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Aim Older adults are susceptible to two or more chronic ailments or multimorbidity. The present study aimed to establish the relationship between multimorbidity and health-related quality of life (HRQoL) amongst Asian elderly patients in primary care in a developed nation. It also assessed how functional disability and chronic musculoskeletal pain are associated with HRQoL. Methods A cross-sectional study was carried out in a Singapore public primary care clinic. An interviewer-administered questionnaire was used to collect data on chronic disease profile, HRQoL (using the European Quality of Life 5 Dimension), basic activities of daily living, instrumental activities of daily living, musculoskeletal pain and sociodemographic characteristics. The association of multimorbidity, functional disability and chronic musculoskeletal pain with HRQoL was assessed using multivariate linear regression analysis. Results A total of 498 outpatients aged 65 years and older with multimorbidity were enrolled. Their mean age was 73.9 years, and approximately 75% had between two and four chronic conditions. The most commonly reported chronic conditions were hypertension (86.1%), hyperlipidemia (80.7%), diabetes (40.2%) and arthritis (33.3%). The European Quality of Life 5 Dimension index score decreased significantly when the number of comorbidities was more than five. Chronic hip and knee pain, one or more “dependent” activities of daily living dimensions and two or more “dependent” IADL dimensions were independently associated with worse HRQoL. Conclusions Multimorbidity is associated with poorer HRQoL amongst older adults in Singapore. Review of chronic musculoskeletal pain and functional disabilities should be integrated into the comprehensive assessment of older adults in an enhanced model of primary care to improve the HRQoL of these older patients. Geriatr Gerontol Int 2016; ••: ••–••.

OBJECTIVES Acute kidney injury (AKI) post-cardiac surgery is associated with significant in-hospital and long-term morbidity. This study aimed to develop a risk score for postoperative AKI in a Southeast-Asian population. METHODS A total of 2508 patients underwent cardiac surgery at the two main heart centres in Singapore between July 2008 and November 2011, of which 2385 met the inclusion criteria. The primary outcome was AKI, defined using the Acute Kidney Injury Network (AKIN) criteria. The scoring model was developed on the test cohort of 2385 and validated with another 500 prospectively recruited patients. Logistic regression analysis was used to identify independent predictors of AKI. RESULTS The risk factors in this model are age ≥65 years, hypertension, estimate glomerular filtration rate (eGFR) ≤60 ml/min, use of intra-aortic balloon pump and cardiopulmonary bypass (CPB) time ≥120 min, which were similar to previous AKI risk models. Other risk factors in our model include preoperative anaemia, intraoperative red blood cell transfusion and lowest haematocrit during CPB, which have not been described previously. The clinical score ranged from 0 to 14 points with three major risk categories. The AKI frequencies are as follows: 0-4 points (18%), 5-8 points (39%) and 9-14 points (64%). The area under the receiver operating curve (ROC) for the test cohort was 0.70 (95% CI 0.68-0.72), similar to the validation cohort (0.75; 95% CI 0.70-0.80). CONCLUSIONS In conclusion, the risk model is valid in predicting AKI post-cardiac surgery and can be used for the early diagnosis and treatment of AKI.

