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Introduction: High users of hospital services require targeted healthcare services planning for effective resource allocation due to their high costs. This study aims to segmentize the population in the "Ageing In Place-Community Care Team" (AIP-CCT), a programme for complex patients with high inpatient service use, and examine the association of segment membership and healthcare utilisation and mortality., Methods: We analysed 1,012 patients enrolled between June 2016 and February 2017. To identify patient segments, a cluster analysis was performed based on medical complexity and psychosocial needs. Next, multivariable negative binomial regression was performed using patient segments as the predictor, with healthcare and programme utilisation over the 180-day follow-up as outcomes. Multivariate cox proportional hazard regression was applied to assess the time to first hospital admission and mortality between segments within the 180-day follow-up. All models were adjusted for age, gender, ethnicity, ward class, and baseline healthcare utilisation., Results: Three distinct segments were identified (Segment 1 (n = 236), Segment 2 (n = 331), and Segment 3 (n = 445)). Medical, functional, and psychosocial needs of individuals were significantly different between segments (p-value<0.001). The rates of hospitalisation in Segments 1 (IRR = 1.63, 95%CI:1.3-2.1) and 2 (IRR = 2.11, 95%CI:1.7-2.6) were significantly higher than in Segment 3 on follow-up. Similarly, both Segments 1 (IRR = 1.76, 95%CI:1.6-2.0) and 2 (IRR = 1.25, 95%CI:1.1-1.4) had higher rates of programme utilisation compared to Segment 3. Patients in Segments 1 (HR = 2.48, 95%CI:1.5-4.1) and 2 (HR = 2.25, 95%CI:1.3-3.6) also had higher mortality on follow-up., Conclusions: This study provided a data-based approach to understanding healthcare needs among complex patients with high inpatient services utilisation. Resources and interventions can be tailored according to the differences in needs among segments, to facilitate better allocation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Ginting et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This study aimed to determine the prevalence of anxiety and burnout, and the coping mechanisms among clinical year undergraduate medical students in Universiti Kebangsaan Malaysia (UKM) during the coronavirus disease 2019 (COVID-19) pandemic. In total, 378 clinical year undergraduate medical students in UKM participated in this cross-sectional study from May to July 2021. A self-administered questionnaire consisting of questions on the participant's sociodemographic data and items from the DASS-21, CBI, and Brief-COPE was distributed. Chi-square and Spearman's correlation tests were used to calculate the correlation coefficient between both anxiety and burnout, and coping mechanisms. The prevalence of anxiety and burnout were 44.2% and 22.2%, respectively. There was a significant difference in the percentage of students with extremely severe anxiety in the presence and absence of burnout, 23.8% vs. 4.8% ( p < 0.001). Among the three coping mechanisms, avoidant coping had a significant positive moderate correlation with both the presence of anxiety ( r = 0.3966, p < 0.001) and the presence of burnout ( r = 0.341, p < 0.001). Meanwhile, coping that was neither approach nor avoidant had a positive weak correlation with the presence of burnout ( r = 0.176, p = 0.001). The prevalence of anxiety and burnout was concerning. Increased anxiety and burnout among students may negatively impact aspects of their personal, professional, and academic lives. Early recognition and preventive measures should be emphasised to prevent negative ramifications.

