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Introduction: Studies of concordance between patients’ self-report of diseases and a criterion standard (e.g. chart review) are usually conducted in epidemiological studies to evaluate the agreement of self-reported data for use in public health research. To our knowledge, there are no published studies on concordance for highly prevalent chronic diseases such as diabetes and pre-diabetes. The aims of this study were to evaluate the concordance between patients’ self-report and their medical records of diabetes and pre-diabetes diagnoses, and to identify factors associated with diabetes concordance. Method: A cross-sectional, interviewer-administered survey was conducted on patients with chronic diseases after obtaining written consent to assess their medical notes. Interviewers were blinded to the participants’ profiles. Concordance was evaluated using Cohen’s kappa (κ). A multivariable logistic regression model was used to identify factors associated with diabetes concordance. Results: There was substantial agreement between self-reported and medical records of diabetes diagnoses (κ=0.76) and fair agreement for pre-diabetes diagnoses (κ=0.36). The logistic regression model suggested that non-Chinese patients had higher odds of diabetes concordance than Chinese patients (odds ratio [OR]=4.10, 95% confidence interval [CI] 1.19–14.13, P=0.03). Patients with 3 or more chronic diseases (i.e. multimorbidity) had lower odds of diabetes concordance than patients without multimorbidity (OR=0.21, 95% CI 0.09–0.48, P

Background: Preclinical studies indicate that cannabidiol (CBD), the primary nonaddictive component of cannabis, has a wide range of reported pharmacological effects such as analgesic and anxiolytic actions; however, the exact mechanisms of action for these effects have not been examined in chronic osteoarthritis (OA). Similar to other chronic pain syndromes, OA pain can have a significant affective component characterized by mood changes. Serotonin (5-HT) is a neurotransmitter implicated in pain, depression, and anxiety. Pain is often in comorbidity with mood and anxiety disorders in patients with OA. Since primary actions of CBD are analgesic and anxiolytic, in this first in vivo positron emission tomography (PET) imaging study, we investigate the interaction of CBD with serotonin 5-HT1A receptor via a combination of in vivo neuroimaging and behavioral studies in a well-validated OA animal model. Methods: The first aim of this study was to evaluate the target involvement, including the evaluation of modulation by acute administration of CBD, or a specific target antagonist/agonist intervention, in control animals. The brain 5-HT1A activity/availability was assessed via in vivo dynamic PET imaging (up to 60 min) using a selective 5-HT1A radioligand ([18F]MeFWAY). Tracer bindings of 17 ROIs were evaluated based on averaged SUVR values over the last 10 min using CB as the reference region. We subsequently examined the neurochemical and behavioral alterations in OA animals (induction with monosodium iodoacetate (MIA) injection), as compared to control animals, via neuroimaging and behavioral assessment. Further, we examined the effects of repeated low-dose CBD treatment on mechanical allodynia (von Frey tests) and anxiety-like (light/dark box tests, L/D), depressive-like (forced swim tests, FST) behaviors in OA animals, as compared to after vehicle treatment. Results: The tracer binding was significantly reduced in control animals after an acute dose of CBD administered intravenously (1.0 mg/kg, i.v.), as compared to that for baseline. This binding specificity to 5-HT1A was further confirmed by a similar reduction of tracer binding when a specific 5-HT1A antagonist WAY1006235 was used (0.3 mg/kg, i.v.). Mice subjected to the MIA-induced OA for 13-20 days showed a decreased 5-HT1A tracer binding (25% to 41%), consistent with the notion that 5-HT1A plays a role in the modulation of pain in OA. Repeated treatment with CBD administered subcutaneously (5 mg/kg/day, s.c., for 16 days after OA induction) increased 5-HT1A tracer binding, while no significant improvement was observed after vehicle. A trend of increased anxiety or depressive-like behavior in the light/dark box or forced swim tests after OA induction, and a decrease in those behaviors after repeated low-dose CBD treatment, are consistent with the anxiolytic action of CBD through 5HT1A receptor activation. There appeared to be a sex difference: females seem to be less responsive at the baseline towards pain stimuli, while being more sensitive to CBD treatment. Conclusion: This first in vivo PET imaging study in an OA animal model has provided evidence for the interaction of CBD with the serotonin 5-HT1A receptor. Behavioral studies with more pharmacological interventions to support the target involvement are needed to further confirm these critical findings.

Introduction: The rising prevalence of multiple chronic diseases is an important public health issue as it is associated with increased healthcare utilisation. This paper aimed to explore the annual per capita healthcare cost in primary care for patients with multiple chronic diseases (multimorbidity). Methods: This was a retrospective cohort study conducted in a cluster of public primary care clinics in Singapore. De-identified data from electronic medical records were extracted from July 2015 to June 2017. Only patients with at least 1 chronic disease were included in the study. Basic demographic data and healthcare cost were extracted. A list of 20 chronic diseases was considered for multimorbidity. Results: There were 254,377 patients in our study population, of whom 52.8% were female. The prevalence of multimorbidity was 62.4%. The median annual healthcare cost per capita for patients with multimorbidity was about twice the amount compared to those without multimorbidity (SGD683 versus SGD344). The greatest percentage increment in cost was when the number of chronic diseases increased from 2 to 3 (43.0%). Conclusion: Multimorbidity is associated with higher healthcare cost in primary care. Since evidence for the optimal management of multimorbidity is still elusive, prevention or delay in the onset of multimorbidity in the general population is paramount. Keywords: Chronic disease, healthcare cost, multimorbidity, primary care

Background In Canada, cost prohibits access to emergency contraception (EC) which may assist to prevent unintended pregnancy. The drug, ulipristal acetate (UPA-EC), is more clinically effective and cost-effective than the prior standard levonorgestrel (LNG-EC). We analyzed provincial EC subsidization policies and examined underlying decision-making processes. Methods We undertook documentary analysis of provincial EC subsidization policies in publicly available drug formularies. We conducted semi-structured interviews with key informants to explore the processes underlying current policies. Results Quebec is the only province to subsidize UPA-EC, whilst all ten provinces subsidize LNG-EC. As such, provincial EC subsidization policies do not align with the latest UPA-EC evidence. Interviews revealed that evidence was valued in the policymaking process and formulary decisions were made through interdisciplinary consensus. Conclusions We identify a gap between EC subsidization policies and the latest evidence. Institutional structures affect policies reflecting evolving evidence. Increasing interdisciplinary mechanisms may encourage evidence-based policies.

