Introduction: To determine the relationship between participation in supervised and unsupervised therapy, and predictors of participation in supervised therapy during the first post-stroke year. Materials & Methods: Design: Prospective longitudinal study with interviews at admission, discharge, one month, six months and one year after discharge. Setting: Two subacute inpatient rehabilitation units and the community after discharge in Singapore. Participants: 215 subacute non-aphasic stroke patients. Intervention: Participation rate in supervised therapy (at outpatient rehabilitation centres) and unsupervised therapy (at home) defined as proportion of time spent performing therapy as prescribed by the subacute hospital’s multidisciplinary rehabilitation team at discharge. Main Outcome Measure: Predictors of participation in supervised and unsupervised therapy. Results: Patients who participated in supervised therapy (i.e. at an outpatient rehabilitation centre) >25% of the time recommended were more likely to participate in unsupervised therapy (i.e. at home) >75% of the time recommended at one, six and 12 months (crude odds ratio, OR = 4.41 [95%CI:2.09–10.17], 4.45 [95%CI:2.17–9.12], 6.93 [95%CI:2.60–18.48] respectively). Greater participation in supervised therapy at one and six months independently predicted greater participation in supervised therapy at six (adjusted OR=11.64 [95%CI:4.52-29.97]) and twelve months (adjusted OR=76.46 [95%CI:12.52-466.98]) respectively. Caregiver availability at six months independently predicted poorer participation in supervised therapy at 12 months. Conclusion: Interventions to increase participation in supervised therapy in the first post-stroke year should focus on transition of care in the first month after discharge. Further studies are needed to understand why caregiver availability was associated with low participation in supervised therapy.

Background: Glomerulonephritis is often treated with kidney-saving, but potentially diabetogenic immunosuppressants such as glucocorticosteroids and calcineurin inhibitors. Unfortunately, there are little data on dysglycemia before and after diagnosis and during treatment of glomerulonephritis. We aimed to evaluate the occurrence and risk factors for pre-diabetes and incident diabetes among non-diabetic patients with glomerular disease with or without treatment with immunosuppressants. Methods: A single-center, retrospective cohort study was performed on 229 non-diabetic immunosuppressantnaïve adults diagnosed with glomerulonephritis and renal vasculitis. Patients with known diabetes and prior immunosuppressant treatment were excluded. Outcomes of new-onset pre-diabetes and new-onset diabetes were defined according to American Diabetic Association criteria. Results: Pre-diabetes was present pre-biopsy in 74 of the 229 patients (32.3%). During the median follow-up of 34.0 (23.3-47.5) months, 29 patients (12.7%) developed new-onset diabetes and 58 (25.3%) had new-onset prediabetes. Immunosuppressive therapy in patients with pre-existing pre-diabetes was associated with increased odds of new-onset diabetes compared to those without either risk factor (26.0% versus 5.0%; odds ratio, 6.67; 95% confidence interval [CI], 1.41 to 31.64), P = 0.02). Conclusion New-onset diabetes after immunosuppressant treatment occurred in one-quarter of patients with glomerulonephritis and pre-existing pre-diabetes. Physicians should screen for pre-diabetes when planning treatment with immunosuppressants, as its presence significantly increases the risk of diabetes mellitus.