Objectives: To identify and describe caregiver profiles based on their psychosocial health characteristics over a 12-month period and transitions among these profiles, to determine if stroke rehabilitation use at 12 months post-stroke differed by caregiver profile transition patterns, and to investigate if caregiver profiles at 3 months post-stroke moderate the association of stroke rehabilitation use at 3 months and 12 months post-stroke after accounting for covariates., Design: Latent profile transition analysis of caregiver psychosocial health with stroke rehabilitation use at 12 month post-stroke as outcome., Setting and Participants: A total of 149 stroke patient-caregiver dyads from the Singapore Stroke Study., Methods: Cross-sectional latent profile analyses were conducted on caregiver psychosocial health indicators of burden, depression, health status, quality of relationship with patient, and social support. Changes in latent profile classification over 3 time points (baseline, 3 months, and 12 months post-stroke) were analyzed using latent transition analysis. A transition model with stroke rehabilitation use at 12 months post-stroke as the outcome was tested after accounting for covariates., Results: Two distinct caregiver psychosocial health latent profiles were found across time: nondistressed and distressed. Most caregivers were classified as nondistressed and remained nondistressed over time. Distressed caregivers at baseline were 76% likely to become nondistressed at 12 month post-stroke. Regardless of profile transition patterns, nondistressed caregivers at 12 months post-stroke tended to have cared for stroke rehabilitation nonusers at 12 months post-stroke. Patient depression explained profile classification at 3 months and 12 months post-stroke. After accounting for covariates, rehabilitation users at 3 months post-stroke tended to continue using rehabilitation at 12 months post-stroke only when they had nondistressed caregivers at 3 months post-stroke., Conclusions and Implications: Whether caregiver adaptation explains the associations between the latent profile transition patterns and rehabilitation use at 12 months post-stroke should be examined. Early psychosocial health assessment and sustained support should be made available to stroke caregivers to enhance their well-being and subsequent patient rehabilitation participation., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Informal caregiving is an integral part of post-stroke recovery with strenuous caregiving demands often resulting in caregiving burden, threatening sustainability of caregiving and potentially impacting stroke survivor's outcomes. Our study aimed to examine and quantify objective and subjective informal care burden after stroke; and to explore the factors associated with informal care burden in Singapore., Methods: Stroke patients and their informal caregivers were recruited from all five tertiary hospitals in Singapore from December 2010 to September 2013. Informal care comprised of assistance provided by informal caregivers with any of the activities of daily living. Informal care burden was measured by patients' likelihood of requiring informal care, hours of informal care required, and informal caregivers' Zarit's Burden Score. We examined informal care burden at 3-months and 12-months post-stroke. Generalized linear regressions were applied with control variables including patients' and informal caregivers' demographic characteristics, arrangement of informal care, and patients' health status including stroke severity (measured using National Institute of Health Stroke Scale), functional status (measured using Modified Rankin Scale), self-reported depression, and common comorbidities., Results: Three hundred and five patients and 263 patients were examined at 3-months and 12-months. Around 35% were female and 60% were Chinese. Sixty three percent and 49% of the patients required informal care at 3-months and 12-months point, respectively. Among those who required informal care, average hours required per week were 64.3 h at 3-months and 76.6 h at 12-months point. Patients with higher functional dependency were more likely to require informal care at both time points, and required more hours of informal care at 3-months point. Female informal caregivers and those caring for patients with higher functional dependency reported higher Zarit's Burden. While informal caregivers who worked full-time reported higher burden, those caring for married stroke patients reported lower burden at 3-months point. Informal caregivers who co-cared with foreign domestic workers, i.e.: stay-in migrant female waged domestic workers, reported lower burden., Conclusions: Informal care burden remains high up to 12-months post-stroke. Factors such as functional dependency, stroke severity, informal caregiver gender and co-caring with foreign domestic workers were associated with informal care burden., (© 2021. The Author(s).)

Background: Outpatient medical follow-up post-stroke is not only crucial for secondary prevention but is also associated with a reduced risk of rehospitalization. However, being voluntary and non-urgent, it is potentially determined by both healthcare needs and the socio-demographic context of stroke survivor-caregiver dyads. Therefore, we aimed to examine the role of caregiver factors in outpatient medical follow-up (primary care (PC) and specialist outpatient care (SOC)) post-stroke., Method: Stroke survivors and caregivers from the Singapore Stroke Study, a prospective, yearlong, observational study, contributed to the study sample. Participants were interviewed 3-monthly for data collection. Counts of PC and SOC visits were extracted from the National Claims Database. Poisson modelling was used to explore the association of caregiver (and patient) factors with PC/SOC visits over 0-3 months (early) and 4-12 months (late) post-stroke., Results: For the current analysis, 256 stroke survivors and caregivers were included. While caregiver-reported memory problems of a stroke survivor (IRR: 0.954; 95% CI: 0.919, 0.990) and caregiver burden (IRR: 0.976; 95% CI: 0.959, 0.993) were significantly associated with lower early post-stroke PC visits, co-residing caregiver (IRR: 1.576; 95% CI: 1.040, 2.389) and negative care management strategies (IRR: 1.033; 95% CI: 1.005, 1.061) were significantly associated with higher late post-stroke SOC visits., Conclusion: We demonstrated that the association of caregiver factors with outpatient medical follow-up varied by the type of service (i.e., PC versus SOC) and temporally. Our results support family-centred care provision by family physicians viewing caregivers not only as facilitators of care in the community but also as active members of the care team and as clients requiring care and regular assessments.