ObjectiveWith the COVID-19 pandemic, telemedicine has been increasingly deployed in lieu of face-to-face consultations for management of diabetes in primary care. There was a need to evaluate clinical effectiveness of telephone consultations for diabetes management and this study aimed to show whether one-off telephone consultation was inferior or not to face-to-face consultation in terms of glycaemic control among patients with suboptimally controlled type 2 diabetes.DesignRetrospective cohort study. Data of all patients with type 2 diabetes who had a chronic disease consultation during the period 9 April 2020–18 September 2020, and met the study’s inclusion and exclusion criteria was obtained from the electronic medical records.SettingA primary care clinic in the north-eastern region of Singapore. The clinic’s patient population was representative of Singapore’s population in terms of gender and age.Participants644 patients with type 2 diabetes and glycated haemoglobin (HbA1c) 7.0% and above, aged 21–80 years old.InterventionsParticipants either underwent telephone or face-to-face consultation for diabetes management.Outcome measureMean HbA1c change (∆HbA1c) between preintervention and postintervention.ResultsOver 4 months, the mean ∆HbA1c was −0.16 percentage points (p.p.) (95% CI −0.26 to –0.07) and −0.11 p.p. (95% CI −0.20 to –0.02) for face-to-face and telephone consultation groups, respectively. The difference in mean ∆HbA1c between the two groups was +0.05 p.p. (95% CI −∞ to 0.16), with the upper limit of the one-sided 95% CI less than the prespecified non-inferiority margin of 0.5 p.p. (pConclusionFor patients with suboptimally controlled type 2 diabetes, one-time telephone consultation was non-inferior to face-to-face consultation in terms of glycaemic control in the short term. However, more studies are required to investigate the long-term effects of telephone consultations and for those with HbA1c≥9%.

Background: Traumatic brain injury (TBI) is a common phenomenon, accounting for significant cost and adverse health effects. While there is information about focal pathologies following TBI, knowledge of more diffuse processes is lacking, particularly regarding how analgesics affect this pathology. As buprenorphine is the most commonly used analgesic in experimental TBI models, this study investigated the acute effects of the opioid analgesic buprenorphine (Bup-SR-Lab) on diffuse neuronal/glial pathology, neuroinflammation, cell damage, and systemic physiology. Methods: We utilized a model of central fluid percussion injury (CFPI) in adult male rats treated with a single subcutaneous bolus of Bup-SR-Lab or saline 15min post-injury. Microscopic assessments were performed at 1 day post-injury. Cell impermeable dextran was infused intraventricularly prior to sacrifice to assess neuronal membrane disruption. Axonal injury was assessed by investigating labeling of the anterogradely transported amyloid precursor protein. Neuroinflammation was assessed by analyzing Iba-1+ microglial and GFAP+ astrocyte histological/morphological features as well as cytokine levels in both regions of interest (ROIs). Myelin pathology was assessed by evaluating the expression of myelin basic protein (MBP) and the propensity of MBP+ myelin debris. Results: Acute physiologic data showed no difference between groups except for reduction in weight loss following cFPI in Bup treated animals compared to saline. There were no discernable differences in axonal injury or membrane disruption between treatment groups. Cytokine levels were consistent between Bup and saline treated animals, however, microglia and astrocytes revealed region specific histological changes at 1d following Bup treatment. Myelin integrity and overall MBP expression showed no differences between Bup and saline treated animals, but there were significant regional differences in MBP expression between the cortex and thalamus.Conclusions: These data suggest effects of Bup treatment on weight following CFPI and potential regional specificity of Bup-associated microglial and astrocyte alterations, but very little change in other acute pathology at 1-day post-injury. Overall, this preliminary study indicates that use of Bup-SR-Lab in preclinical work does have effects on acute glial pathology, however, longer term studies will be needed to assess potential effects of Bup treatment on more chronic pathological progressions.

Background Obese patients have lower plasma concentrations of the cardiac natriuretic peptides (NPs) than their age- and sex-matched counterparts. This may reflect lower production and/or increased peptide clearance. It is unclear whether NP bioactivity is affected by obesity. Methods We studied the effects of obesity on B-type natriuretic peptide (BNP) clearance and bioactivity by comparing results from standardized intravenous infusions of BNP administered 2 weeks before and 6 months after bariatric surgery in 12 consecutive patients with morbid obesity (body mass index, BMI > 35 kg/m2). Anthropometric, clinical, neurohormonal, renal, and echocardiographic variables were obtained pre- and postsurgery. Pre- vs postsurgery calculated intrainfusion peptide clearances were compared. Results BMI (44.3 ± 5.0 vs 33.9 ± 5.2 kg/m2, P Conclusion Obesity is associated with increased clearance, but preserved bioactivity, of BNP.

