional semi-structured interviews, which, while valuable, come with inherent limitations. Consequently, there remains a gap in our comprehension of the broader public discourse surrounding living liver donation. This study aims to bridge this gap by delving into public conversations related to living liver donation through a qualitative analysis of Twitter (now X) posts, offering a fresh perspective on this critical issue. METHODS: To compile a comprehensive dataset, we extracted original tweets containing the hashtags "#donateliver" OR "#liverdonor", all posted in English from January 1, 2012, to December 31, 2022. We then selected tweets from individual users whose Twitter (X) accounts featured authentic human names, ensuring the credibility of our data. Employing Braun and Clarke's reflexive thematic analysis approach, the study investigators read and analysed the included tweets, identifying two main themes and six subthemes. The Health Policy Triangle framework was applied to understand the roles of different stakeholders involved in the discourse and suggest areas for policy improvement. RESULTS: A total of 361 unique tweets from individual users were analysed. The major theme that emerged was the persistent shortage of liver donors, underscoring the desperation faced by individuals in need of life-saving liver transplants and the urgency of addressing the organ shortage problem. The second theme delved into the experiences of liver donors post-surgery, shedding light on a variety of aspects related to the transplantation process, including the visibility of surgical scars, and the significance of returning to physical activity and exercise post-surgery. CONCLUSION: The multifaceted experiences of individuals involved in the transplantation process, both recipients and donors, should be further studied in our efforts to improve the critical shortage of liver donors.

The perceptions and adoption of environmentally sustainable practices among anesthesiologists-a qualitative study.

PURPOSE: Previous surveys of anesthesiologists showed that despite a strong interest in implementing environmentally sustainable anesthetic practices, less than a third do so. Qualitative understanding of the capability, opportunity, and motivational factors that influence "green" behavior will inform the design of effective interventions to promote environmentally sustainable practices in the operating room (OR). METHODS: We conducted 23 semistructured interviews with anesthesiologists, with data saturation achieved. Applying the Behavior Change Wheel, interview questions addressed "capability," "opportunity," and "motivation" determinants of behavior. RESULTS: Preference for sevoflurane and syringe reuse were most commonly cited as existing environmentally sustainable anesthetic practices. Several participants reported lack of knowledge and feedback as impediments to sustainable anesthetic practices. Reported physical barriers included inadequate recycling facilities and abundance of supplies. Interviewees also discussed the importance of habitual behavior in improving skill sets and reducing cognitive load required to perform environmentally sustainable practices. General awareness of environmental issues and aggregation of marginal gains were reasons for environmentally sustainable measures in the OR. Organizational practice and culture played a significant role in the propagation of sustainable anesthetic practices, with senior staff often carrying a greater influence. While the majority preferred a top-down approach to effect change, others favored the use of incentives. CONCLUSION: This study provides insight into the factors that influence the adoption of environmentally sustainable practices in the OR. Measures to promote these practices include education and training, feedback on efforts, engagement of senior anesthetists as role models and for change management, environmental restructuring, and policy designs that balance a top-down vs bottom-up approach to influencing change.