INTRODUCTION: Primary healthcare providers play a crucial role in educating their patients on chronic disease self-management (CDSM). This study aims to evaluate CDSM competency and satisfaction in patients receiving their healthcare from public or private healthcare providers. METHODS: A cross-sectional household study was conducted in a public housing estate using a standardised questionnaire to interview Singaporeans and permanent residents aged 40 years and above, who were diagnosed with at least 1 of these chronic diseases: hyperlipidaemia, hypertension or diabetes mellitus. CDSM competency was evaluated with the Partners In Health (PIH) scale and a knowledge based questionnaire. Satisfaction was evaluated using a satisfaction scale. RESULTS: In general, the 420 respondents demonstrated good CDSM competency, with 314 followed up at polyclinics and 106 by general practitioners (GPs). There was no significant difference between patients of polyclinics and GPs in CDSM competency scores (mean PIH score 72.9 vs 75.1, P=0.563), hypertension knowledge scores (90.9 vs 85.4, P=0.16) and diabetes knowledge scores (84.3 vs 79.5, P=0.417), except for hyperlipidaemia knowledge scores (78.6 vs 84.7, P=0.043). However, respondents followed up by GPs had higher satisfaction rates than did those followed up at polyclinics (odds ratio 3.6, confidence interval 2.28-5.78). Favourable personality of the doctors and ideal consultation duration led to higher satisfaction in the GP setting. A longer waiting time led to lower satisfaction in the polyclinic group. CONCLUSION Polyclinics and GPs provide quality primary care as evidenced by high and comparable levels of CDSM competency. Redistribution of patients from public to private clinics may result in improvements in healthcare service quality.

Background: Cardiovascular disease causes significant morbidity and mortality in patients with glomerulonephritis, which is increasingly diagnosed in older individuals who may have diabetes mellitus (DM). We evaluated the impact of DM on metabolic profile, renal and cardiovascular outcomes during treatment and follow-up of individuals with glomerulonephritis. Methods: We performed a retrospective cohort study of 601 consecutive adults with biopsy-proven glomerulonephritis for factors associated with kidney failure, hospitalization for cardiovascular events, and death. Biopsies with isolated diabetic nephropathy were excluded. Results: The median patient age was 49.8 years (36.7–60.9 years) with estimated glomerular filtration rate of 56.7 mL/min/1.73 m2 (27.7–93.2 mL/min/1.73 m2). DM was present in 25.4%. The most frequent diagnoses were minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS) (29.5%), lupus nephritis (21.3%), immunoglobulin A (IgA) nephropathy (19.1%), and membranous nephropathy (12.1%). The median follow-up was 38.8 months (interquartile range [IQR], 26.8–55.8 months). Among 511 individuals with lupus nephritis, anti-neutrophil cytoplasmic antibody-associated vasculitis, MCD/FSGS, membranous nephropathy, and IgA nephropathy, 52 (10.2%) developed kidney failure at a median 16.4 months (IQR, 2.3–32.2 months), while 29 (5.7%) had cardiovascular-related hospitalizations at 12.9 months (IQR, 4.8–31.8 months) and 31 (6.1%) died at 13.5 months (IQR, 2.5–42.9 months) after diagnosis. Cox regression analysis found that baseline DM was independently associated with kidney failure (adjusted hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.06–4.05, p = 0.03) and cardiovascular-related hospitalization (adjusted HR, 2.69; 95% CI, 1.21–5.98, p = 0.02) but not with mortality. Conclusion DM was strongly associated with kidney failure and hospitalization for cardiovascular events in patients with biopsy-proven glomerulonephritis.

Background: Cardiovascular disease causes significant morbidity and mortality in patients with glomerulonephritis, which is increasingly diagnosed in older individuals who may have diabetes mellitus (DM). We evaluated the impact of DM on metabolic profile, renal and cardiovascular outcomes during treatment and follow-up of individuals with glomerulonephritis. Methods: We performed a retrospective cohort study of 601 consecutive adults with biopsy-proven glomerulonephritis for factors associated with kidney failure, hospitalization for cardiovascular events, and death. Biopsies with isolated diabetic nephropathy were excluded. Results: The median patient age was 49.8 years (36.7–60.9 years) with estimated glomerular filtration rate of 56.7 mL/min/1.73 m2 (27.7–93.2 mL/min/1.73 m2). DM was present in 25.4%. The most frequent diagnoses were minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS) (29.5%), lupus nephritis (21.3%), immunoglobulin A (IgA) nephropathy (19.1%), and membranous nephropathy (12.1%). The median follow-up was 38.8 months (interquartile range [IQR], 26.8–55.8 months). Among 511 individuals with lupus nephritis, anti-neutrophil cytoplasmic antibody-associated vasculitis, MCD/FSGS, membranous nephropathy, and IgA nephropathy, 52 (10.2%) developed kidney failure at a median 16.4 months (IQR, 2.3–32.2 months), while 29 (5.7%) had cardiovascular-related hospitalizations at 12.9 months (IQR, 4.8–31.8 months) and 31 (6.1%) died at 13.5 months (IQR, 2.5–42.9 months) after diagnosis. Cox regression analysis found that baseline DM was independently associated with kidney failure (adjusted hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.06–4.05, p = 0.03) and cardiovascular-related hospitalization (adjusted HR, 2.69; 95% CI, 1.21–5.98, p = 0.02) but not with mortality. Conclusion DM was strongly associated with kidney failure and hospitalization for cardiovascular events in patients with biopsy-proven glomerulonephritis.