Objective Hyperglycemia is associated with surgical site infection and mortality in cardiac surgical patients. There is overriding evidence that glycemic control improves morbidity and mortality. However, the optimal glucose range in these patients remains controversial. Intensive glucose control can lead to mortality among critically ill adults because of episodic, moderate hypoglycemia. Therefore, we examined the effect of different glucose target control on the incidence of surgical site infection in our prospective cohort of diabetic and nondiabetic patients undergoing coronary artery bypass grafting. Methods Data from 1442 patients who underwent elective coronary artery bypass grafting at a tertiary heart center in Singapore from 2009 to 2011 were obtained. The first glucose level on arrival in the cardiothoracic intensive care unit was set at 4 to 8 mmol/L in 2009 and 2010 and 4 to 10 mmol/L in 2011. Glucose control was achieved with intravenous insulin infusion with a strict glucose monitoring protocol. Clinical covariates were analyzed, with surgical site infection as the primary outcome. Results The majority of patients presenting for coronary artery bypass grafting were male, Chinese, and diabetic. Diabetic patients had significantly higher glucose levels on arrival in the cardiothoracic intensive care unit. The change in target glucose control was independently associated with an increase in surgical site infection (odds ratio, 2.280; 95% confidence interval, 1.250-4.162; P = .007). Subgroup analysis revealed that unlike in nondiabetic patients, a less stringent target was independently associated with a significant increase in surgical site infection incidence from 2.2% to 6.9% for the diabetic patients (odds ratio, 3.131; 95% confidence interval, 1.431-6.851; P = .004). Conclusions A target blood glucose of less than 8 mmol/L was associated with a lower incidence of surgical site infection in diabetic patients presenting for elective coronary artery bypass grafting in the local Southeast Asian population.

Background: Neurocognitive dysfunction is a common complication of coronary artery bypass grafting (CABG) with incidence of 19–38%. The miniaturized cardiopulmonary bypass (MCPB) system was developed to reduce hemodilution and inflammation and provides better cerebral protection than conventional cardiopulmonary bypass (CCPB). In a meta-analysis, MCPB was associated with a 10-fold reduction in the incidence of strokes. However, its effect on postoperative cognitive decline (POCD) is unknown. We assessed if MCPB decreases POCD after CABG and compared the risk factors. Methods: A total of 71 Asian patients presenting for elective CABG at a tertiary center were enrolled. They were randomly assigned to MCPB (n = 36) or CCPB group (n = 35) and followed up in a single-blinded, prospective, randomized controlled trial. The primary outcome was POCD as measured by the repeatable battery of neuropsychological status (RBANS). Inflammatory markers (tumor necrosis factor-alpha and interleukin-6), hematocrit levels, and neutron-specific enolase (NSE) levels were studied. Results: Overall, the incidence of POCD at 3 months was 50%, and this was not significantly different between both groups (51.4 vs 50.0%, P = 0.90). Having

Acute kidney injury is a serious complication after cardiac surgery. Although it resolves in most cases, a significant portion of patients persistently have raised creatinine values at hospital discharge. These patients are at greater risk for developing chronic kidney disease and mortality. Therefore, the present study aimed to ascertain risk factors of persistent acute kidney injury after cardiac surgery in patients with normal preoperative renal function.Prospective cohort study.Tertiary heart centers.2,181 adult cardiac surgical patients, predominantly Asian.Cardiac surgery between August 2008 and July 2012.The incidence of acute kidney injury, as defined by the Acute Kidney Injury Network stage 1 criteria, was 21.7%. At discharge, 10.5% of these patients had persistent kidney injury, which was defined as a ≥ 26.4 μmol/L (≥ 0.3 mg/dL) difference between preoperative and discharge creatinine levels and/or a 50% rise in serum creatinine. These patients were more likely to be aged ≥ 70 years (relative risk = 2.232, 95% confidence interval = 1.326-3.757, p = 0.003), have a higher peak postoperative creatinine value within 48 hours (relative risk = 1.007, 95% confidence interval = 1.004-1.010, p0.001), and have lower hemoglobin on intensive care unit arrival (relative risk = 0.759, 95% confidence interval = 0.577-0.998, p = 0.048).Age ≥ 70 years, higher peak postoperative creatinine within 48 hours, and lower hemoglobin on intensive care unit arrival are associated with persistent acute kidney injury. Strategies to improve hemoglobin on intensive care unit arrival potentially can reduce persistent acute kidney injury. The authors recommend that patients aged ≥ 70 years undergo further renal evaluation for better risk stratification.