RéSUMé: OBJECTIF: Des enquêtes antérieures auprès d'anesthésiologistes ont montré que, malgré un vif intérêt pour la mise en œuvre de pratiques anesthésiques durables sur le plan environnemental, moins d'un tiers les mettent en pratique. La compréhension qualitative de la capacité, des possibilités et des facteurs de motivation qui influencent les comportements « verts ¼ éclairera la conception d'interventions efficaces pour promouvoir des pratiques durables sur le plan environnemental en salle d'opération. MéTHODE: Nous avons mené 23 entretiens semi-structurés avec des anesthésiologistes, avec une saturation des données atteinte. En appliquant la roue du changement de comportement, les questions d'entrevue portaient sur les déterminants du comportement liés à la « capacité ¼, à l'« occasion ¼ et à la « motivation ¼. RéSULTATS: La préférence pour le sévoflurane et la réutilisation des seringues ont été le plus souvent citées comme des pratiques anesthésiques durables. Plusieurs participants ont signalé que le manque de connaissances et de rétroaction constituait un obstacle à des pratiques anesthésiques durables. Parmi les obstacles physiques signalés, mentionnons l'insuffisance des installations de recyclage et l'abondance des fournitures. Les personnes interrogées ont également discuté de l'importance du comportement habituel pour améliorer les compétences et réduire la charge cognitive requise pour mettre en œuvre des pratiques durables. La prise de conscience générale des questions environnementales et l'agrégation des gains marginaux étaient les raisons citées pour lesquelles des mesures écologiquement viables ont été prises en salle d'opération. La pratique organisationnelle et la culture ont joué un rôle important dans la diffusion de pratiques anesthésiques durables, les cadres supérieurs ayant souvent une plus grande influence. Alors que la majorité préférerait une approche descendante pour apporter des changements, d'autres étaient en faveur de l'utilisation d'incitatifs. CONCLUSION: Cette étude donne un aperçu des facteurs qui influencent l'adoption de pratiques durables sur le plan environnemental en salle d'opération. Les mesures visant à promouvoir ces pratiques comprennent l'éducation et la formation, la rétroaction sur les efforts, l'engagement des anesthésistes plus établis ou senior en tant que modèles et gestionnaires du changement, la restructuration environnementale et la conception de politiques qui équilibrent une approche descendante vs une approche ascendante pour influencer le changement.

Validation of a smartphone-based screening tool (Biliscan) for neonatal jaundice in a multi-ethnic neonatal population.

AIM: Neonatal jaundice is an important and prevalent condition that can cause kernicterus and mortality. This study validated a smartphone-based screening application (Biliscan) in detecting neonatal jaundice. METHODS: A cross-sectional prospective study was conducted at the neonatal unit in a tertiary teaching hospital between August 2020 and October 2021. All babies born at the gestation of 35 weeks and above with clinical jaundice or are recommended for screening of jaundice within 21 days of post-natal age were recruited. Using Biliscan, images of the babies' skin over the sternum were taken against a standard colour card. The application uses feature extraction and machine learning regression to estimate the bilirubin level. Independent Biliscan bilirubin estimates (BsB) were made and compared with total serum bilirubin (TSB) and transcutaneous bilirubin (TcB) levels. Bland Altman plots were used to establish the agreement between BsB and TSB, as well as TcB, using the clinically acceptable limits of agreement of ±35 µmol/L, which were defined a priori. Pearson correlation coefficient was assessed to establish the strength of the relationship between BsB versus TSB and TcB. Diagnostic accuracy was assessed through receiver operating characteristic curve analysis. RESULTS: Sixty-one paired TSB-BsB and 85 paired TcB-BsB measurements were obtained. Bland Altman plot for the entire group showed that 54% (33/61) of the pairs of TSB and BsB readings and 66% (56/85) of the pairs of TcB and BsB readings were within the maximum clinically acceptable difference of 35 µmol/L. Pearson r for BsB versus TSB and TcB was 0.54 (P < 0.001) and 0.66 (P < 0.001) respectively. Compared with TSB, the recommended gold standard measure for jaundice, Biliscan has a sensitivity of 76.92% and specificity of 70.83% for jaundice requiring phototherapy. The positive and negative predictive values in term infants were 93.3% and 36.9%, respectively. CONCLUSION: Our results suggest that there is moderate correlation and mediocre agreement between BsB and TSB, as well as TcB. Improvement to the application algorithm and further studies that include a larger population, and a wider range of bilirubin values are necessary before the tool may be considered for use in screening of jaundice in newborns.

Medical school curriculum in the digital age: perspectives of clinical educators and teachers.