Recent advancements in Alzheimer’s disease treatment have focused on the elimination of amyloid-beta (Aβ) plaque, a hallmark of the disease. Monoclonal antibodies such as lecanemab and donanemab can alter disease progression by binding to different forms of Aβ aggregates. However, these treatments raise concerns about adverse effects, particularly amyloid-related imaging abnormalities (ARIA). Careful assessment of safety, especially regarding ARIA, is crucial. ARIA results from treatmentrelated disruption of vascular integrity and increased vascular permeability, leading to the leakage of proteinaceous fluid (ARIA-E) and heme products (ARIA-H). ARIA-E indicates treatment-induced edema or sulcal effusion, while ARIA-H indicates treatment-induced microhemorrhage or superficial siderosis. The minimum recommended magnetic resonance imaging sequences for ARIA assessment are T2-FLAIR, T2* gradient echo (GRE), and diffusion-weighted imaging (DWI). T2-FLAIR and T2* GRE are necessary to detect ARIA-E and ARIA-H, respectively. DWI plays a role in differentiating ARIA-E from acute to subacute infarcts.Physicians, including radiologists, must be familiar with the imaging features of ARIA, the appropriate imaging protocol for the ARIA workup, and the reporting of findings in clinical practice. This review aims to describe the clinical and imaging features of ARIA and suggest points for the timely detection and monitoring of ARIA in clinical practice.

The Ministry of Health (MOH) has developed the clinical practice guidelines on Prevention, Diagnosis and Management of Tuberculosis to provide doctors and patients in Singapore with evidence-based treatment for tuberculosis. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH clinical practice guidelines on Prevention, Diagnosis and Management of Tuberculosis, for the information of SMJ readers. The chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.
Disease Management ; Evidence-Based Medicine ; methods ; Government ; Humans ; Morbidity ; trends ; Practice Guidelines as Topic ; Singapore ; epidemiology ; Tuberculosis ; diagnosis ; epidemiology ; prevention & control

INTRODUCTIONThe 'DOT & Shop' scheme is sponsored by SATA CommHealth, a local non-governmental organisation. It was launched in July 2009, in collaboration with Singapore's Tuberculosis Control Unit (TBCU). Under this scheme, grocery vouchers are disbursed to low-income patients with tuberculosis (TB) at each clinic visit if they have been adherent to directly observed therapy (DOT). This study aimed to determine the effect of this incentive scheme on treatment completion rates and to report the characteristics of patients who were non-adherent to the scheme.

METHODSThis descriptive study used data from the TBCU medical social worker database and the National TB Registry.

RESULTSFrom July 2009 to December 2012, a total of 883 TB patients were enrolled in the scheme. The overall treatment completion rates of the patients before (July 2006-June 2009) and after (July 2009-December 2012) the implementation of the scheme improved from 85.3% to 87.2% (p = 0.02). Patients under this scheme had a higher treatment completion rate (90.0%) than those not under this scheme (86.4%) (p < 0.01). It was found that the non-adherent patients were more likely to be of Malay ethnicity, younger and unemployed.

