A community-based single fall prevention exercise intervention for older adults (STEADY FEET): Study protocol for a randomised controlled trial.

BACKGROUND: Falls and fall-related injuries in older adults are a leading cause of disability and death. Evidence has shown the benefits of exercises in improving functional outcomes and reducing fall rates among community-dwelling older adults. However, there is lack of effective community-based single exercise intervention for a broad population of older adults who are at high risk for falls. We aim to evaluate the effectiveness of Steady Feet (SF), a 6-month tailored community fall prevention exercise programme for improving functional outcomes. SF classes are facilitated by community fitness instructors and an exercise video. The main outcome is between-group changes in short physical performance battery (SPPB) scores. Secondary outcomes include balance confidence, fear of falling, quality of life, fall rates, and cost effectiveness. METHODS: We present the design of a 6-month randomised controlled trial of 260 older adults (≥ 60 years old). Individuals will be randomised in a 1:1 allocation ratio to the SF group or usual care group. Participants will be assessed at baseline, 3-month, and 6-month. Data on socio-demographics, co-morbidities, balance confidence, fear of falling, quality of life, physical activity level, rate of perceived exertion, fall(s) history, healthcare utilisation and cost, and satisfaction levels will be collected. Participants will also undergo functional assessments such as SPPB. Moreover, providers' satisfaction and feedback will be obtained at 3-month. DISCUSSION: An effective community fall prevention programme may lead to improved functional outcomes and reduced fall rates. Findings will also help inform the implementation and scaling of SF nation-wide. TRIAL REGISTRATION: Clinicaltrials.gov registration: NCT04801316. Registered on 15th March 2021.

The impact of community nursing program on healthcare utilization: A program evaluation.

BACKGROUND: The role of nurses has evolved to meet the dynamic needs of an aging population. Community nursing has been established in Singapore with the aim to anchor population health and provide sustainable healthcare services beyond the hospital to the community. Community nurses provide health services to residents at the Community Nurse Posts (CNP) situated within the heartland residential estates. OBJECTIVE: To investigate the effect on healthcare utilization six months pre and post first community nurse visit in older adults, and if the effect is modified by the presence of two or more community nurse visits or absence of a polyclinic chronic disease diagnosis. DESIGN: A single-group pretest-posttest study SETTING(S): Fifty-one SingHealth CNPs at the southeast and east regions of Singapore PARTICIPANTS: Community-dwelling older adults aged ≥ 60 years, seen at any of the SingHealth CNPs between 1 April and 30 November 2019. METHODS: The number of emergency department (ED) visits, unplanned inpatient admissions, length of inpatient stay, specialist outpatient clinic (SOC) and polyclinic visits at SingHealth institutions six months from the first community nurse visit were compared to six months prior. Negative binomial generalized estimating equations were used to model healthcare utilization events, adjusting for baseline age, gender, and race. RESULTS: 1,600 community-dwelling participants were included, of whom 1,561 (median age of 71 years) survived the post-test period. There was a population-average 23% lower rate of ED visits (incidence rate ratio 0.77, 95% confidence interval 0.68 to 0.87, p<0.001) and 15% lower rate of unplanned inpatient admissions (0.85, 0.75 to 0.96, p=0.011). A trend towards a lower rate of inpatient length of stay and a higher rate of SOC and polyclinic visits was also observed. The reduction in acute care utilization may have been greater among adults with two or more community nurse visits. Participants with no recent polyclinic chronic disease diagnosis had a greater increase in SOC visits. CONCLUSIONS: Community nursing services are associated with reduced acute care utilization, especially for older adults with two or more community nurse visits. The trend of a higher rate of SOC visits could be attributed to the community nurses' referrals for undiagnosed/ new conditions and/or treatment of suboptimal health issues. There is a potential role for community nursing towards a sustainable healthcare system.

Development of a Community-Based e-Health Program for Older Adults With Chronic Diseases: Pilot Pre-Post Study.

