Achieving triple treatment goals in multi-ethnic Asian patients with type 2 diabetes mellitus in primary care.

INTRODUCTION: Achieving optimal glycated hemoglobin (HbA1c), blood pressure (BP), and LDL-Cholesterol (LDL-C) in patients mitigates macro- and micro-vascular complications, which is the key treatment goal in managing type 2 diabetes mellitus (T2DM). This study aimed to determine the proportion of patients in an urban community with T2DM and the above modifiable conditions attaining triple vascular treatment goals based on current practice guidelines. METHODS: A questionnaire was distributed to adult Asian patients with dyslipidemia at two primary care clinics (polyclinics) in northeastern Singapore. The demographic and clinical data for this sub-population with both T2DM and dyslipidemia were collated with laboratory and treatment information retrieved from their electronic health records. The combined data was then analyzed to determine the proportion of patients who attained triple treatment goals, and logistic regression analysis was used to identify factors associated with this outcome. RESULTS: 665 eligible patients [60.5% female, 30.5% Chinese, 35% Malays, and 34.4% Indians] with a mean age of 60.6 years were recruited. Of these patients, 71% achieved LDL-C ≤2.6 mmol/L, 70.4% had BP

Evaluating an iPad app in measuring wound dimension: a pilot study.

OBJECTIVE: This pilot study tested the reliability, validity and sensitivity of an innovative prototype iPad app, WoundAide, developed to measure wound dimension (length, width and surface area) using image analysis. METHOD: A prospective evaluation was conducted comparing WoundAide (WA) with two gold standard instruments, Wound Zoom (WZ) and Visitrak (VT). The study was conducted in a tertiary hospital in Singapore. Patients were recruited after obtaining local ethics approval. RESULTS: We recruited six patients with 10 venous wounds. Images were captured by two researchers. Generally, 7/10 (70%) of the wounds had surface areas of less than 16cm². The intraclass correlation coefficient was greater than 0.95 for length, width and surface area for all measuring devices. The mean differences for length, width and surface area were not statistically significant. The average percentage of coefficient of variation for WA ranged from 3% to 33.3%, WZ 1.3% to 19.3%, and VT 2.1% to 43.4%. Length, width and surface area fell within the 95% limit of agreement. The capturing sensitivity was, on average, 75% for WA, 99.4% for VT, and 100% for WZ. CONCLUSION: WA has similar reliability and validity as WZ and VT. However, WA has the least sensitivity in image captures. Nonetheless, with enhancements made to its user-interface and system algorithm, this limitation can be addressed.

The effect of the intensity of lipid-lowering medications on the LDL cholesterol treatment goals of Asian patients with dyslipidaemia in primary care.

WHAT IS KNOWN AND OBJECTIVE: Dyslipidaemia is the key risk factor for arthrosclerosis, leading to myocardial infarctions and strokes. Achieving LDL cholesterol (LDL-C) treatment goals using lipid-lowering therapy (LLT) mitigates such cardiovascular risks. This study aimed to determine the proportions and factors influencing patients with dyslipidaemia on LLT who achieved their recommended LDL-C treatment goals. METHODS: Adult Asian patients with dyslipidaemia, aged 31-80 years, were enrolled in a questionnaire survey. Using simplified Framingham risk scores, these patients were classified into low (LR), medium (MR) and high (HR) cardiovascular risk groups. Their lipid-lowering therapy was classified into low-intensity (LI), medium-intensity (MI) and high-intensity (HI) groups according to the 2013 American College of Cardiology and American Heart Association (ACC/AHA) Blood Cholesterol Guidelines. Data on their demographic, clinical, self-reported attitude and adherence to LLT were correlated with their latest lipid profiles from their electronic health records. These data were analysed using chi-square test, or independent t-test where appropriate for categorical variables and continuous data. Logistic regression was used to identify factors relating to LDL-C goal attainment. RESULTS AND DISCUSSION: Amongst the 917 patients treated with LLT, 60·9% were females and 56·2% aged >60 years. The commonest statins prescribed were simvastatin (77·7%), atorvastatin (15·3%), rosuvastatin (4·3%) and lovastatin (3·4%). Those who attained LDL-C treatment goals included 89·4%, 77·4% and 70% of the LR, MR and HR groups. Overall, 72·4% of the patients achieved LDL-C treatment goals. Despite 98·4% of them self-reported LLT adherence, only 85·5%, 69·5% and 50% of the LI, MI and HI subgroups attained the desired outcomes, respectively. WHAT IS NEW AND CONCLUSION: Overall, 27·6% of patients with dyslipidaemia, including 30% of the HR group, did not achieve LDL-C treatment goals, despite on LLT. Addressing their concerns and adjusting medication doses of their LLT are needed for better outcomes.