Objective: To study the association of caregiver factors and stroke survivor factors with supervised community rehabilitation (SCR) participation over the first 3 months and subsequent 3 to 12 months post-stroke in an Asian setting., Design: Prospective cohort study., Setting: Community setting., Participants: We recruited stroke survivors and their caregivers into our yearlong cohort. Caregiver and stroke survivor variables were collected over 3-monthly intervals. We performed logistic regression with the outcome variable being SCR participation post-stroke., Outcome Measures: SCR participation over the first 3 months and subsequent 3 to 12 months post-stroke RESULTS: 251 stroke survivor-caregiver dyads were available for the current analysis. The mean age of caregivers was 50.1 years, with the majority being female, married and co-residing with the stroke survivor. There were 61%, 28%, 4% and 7% of spousal, adult-child, sibling and other caregivers. The odds of SCR participation decreased by about 15% for every unit increase in caregiver-reported stroke survivor's disruptive behaviour score (OR: 0.845; 95% CI: 0.769 to 0.929). For every 1-unit increase in the caregiver's positive management strategy score, the odds of using SCR service increased by about 4% (OR: 1.039; 95% CI: 1.011 to 1.068)., Conclusion: We established that SCR participation is jointly determined by both caregiver and stroke survivor factors, with factors varying over the early and late post-stroke period. Our results support the adoption of a dyadic or more inclusive approach for studying the utilisation of community rehabilitation services, giving due consideration to both the stroke survivors and their caregivers. Adopting a stroke survivor-caregiver dyadic approach in practice settings should include promotion of positive care management strategies, comprehensive caregiving training including both physical and behavioural dimensions, active engagement of caregivers in rehabilitation journey and conducting regular caregiver needs assessments in the community., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To study the association of caregiver factors and stroke patient factors with rehospitalizations over the first 3 months and subsequent 3-12 months post-stroke in Singapore., Methods: Patients with stroke and their caregivers were recruited in the Singapore Stroke Study, a prospective yearlong cohort. While caregiver and patient variables were taken from this study, hospitalization data were extracted from the national claims database. We used Poisson modelling to perform bivariate and multivariable analysis with counts of hospitalization as the outcome., Results: Two hundred and fifty-six patient with stroke and caregiver dyads (N = 512) were analysed, with patients having spouse (60%), child (29%), sibling (4%) and other (7%) as their caregivers. Among all participants, 89% of index strokes were ischemic, 57% were mild in severity and more than half (59%) of the patients had moderate or severe disability post-stroke as measured on the Modified Rankin Scale. Having social support in the form of a foreign domestic worker for general help of caregiver reduced the hospitalization rate over 3 months post-stroke by 66% (IRR: 0.342; 95% CI: 0.180, 0.651). Compared to having a spousal caregiver, those with a child caregiver had an almost three times greater rate of hospitalizations over 3-12 months post-stroke (IRR: 2.896; 95% CI: 1.399, 5.992). Higher reported caregiving burden at the 3-month point was associated with the higher subsequent rate of hospitalization., Conclusion: Recommendations include the adoption of a dyadic or holistic approach to post-stroke care provision by healthcare practitioners, giving due importance to both patients with stroke and their caregivers, integrating caregivers in the healthcare system to extend the care continuum to include informal care in the community and provision of timely support for caregivers.

Introduction: Genetic polymorphisms are important in explaining the wide interpatient variability that exists in the development of acute kidney injury (AKI) post cardiac surgery. We hypothesised that polymorphisms in 4 candidate genes, namely angiotensin-converting enzyme (ACE), apolipoprotein-E (ApoE), interleukin-6 (IL-6), and tumour necrosis factor-alpha (TNF-α) are associated with AKI., Methods: 870 patients who underwent cardiac surgery in Singapore were analysed. All patients who fulfilled stage 1 KDIGO criteria and above were considered to have AKI. This was investigated against various demographic, clinical and genetic factors., Results: Increased age, history of hypertension, anaemia and renal impairment remained important preoperative risk factors for AKI. Intraoperatively, longer cardiopulmonary bypass (CPB) time and the use of intra-aortic balloon pump (IABP) were shown to be associated with AKI. Among the genetic factors, ACE-D allele was associated with an increased risk of AKI while IL6-572C allele was associated with a decreased risk of AKI., Conclusion: ACE-D allele was associated with the development of AKI similar to other studies. On the other hand, IL6-572C was shown to have a protective role against the development of AKI, contradictory to studies done in the Caucasian population. This contradictory effect of IL6-572C is a result of a complex interplay between the gene and population specific modulating factors. Our findings further underscored the necessity of taking into account population specific differences when developing prediction models for AKI., Competing Interests: The authors have declared that no competing interests exist.