BackgroundThe prevalence of multimorbidity varies widely due to the lack of consensus in defining multimorbidity. This study aimed to measure the prevalence of multimorbidity in a primary care setting using two definitions of multimorbidity with two different lists of chronic conditions.MethodsWe conducted a cross-sectional study of 787,446 patients, aged 0 to 99 years, who consulted a family physician between July 2015 to June 2016. Multimorbidity was defined as ‘two or more’ (MM2+) or ‘three or more’ (MM3+) chronic conditions using the Fortin list and Chronic Disease Management Program (CDMP) list of chronic conditions. Crude and standardised prevalence rates were reported, and the corresponding age, sex or ethnic-stratified standardised prevalence rates were adjusted to the local population census.ResultsThe number of patients with multimorbidity increased with age. Age-sex-ethnicity standardised prevalence rates of multimorbidity using MM2+ and MM3+ for Fortin list (25.9, 17.2%) were higher than those for CDMP list (22.0%; 12.4%). Sex-stratified, age-ethnicity standardised prevalence rates for MM2+ and MM3+ were consistently higher in males compared to females for both lists. Chinese and Indians have the highest standardised prevalence rates among the four ethnicities using MM2+ and MM3+ respectively.ConclusionsMM3+ was better at identifying a smaller number of patients with multimorbidity requiring higher needs compared to MM2+. Using the Fortin list seemed more appropriate than the CDMP list because the chronic conditions in Fortin’s list were more commonly seen in primary care. A consistent definition of multimorbidity will help researchers and clinicians to understand the epidemiology of multimorbidity better.

Introduction Singapore is facing an ageing population and the care needs of the population will increase in tandem. A segment of this population would be living with multimorbidity and frailty. Frailty is defined as an age-related state characterised by reduced strength and physiologic malfunctioning. Multimorbidity refers to the coexistence of multiple chronic conditions in an individual. Older adults are more likely to have frailty and multimorbidity, and this would increase the burden of their caregiver. Our study aimed to determine the prevalence of caregiver burden for primary family caregivers of frail older adults with multimorbidity. We also investigated the factors that were associated with primary family caregiver burden. Methods This was an interviewer-administered, cross-sectional study of primary family caregivers of frail older patients with multimorbidity that was conducted in two National Healthcare Group polyclinics. Convenience sampling was used. The 12-item Zarit Burden Index (ZBI) was used to assess primary family caregiver burden. The scores of the ZBI range from 0 to 48, with a score of 10 or above indicating that the primary family caregiver perceives burden. Descriptive statistics were used to provide information regarding the caregivers and the care recipients. Multivariable logistic regression was used to investigate the factors affecting primary family caregiver burden. Results One hundred eighty-eight family caregivers were interviewed and 71.8% of them perceived burden on the ZBI. 59.6% were caregivers to their parents and 18.1% of them had multimorbidity. Almost two-thirds of the caregivers interviewed were female. After adjusting for other factors via multivariable analysis, the ethnicity of the caregiver and the increase in time spent caregiving per week were the two factors positively associated with family caregiver burden. A Chinese primary family caregiver had almost three times the odds of perceiving burden when compared to a non-Chinese primary family caregiver. Conclusion Caregiver burden was high amongst primary family caregivers of frail older adults with multimorbidity. Being a Chinese primary family caregiver compared to non-Chinese ethnic groups as well as being a primary family caregiver who spent increased time caregiving per week were the two factors positively associated with family caregiver burden. Further exploratory, qualitative studies can be done to find out the reasons to Chinese primary family caregivers being more burdened compared to the non-Chinese primary family caregivers. In addition, the specific factors related to increased time caregiving per week and family caregiver burden can also be studied.

Background—One year has passed since the first COVID-19 case in Singapore. This scoping review commemorates Singaporean researchers that have expanded the knowledge on this novel virus. We aim to provide an overview of healthcare-related articles published in peer-reviewed journals, authored by the Singapore research community about COVID-19 during the first year of the pandemic. Methods—This was reported using the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) protocol. It included healthcare-related articles about COVID-19 published between 23 January 2020 and 22 January 2021 with a Singapore-affiliated author. MEDLINE, Embase, Scopus, Web of Science, CINAHL, PsycINFO, Google Scholar, and local journals were searched. The articles were screened independently by two reviewers. Results—The review included 504 articles. Most of the articles narrated the changes to hospital practice (210), while articles on COVID-19 pathology (94) formed most of the non-narrative papers. Publications on public health (61) and the indirect impacts to clinical outcomes (45) were other major themes explored by the research community. The remaining articles detailed the psychological impact of the pandemic (35), adaptations of medical education (30), and narratives of events (14). Conclusion—Amidst a resurgence of community cases involving variant COVID-19 strains, the resources from the research community will provide valuable guidance to navigate these uncertain times.

Background: Multimorbidity presents a key challenge to healthcare systems globally. However, heterogeneity in the definition of multimorbidity and design of epidemiological studies results in difficulty in comparing multimorbidity studies. This scoping review aimed to describe multimorbidity prevalence in studies using large datasets and report the differences in multimorbidity definition and study design. Methods: We conducted a systematic search of MEDLINE, EMBASE, and CINAHL databases to identify large epidemiological studies on multimorbidity. We used the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) protocol for reporting the results. Results: Twenty articles were identified. We found two key definitions of multimorbidity: at least two (MM2+) or at least three (MM3+) chronic conditions. The prevalence of multimorbidity MM2+ ranged from 15.3% to 93.1%, and 11.8% to 89.7% in MM3+. The number of chronic conditions used by the articles ranged from 15 to 147, which were organized into 21 body system categories. There were seventeen cross-sectional studies and three retrospective cohort studies, and four diagnosis coding systems were used. Conclusions: We found a wide range in reported prevalence, definition, and conduct of multimorbidity studies. Obtaining consensus in these areas will facilitate better understanding of the magnitude and epidemiology of multimorbidity.