Background Acute kidney injury (AKI) after cardiac surgery is associated with increased morbidity and mortality. The long-term association between AKI and end-stage renal disease (ESRD) in an Asian population is unknown. Given the high prevalence of diabetes and a younger age of presentation for cardiac surgery, it is important to track this progression of kidney disease. Therefore, we studied the long-term risk of ESRD and mortality in our Asian patients who developed AKI after cardiac surgery. Methods With ethics approval, we prospectively recruited 3008 patients who underwent cardiac surgery in Singapore between 2008 and 2012, and followed them up till 2014. ESRD and mortality information were obtained from the Singapore Renal Registry and Singapore Registry of Births and Deaths respectively. AKI was defined using the Acute Kidney Injury Network (AKIN) criteria, and ESRD was defined as stage 5 chronic kidney disease requiring renal replacement therapy. The Cox proportional hazards regression model was used to analyze associations between AKI and the primary outcome of ESRD and the secondary outcome of death. Results The AKI incidence was 29.1%. During a mean follow-up of 4.4 ± 2.8 years, 0.9% developed ESRD. The hazard ratio (HR) for developing ESRD was 4.7 (95% C.I. = 1.736–12.603, p = 0.002) for AKIN stage 1 patients, and 5.8 (95% C.I. = 1.769–18.732, p = 0.004) for AKIN stage 2 and 3 patients; while the HR for mortality was 1.7 (95% C.I. = 1.165–2.571, p = 0.007) for AKIN stage 1 patients, and 2.5 (95% C.I. = 1.438–4.229, p

ObjectivePostoperative acute kidney injury (AKI) after cardiopulmonary bypass (CPB) with coronary artery bypass grafting is common and increases patient morbidity and mortality. Studies have identified the lowest hematocrit during CPB, preoperative anemia, and intraoperative transfusion as modifiable AKI risk factors. Because Asians are smaller in body size, the use of standard CPB circuits can result in excessive hemodilution and subsequent transfusion to maintain the desired hematocrit target of ≥21% during CPB. Thus, we aimed to ascertain whether the lowest hematocrit during CPB, preoperative anemia, and intraoperative transfusion remained as independent modifiable risk factors associated with AKI in our prospective cohort of Asians.MethodsData from 1448 patients who had undergone coronary artery bypass grafting with CPB from December 2008 to December 2010 at Singapore's 2 national heart centers were obtained. The perioperative risk factors were analyzed for their associations with postoperative AKI. AKI was defined using the Acute Kidney Injury Network stage 1 criteria.ResultsThe incidence of AKI was 27.0% and mean lowest hematocrit during CPB was 24.5% ± 3.8%. The risk of AKI increased with a decreasing lowest hematocrit during CPB (relative risk, 0.933; 95% confidence interval, 0.899-0.968; P

Acute kidney injury (AKI) and atrial fibrillation (AF) after cardiac surgery are common occurrences and increase patient morbidity and mortality. Inflammation plays a role in increased incidence of AF in patients with chronic kidney disease (CKD); reactive oxygen species and inflammatory markers which are increased in patients with CKD were found to affect the proper functioning of the intracellular ion channels, connexions (transmembrane proteins found in intercellular gap junctions), and electrical homogeneity of the extracellular matrix which are essential for electrical stability and proper conduction of electrical impulses in the atrium. However, it is not known if similar mechanisms are also involved in AKI. We tested the hypothesis that patients with AKI after cardiac surgery have a higher incidence of postoperative AF. Data from 2885 patients, who had undergone cardiac surgery between August 2008 and July 2012 from the Singapore's 2 major heart centers, were obtained prospectively. Postoperative AKI was defined using the Acute Kidney Injury Network criteria. The primary outcome was postoperative AF, and subjects were considered to have postoperative AF if the AF lasted more than an hour, affected hemodynamics, or required medical treatment. The incidence of AKI was 29.7% and the incidence of postoperative AF was 16.8%. A total of 27.7% of AKI patients developed AF. Patients with AKI had a 2-fold increased risk of developing AF (relative risk [RR], 1.716; 95% confidence interval [CI], 1.433–2.055; P