Objectives: This study aimed to quantify health-related quality of life (HRQoL) loss associated with first episode of stroke by comparing patient-reported HRQoL before and after stroke onset. The impact of stroke in local population was also evaluated by comparing the pre- and post-stroke HRQoL with that of the general population., Methods: The HRQoL of stroke survivors was assessed with the EQ-5D-3L index score at recruitment, for recalled pre-stroke HRQoL, and at 3 and 12 month post-stroke. Change in HRQoL from pre-stroke to 3 and 12 month was self-reported by 285 and 238 patients, respectively. Mean EQ index score at each time point (baseline: 464 patients; 3 month post-stroke: 306 patients; 12 month post-stroke: 258 patients) was compared with published population norms for EQ-5D-3L., Results: There was a significant decrease in HRQoL at 3 (0.25) and 12 month (0.09) post-stroke when compared to the retrospectively recalled patients' mean pre-stroke HRQoL level (0.87). The reduction at 3 month was associated with the reduction in all EQ-5D-3L health dimensions; reductions remaining at 12 month were limited to dimensions of mobility, self-care, usual activities, and anxiety/depression. Stroke patients had a lower mean EQ index than the general population by 0.07 points pre-stroke (0.87 vs. 0.94), 0.33 points at 3 month (0.61 vs. 0.94) and 0.18 points at 12 month (0.76 vs. 0.94) post-stroke., Conclusions: Stroke has a substantial impact on HRQoL in Singapore, especially in the first three months post-stroke. Compared to the general population, stroke survivors have lower HRQoL even before stroke onset. This pre-stroke deficit in HRQoL should be taken into account when quantifying health burden of stroke or setting goals for stroke rehabilitation., Competing Interests: The authors have declared that no competing interests exist.

Background: It is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors., Methods: Patient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke., Results: Five hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter., Conclusion: Highlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver's role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Background: Health-related quality of life (HRQoL) is a key metric to understand the impact of stroke from patients' perspective. Yet HRQoL is not readily measured in clinical practice. This study aims to investigate the extent to which clinical outcomes during admission predict HRQoL at 3 months and 1 year post-stroke., Methods: Stroke patients admitted to five tertiary hospitals in Singapore were assessed with Shah-modified Barthel Index (Shah-mBI), National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Mini-Mental State Examination (MMSE), and Frontal Assessment Battery (FAB) before discharge, and the EQ-5D questionnaire at 3 months and 12 months post-stroke. Association of clinical measures with the EQ index at both time points was examined using multiple linear regression models. Forward stepwise selection was applied and consistently significant clinical measures were analyzed for their association with individual dimensions of EQ-5D in multiple logistic regressions., Results: All five clinical measures at baseline were significant predictors of the EQ index at 3 months and 12 months, except that MMSE was not significantly associated with the EQ index at 12 months. NIHSS (3-month standardized β = - 0.111; 12-month standardized β = - 0.109) and mRS (3-month standardized β = - 0.122; 12-month standardized β = - 0.080) were shown to have a larger effect size than other measures. The contribution of NIHSS and mRS as significant predictors of HRQoL was mostly explained by their association with the mobility, self-care, and usual activities dimensions of EQ-5D., Conclusions: HRQoL at 3 months and 12 months post-stroke can be predicted by clinical outcomes in the acute phase. NIHSS and mRS are better predictors than BI, MMSE, and FAB.

