Patients are often advised to adopt healthier behaviours or change unhealthy ones on the basis that what they are doing or not doing is detrimental to their health. Some of these changes may include going on a diet, exercising, stopping cigarette smoking and even relaxing and sleeping more. MI was initially developed by Rollnick and Miller as a strategy for addictive behaviour change, but it has found many applications in helping patients change other health related behaviours. MI was initially defined as a client-oriented, directive method for enhancing intrinsic motivation to change by exploring and resolving ambivalence. The guiding stance, whilst respecting the patient's autonomy and the patient as the agency of change, maintain controls of the direction and structure of the consultation to evoke the patient's own arguments and strategies for change. The guiding process thus avoids the struggle or "fights" with the patient over changing behaviour and has been likened more to "dancing" with the patient. The four counselling principles in MI are: Develop discrepancy; Express empathy; Roll with resistance; and Support self-efficacy. Facilitating the patient to process and speak more about why and how to change then becomes one of the strategies to motivate change. In MI, this is known as change talk. Once change talk is elicited, the ways the practitioner can respond are: Elicit more (with open questions); Affirm; Reflect; and Summarise. Once the patient decides to change, goal setting becomes the next important process. Needless to say, the goal setting process must be done in collaboration with the patient, with the patient having the final say.

Agitation and delirium are commonly encountered symptoms in palliative care. Based on the clinical features, delirium may present in the hypoactive, hyperactive and mixed forms. By reason of the prevalence, the significant distress and symptom burden, as well as the possibility of reversibility, it is vital that the clinician be vigilant in identifying and treating delirium and its symptoms. This article describes how delirium may present, the clinical features, aetiologies and the methods to screen and diagnose delirium. When managing a delirious patient in the palliative care setting, it is necessary to contextualise any investigation and intervention in terms of the disease condition and trajectory, the level of distress and the care preferences and goals of the patient and family. Non-pharmacological management should always be in place though pharmacological treatments also have a definite role in the relief of distressing symptoms of agitation and delirium. Support and education for the patient, family and care providers are integral and continuous aspects of care for the agitated or delirious terminally ill patient.

The COVID-19 outbreak touches the vulnerabilities of frontline doctors. The scope of their inner experiences includes fear/anxiety, uncertainty, isolation, fatigue, moral distress or outrage. Learning how to manage the inner subjective experiences can improve the doctors’ capacity to serve at the frontline. Fear, though common and multi-layered, may be masked by storylines that externalises our difficulties. A method to contain and process fear and other unsettling emotional states is RAIN: Recognise, Allow, Investigate and Nurture. To cope with uncertainty, one needs to stay open to tolerate various outcomes and remainder issues. A framework that provides a narrative for groundedness is described, which comprises the elements of faith in the medical science and our practice, due diligence that supports the faith, acting with courage and compassion, and the focus of another- or community-directed service.

Family engagement should be part of a holistic management of any patient. This is especially so in patients who have an acute change in their health condition or function that stresses their social setup. Conducting a family conference is one of the many ways to engage patients and their caregivers and address their bio-psycho-social needs. It is a focused and purposeful approach that engages every member of the health care team and family members in facilitating a common understanding and decision-making with the aim of improving patient care and outcome. A family conference is resource intensive, and should be planned well to maximise the goals that it was set out to achieve. This article was written as a primer to help family physicians understand the indications, preparations needed, and steps to take in conducting a family conference. To facilitate a family conference confidently is a skill and an art that requires practice and constant refinement.

Health outcomes evaluation seeks to compare a new treatment or novel programme with the current standard of care, or to identify variation of outcomes across different healthcare providers. In the real world, it is not always possible to conduct randomised controlled trials to address the issue of comparator groups being different with respect to baseline risk factors for the outcomes. Therefore, risk adjustment is required to address patient factors that may lead to biases in estimates of treatment effects. It is essential when conducting outcomes evaluation of more than trivial significance. Risk adjustment begins by asking 4 questions: what outcome, what time frame, what population, and what purpose. Next, design issues are considered. This involves choosing the data source, planning data collection, defining the sample required, and selecting the variables carefully. Finally, analytical issues are considered. Regression modelling is central to every analytic strategy. Other methods that may augment regression include restriction, stratification, propensity scores, instrumental variables, and difference-in-differences. The construction of risk adjustment models is an iterative process requiring both art and science. Derived models should be validated. Limitations of risk adjustment include reliance on data availability and quality, imperfect method, ineffectiveness when comparators are very different, and sensitivity to different methods used. Thoughtful application of risk adjustment can improve the validity of comparisons between different treatments, programmes and providers. The extent of risk adjustment should be guided by its purpose. Finally, its methodology should be made explicit, so that informed readers can judge the robustness of results obtained.
Health Services Research ; Outcome Assessment (Health Care) ; Regression Analysis ; Risk Adjustment ; standards