Binaural pitch fusion is the perceptual integration of stimuli that evoke different pitches between the ears into a single auditory image. This study was designed to investigate how steady background noise can influence binaural pitch fusion. The binaural fusion ranges, the frequency ranges over which binaural pitch fusion occurred, were measured with three signal-to-noise ratios (+15, +5, and −5dB SNR) of the pink noise and compared with those measured in quiet. The preliminary results show that addition of an appropriate amount of noise can reduce binaural fusion ranges, an effect called stochastic resonance. This finding increases the understanding of how specific noise levels can sharpen binaural pitch fusion in normal hearing individuals. Furthermore, it elicits more pathways for research to explore how this benefit can practically be used to help improve binaural auditory perception.

To evaluate differences in quality metrics between hysterectomies performed by fellowship-trained surgeons and those performed by generalists.Retrospective review of 2845 consecutive hysterectomies by 75 surgeons (23 fellowship-trained, 52 generalists) at 7 hospitals in Ontario, Canada. The primary outcome was a composite of any complication or return to the emergency department (ED) within 30 days of hysterectomy. Secondary outcomes were 2 quality outcome measures (grade of complication and return to ED within 30 days) and 4 quality process measures (minimally invasive hysterectomy rate, rate of preoperative anemia, same-day discharge for laparoscopic hysterectomy [LH], and performing cystoscopy at LH).Fellowship-trained surgeons were more likely to perform concurrent resection of endometriosis, bilateral ureterolysis, lysis of adhesions, uterine/internal iliac artery ligation, and morcellation (all P0.001). Generalists performed more vaginal procedures, including vaginal repair, vault suspension, and insertion of mid-urethral sling (all P0.001). After controlling for patient and surgical factors, there was no difference in the primary outcome (adjusted odds ratio [aOR] 1.07; 95% CI 0.79-1.45, P = 0.667). Fellowship-trained surgeons were more likely to perform minimally invasive hysterectomy (aOR 2.38; 95% CI 1.15-4.93, P = 0.020), had higher rates of same-day discharge for LH (aOR 2.23; 95% CI 1.31-3.81, P = 0.003), and were more likely to perform cystoscopy (unadjusted OR 2.94; 95% CI 2.30-3.85, P0.001). There were no differences in the rates of preoperative anemia, surgical complications, and ED visits.Differences exist between fellowship-trained surgeons and generalists regarding case mix and process quality metrics. Postoperative complications and readmissions were comparable for both groups of surgeons.

Background: Patients with multimorbidity must bear not just the burden of their illness, but also the burden of treatment which is, in part, induced by their interactions with the healthcare system. The need to shuttle between different healthcare institutions and multiple healthcare providers can make navigating the healthcare system challenging, and this may be even more so for older patients with limited resources and support. Objectives: Few qualitative studies have explored the experiences of patients with multimorbidity in navigating the healthcare system. This study will explore the experiences of older patients with multimorbidity and their caregivers as they navigate through the healthcare system. We aim to arrive at a better understanding of patient experiences of possible gaps in the continuity of care and how the current system can be modified and adapted to better address the needs of older patients with multimorbidity. Method: Semi-structured, in-depth interviews will be conducted with purposively sampled older patients with multimorbidity, aged 60 and above seen in primary care, together with their caregivers. Interviews will be transcribed verbatim and analysed by the study team using inductive thematic analysis. Conclusions: Our study seeks to explore the navigational experiences within the healthcare system for older patients with multimorbidity in an Asian, multi-ethnic society. The findings will be shared with decision-makers in the healthcare setting in order to improve patient care for this population and ultimately maximise their positive health outcomes, and will add to better understanding how the burden of treatment arising from navigational challenges within the healthcare system may be reduced for older patients with multimorbidity.

Patients with multimorbidity are commonly seen in primary care. An increasing number of multimorbidity patterns are being reported in the Western literature with a few from Asia. The main objective of this systematic review was to describe patterns of associative multimorbidity, defined as associations beyond chance or patterns of diseases, in the Asian population. We searched Medical Literature Analysis and Retrieval System Online (MEDLINE (Ovid)), Excerpta Medica Database (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science (Clarivate Analytics), and Scopus (Elsevier) databases from their inception to April 22, 2019 using medical subject headings, keywords in titles, abstracts, and text. We used the Modified Newcastle-Ottawa Scale for risk-of-bias assessment. Eight articles from China, India, Indonesia, and Japan met the inclusion criteria. Patterns of associative multimorbidity were reported as dyadic/triadic disease combinations or disease clusters. The most common multimorbidity pattern, “cardiovascular and metabolic diseases,” was identified in six of eight articles. The other four multimorbidity patterns are comprised of “mental health problems,” “degenerative diseases,” pulmonary diseases,” and “cancer diseases.” The eight articles showed methodological heterogeneity in terms of the list of chronic diseases, ascertainment of multimorbidity, statistical methods, and study populations. This systematic review identified five common patterns of associative multimorbidity in Asia. “Cardiovascular and metabolic diseases” and “mental diseases” were two patterns that were similarly reported in the Western world. Alignment of the definition of multimorbidity and the statistical methodology are needed to identify the unique patterns of multimorbidity in Asia so that clinical practice guidelines on multimorbidity can be developed for the Asian population.