BACKGROUND: There is a need to reexamine Singapore's medical school curricula in light of the increasing digitalization of healthcare. Notwithstanding Singapore's digital competitiveness, there is a perceived gap in preparing its medical students for the digital age. Furthermore, limited research has evaluated the extent to which skills in using digital technologies should be taught to medical students in Asian medical schools to prepare them for future clinical practice- a gap that is filled by this study. Using Singapore as a case study, it explores the views of some local clinical educators and teachers towards the need to impart skills in digital technologies to medical students. It also offers recommendations on ways to balance the clinicians' concerns about these technologies with the digital competencies needed for clinical practice. METHODS: Findings were drawn from individual interviews with 33 clinical educators and teachers from Singapore's public and private healthcare sectors. They were recruited using purposive sampling. Data were interpreted using qualitative thematic analysis. RESULTS: Participants included vice deans of education from all three local medical schools and senior consultants from a wide variety of disciplines. Overall, they acknowledged two benefits of equipping students with skills in digital technologies including promoting the culture of innovation and improving work efficiency. However, they also highlighted four main concerns of imparting these skills: (i) erosion of basic clinical skills, (ii) neglect of a generalist approach to healthcare characterized by holistic management of patients, inter-professional collaboration, and commitment to breadth of practice within each specialty, (iii) rapid pace of technological advances, and (iv) de-personalisation by technology. CONCLUSIONS: The findings show that medical students in Singapore would benefit from a curriculum that teaches them to use digital technologies alongside core clinical skills.

Viewing interprofessional collaboration through the lens of networked ecological systems theory.

Interprofessional collaboration (IPC) is key to ensuring safe quality care for patients. However, IPC intervention outcomes are variable, leading to calls for systems theories to understand complex interactions in healthcare. Using networked ecological systems theory (NEST), we aimed to uncover facilitators and barriers impacting the interactions between nurses and physicians in a specialty healthcare center. A qualitative study involving 55 non-participant observations and 17 individual semi-structured interviews was conducted at the National Neuroscience Institute of Singapore from April 2019 to March 2021. Template analysis was used to analyze the data. The most important IPC facilitators were exosystemic institutional support and physicians' willingness to engage in IPC in the microsystems that together enabled the establishment of disease-based outpatient programs fostering patient-centered interactions among different healthcare professionals (HCP). We also found that patient-, disease-, and systems-related knowledge played an important role in facilitating IPC. Macrosystemic entrenchments such as intraprofessional composition of ward rounds emerged as a significant barrier. However, microsystemic efforts such as chat groups connecting all HCP involved in the care of the patients in the wards have fostered IPC. Although still preliminary, these findings suggest NEST can be useful to inform systematic interventions to improve IPC.

Improving sensitivity of the connective tissue disease screening questionnaire: A comparative study of various scoring methods.

OBJECTIVES: Early detection of autoimmune rheumatic diseases is crucial given their high morbidity and mortality and short window of opportunity to improve patient outcomes. Self-administered screening questionnaires such as the connective tissue disease screening questionnaire (CSQ) have been shown to promote early detection of autoimmune rheumatic diseases. However, optimal scoring of screening questionnaires may differ with prevalence of clinical features and changes in classification criteria. We compared the performance of 3 scoring methods for the CSQ for early detection of autoimmune rheumatic diseases in a multi-ethnic Asian population. METHODS: Patients who were newly referred for evaluation of possible autoimmune rheumatic diseases were invited to answer the cross-culturally adapted CSQ. Detection of autoimmune rheumatic diseases using 1) the original CSQ scoring, 2) a modified CSQ scoring and 3) a scoring based on current classification criteria, were compared to classification of autoimmune rheumatic diseases by classification criteria. RESULTS: Of 819 participants, 85 were classified as having autoimmune rheumatic diseases screened for by the adapted CSQ. The original CSQ scoring yielded relatively lower sensitivities in detecting both any and individual autoimmune rheumatic diseases (67% and 20-57%, respectively) compared to the modified CSQ scoring (81% and 60-73%, respectively) and the scoring based on current classification criteria (89% and 50-88%, respectively). CONCLUSION: The adapted CSQ with the classification criteria-based scoring achieved relatively high sensitivities in detecting autoimmune rheumatic diseases, suggesting this could be employed as the first step in population screening.

The impact of the coronavirus disease 2019 pandemic on gastroenterologists in Southeast Asia: A mixed-methods study.