When the phone rings - factors influencing its impact on the experience of patients and healthcare workers during primary care consultation: a qualitative study.

BACKGROUND: In the primary health care setting, patients interact directly with their healthcare workers (HCW), which include their primary physicians, nurses and pharmacists. Studies have shown that such interactions, when interrupted by phone calls received by either party, can lead to adverse outcomes and negative experiences. There is insufficient data however on the factors affecting the reaction and responses of both patients and HCWs when phone calls occur amidst their interaction. Understanding these factors will allow for the introduction of targeted measures to mitigate the negative impact of such interruptions and improve patient-HCW relationships. This study therefore aims to understand the impact of unplanned phone calls during primary health care consultations on patient-HCW interactions and the factors affecting the patient and the HCW responses. METHOD: This study used focus group discussions (FGD) to gather qualitative data from patients and HCWs who had visited or worked in a major public primary healthcare institution in Singapore. The FGDs were audio-recorded, transcribed, audited and analyzed using standard content analysis to identify emergent themes. RESULTS: 15 patients and 16 HCWs participated in 5 FGDs. The key themes that emerged from these FGDs were patients' and HCWs' attitudes toward professionalism and respect, task and thought interruption, call characteristics, the impact on patient safety and stakeholders' experiences. Phone calls during consultations answered by either party often resulted in the answering party feeling apologetic and would usually keep the phone conversations short as a sign of respect to the other party. Both stakeholders valued the consultation time and similarly reported negative experiences if the phone-call interruptions became prolonged. Calls from the desk phone answered by HCWs were perceived by most patients to be relevant to healthcare services, with the assumption that HCWs exercised professionalism and would not attend to personal calls during their clinical duties.HCWs expressed their concerns and distress about potential medical errors due to phone-calls interrupting their clinical tasks and thinking processes. However, they acknowledged that these same phone-calls were important to allow clarifications of instructions and improved the safety of other patients. CONCLUSION: Phone interruptions affected patient and HCW interaction during consultations and factors leading to their adverse reactions need to be recognized and addressed.

Bibliography of clinical research in malaysia: methods and brief results.

This article describes the methodology of this bibliography. A search was conducted on the following: (1) bibliographic databases (PubMed, Scopus, and other databases) using search terms that maximize the retrieval of Malaysian publications; (2) Individual journal search of Malaysian healthrelated journals; (3) A targeted search of Google and Google Scholar; (4) Searching of Malaysian institutional repositories; (5) Searching of Ministry of Health and Clinical Research Centre website. The publication years were limited to 2000- 2013. The citations were imported or manually entered into bibliographic software Refworks. After removing duplicates, and correcting data entry errors, PubMed's Medical Subject Headings (MeSH terms) were added. Clinical research is coded using the definition "patient-oriented-research or research conducted with human subjects (or on material of human origin) for which the investigator directly interacts with the human subjects at some point during the study." A bibliography of citations [n=2056] that fit the criteria of clinical research in Malaysia in selected topics within five domains was generated: Cancers [589], Cardiovascular diseases [432], Infections [795], Injuries [142], and Mental Health [582]. This is done by retrieving citations with the appropriate MESH terms, as follow: For cancers (Breast Neoplasms; Colorectal Neoplasms; Uterine Cervical Neoplasms), for cardiovascular diseases (Coronary Disease; Hypertension; Stroke), for infections (Dengue; Enterovirus Infections, HIV Infections; Malaria; Nipah Virus; Tuberculosis), for injuries (Accidents, Occupational; Accidents, Traffic; Child Abuse; Occupational Injuries), for mental health (Depression; Depressive Disorder; Depressive Disorder, Major; Drug Users; Psychotic Disorders; Suicide; Suicide, Attempted; Suicidal Ideation; Substance- Related Disorders).