Microgrids are emerging throughout the world as a means of integrating decentralized, renewable energy power generation. The flexibility of this customer-driven, behind the meter solution allows it to address unique challenges. This variability that drives microgrid adoption is the same thing that keeps them from being categorized and repeatable. This lack of specific modeling leads to a stalling in financing and wide-scale adoption. By analyzing the microgrid system development, evolution, architecture, integration zones, technological advances, and business models, a clearer picture of how these entities are intertwined emerges. Several case studies of deployed microgrids will showcase the cutting-edge solutions they apply. The future implications of this new energy revolution will be highlighted and shown to create an energy generation equilibrium and the significant role played by microgrids in this new energy revolution. Although many compilations of research work on microgrids have been previously presented by various reviewers, most of them are specific to an electrical or power quality-related issue, which addresses a discrete audience. This work only includes within its scope a general outlook of microgrids and the present-day challenges in its use of rural/urban renewable energy production and distribution. The results allowed for the researchers to conclude that microgrids have emerged as a great solution in situations where energy has to be transmitted from a decentralized system to a centralized system. Challenges will arise in the microgrid management and government laws and regulations if rectified microgrids can lead to an equilibrium between decentralized and centralized bulk energy networks.

Background Multimorbidity, the coexistence of multiple chronic conditions in an individual, is a growing public health challenge. Amidst the COVID-19 pandemic, physical distancing remains an indispensable measure to limit the spread of the virus. This pertains especially to those belonging to high-risk groups, namely older adults with multimorbidity. In-person visits are discouraged for this cohort; hence, there is a need for an alternative form of consultation such as video consultations to continue the provision of care. Objective The potential of video consultations has been explored in several studies. However, the emergence of COVID-19 presents us with an unprecedented opportunity to explore the use of this technological innovation in a time when physical distancing is imperative. This study will evaluate the sustainability of video consultations on a micro-, meso-, and macro-level by assessing the views of patients, physicians, and organizational and national policymakers, respectively. Methods The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework was designed as a guide for the development of health care technologies. In this study, the implementation of and experiences related to video consultations will be studied using the NASSS framework. Individual in-depth interviews or focus group discussions will be conducted with participants using the Zoom platform. Data will be analyzed by at least two investigators trained in qualitative methodology, organized thematically, and coded in two phases—an initial phase and a focused selective phase. All disagreements will be resolved by consulting the larger research team until consensus is reached. Results This study was approved for funding from the Geriatric Education and Research Institute. Ethics approval was obtained from the National Healthcare Group Domain Specific Review Board (reference #2020/00760). Study recruitment commenced in July 2020. The results of the data analysis are expected to be available by the end of the year. Conclusions This study aims to evaluate the adoption and sustainability of video consultations for older adults with multimorbidity during the pandemic as well as post COVID-19. The study will yield knowledge that will challenge the current paradigm on how care is being delivered for community-dwelling older adults with multimorbidity. Findings will be shared with administrators in the health care sector in order to enhance the safety and quality of these video consultations to improve patient care for this group of population. International Registered Report Identifier (IRRID) DERR1-10.2196/22679

ObjectiveOur aim was to identify the patterns of multimorbidity among a group of patients who visited primary care in Singapore.MethodsA cross-sectional study of electronic medical records was conducted on 437,849 individuals aged 0-99 years who visited National Healthcare Group Polyclinics from 1 Jul 2015 to 30 Jun 2016 for the management of chronic conditions. Patients' health conditions were coded with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10), and patient records were extracted for analysis. Patients' diagnosis codes were grouped by exploratory factor analysis (EFA), and patterns of multimorbidity were then identified by latent class analysis (LCA).ResultsEFA identified 19 groups of chronic conditions. Patients with at least three chronic conditions were further separated into eight classes based on demographics and probabilities of various diagnoses. We found that older patients had higher probabilities of comorbid hypertension, kidney disease and ischaemic heart disease (IHD), while younger patients had a higher probability of comorbid obesity. Female patients had higher probabilities of comorbid arthritis and anaemia, while male patients had higher probabilities of comorbid kidney diseases and IHD. Indian patients presented with a higher probability of comorbid diabetes than Chinese and Malay patients.ConclusionsThis study demonstrated that patients with multimorbidity in primary care could be classified into eight patterns. This knowledge could be useful for more precise management of these patients in the multiethnic Asian population of Singapore. Programmes for early intervention for at-risk groups can be developed based on the findings.

BACKGROUND Multimorbidity, the coexistence of multiple chronic conditions in an individual, is a growing public health challenge. Amidst the COVID-19 pandemic, physical distancing remains an indispensable measure to limit the spread of the virus. This pertains especially to those belonging to high-risk groups, namely older adults with multimorbidity. In-person visits are discouraged for this cohort; hence, there is a need for an alternative form of consultation such as video consultations to continue the provision of care. OBJECTIVE The potential of video consultations has been explored in several studies. However, the emergence of COVID-19 presents us with an unprecedented opportunity to explore the use of this technological innovation in a time when physical distancing is imperative. This study will evaluate the sustainability of video consultations on a micro-, meso-, and macro-level by assessing the views of patients, physicians, and organizational and national policymakers, respectively. METHODS The NASSS (nonadoption, abandonment, scale-up, spread, and sustainability) framework was designed as a guide for the development of health care technologies. In this study, the implementation of and experiences related to video consultations will be studied using the NASSS framework. Individual in-depth interviews or focus group discussions will be conducted with participants using the Zoom platform. Data will be analyzed by at least two investigators trained in qualitative methodology, organized thematically, and coded in two phases—an initial phase and a focused selective phase. All disagreements will be resolved by consulting the larger research team until consensus is reached. RESULTS This study was approved for funding from the Geriatric Education and Research Institute. Ethics approval was obtained from the National Healthcare Group Domain Specific Review Board (reference #2020/00760). Study recruitment commenced in July 2020. The results of the data analysis are expected to be available by the end of the year. CONCLUSIONS This study aims to evaluate the adoption and sustainability of video consultations for older adults with multimorbidity during the pandemic as well as post COVID-19. The study will yield knowledge that will challenge the current paradigm on how care is being delivered for community-dwelling older adults with multimorbidity. Findings will be shared with administrators in the health care sector in order to enhance the safety and quality of these video consultations to improve patient care for this group of population. INTERNATIONAL REGISTERED REPORT DERR1-10.2196/22679