Background: Health services research aimed at understanding service use and improving resource allocation often relies on collecting subjectively reported or proxy-reported healthcare service utilization (HSU) data. It is important to know the discrepancies in such self or proxy reports, as they have significant financial and policy implications. In high-dependency populations, such as stroke survivors, with varying levels of cognitive impairment and dysphasia, caregivers are often potential sources of stroke survivors' HSU information. Most of the work conducted on agreement analysis to date has focused on validating different sources of self-reported data, with few studies exploring the validity of caregiver-reported data. Addressing this gap, our study aimed to quantify the agreement across the caregiver-reported and national claims-based HSU of stroke patients., Methods: A prospective study comprising multi-ethnic stroke patient and caregiver dyads (N = 485) in Singapore was the basis of the current analysis, which used linked national claims records. Caregiver-reported health services data were collected via face-to-face and telephone interviews, and similar health services data were extracted from the national claims records. The main outcome variable was the modified intraclass correlation coefficient (ICC), which provided the level of agreement across both data sources. We further identified the amount of over- or under-reporting by caregivers across different service types., Results: We observed variations in agreement for different health services, with agreement across caregiver reports and national claims records being the highest for outpatient visits (specialist and primary care), followed by hospitalizations and emergency department visits. Interestingly, caregivers over-reported hospitalizations by approximately 49% and under-reported specialist and primary care visits by approximately 20 to 30%., Conclusions: The accuracy of the caregiver-reported HSU of stroke patients varies across different service types. Relatively more objective data sources, such as national claims records, should be considered as a first choice for quantifying health care usage before considering caregiver-reported usage. Caregiver-reported outpatient service use was relatively more accurate than inpatient service use over shorter recall periods. Therefore, in situations where objective data sources are limited, caregiver-reported outpatient information can be considered for low volumes of healthcare consumption, using an appropriate correction to account for potential under-reporting.

Rationale: Because of its rapidly-growing and aging populations, the global burden of stroke will be felt most strongly in Asia. Data from Asia are scarce. Even rarer are data from multiethnic populations., Aim: The Singapore Stroke Registry is a countrywide registry of risk factors, stroke subtypes, management and outcome of incident and recurrent stroke in multiethnic Singapore., Methods and Design: Using a cold-pursuit design, potential subjects are identified from medical claims, hospital discharge summaries and death certificates. Standardized methods are used for case ascertainment and data recording by trained staff into standardized case report forms. All ages and both genders are included., Study Outcome: Stroke incidence, subtypes and mortality will be calculated. Trend data will be obtained. Inter-ethnic differences will be explored., Discussion: The Registry has many features of an 'ideal' incidence study. Previously unavailable countrywide data on an Asian population will be acquired. The unique data on inter-ethnic differences will help fill knowledge gaps in stroke epidemiology., (© 2015 World Stroke Organization.)

Unlabelled: CCAAT enhancer binding protein α (C/EBPα) plays an essential role in cellular differentiation, growth, and energy metabolism. Here, we investigate the correlation between C/EBPα and hepatocellular carcinoma (HCC) patient outcomes and how C/EBPα protects cells against energy starvation. Expression of C/EBPα protein was increased in the majority of HCCs examined (191 pairs) compared with adjacent nontumor liver tissues in HCC tissue microarrays. Its upregulation was correlated significantly with poorer overall patient survival in both Kaplan-Meier survival (P=0.017) and multivariate Cox regression (P=0.028) analyses. Stable C/EBPα-silenced cells failed to establish xenograft tumors in nude mice due to extensive necrosis, consistent with increased necrosis in human C/EBPα-deficient HCC nodules. Expression of C/EBPα protected HCC cells in vitro from glucose and glutamine starvation-induced cell death through autophagy-involved lipid catabolism. Firstly, C/EBPα promoted lipid catabolism during starvation, while inhibition of fatty acid beta-oxidation significantly sensitized cell death. Secondly, autophagy was activated in C/EBPα-expressing cells, and the inhibition of autophagy by ATG7 knockdown or chloroquine treatment attenuated lipid catabolism and subsequently sensitized cell death. Finally, we identified TMEM166 as a key player in C/EBPα-mediated autophagy induction and protection against starvation., Conclusion: The C/EBPα gene is important in that it links HCC carcinogenesis to autophagy-mediated lipid metabolism and resistance to energy starvation; its expression in HCC predicts poorer patient prognosis., (© 2014 The Authors. Hepatology published by Wiley Periodicals, Inc., on behalf of the American Association for the Study of Liver Diseases.)