CONCLUSIONWe demonstrate the salutary effect of a non-governmental organisation-funded grocery voucher incentive scheme for low-income TB patients on DOT in Singapore.

Adult ; Age Factors ; Aged ; Antitubercular Agents ; therapeutic use ; Databases, Factual ; Directly Observed Therapy ; methods ; Female ; Food Assistance ; Humans ; Male ; Middle Aged ; Motivation ; Patient Compliance ; Poverty ; Program Evaluation ; Singapore ; Tuberculosis ; drug therapy ; Unemployment

Humans ; Child ; Caregivers ; Singapore ; Software

BACKGROUND AND OBJECTIVES

The Department of Clinical Epidemiology (DCE) of the University of the Philippines Manila is the only higher education institution in the Philippines offering graduate studies in clinical epidemiology. The Master of Science Epidemiology (Clinical Epidemiology) was first offered in 1992, while the Diploma in Epidemiology (Clinical Epidemiology) was offered in 1998. While the courses of the programs are continuously updated based on students’ feedback and advances on topics covered, the point of view of the students and alumni on the program as a whole has not been done. This study aimed to determine 1) self-reported current positions and affiliations, work areas where clinical epidemiology (CE) training is useful, and skills gained from CE training; 2) research studies completed and deemed by respondents to have considerable impact; and 3) strengths, weaknesses, and areas of improvement of the DCE graduate programs.

METHODS

This is an online survey of students and alumni of the DCE graduate programs. We sent email invites to all 287 students and alumni. We collected data on their profession, institutional affiliations, positions, skills gained from their training, areas of clinical epidemiology applications, important research involvement, reasons for recommending or not recommending the programs, and how the graduate programs can be improved. Responses were summarized by frequencies and percentages. An analyst performed qualitative content analysis (QCA) to generate strengths and weaknesses of the program. We validated the results of the QCA through 1) presentation to the research team, 2) sending the survey report to study participants and other students and alumni for feedback, and 3) presentation to the DCE faculty and staff.

RESULTS

We received 159 responses (55.4% of the total study population)—145 (91.2%) were from the MSc program and 11 (6.9%) were from the Diploma program. Majority of the respondents were physicians (93.7%), had hospital affiliations (81.8%), and were affiliated with the academe (61%). Majority of the respondents used clinical epidemiology in their research endeavors (87.4%), clinical practice (85.5%), and teaching (78%). Majority (93.1%) would recommend the program they have taken. Eleven (6.9%) respondents were hesitant due to the possible mismatch with the students’ career path, challenging thesis work, and potential conflicting personal responsibilities. Several strengths of the programs were identified, including excellent and well-implemented programs, supportive faculty and staff, and relevant course work. While completing the course work had not been a problem in general, the main challenge encountered by students is the completion of their thesis, leading to a low graduation rate in the Master of Science program. Suggestions to improve the Master of Science and Diploma programs include 1) Improvement in program implementation, including thesis policies and support, smoother transition from Diploma to MSc Program and vice-versa, and implementation of a blended learning platform; 2) Curricular improvements such as wider choices for electives and tracking towards specialty areas; 3) Innovations in conduct of courses; and 4) Personnel and infrastructure development.

CONCLUSION

This survey reiterated the importance of clinical epidemiology graduate programs in research capacity building of health care professionals. Students and alumni occupied diverse positions in academic, research, clinical, and pharmaceutical setting, and majority accomplished research studies with considerable impact. A major challenge leading to a low graduation rate in the Master of Science program is the completion of thesis work. The survey identified several initiatives towards continuous quality improvement of clinical epidemiology programs, including improvement of thesis policies and support, updating the curriculum content and materials, increasing allotment of hours for hands-on activities, exploring possibilities of offering electives in partnership with other institutions, offering a blended learning platform, maintaining an efficient administrative support for students, and continuing education for alumni. Strong institutional support for personnel and infrastructure development is essential for these initiatives to succeed.

Cross-sectional Studies