Endothelial progenitor cells (EPCs) are bone-marrow derived cells that are critical in the maintenance of endothelial wall integrity and protection of ischemic myocardium through the formation of new blood vessels (vasculogenesis) or proliferation of pre-existing vasculature (angiogenesis). Diabetes mellitus (DM) and the metabolic syndrome are commonly associated with ischemic heart disease through its pathological effects on the endothelium and consequent endothelial dysfunction. Thymosin-&beta, 4 (T&beta, 4) which expressed in the embryonic heart is critical in epicardial and coronary artery formation. In this study, we explored the effects of T&beta, 4 treatment on diabetic EPCs in vitro and intramyocardial injection of T&beta, 4-treated and non-T&beta, 4 treated EPCs following acute myocardial infarction (MI) of diabetic rats in vivo. It was found that 10 ng/mL T&beta, 4 increased migration, tubule formation, and angiogenic factor secretion of diabetic EPCs in vitro. In vivo, although implantation of T&beta, 4 treated diabetic EPCs significantly increased capillary density and attracted more c-Kit positive progenitor cells into the infarcted hearts as compared with implantation of non-T&beta, 4 treated diabetic EPCs, the significantly improved left ventricular ejection fraction was only found in the rats which received non-T&beta, 4 treated EPCs. The data suggests that a low dose T&beta, 4 increases diabetic EPC migration, tubule formation, and angiogenic factor secretion. However, it did not improve the effects of EPCs on left ventricular pump function in diabetic rats with MI.

Introduction: Single-disease clinical practice guidelines (CPGs) are not designed to consider patients with multiple chronic conditions, or multimorbidity. Applying multiple CPGs to a single patient may create an overwhelming treatment burden resulting in poor adherence and clinical outcomes. No studies on the cumulative treatment burden from multiple CPGs have been done in Singapore. We described the treatment burden on a hypothetical patient with six chronic conditions when multiple CPGs were applied, and appraised each CPG with respect to the patient-centred care of older adults with multimorbidity. Methods: A treatment plan was developed for a hypothetical 72-year-old woman with asthma, depression, diabetes mellitus, dyslipidaemia, hypertension and osteoarthritis according to the latest CPG recommendations. Treatment burden was quantified in terms of time spent, cost, and the number of appointments and medications. Each CPG was appraised with respect to the care of older adults, patients with multimorbidity and patient-centred care. Results: Following the CPGs strictly, an average of about two hours was spent daily taking 14 different medications and following 21 non-pharmacological recommendations. Her out-of-pocket payment was SGD 104.42 monthly despite a near 90% subsidy on healthcare bills. Patient-centred care of older adults with multimorbidity was inadequately addressed in all six CPGs. Conclusion: When six CPGs were cumulatively followed, the treatment burden was time-consuming, costly and disruptive. Patients' goals and preferences must guide prioritisation of care such that treatment burden remains minimally disruptive to their lives. Developing future CPGs to deliver patient-centred rather than disease-focused care will be crucial to the management of multimorbidity. Ministry of Health (MOH) National Medical Research Council (NMRC) Published version This research was supported by the Singapore Ministry of Health’s National Medical Research Council under the Centre Grant Programme (reference no. CGAug16C019).

Supplemental Material, sj-docx-1-cob-10.1177_2235042X20984064 for Experiences of older primary care patients with multimorbidity and their caregivers in navigating the healthcare system: A qualitative study protocol by Eng Sing Lee, Gayathri Muthulingam, Evelyn Ai Ling Chew, Poay Sian Sabrina Lee, Hui Li Koh, Stephanie Xin En Quak, Yew Yoong Ding, Mythily Subramaniam and Janhavi Ajit Vaingankar in Journal of Comorbidity

This exploratory study used a qualitative research approach to examine a predominantly Latino Title I elementary school's existing health plan to identify how the plan addresses obesity in children and how the school engages parents in these activities. Additionally, the researcher employed photovoice to interview mothers and elicit information about their food purchase, preparation, consumption, physical activity practices, and channels of communication for health information within their household. This study was guided by the following research questions: (1) How does the current school health plan address obesity in children? (2) In what ways is the school working with families to lower obesity in children? (3) What are the elements of a contextually relevant health program for a Title I school? The findings from this study suggest that, while the school's health plan components may provide a framework for obesity intervention, the plan does not include a comprehensive obesity intervention program for students. Moreover, there was no evidence of widespread participation among parents in any of the health and nutrition activities provided by the school. From the data emerged the unexpected finding that suggests that low-income mothers are making deliberate choices around high-quality food and physical activity to establish a micro-environment of health within their households in spite of the influence of the obesogenic, underresourced environment that encompasses the local neighborhood. This study contributes new knowledge about four elements of a contextually relevant school health plan for a predominantly Latino Title I school. The model comprised by these four elements acknowledges multicultural and multiethnic food traditions while providing research-based nutrition information, facilitates student and family access to physical activity and health information, and addresses the economic constraints on food purchase experienced by low-income families. Additionally, this model outlines a paradigm in which parent engagement is facilitated by decreasing barriers to participation and increasing two-way communication between schools and families in a way that is idiosyncratic, driven by the needs of the families, supported by the socioecological resources of the community, and is economically and linguistically appropriate for the students and families served by Title I schools.