BACKGROUND AND AIM: The coronavirus disease 2019 pandemic has impacted gastroenterology practices worldwide; however, its protracted effects within Southeast Asia were unknown. The primary aim of the study was to determine the impact of the pandemic on clinical demands including burnout among gastroenterologists within the region. The secondary aim was to identify risk factors for burnout and determine regional stressors. METHODS: This was a mixed-methods study. Gastroenterologists were surveyed electronically between September 1 and December 7, 2020, via gastroenterology and endoscopy societies of Brunei, Indonesia, Malaysia, Philippines, Singapore, and Thailand. Quantitative and qualitative data were collected. The 22-item Maslach Burnout Inventory-Human Services Survey (MBI-HSS) was used to detect burnout. Quantitative data were non-parametric; non-parametric methods were used for statistical comparisons. Logistic regression was used to determine risk factors for burnout. Content analysis method was used to analyze qualitative data. Ethical approval was obtained. RESULTS: A total of 73.0% reported that they were still significantly affected by the pandemic. Of these, 40.5% reported increased workload and 59.5% decreased workload. Statistically significant differences in weekly working hours, endoscopy, and inpatient volumes were present. No differences were observed in outpatient volumes, likely because of telemedicine. Burnout was common; however, 50.1% of gastroenterologists were unaware of or did not have access to mental health support. This, as well as depression, being a trainee, and public sector work, increased burnout risk significantly. CONCLUSION: The effects of the pandemic are multifaceted, and burnout is common among Southeast Asian gastroenterologists. Safeguards for mental health are suboptimal, and improvements are urgently needed.

Developing item banks to measure three important domains of health-related quality of life (HRQOL) in Singapore.

OBJECTIVES: To develop separate item banks for three health domains of health-related quality of life (HRQOL) ranked as important by Singaporeans - physical functioning, social relationships, and positive mindset. METHODS: We adapted the Patient Reported Outcomes Measurement Information System Qualitative Item Review protocol, with input and endorsement from laymen and experts from various relevant fields. Items were generated from 3 sources: 1) thematic analysis of focus groups and in-depth interviews for framework (n = 134 participants) and item(n = 52 participants) development, 2) instruments identified from a literature search (PubMed) of studies that developed or validated a HRQOL instrument among adults in Singapore, 3) a priori identified instruments of particular relevance. Items from these three sources were "binned" and "winnowed" by two independent reviewers, blinded to the source of the items, who harmonized their selections to generate a list of candidate items (each item representing a subdomain). Panels with lay and expert representation, convened separately for each domain, reviewed the face and content validity of these candidate items and provided inputs for item revision. The revised items were further refined in cognitive interviews. RESULTS: Items from our qualitative studies (51 physical functioning, 44 social relationships, and 38 positive mindset), the literature review (36 instruments from 161 citations), and three a priori identified instruments, underwent binning, winnowing, expert panel review, and cognitive interview. This resulted in 160 candidate items (61 physical functioning, 51 social relationships, and 48 positive mindset). CONCLUSIONS: We developed item banks for three important health domains in Singapore using inputs from potential end-users and the published literature. The next steps are to calibrate the item banks, develop computerized adaptive tests (CATs) using the calibrated items, and evaluate the validity of test scores when these item banks are administered adaptively.

Perception survey of crisis and emergency risk communication in an acute hospital in the management of COVID-19 pandemic in Singapore.

BACKGROUND: Emergency risk communication is a critical component in emergency planning and response. It has been recognised as significant for planning for and responding to public health emergencies. While there is a growing body of guidelines and frameworks on emergency risk communication, it remains a relatively new field. There has also been limited attention on how emergency risk communication is being performed in public health organisations, such as acute hospitals, and what the associated challenges are. This article seeks to examine the perception of crisis and emergency risk communication in an acute hospital in response to COVID-19 pandemic in Singapore and to identify its associated enablers and barriers. METHODS: A 13-item Crisis and Emergency Risk Communication (CERC) Survey, based on the US Centers for Disease and Control (CDC) CERC framework, was developed and administered to hospital staff during February 24-28, 2020. The survey also included an open-ended question to solicit feedback on areas of CERC in need of improvement. Chi-square test was used for analysis of survey data. Thematic analysis was performed on qualitative feedback. RESULTS: Of the 1154 participants who responded to the survey, most (94.1%) reported that regular hospital updates on COVID-19 were understandable and actionable. Many (92.5%) stated that accurate, concise and timely information helped to keep them safe. A majority (92.3%) of them were clear about the hospital's response to the COVID-19 situation, and 79.4% of the respondents reported that the hospital had been able to understand their challenges and address their concerns. Sociodemographic characteristics, such as occupation, age, marital status, work experience, gender, and staff's primary work location influenced the responses to hospital CERC. Local leaders within the hospital would need support to better communicate and translate hospital updates in response to COVID-19 to actionable plans for their staff. Better communication in executing resource utilization plans, expressing more empathy and care for their staff, and enhancing communication channels, such as through the use of secure text messaging rather than emails would be important. CONCLUSION: CERC is relevant and important in the hospital setting to managing COVID-19 and should be considered concurrently with hospital emergency response domains.