Background: This study aims to determine the prevalence, profile, and severity of neuropsychiatric symptoms (NPS) across the dementia continuum and their relative impact on caregiver distress and quality of life (QoL) in persons with dementia (PWD)., Method: Six hundred and sixty-seven PWD and their family caregivers presented to a memory clinic in a tertiary hospital across a 60-month period. Clinicians determined the dementia diagnosis and severity using the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition and the Clinical Dementia Rating scale, respectively. The Neuropsychiatric Inventory Questionnaire was administered to assess NPS in PWD and the corresponding distress experienced by the caregiver. QoL for PWD (PWD-QoL) was assessed by the Quality of Life-Alzheimer's Disease scale., Results: Ninety-six percent of PWD presented with at least one NPS, 18% experiencing mild, 31% moderate, and 47% severe symptoms, respectively. While agitation (63.1%), apathy (61.8%), depression (55.5%), and irritability (55.5%) were the most common NPS; disinhibition (35.2%), hallucination (25.5%), and elation (14.2%) were the least common. NPS increased generally but differentially as dementia progressed and significantly predicted caregiver distress (ηp 2 = 0.732, p < 0.0001) and PWD-QoL (ηp 2 = 0.066, p < 0.0001). Factor analysis revealed two NPS clusters, disruptive and affective; the former exerting greater impact on caregiver distress and the latter on PWD-QoL., Conclusion: The results show a high prevalence of NPS which increase caregiver distress and negatively impact PWD-QoL. The differential profile of NPS across the dementia stages warrants stage-specific interventions and due consideration in resource planning and service design for PWD and their caregivers.

Macro-creatine kinase (CK) is a cause of falsely elevated CK. Macro-CK type 1 is immunoglobulin-associated CK; type 2 is polymeric mitochondrial-CK. An elderly asymptomatic lady had an elevated CK level after receiving statin therapy. Her CK gel electrophoresis analysis demonstrated coexisting macro-CK type 1 and type 2 patterns. Further analysis by immunofixation and mixing this patient's serum with CK control material revealed an IgG-associated macro-CK that mimicked the electrophoretic pattern of macro-CK type 2. This highly unusual discovery suggests the possibility of the misinterpretation of macro-CK type 1 as macro-CK type 2. Falsely elevated CK is still common despite modern laboratory instrumentation and should be investigated.

Introduction: While the readmission rate from community hospitals is known, the factors affecting it are not. Our aim was to determine the factors predicting unplanned readmissions from community hospitals (CHs) to acute hospitals (AHs)., Materials and Methods: This was an observational prospective cohort study, involving 842 patients requiring post-acute rehabilitation in 2 CHs admitted from 3 AHs in Singapore. We studied the role of the Cumulative Illness Rating Scale (CIRS) organ impairment scores, the Mini-mental State Examination (MMSE) score, the Shah modified Barthel Index (BI) score, and the triceps skin fold thickness (TSFT) in predicting the rate of unplanned readmissions (UR), early unplanned readmissions (EUPR) and late unplanned readmissions (LUPR). We developed a clinical prediction rule to determine the risk of UR and EUPR., Results: The rates of EUPR and LUPR were 7.6% and 10.3% respectively. The factors that predicted UR were the CIRS-heart score, the CIRS-haemopoietic score, the CIRS-endocrine / metabolic score and the BI on admission. The MMSE was predictive of EUPR. The TSFT and CIRS-liver score were predictive of LUPR. Upon receiver operator characteristics analysis, the clinical prediction rules for the prediction of EUPR and UR had areas under the curve of 0.745 and 0.733 respectively. The likelihood ratios of the clinical prediction rules for EUPR and UR ranged from 0.42 to 5.69 and 0.34 to 3.16 respectively., Conclusions: Patients who have UR can be identified by the admission BI, the MMSE, the TSFT and CIRS scores in the cardiac, haemopoietic, liver and endocrine/metabolic systems.

Stroke is a major cause of death and disability in Singapore and many parts of the world. Chronic disease management programmes allow seamless care provision across a spectrum of healthcare facilities and allow appropriate services to be brought to the stroke patient and the family. Randomised controlled trials have provided evidence for efficacious interventions. After the management of acute stroke in a stroke unit, most stable stroke patients can be sent to their family physician for continued treatment and rehabilitation supervision. Disabled stroke survivors may need added home-based services. Suitable community resources will need to be harnessed. Clinic-based stroke nurses may enhance service provision and coordination. Close collaboration between the specialist and family physician would be needed to right-site patients and also allow referrals in either direction where necessary. Barriers to integration can be surmounted by trust and improved communication. Audits would allow monitoring of care provision and quality care enhancement. The Wagner model of chronic care delivery involves self-management support, shared clinical information systems, delivery system redesign, decision support, healthcare organisation and community resources. The key and critical feature is the need for an informed, activated (or motivated) patient, working in collaboration with the specialist and family physician, and a team of nursing and allied healthcare professionals across the continuum of care. The 3-year Integrating Services and Interventions for Stroke (ISIS) project funded by the Ministry of Health will test such an integrative system.