Study Objective To compare surgical experience at myomectomy between patients with myomas pretreated with ulipristal acetate versus no pretreatment. Design A prospective, observational, multicenter study of myomectomy procedures by any route (hysteroscopic, laparoscopic, or laparotomy) (Canadian Task Force classification II-2). Setting Five university-affiliated hospitals including tertiary care and community sites. Patients Any patient who underwent hysteroscopic, laparotomic, or laparoscopic myomectomy regardless of medical pretreatment. Interventions Surgeons completed a Web-based questionnaire after each myomectomy procedure. Surgeons evaluated visualization, the myoma-myometrium relationship, extrusion, fluid deficit, blood loss, and overall ease of hysteroscopic myomectomies. For laparotomic/laparoscopic myomectomies, plane delineation, myoma separation, blood loss, and overall ease were assessed. The total surgical experience score was calculated by summing the values for each subscale. Measurements and Main Results A total of 309 myomectomies were evaluated by 52 surgeons (response rate = 83%) at 5 institutions. Of 140 hysteroscopic myomectomies, 84 (60%) were performed without pretreatment, 29 (21%) after ulipristal acetate pretreatment, and 27 (19%) after pretreatment with gonadotropin-releasing hormone agonist/other. Of 169 laparotomic/laparoscopic myomectomies, 104 (62%) were performed without pretreatment, 46 (27%) after ulipristal acetate, and 19 (11%) after gonadotropin-releasing hormone agonist/other. The mean surgical experience score (±standard deviation) was comparable between the no pretreatment and ulipristal acetate groups for hysteroscopic myomectomies (13.8 ± 2.2 vs 13.3 ± 2.2, p = .35) and laparotomic/laparoscopic myomectomies (12.9 ± 4.1 vs 12.1 ± 4.2, p = .30). Compared with no pretreatment, more laparotomic/laparoscopic myomectomies after ulipristal acetate pretreatment were associated with difficult delineation of surgical planes (22 [47.8%] vs 23 [22.1%], p = .002) and difficult myoma separation (20 [43.5%] vs 21 [20.2%], p = .003). More myomas were described as soft with ulipristal acetate pretreatment (14 [30.4%] vs 17 [16.4%], p = .049). The rates of profuse/abundant endometrium during hysteroscopy were similar between the no pretreatment (21 [25.0%]) and ulipristal acetate (7 [24.1%], p = .93) groups. Conclusion Despite differences in surgical nuances, the overall myomectomy experience was not negatively affected by ulipristal acetate pretreatment.

The introduction of assays for donor-derived cell-free DNA into clinical transplant medicine has provided an additional method to assess allograft health. We compared the performance of two of these assays, Prospera™ and AlloSure®. A series of 15 paired-samples from individual kidney transplant recipients were tested using both Prospera™ and AlloSure® assays simultaneously. Test performances were determined using the company cutoff of >1% to indicate active rejection. Additional analysis was also performed using a cutoff of 0.5%. Acute rejections were all confirmed by biopsy. There was one discordant result for 15 paired-samples when using a cutoff level of 1%, and results were concordant using a cutoff level of 0.5%. Seven biopsy were performed, six of which showed rejection. Using cutoff of 1%, Prospera™ identified 80% (4/5) of T cell-mediated rejections (TCMR) compared to 60% for AlloSure® (3/5). Both assays recognized the only case of antibody-mediated rejection. When using cutoff level of 0.5%, both assays correctly identified all cases of rejection. In this cohort, the two tests showed different sensitivities when using the validated cutoff of 1% dd-cfDNA, and the same sensitivity when using a lower cutoff of 0.5%. The result accuracy was confirmed by kidney biopsy.

ObjectivesMultimorbidity is a norm in primary care. A consensus on its operational definition remains lacking especially in the list of chronic conditions considered. This study aimed to compare six different operational definitions of multimorbidity previously reported in the literature for the context of primary care in Singapore.Design, setting and participantsThis is a retrospective study using anonymised primary care data from a study population of 787 446 patients. We defined multimorbidity as having three or more chronic conditions in an individual. The prevalence of single conditions and multimorbidity with each operational definition was tabulated and standardised prevalence rates (SPRs) were obtained by adjusting for age, sex and ethnicity. We compared the operational definitions based on (1) number of chronic diseases, (2) presence of chronic diseases of high burden and (3) relevance in primary care in Singapore. IBM SPSS V.23 and Microsoft Office Excel 2019 were used for all statistical calculations and analyses.ResultsThe SPRs of multimorbidity in primary care in Singapore varied from 5.7% to 17.2%. The lists by Fortin et al, Ge et al, Low et al and Quah et al included at least 12 chronic conditions, the recommended minimal number of conditions. Quah et al considered the highest proportion of chronic diseases (92.3%) of high burden in primary care in Singapore, with SPRs of at least 1.0%. Picco et al and Subramaniam et al considered the fewest number of conditions of high relevance in primary care in Singapore.ConclusionsFortin et al’s list of conditions is most suitable for describing multimorbidity in the Singapore primary care setting. Prediabetes and ‘physical disability’ should be added to Fortin et al’s list to augment its comprehensiveness. We propose a similar study methodology be performed in other countries to identify the most suitable operational definition in their own context.

Voice pitch is an important cue for auditory object segregation in a multi-talker environment. A recent study showed that the ability to segregate and identify speech based on voice pitch differences is highly correlated with the breadth of binaural pitch fusion, the perceptual integration of dichotic stimuli that evoke different pitches across ears [Oh et al., ASA (2018)]. The goal of this study was to investigate effects of steady background noise on binaural pitch fusion and speech perception abilities in background noise consisting of multiple talkers. Subjects were tested in both quiet and various “soft” audible noise levels (15, 5, and -5 dB SNR) inboth ears with the following experiments. First, binaural pitch fusion measurements were conducted using pure tones. Second, speech on speech masking performance was measured as the threshold target-to-masker ratio needed to understand a target talker in the presence of either same- or different-gender masker talkers. The results showed that both breadth of binaural pitch fusion was minimized and voice pitch difference benefit in multi-talker conditions was maximized at an optimal amount of the noise levels, which is called suprathreshold stochastic resonance effects. A strong negative correlation was also observed between voice gender benefit and breadth of binaural fusion. The findings suggest potential rehabilitation approaches, such as low-level noise, to sharpen binaural pitch fusion and improve related speech perception ability in multi-talker listening environments.