BACKGROUND: Chronic diseases may impact older adults' health outcomes, health care costs, and quality of life. Self-management is expected to encourage individuals to make autonomous decisions, adhere to treatment plans, deal with emotional and social consequences, and provide choices for healthy lifestyle. New eHealth solutions significantly increase the health literacy and empower patients in self-management of chronic conditions. OBJECTIVE: This study aims to develop a Community-Based e-Health Program (CeHP) for older adults with chronic diseases and conduct a pilot evaluation. METHODS: A pilot study with a 2-group pre- and posttest repeated measures design was adopted. Community-dwelling older adults with chronic diseases were recruited from senior activity centers in Singapore. A systematic 3-step process of developing CeHP was coupled with a smart-device application. The development of the CeHP intervention consists of theoretical framework, client-centric participatory action research process, content validity assessment, and pilot testing. Self-reported survey questionnaires and health outcomes were measured before and after the CeHP. The instruments used were the Self-care of Chronic Illness Inventory (SCCII), Healthy Aging Instrument (HAI), Short-Form Health Literacy Scale, 12 Items (HLS-SF 12), Patient Empowerment Scale (PES), and Social Support Questionnaire, 6 items. The following health outcomes were measured: Montreal Cognitive Assessment, Symbol Digit Modalities Test, total cholesterol (TC), high-density lipoproteins, low-density lipoproteins/very-low-density lipoproteins (LDL/VLDL), fasting glucose, glycated hemoglobin (HbA1c), and BMI. RESULTS: The CeHP consists of health education, monitoring, and an advisory system for older adults to manage their chronic conditions. It is an 8-week intensive program, including face-to-face and eHealth (Care4Senior App) sessions. Care4Senior App covers health education topics focusing on the management of hypertension, hyperlipidemia, and diabetes, brain health, healthy diet, lifestyle modification, medication adherence, exercise, and mindfulness practice. Content validity assessment indicated that the content of the CeHP is valid, with a content validity index (CVI) ranging 0.86-1 and a scale-CVI of 1. Eight participants in the CeHP group and 4 in the control group completed both baseline and post intervention assessments. Participants in the CeHP group showed improvements in fasting glucose, HbA1c, TC, LDL/VLDL, BMI, SCCII indices (Maintenance, Monitoring, and Management), HAI, and PES scores post intervention, although these changes were not significant. For the participants in the control group, the scores for SCCII (management and confidence) and HLS-SF 12 decreased post intervention. CONCLUSIONS: The CeHP is feasible, and it engages and empowers community-dwelling older adults to manage their chronic conditions. The rigorous process of program development and pilot evaluation provided valid evidence to expand the CeHP to a larger-scale implementation to encourage self-management, reduce debilitating complications of poorly controlled chronic diseases, promote healthy longevity and social support, and reduce health care costs.

Regional Citrate Anticoagulation for Continuous Renal Replacement Therapy - A Safe and Effective Low-Dose Protocol.

AIMS: Regional citrate anticoagulation (RCA) is the preferred mode of anticoagulation for continuous renal replacement therapy (CRRT). Conventional RCA-CRRT citrate dose ranges from 3 to 5 mmol/L of blood. This study explored the effectiveness of an RCA protocol with lower citrate dose and its impact on citrate-related complications. METHODS: This prospective observational study compared two RCA-CRRT protocols in the intensive care unit. RCA Protocol 1 used an initial citrate dose of 3.0 mmol/L while Protocol 2 started with 2.5 mmol/L. The citrate dose was titrated by sliding scale to target circuit-iCa 0.26-0.40 mmol/L. Calcium was re-infused post-dialyzer and titrated by protocol to target systemic-iCa 1.01-1.20 mmol/L. RESULTS: Two hundred RCA-CRRT sessions were performed (81 Protocol 1; 119 Protocol 2). The median age was 65.4 years and median APACHE-II score was 23. Citrate dose for Protocol 1 was significantly higher than Protocol 2 in the first 12 h. The circuit clotting rate was similar in both arms (Protocol 1: 9.9%; Protocol 2: 9.2%; P = 0.881). With Protocol 2, circuit-iCa levels were 2.42 times more likely to be on target (P = 0.003) while the odds of hypocalcaemia was 4.67 times higher with Protocol 1 (P < 0.001). There was a wider anion gap was noted with Protocol 1, which suggests a propensity for citrate accumulation with higher citrate exposure. CONCLUSION: The RCA protocol with a lower initial citrate dose of 2.5 mmol/L blood had less citrate-related complications with no loss of efficacy. A more precise RCA prescription at the start of treatment avoids unnecessary citrate exposure and improves safety.