Development and calibration of a novel social relationship item bank to measure health-related quality of life (HRQoL) in Singapore.

BACKGROUND: Social relationships (SR) is an important domain of health-related quality of life. We developed and calibrated a novel item bank to measure SR in Singapore, a multi-ethnic city in Southeast Asia. METHODS: We developed an initial candidate pool of 51 items from focus groups, individual in-depth interviews and existing instruments that had been developed and/or validated for use in Singapore. We administered all items in English to a multi-stage sample of subjects, stratified for age and gender, with and without medical conditions, recruited from community and hospital settings. We calibrated their responses using Samejima's Graded Response Model (SGRM). We evaluated a final 30-item bank with respect to Item Response Theory (IRT) model assumptions, model fit, differential item functioning (DIF), and concurrent and known-groups validity. RESULTS: Among 503 participants (47.7% male, 41.4% above 50 years old, 34.0% Chinese, 33.6% Malay and 32.4% Indian), bi-factor model analyses supported essential unidimensionality: explained common variance of the general factor was 0.805 and omega hierarchical was 0.98. Local independence was deemed acceptable: the average absolute residual correlations were < 0.06 and 1.8% of the total item-pair residuals were flagged for local dependence. The overall SGRM model fit was adequate (p = 0.146). Five items exhibited DIF with respect to age, ethnicity and education, but were retained without modification of scores because they measured important aspects of SR. The SR scores correlated in the hypothesized direction with a self-reported measure of global health (Spearman's rho = - 0.28, p < 0.001). CONCLUSION: The 30-item SR item bank has shown acceptable psychometric properties. Future studies to evaluate the validity of SR scores when items are administered adaptively are needed.

Utility of a Medical Alert Protection System compared to telephone follow-up only for home-alone elderly presenting to the ED - A randomized controlled trial.

OBJECTIVE: Medical Alert Protection Systems (MAPS) are a form of assistive technology designed to support independent living in the care of elderly patients in the community. We aimed to investigate the utility of using such a device (eAlert! System) in elderly patients presenting to an Emergency Department (ED). METHODS: Elderly patients presenting to an ED were randomized to receive MAPS or telephone follow-up only (control arm). All patients were followed up at one-week, one-month and six-month post-intervention. A confidence scale (at 1week, 1month and 6months) and EQ-5D score (at 6months) were also administered. RESULTS: 106 and 91 participants enrolled in the MAPS and control arms respectively. Within both individual arms, there were significant reductions in the median number of ED visits and median number of admissions in the six month periods before, compared to after intervention (p<0.01 for both). However, the reductions were not significantly different between the two arms. Among participants who have had one or more admissions during the six months period post intervention, the MAPS arm had significantly lower median total length of stay (8days, Interquartile Range [IQR]=(4, 14)) compared to the control arm (15days, IQR=(3, 25), p=0.045). The median health state score for health state was significantly higher in the MAPS arm (70 IQR=(60,80) versus 60 IQR=(50,70), p=0.008). CONCLUSION: In this population of elderly ED patients, the use of a MAPS decreased length of stay for admissions and improved quality of life measures.

Inpatient glucose management programme in the Asian healthcare setting.