Study Objective Evaluate differences in patient outcomes for hysterectomies performed by Fellowship-trained surgeons compared to Generalists. Design Retrospective review. Setting 5 Toronto hospitals. Patients or Participants Patients undergoing hysterectomy from July 2016-June 2018. Interventions Patient outcomes for surgeons with 6 months (minimum) of fellowship training in minimally invasive gynecology (Fellowship) were compared to those without post-residency training (Generalist). Hysterectomies performed by urogynecologists were excluded. Measurements and Main Results Primary outcome was complications (in-hospital and within 30-days of discharge). Secondary outcomes were grade of complication, return to emergency room (ER), surgeon case volume. Binary logistic regression analysis was performed comparing hysterectomies by Fellowship versus Generalist surgeons controlling for factors associated with case complexity. Odds ratios (OR), 95% confidence intervals (CI) and p-values were calculated. 1379 hysterectomies were included (702 cases by 17 Fellowship surgeons and 677 cases by 41 Generalists). Fellowship cases were more likely to have endometriosis (19.9% vs. 7.9%, p Conclusion There was no difference in complications for hysterectomies performed by Fellowship compared to Generalist surgeons. Fellowship surgeons had greater technicity rate. Cases performed by Fellowship surgeons were more complex with higher chance of additional procedures.

Study Objective To determine hysterectomy complication rate and patient, surgical and provider factors associated with complications. Design Retrospective review Setting 5 Toronto hospitals Patients or Participants Patients undergoing hysterectomy from July 2016-December 2017 Interventions Hysterectomy procedure Measurements and Main Results Retrospective review of Generalist hysterectomies at 5 Toronto hospitals from July 2016 to Dec 2017. Data was extracted from health records coding (ICD-10) and electronic medical records. Complications (in-hospital to 30 days of discharge) were classified using Clavien-Dindo Scale. Patient characteristics (BMI, anemia status), surgical factors (technicity, uterine presence of endometriosis and adhesions, uterine weight) and provider characteristics (case volume) were obtained. Logistic models were used to evaluate variables associated with complications. 1328 hysterectomy cases were performed by 67 surgeons over 1.5 years. The 294 recorded complications were classified as: 119 (40%) Grade 1, 102 (35%) Grade 2, 12 (4%) Grade IIIA, 61 (21%) Grade IIIB. Presence of endometriosis increased odds of any complication (OR 1.87, 95%CI 1.05-3.35, p=0.035). For every 100g increase in uterine weight, odds of ≥ Grade II complication increased by 4.5% (95%CI 0.3% - 9.4%, p=0.035). Low volume surgeons (≤1 hysterectomy/month) had higher unadjusted complication rate (28.6% vs 15.3%, p=0.01). After adjusting for case complexity (composite score incorporating BMI, presence of adhesions, endometriosis and uterine weight) and technicity, low volume surgeons had 2.21 OR (95% CI 1.08 – 4.52, p=0.03) of having ≥ Grade II complication. Conclusion Endometriosis and uterine weight increase risk of hysterectomy complications. Low volume surgeons perform more challenging hysterectomies and have lower technicity rates. After adjusting for patient and surgical factors, low volume surgeons have higher odds of complications.

Binaural pitch fusion is the fusion of dichotic stimuli across the two ears. The current study was designed to investigate how steady background noise can influence binaural fusion. The binaural fusion ranges, the frequency ranges over which binaural fusion occurred, were measured with various levels (30—70 dB/ERBN) of the threshold-equalizing noise (Moore et al., 2004) and compared with those measured in quiet. Two interleaved adaptive procedures were used to estimate the fusion ranges at the reference frequencies of 2 and 3 kHz: Single-Interval Adjustment Matrix (SIAM; Kaernbach, 1990) and Maximum-Likelihood (ML; Green, 1992). The results show that the TEN decreases the fusion ranges to about 1.5 to 2 times narrower than those in the quiet condition. Even soft noise levels (i.e., the 30 dB/ERBN) significantly decreased fusion ranges. For some subjects, the fusion range asymptoted with a soft level and did not increase with increased noise level; for other subjects, the fusion range minimized only at the specific noise level. Both SIAM and ML procedures showed similar performance in fusion range estimation. The findings suggest that the importance of steady background noise, specifically TEN, in binaural fusion may vary across subjects. This may provide potential rehabilitation approaches to reduce broad fusion in hearing impaired listeners.Binaural pitch fusion is the fusion of dichotic stimuli across the two ears. The current study was designed to investigate how steady background noise can influence binaural fusion. The binaural fusion ranges, the frequency ranges over which binaural fusion occurred, were measured with various levels (30—70 dB/ERBN) of the threshold-equalizing noise (Moore et al., 2004) and compared with those measured in quiet. Two interleaved adaptive procedures were used to estimate the fusion ranges at the reference frequencies of 2 and 3 kHz: Single-Interval Adjustment Matrix (SIAM; Kaernbach, 1990) and Maximum-Likelihood (ML; Green, 1992). The results show that the TEN decreases the fusion ranges to about 1.5 to 2 times narrower than those in the quiet condition. Even soft noise levels (i.e., the 30 dB/ERBN) significantly decreased fusion ranges. For some subjects, the fusion range asymptoted with a soft level and did not increase with increased noise level; for other subjects, the fusion range minimized only at the...