Impact of microbial Aetiology on mortality in severe community-acquired pneumonia.

BACKGROUND: The impact of different classes of microbial pathogens on mortality in severe community-acquired pneumonia is not well elucidated. Previous studies have shown significant variation in the incidence of viral, bacterial and mixed infections, with conflicting risk associations for mortality. We aimed to determine the risk association of microbial aetiologies with hospital mortality in severe CAP, utilising a diagnostic strategy incorporating molecular testing. Our primary hypothesis was that respiratory viruses were important causative pathogens in severe CAP and was associated with increased mortality when present with bacterial pathogens in mixed viral-bacterial co-infections. METHODS: A retrospective cohort study from January 2014 to July 2015 was conducted in a tertiary hospital medical intensive care unit in eastern Singapore, which has a tropical climate. All patients diagnosed with severe community-acquired pneumonia were included. RESULTS: A total of 117 patients were in the study. Microbial pathogens were identified in 84 (71.8%) patients. Mixed viral-bacterial co-infections occurred in 18 (15.4%) of patients. Isolated viral infections were present in 32 patients (27.4%); isolated bacterial infections were detected in 34 patients (29.1%). Hospital mortality occurred in 16 (13.7%) patients. The most common bacteria isolated was Streptococcus pneumoniae and the most common virus isolated was Influenza A. Univariate and multivariate logistic regression showed that serum procalcitonin, APACHE II severity score and mixed viral-bacterial infection were associated with increased risk of hospital mortality. Mixed viral-bacterial co-infections were associated with an adjusted odds ratio of 13.99 (95% CI 1.30-151.05, p = 0.03) for hospital mortality. CONCLUSIONS: Respiratory viruses are common organisms isolated in severe community-acquired pneumonia. Mixed viral-bacterial infections may be associated with an increased risk of mortality.

A randomized, multicenter, open-label trial to establish therapeutic equivalence between the Carex and ultra disconnect systems in patients on continuous ambulatory peritoneal dialysis.

OBJECTIVE: In the present study, we undertook to establish therapeutic equivalence with respect to peritonitis and technique failure between the Carex disconnect system (B. Braun Carex, Mirandola, Italy) and the standard Ultra system (Baxter Healthcare, Tokyo, Japan) in patients on continuous ambulatory peritoneal dialysis (CAPD). DESIGN: This multicenter, parallel group, randomized controlled trial involved 363 prevalent CAPD patients from 8 centers. The primary endpoint was peritonitis rate; secondary endpoints were technique failure and technical problems encountered. The duration of the evaluation was 1 year. RESULTS: The risk of peritonitis on Carex varied between the centers. We found a significant treatment-center interaction effect (likelihood ratio test: p = 0.03). The incidence rate ratio (IRR) of peritonitis on Carex as compared with Ultra ranged from 0.4 to 7.2. In two centers, Carex was inferior to Ultra with regard to peritonitis; but, in five centers, the results were inconclusive. Equivalence was not demonstrated in any center. The overall rate of peritonitis in the Carex group was twice that in the Ultra group [IRR: 2.18; 95% confidence interval (CI): 1.51 to 3.14]. Technique failure and technical problems were more common with the Carex system. Technique failure rate at 1 year was 44% in the Carex group and 22% in the Ultra group. CONCLUSIONS: Equivalence between the Carex disconnect system and the Ultra disconnect system could not be demonstrated. The risk of peritonitis on Carex varied significantly between centers.

Training of peritoneal dialysis nurses.

Clinical disciplines in which the nurse plays as pre-eminent a role in total patient care as in peritoneal dialysis (PD) are few. The PD nurse is readily identified by the patient as the principal source of advice on day-to-day aspects of treatment, as a resource manager for supplies of PD disposables and fluids, and as a general counselor for all kinds of advice, including diet, rehabilitation, and medication, among others. The PD nurse is thus the key individual in the PD unit, and most activities involve and revolve around the nursing staff. It is therefore not surprising that most nephrologists pay considerable attention to the selection of PD nurses, particularly in long-term PD programs such as continuous ambulatory peritoneal dialysis (CAPD). The appointment of a PD nurse depends on finding an individual with the right attributes, broad general experience, and appropriate training.