Pragmatic multicentre stepped-wedge cluster randomised trial to investigate the effectiveness of community-based falls prevention programme for older adults with falls risk in Singapore: a protocol paper.

INTRODUCTION: Falls are an important public health issue with consequences that include injuries, quality of life reduction and high healthcare costs. Studies show that falls prevention strategies are effective in reducing falls rate among community-dwelling older adults. However, the evaluation for effectiveness was usually done in a controlled setting with homogeneous population, and thus may not be generalisable to a wider population. This study aims to evaluate the impact of community falls prevention programmes with group-based strength and balance exercises, on falls risk and health outcomes for older adults with falls risk in Singapore. METHODS AND ANALYSIS: This is a pragmatic closed cohort stepped-wedge cluster randomised trial design study, which involves sequential crossover of clusters from the waitlist control condition to the intervention condition, with the sequence of crossover randomly determined. The intervention will be sequentially rolled out to 12 clusters (a minimum of 5 participants/cluster), over 6 time periods with 8-week intervals in Central and North regions of Singapore. The primary analysis will be conducted under the intention-to-treat principle. A general linear mixed model or generalised estimating equation analysis appropriate for a multilevel longitudinal study incorporating an appropriate error distribution and link function will be used. Markov model will be developed to estimate the incremental cost per quality-adjusted life years and incremental cost per fall prevented from the implementation of falls prevention strategies from a societal perspective. Conditional on there being clinically relevant differences in short-term outcomes, we will implement simulation modelling to project the long-term divergence in trajectories for outcomes and costs using the Markov model. ETHICS AND DISSEMINATION: Ethics approval has been obtained. Results will be disseminated in publications and other relevant platforms. TRIAL REGISTRATION NUMBER: NCT04788251.

Clinical Features Associated with COVID-19 Outcome in MM: First Results from International Myeloma Society COVID-19 Dataset

The primary cause of morbidity and mortality in patients with multiple myeloma (MM) is an infection. Therefore there is great concern about the susceptibility to the outcome of COVID-19 infected patients with multiple myeloma. This retrospective study describes the baseline characteristics and outcome data of COVID-19 infection in 650 patients with plasma cell disorders (98 outpatinets and 538 hospitilized patinets), collected from 10 countries by the International Myeloma Society to understand the initial challenges faced by Myeloma patients during COVID-19 pandemic. Descriptive statistics, univariate logistic regression, and multivariate analysis were performed for hospitalized MM patinets. The median age was 69 years, and nearly all patients (96%) had MM. Approximately 36% were recently diagnosed (2019-2020), and 54% of patients were receiving first-line therapy. Thirty-three percent of patients have died, with significant geographic variability, ranging from 27% to 57% of hospitalized patients. Univariate analysis identified age, ISS3, high-risk disease, renal disease, suboptimal myeloma control (active or progressive disease), and one or more comorbidities as risk factors for higher rates of death. Neither history of transplant, including within a year of COVID-19 diagnosis nor other anti-MM treatments were associated with outcomes. Multivariate analysis found that only age, high-risk MM, renal disease, and suboptimal MM control remained independent predictors of adverse outcome with COVID-19 infection. The management of MM in the era of COVID-19 requires careful consideration of patient and disease-related factors to decrease the risk of acquiring COVID-19 infection, while not compromising the disease control through appropriate MM treatment. This study provides the data to develop recommendations for the management of MM patients at risk of COVID-19 infection. Key PointsO_LIHigh but variable mortality for hospitalized MM patients (27% to 57%) C_LIO_LIOptimal MM control was associated with COVID-19 associated death for MM patinets C_LI Explanation of noveltyThis study investigated the risk and outcome of COVID-19 infection in MM patients globally (10 countries)

Interprofessional bedside rounds: Nurse-physician collaboration and perceived barriers in an Asian hospital.

Interprofessional bedside rounds by nurses and physicians provide valuable space and time for the discussion of patient care, which is essential for providing quality care. However, nurse-physician collaboration and barriers to attending these rounds are not well-examined. This study aimed to examine the collaboration of nurses and physicians and their perceived barriers to interprofessional bedside rounds. A cross-sectional survey was conducted on 371 medical ward-based nurses and physicians from an acute care tertiary hospital in Singapore, using a 27-item Nurse-Physician Collaboration Scale and a 21-item Perceived Barriers to Interprofessional Bedside Rounds questionnaire. The overall Nurse-Physician Collaboration scores indicated positive attitudes toward nurse-physician collaboration in bedside rounds, with no significant difference found between nurses and physicians. While the sharing of information was reported to be the most frequent collaborative activity, the cooperative relationship was rated to be the least frequent behavior. The highest ranked barriers were related to time-related issues. The nurses reported a significantly greater perceived barrier in attending bedside round than the physicians. To optimize nurse-physician collaboration, the study advocates healthcare leaders to foster cooperative relationships between nurses and physicians and to reorganize ward routines to provide designated time periods for nurses to attend rounds.

Expansive spread of IncI1 plasmids carrying blaCMY-2 amongst Escherichia coli.

Escherichia coli is a leading cause of urinary tract infections. One of the most common antibiotic classes used to treat such infections is the ß-lactams, including cephalosporins. Resistance to the third-generation cephalosporins can be caused by production of extended-spectrum ß-lactamases (ESBLs) or plasmid-mediated AmpC ß-lactamases. The most commonly reported AmpC ß-lactamase in E. coli is CMY-2. Plasmid-mediated CMY-2 has been frequently reported in E. coli and Salmonella sp. from food-producing animals. This study aimed to elucidate the molecular characteristics of clinical E. coli isolates carrying plasmids encoding CMY-2. A total of 67 CMY-2-producing E. coli were characterised by clonal analysis and phylogenetic typing. Characterisation of the plasmids carrying blaCMY-2 included replicon typing, plasmid profiling, plasmid transferability and sequencing of the blaCMY-2 genetic environment. As a result, E. coli producing CMY-2 was found to be highly polyclonal. The majority of CMY-2-producing E. coli belonged to phylogenetic group D. IncI1 plasmids were predominant among those carrying blaCMY-2 (96%). Restriction analysis revealed a single IncI1 plasmid carrying blaCMY-2 to be predominant and present in different clones of E. coli. IS1294-ISEcp1 complex or ISEcp1 that was truncated by IS1294 was the predominant insertion sequence upstream of blaCMY-2. The homogeneous genetic environment of blaCMY-2 observed among different strains of E. coli strongly suggests horizontal transfer of this IncI1, blaCMY-2-carrying plasmid. In summary, horizontal plasmid transfer plays a major role in the spread of blaCMY-2 in E. coli.