Introduction: This study aims to determine if risk factors present on admission to the nursing home could be predictive of later functional decline and to determine the causes of decline., Methods: This is a retrospective case-control study conducted in 2000 at a voluntary welfare nursing home. Functional decline was defined as deterioration in two or more of the five activities of daily living (ADLs), namely: mobility, toileting, bathing, dressing and feeding, from the time of admission to the study period. Potential risk factors for decline studied were: age, sex, marital status, number of medical diagnoses and medications, types of medical diagnoses, and the presence of dementia on admission to the home. Causes of decline were categorised as (A) Development of new illness, (B) Progression of chronic illness, or (C) Both of the above., Results: 36 out of 103 residents had functional decline. On analysis, univariate and multivariable logistic regression models, adjusted for length of stay, yielded the same significant risk factors for decline, namely: age (p-value is 0.02) and dementia (p-value is 0.04). Majority of decline (78 percent) was due to progression of chronic illnesses, most commonly dementia (15 out of 36), eight percent were due to acute illness (stroke), and 14 percent were due to both. In January 2003, 18 out of the 36 residents who declined had died., Conclusions: Functional decline is common in the nursing home. More attention should be paid to the older residents and those with dementia, right from the point of admission.

Introduction: This study aims to examine the demography of falls, factors that contribute to falls and fall risk factors in residents of a nursing home for the elderly in Singapore., Materials and Methods: An 18-month follow-up study was carried out on 95 nursing home residents. Information on the subjects' potential risk factors for falls was obtained through a review of their casenotes and physical examination. At the end of the study period, the casenotes were reviewed for any documented fall, the circumstances surrounding each fall and whether complications resulted from the fall. The likely factors and events associated with each fall were categorised where possible. Logistic regression was performed to determine the risk factors for falls. Subjects who died or were discharged during the study were included in the analysis., Results: Several subjects (72.6%) were > or = 75 years old, required assistance in activities of daily living (71.6%), cognitively impaired (52.6%), diagnosed with mental illness (49.5%) and non-ambulant (43.2%). A total of 63 falls contributed by 38 (40%) subjects were documented over 18 months, giving an incidence of 0.5 fall per bed year. Thirteen (20.6%) injuries resulted from the falls, of which 3 were fractures. Falls associated with both intrinsic and extrinsic factors were identified in 38.1% of falls. The most common intrinsic factors were gait disorders (31.7%) and confusion/difficult behaviour (31.7%). Contributory extrinsic factors include wheelchair/commode (22.2%) and bathroom-related (15.9%) incidents. Most falls occurred during ambulation (31.7%) and transfers (17.5%). On multivariate logistic regression, the only significant risk factors for falls were "need for ambulatory aids" (odds ratio, 24.4) and "cognitive impairment" (odds ratio, 8.1)., Conclusion: The study confirms that falls are common amongst elderly in a local nursing home. Residents with gait instability and behavioural problems due to underlying dementia or mental illnesses are most at risk. Extrinsic factors, such as bathroom activities and the use of wheelchair/commodes, are contributory. Thus, falls reduction protocols in nursing homes should include behavioural measures, enhanced care practices and environmental modifications to be effective.

Objectives: To compare hospital length of stay (LOS) and outcome after stroke between patients in a stroke unit offering combined acute and rehabilitation services and patients treated elsewhere in New South Wales., Design: Retrospective audit of two hospital databases (Diagnosis-Related Groups [DRG] database and Australian National Subacute Non-Acute Patient Classification System [AN-SNAP] database), with comparison with DRG and AN-SNAP data for NSW., Setting and Participants: 242 episodes of acute stroke in patients admitted to the stroke unit of a metropolitan teaching hospital between July 1999 and November 2000, 113 of whom also underwent rehabilitation in the unit; 9777 episodes of acute stroke in the NSW DRG database, and 2350 in the NSW AN-SNAP database., Main Outcome Measures: Acute and rehabilitation LOS; mortality in acute care; FIM (Functional Independence Measure) score at discharge and change in FIM score; and discharge destination., Results: Patients in the combined stroke unit had shorter LOS and better functional outcome in all DRG and AN-SNAP groups, with both higher discharge FIM scores and greater gain in FIM scores than NSW patients. Acute stroke mortality of 12% and nursing home admission rate of 15.5% in the combined stroke unit were not significantly different from rates for NSW (15.7% and 11.2%, respectively)., Conclusions: Combining acute and rehabilitation services in a stroke unit may reduce LOS and improve functional outcome of patients with acute stroke.