AIM: To implement an inpatient glucose management (IGM) programme in the general medical wards and evaluate its clinical efficacy. METHOD: Consecutive patients admitted to selected medical wards over a 12-month period were included in the IGM programme. All patients with ≥3 capillary blood glucose (CBG) readings (>10.0 mmol/L and/or <4.0 mmol/L) over a 24-hour period were identified electronically. A multidisciplinary team of diabetes care providers would provide specialist input to these patients. The control group comprised of consecutive patients admitted over the preceding 12 months. Outcome glucose measures include mean in-hospital glucose (MHG), mean patient-day glucose (MDG), proportion of CBG readings at predefined cut-offs and length of stay (LOS). RESULTS: Both the MHG and MDG were significantly lower following intervention (10.0±2.4 mmol/L vs 11.2±2.6 mmol/L, P<.001; 10.0±2.3 mmol/L vs 11.2±2.6 mmol/L, P<.001, respectively). Prevalence of hyperglycaemic events, defined by CBG >10.0 mmol/L, was significantly lower at 36.5% versus 51.6% (P<.001). Hypoglycaemic events of CBG <4.0 mmol/L remained infrequent at <1.0% before and after IGM programme. A greater proportion of glucose readings was controlled within the target range of 4.0-10.0 mmol/L (62.6% vs 47.6%, P<.001). With the IGM programme in place, more patients received scheduled CBG monitoring, and a significant shortening of mean LOS by 3.2 days was observed (P=.02). CONCLUSIONS: The IGM programme was effective in improving inpatient glycaemic monitoring and control in the general medical wards, with a significant reduction in LOS observed. These demonstrated the programme's potential to enhance quality and efficiency of patient care.

Going beyond compliance: A qualitative study of the practice of surgical safety checklist.

BACKGROUND: The World Health Organization Surgical Safety Checklist (SSC) is a tool designed to enhance team communication and patient safety. When used properly, the SSC acts as a layer of defence against never events. In this study, we performed secondary qualitative analysis of operating theatres (OT) SSC observational notes to examine how the SSC was used after an intensive SSC re-implementation effort and drew on relevant theories to shed light on the observed patterns of behaviours. We aimed to go beyond assessing checklist compliance and to understand potential sociopsychological mechanisms of the variations in SSC practices. METHODS: Direct observation notes of 109 surgical procedures across 13 surgical disciplines were made by two trained nurses in the OT of a large tertiary hospital in Singapore from February to April 2022, three months after SSC re-implementation. Only notes relevant to the use of SSC were extracted and analyzed using reflexive thematic analysis. Data were coded following an inductive process to identify themes or patterns of SSC practices. These patterns were subsequently interpreted against a relevant theory to appreciate the potential sociopsychological forces behind them. RESULTS: Two broad types of SSC practices and their respective sub-themes were identified. Type 1 (vs. Type 2) SSC practices are characterized by patience and thoroughness (vs. hurriedness and omission) in carrying out the SSC process, dedication and attention (vs. delegation and distraction) to the SSC safety checks, and frequent (vs. absence of) safety voices during the conduct of SSC. These patterns were conceptualized as safety-seeking action vs. ritualistic action using Merton's social deviance theory. CONCLUSION: Ritualistic practice of the SSC can undermine surgical safety by creating conditions conducive to never events. To fully realize the SSC's potential as an essential tool for communication and safety, a concerted effort is needed to balance thoroughness with efficiency. Additionally, fostering a culture of collaboration and collegiality is crucial to reinforce and enhance the culture of surgical safety.

Relationship between CGM-derived nocturnal hypoglycemia and subjective sleep quality in people with type 1 diabetes.

This pilot study explores the relationship between nocturnal hypoglycemia (NH) and subjective sleep quality in people with type 1 diabetes (T1D). Twenty-seven adults with T1D wore a Freestyle Libre Pro CGM and recorded subjective sleep quality daily, as assessed by a single Likert scale question. Frequency, duration, area under the curve (AUC) of NH (00:00-06:00) defined as sensor glucose below threshold (< 3.9 mmol/L; < 3 mmol/L) for ≥ 15 min, nocturnal mean glucose, Time in Range (3.9-10 mmol/L), and coefficient of variation were calculated. Twenty-seven adults, 18 (66.7%) women, with median (IQR) age of 27 (26, 32) years and HbA1c of 7.6 (7.1, 8.1) participated. Nights with NH < 3.9 mmol/L resulted in a lower (worse) sleep score than nights without NH [Mean (SD): 3.3 (1.2) vs 3.5 (1.0), p = 0.03). A higher frequency and longer duration but not AUC [adjusted OR (95% CI) 0.52 (0.38, 0.72), 0.961 (0.932, 0.991), 0.999 (0.998, 1.001) respectively)], of NH < 3.9 mmol/L, were associated with a lower sleep score. NH < 3.0 mmol/L metrics were not associated with sleep quality. Recurrent NH < 3.9 mmol/L, rather than prolonged NH < 3.0 mmol/L, seems associated with subjective sleep quality, implying that those with the highest burden of NH are likely unaware of it.