Lengthy cold ischemia time is a modifiable risk factor associated with low glomerular filtration rates in expanded criteria donor kidney transplant recipients.

The proportion of expanded criteria donor (ECD) kidneys transplanted in North America is steadily increasing. By definition, graft survival is shorter for ECD than standard criteria donor (SCD) kidneys. Seeking to identify factors associated with low posttransplant glomerular filtration rates (GFR), we retrospectively reviewed data on 390 consecutive patients transplanted in our center from January 1999 to December 2006 including 78% SCD and 22% ECD by UNOS criteria. We analyzed donor and patient characteristics, HLA mismatches, cold ischemia time (CIT) and delayed graft function (DGF). Pulsatile perfusion was not used. The average CIT was 14.6 hours for all SCD and ECD cases. All patients received thymoglobulin, a calcineurin inhibitor, mycophenolate mofetil, and steroids. The only factor associated with low estimated GFR in the entire ECD cohort was CIT. The average CIT for the ECD group was 18.3 hours, whereas it was only 13.6 hours for those in the SCD group (P < .001). We observed that at 6 months posttransplant, those in the ECD group are 2.2 times more likely (odds ratio, 2.23; 95% confidence interval, 1.065-4.654; P = .033) to have an estimated GFR < or =50 mL/min/1.73 m(2) compared with those in the SCD group for CIT up to 18 hours. The higher odds ratio for low estimated GFR was sustained at 3 years posttransplant. In our center, a lengthy CIT was an early risk factor associated with impaired renal function. We concluded that all efforts should be made to reduce CIT.

Metabolic alterations produced by 3-nitropropionic acid in rat striata and cultured astrocytes: quantitative in vitro 1H nuclear magnetic resonance spectroscopy and biochemical characterization.

Quantitative high resolution in vitro 1H nuclear magnetic resonance spectroscopy was employed to study the metabolic effects of 3-nitropropionic acid associated with aging from perchloric acid extracts of rat striata. Systemic injection of 3-nitropropionic acid in rats at a dose of 10 mg/kg/day for seven consecutive days significantly impaired energy metabolism in rats one, four and eight months of age, as evidenced by a marked elevation of succinate and lactate levels. However, a significant decrease in N-acetyl-L-aspartate level, a neuronal marker, was observed in four- and eight-month-old rats but not in one-month-old rats. This would indicate that rats at four to eight months are more susceptible to 3-nitropropionic acid than those at one month. A significant decrease in GABA level was observed in four-month-old 3-nitropropionic acid-treated rats, which is consistent with the literature that GABAergic neurons are particularly vulnerable to 3-nitropropionic acid treatment. In addition, glutamine and glutamate levels were markedly decreased at four and eight months in 3-nitropropionic acid-treated rats. Since glutamine is synthesized predominantly in glia, the observation above suggests that 3-nitropropionic acid intoxication may involve perturbation of energy metabolism, glial injury and consequent neuronal damage. Astrocytes which are essential in the metabolism of glutamate and glutamine were used to further assess 3-nitropropionic acid-induced toxicity. Glial proliferation, mitochondrial metabolism and glutamine synthetase activity were all reduced by 3-nitropropionic acid treatment with a concomitant increase, in a dose-dependent manner, of lactate levels, suggesting that 3-nitropropionic acid is also detrimental to astrocytes in vivo and thus may affect metabolic interaction between neurons and glia. These results not only imply that 3-nitropropionic acid blocks energy metabolism prior to exerting neurotoxic damage but also demonstrate that the degree of energy depletion determines the detrimental effects of 3-nitropropionic acid. In the present study, we also demonstrate that glutamate and glutamine levels as well as astrocytic functions may play pivotal roles in 3-nitropropionic acid-induced striatal lesions.