Aim of Study: To describe the residents of a nursing home for the elderly in terms of their socio-demographic profile, mental and physical attributes, functional abilities and existing medical problems., Method: A random sample of 120 subjects was obtained from a total of 350 residents in a voluntary welfare nursing home. Two subjects were excluded as they did not satisfy inclusion criteria (age > or = 60 years). The subjects' biodata, social background, medical problems and functional status at the time of admission were obtained by a review of the case records. Each of the subjects was examined with attention to their general condition, hearing and vision, presence of postural hypotension, cognition and ability to perform basic activities of daily living (ADL)., Results: Results were available for 106 out of the 118 subjects as the rest were either discharged in the course of the study or had died. Single (36%), widowed (41%), female (71%) and age > or = 75 years (73%) consisted the majority. Most subjects (43%) were admitted because of both medical and social factors. Twenty-two percent appeared undernourished and of those who could be assessed, 14% had postural hypotension, 18% were hearing impaired and 53% had visual impairment. Fifty-two per cent suffered from mental problems while 46% and 40% had been diagnosed with hypertension and stroke respectively. Forty-eight percent had probable cognitive impairment (according to ECAQ scores) and 41% were very severely disabled (according to Barthel Index). Fifty-five percent were dependent in bathing, 50% dependent in dressing, 50% incontinent of urine (and requiring diapers), 48% were non-ambulant and 21% dependent in feeding., Conclusion: With a significant proportion of the population requiring nursing home care in the future, a closer review of the situation is needed. This study has identified malnutrition, urinary incontinence, falls, functional decline and impaired vision/hearing as issues that deserve greater attention and, where necessary, intervention. Whether implementing recognised effective interventions will truly benefit our nursing home residents would warrant more local studies.

Aim: To study the death rate of noninstitutionalised elderly after discharge from hospital, describe the causes of death and identify predictive factors of mortality., Methods: Vital status and cause of death of patients was ascertained by linkage to the death registry I year post discharge. Age, sex, race, marital status, housing and class of ward (to reflect socioeconomic status), presence of carer, Elderly Cognitive Assessment Questionnaire (ECAQ) score, Barthel score, presence of depression, number of chronic illnesses and length of stay in the hospital were studied as potential predictive factors for mortality using Cox proportional hazard regression models., Results: Death occurred in 38 out of 113 patients. The commonest causes of death were malignancy (18%) and cerebrovascular disease (18%). Barthel score and length of stay were independent significant predictive factors of mortality. Elderly with low ECAQ score, with carers and from C class wards also had higher mortality although these results were not statistically significant., Conclusion: Post-discharge mortality is high in the elderly. We recommend that further studies be done to determine if amelioration of these predictive factors would lead to decreased mortality or improvement of quality of life.

Our primary aim was to study the need for community services as perceived by the elderly and their relatives. A secondary objective was to determine the predictive factors of need for these services. This is a survey of 115 consecutive non-institutionalised patients admitted to a hospital geriatric department and their relatives. Twenty-seven elderly patients without cognitive impairment and 115 relatives were interviewed as to their need for community services after discharge. Services most needed by patients were: 24-hour medical helpline (33%), emergency alarm system (19%), social helpline (14%) and day care centre (13%). Services most needed by relatives were: 24-hour medical helpline (70%), emergency alarm system (40%), home visits by doctors (40%), respite care (35%), day care centre (35%) and transport service (33%). There were low levels of need for home help service, meal delivery service and the befriender service. Important predictive factors of need were: low ECAQ (Elderly Cognitive Assessment Questionnaire) score, low Barthel score, and absence of a carer. The development of community geriatric services in Singapore should be guided by the perceived needs of the elderly and their relatives/care-givers. This study is limited by its hospital-based perspective and small numbers. We recommend that further community-based studies be carried out to complement our study and extend our findings.