Battling against the great disruption to surgical care in a pandemic: experiences of 11 South and Southeast Asian countries.

OBJECTIVES: The majority of the cancelled elective surgeries caused by the COVID-19 pandemic globally were estimated to occur in low- and middle-income countries (LMICs), where surgical services had long been in short supply even before the pandemic. Therefore, minimising disruption to existing surgical care in LMICs is of crucial importance during a pandemic. This study aimed to explore contributory factors to the continuity of surgical care in LMICs in the face of a pandemic. DESIGN: Semistructured interviews were conducted over zoom with surgical leaders of 25 tertiary hospitals from 11 LMICs in South and Southeast Asia in September to October 2020. Key themes were subsequently identified from the interview transcripts using the Braun and Clarke's method of thematic analysis. RESULTS: The COVID-19 pandemic affected all surgical services of participating institutions to varying degrees. Overall, elective surgeries suffered the gravest disruption, followed by outpatient surgical care, and finally emergency surgeries. Keeping healthcare workers safe and striving for continuity of essential surgical care emerged as notable response strategies observed across all participating institutions. CONCLUSION: This study suggested that four factors are important for the resilience of surgical care against COVID-19: adequate COVID-19 testing capacity and effective institutional infection control measures, designated COVID-19 treatment facilities, whole-system approach to balancing pandemic response and meeting essential surgical needs, and active community engagement. These findings can inform healthcare institutions in other countries, especially LMICs, in their effort to tread a fine line between preserving healthcare capacity for pandemic response and protecting surgical services against pandemic disruption.

Association of Smartphone-Based Activity Tracking and Nocturnal Hypoglycemia in People With Type 1 Diabetes.

BACKGROUND: Nocturnal hypoglycemia (NH) remains a major burden for people with type 1 diabetes (T1D). Daytime physical activity (PA) increases the risk of NH. This pilot study tested whether cumulative daytime PA measured using a smartphone-based step tracker was associated with NH. METHODS: Adults with T1D for ≥ 5 years (y) on multiple daily insulin or continuous insulin infusion, not using continuous glucose monitoring and HbA1c 6 to 10% wore blinded Freestyle Libre Pro sensors and recorded total daily carbohydrate (TDC) and total daily dose (TDD) of insulin. During this time, daily step count (DSC) was tracked using the smartphone-based Fitbit MobileTrack application. Mixed effects logistic regression was used to estimate the effect of DSC on NH (sensor glucose <70, <54 mg/dl for ≥15 minutes), while adjusting for TDC and TDD of insulin, and treating participants as a random effect. RESULTS: Twenty-six adults, with 65.4% females, median age 27 years (interquartile range: 26-32) mean body mass index 23.9 kg/m2, median HbA1c 7.6% (7.1-8.1) and mean Gold Score 2.1 (standard deviation 1.0) formed the study population. The median DSC for the whole group was 2867 (1820-4807). There was a significant effect of DSC on NH episodes <70 mg/dl. (odds ratio 1.11 [95% CI: 1.01-1.23, P = .04]. There was no significant effect on NH <54 mg/dl. CONCLUSION: Daily PA measured by a smartphone-based step tracker was associated with the risk of NH in people with type 1 diabetes.

Experiences of environmental services workers in a tertiary hospital in Asia during the COVID-19 pandemic: a qualitative study.