Current polyvinylpyrrolidone-modified polysulfone (PVP-PSU) membranes in haemodialysers do not facilitate the attachment and proliferation of renal proximal tubule cells (RPTCs) For bioartificial kidney (BAK) development expensive extracellular matrices are employed to ensure the PVP-PSU membranes can serve as a substrate for RPTCs In this study we modified PSU using an acrylic monomer (am-PSU) and polymerization using ultraviolet irradiation. We demonstrated that on adjusting the PSU or acrylic content of the membranes the wettability and surface chemistry were altered, and this affected the amount of fibronectin (Fn) that was adsorbed onto the membranes Using an integrin blocking assay we ascertained that Fn is an important extracellular matrix component that mediates RPTC attachment The amount of Fn adsorbed also led to different bioresponses of RPTCs, which were evaluated using attachment and proliferation assays and qualitative quantification of vinculin, focal adhesion kinase, zonula occludens and Na+/K+ ATPase Our optimized membrane, am-PSU1 (21 4% C-O groups, 19 1% PVP-PSU, contact angle 71 5-80.80, PVP-PSU. 52.4-67.50), supports a confluent monolayer of RPTCs and prevents creatinine and mulin diffusion from the apical to the basal side, meeting the requirements for application in BAKs However, further in vivo evaluation to assess the full functionality of RPTCs on am-PSU1 is required. (C) 2011 Acta Materialia Inc Published by Elsevier Ltd All rights reserved

Acute kidney injury (AKI) is a common complication after cardiac surgery. Recent studies have revealed emerging associations between the magnitude of acute glycemic fluctuations and intensive care unit (ICU) mortality rates. However, the effect of acute glycemic fluctuations on the development of postoperative AKI remains unclear. Thus, we aim to investigate the effect of the magnitude of acute perioperative glycemic fluctuations on the incidence of postoperative AKI.We conducted a prospective cohort study by prospectively obtaining data from all patients who underwent elective coronary artery bypass grafting in a tertiary heart institution from 2009 to 2011. The magnitude of the difference between the highest and lowest perioperative glucose levels within 48 hr was calculated as a measure of perioperative glycemic fluctuation. Patients were divided into 4 groups for analysis based on the magnitude of perioperative glycemic fluctuation-A: 0 to 2 mmol/L; B: >2 to 4 mmol/L; C: >4 to 6 mmol/L; and D: >6 mmol/L. We analyzed the incidence of postoperative AKI, ICU mortality and ICU length of stay as primary and secondary outcomes, respectively. Both univariate and multivariate analyses were used.We analyzed data from 1386 patients. The overall incidence of AKI was 29.9% and increased with wider glycemic fluctuation. The incidence of AKI was statistically highest in Group D (38.3%), followed by Groups C (28.6%), B (21.7%), and A (17.4%), respectively (P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.001). A similar trend was observed among both diabetics and nondiabetics (P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.001 and P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.002, respectively). Multivariate logistic regression showed the magnitude of perioperative glycemic fluctuations to be an independent risk factor in the development of AKI (P < 0.001, odds ratio 1.180, 95% confidence interval 1.116-1.247). ICU length of stay was statistically highest in Group D (58.3[REPLACEMENT CHARACTER]hr) compared with Groups C (44.5[REPLACEMENT CHARACTER]hr), B (37.3[REPLACEMENT CHARACTER]hr), and A (32.8[REPLACEMENT CHARACTER]hr, P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.003). ICU mortality rate was comparable among all 4 groups (P[REPLACEMENT CHARACTER]=[REPLACEMENT CHARACTER]0.172).Wide acute perioperative glycemic fluctuations should be avoided as they are associated with a significantly increased risk of AKI and ICU length of stay in both the diabetics and the nondiabetics.