Background: The Coronavirus Disease 2019 (COVID-19) pandemic has had a significant impact on all walks of life, in particular, environmental services workers in healthcare settings had higher workload, increased stress and greater susceptibility to COVID-19 infections during the pandemic. Despite extensive literature describing the impact of the pandemic on healthcare workers such as doctors and nurses, studies on the lived experiences of environmental services workers in healthcare settings are sparse and none has been conducted in the Asian context. This qualitative study thus aimed to examine the experiences of those who worked for a year of the COVID-19 pandemic. Methods: A purposive sample of environmental services workers was recruited from a major tertiary hospital in Singapore. Semi-structured interviews were conducted in-person, lasting around 30min, and included open-ended questions pertaining to five main domains: work experiences during COVID-19, training and education needs, resource and supplies availability, communication with management and other healthcare staff, and perceived stressors and support. These domains were identified based on team discussions and literature review. The interviews were recorded and transcribed for thematic analysis, as guided by Braun and Clarke. Results: A total of 12 environmental services workers were interviewed. After the first seven interviews, no new themes emerged but an additional five interviews were done to ensure data saturation. The analysis yielded three main themes and nine subthemes, including (1) practical and health concerns, (2) coping and resilience, and (3) occupational adaptations during the pandemic. Many expressed confidence in the preventive efficacy of proper PPE, infection control practice and COVID-19 vaccination in protecting them against COVID-19 and severe illness. Having prior experience with infectious disease outbreaks and previous training in infection control and prevention appeared to be useful as well for these workers. Despite the various challenges presented by the pandemic, they could still find meaning in their everyday work by positively impacting the wellbeing of patients and other healthcare workers in the hospital. Conclusion: Besides uncovering the concerns shared by these workers, we identified helpful coping strategies, resilience factors and certain occupational adaptations, which have implications for future pandemic planning and readiness.

Economic Evaluation of Novel Models of Care for Patients With Acute Medical Problems.

Importance: During COVID-19, Singapore simultaneously experienced a dengue outbreak, and acute hospitals were under pressure to lower bed occupancy rates. This led to new models of care to treat patients with acute, low-severity medical conditions either at home, in a hospital-at-home (HaH) model, or in a clinic-style setting sited at the emergency department in an ambulatory care team (ACT) model, but a reliable cost analysis for these models is lacking. Objective: To compare personnel costs of HaH and ACT with inpatient care. Design, Setting, and Participants: In this economic evaluation study, time-driven activity-based costing was used to compare the personnel cost of inpatient care with treating dengue via HaH and treating chest pain via ACT. Participants were patients with nonsevere dengue and chest pain unrelated to a coronary event admitted via the emergency department to the internal medicine service of a tertiary hospital in Singapore. Exposures: HaH for dengue and ACT for chest pain. Main Outcomes and Measures: A process map was created for the patient journey for a typical patient with each condition. The amount of time personnel spent on delivering care was estimated and the cost per minute determined based on their wages in 2022. The total cost of care was calculated by multiplying the time spent by the per-minute cost of the personnel resource and summing all costs. Results: Compared with inpatient care, HaH used 50% less nursing time (418 minutes, 95% uncertainty interval [UI], 370 to 465 minutes) but 80% more medical time (303 minutes, 95% UI, 270 to 338 minutes) per case of dengue. If implemented nationally, HaH would save an estimated 56 828 SGD per year (95% UI, -169 497 to 281 412 SGD [US $41 856; 95% UI, -$124 839 to $207 268]). The probability that HaH is cost saving was 69.2%. Compared with inpatient care, ACT used 15% less nursing time (296 minutes, 95% UI, 257 to 335 minutes) and 50% less medical time (57 minutes, 95% UI, 46 to 69 minutes) per case of chest pain. If implemented nationally, ACT would save an estimated 1 561 185 SGD per year (95% UI, 1 040 666 to 2 086 518 SGD [US $1 149 862; 95% UI, $766 483 to $1 536 786]). The probability that ACT is cost saving was 100%. Conclusions and Relevance: This economic evaluation found that the HaH and ACT models decreased the overall personnel cost of care. Reorganizing hospital resources may help hospitals reap the benefits of reduced hospital-acquired infections, improved patient recovery, and reduced hospital bed occupancy rates.