Electrocardiography ; Humans ; ST Elevation Myocardial Infarction/therapy*

INTRODUCTION: Infective haemodialysis catheter-related right atrial thrombus (CRAT) is a complication of tunnelled catheter use. Management recommendations are based mainly on published case series prior to 2011. We report our institution's recent experience in managing infective haemodialysis CRAT and correlate treatment with outcomes. METHODS: We conducted a retrospective analysis of haemodialysis CRAT cases diagnosed on transthoracic echocardiography between 1 January 2011 and 31 December 2017. Clinical outcomes, including mortality at 180 days post diagnosis and thrombus resolution, were traced from electronic medical records. RESULTS: There were 14 cases identified. The median age was 59 (range 47-88) years and 11 (78.6%) were male. Sepsis was the most common reason for hospitalisation (71.4%). Blood cultures identified Staphylococcus aureus in seven cases, of which two were methicillin-resistant. Three had coagulase-negative Staphylococcus. All cases received antibiotics with infectious disease physician input. Seven were treated with catheter removal alone, of which three died within 180 days. Both cases treated with catheter removal plus anticoagulation survived at 180 days. Of the two cases who had anticoagulation without catheter removal, one died within 180 days and the other did not have thrombus resolution. Three underwent surgical thrombus removal, of which two died postoperatively and the last required repeated operations and prolonged hospitalisation. Mortality at 180 days post diagnosis was 42.9%. CONCLUSION Catheter removal and anticoagulation are modestly effective. Surgery is associated with poor outcomes. Despite contemporary management, infective haemodialysis CRAT still results in high mortality. Prospective studies are needed to identify the optimal management.

Heparin has been widely used for intradialytic anticoagulation since the 1940s. Heparin induced anaphylaxis can be life threatening, mandating early recognition and intervention. However, due to its relative rarity many physicians remain unaware. We report the case of a 70-year-old woman requiring dialysis, who developed recurrent anaphylaxis to intradialytic heparin. We describe a systematic approach to confirm the suspected heparin allergy, which must include an evaluation of predisposing factors, the dialysis equipment and concomitant medications. Further workup for safe alternatives employing skin prick and intradermal tests, as well as provocation tests are discussed.
Aged ; Anaphylaxis ; Causality ; Dialysis ; Drug Hypersensitivity ; Female ; Heparin ; Humans ; Hypersensitivity ; Intradermal Tests ; Skin ; Skin Tests

Coronavirus disease 2019 (COVID-19) is associated with an increased risk of thromboembolic events in the acute setting. However, the abnormal thrombotic diathesis is not known to persist into the recovery phase of COVID-19 infection. We described 3 cases of ST-segment elevation myocardial infarction in healthy male patients who recovered from COVID-19 with no prior cardiovascular risk factors. They shared features of elevated von Willebrand factor antigen, factor VIII and D-dimer level. One patient had a borderline positive lupus anticoagulant. Intravascular ultrasound of culprit vessels revealed predominantly fibrotic plaque with minimal necrotic core. Clot waveform analysis showed parameters of hypercoagulability. They were treated with dual antiplatelet therapy, angiotensin-converting-enzyme inhibitor, beta blocker and statin. These cases highlight the strong thrombogenic nature of COVID-19 that persisted among patients who recovered from infection. Several suspected mechanisms could explain the association between vascular thrombosis in the convalescent period (endothelial dysfunction, hypercoagulability, systemic inflammatory response and vasculopathy). Additional studies on "long COVID" are essential for identifying endotheliopathy and thrombotic sequalae.

INTRODUCTIONThe objective of this study was to determine factors, other than the Diagnostic Related Grouping (DRG), that can explain the variation in the cost of hospitalisation and length of hospital stay (LOS) in older patients.

MATERIALS AND METHODSThis was a prospective, observational cohort study involving 397 patients, aged 65 years and above. Data collected include demographic information, admission functional and cognitive status, overall illness severity score, number of referral to therapists, referral to medical social worker, cost of hospitalisation, actual LOS, discharge DRG codes and their corresponding trimmed average length of stay (ALOS).

RESULTSThe mean age of the cohort was 80.2 years. The DRG's trimmed ALOS alone explained 21% of the variation in the cost of hospitalisation and actual LOS. Incorporation of an illness severity score, number of referral to therapists and referral to medical social worker into the trimmed ALOS explained 30% and 31% of the variation in the cost and actual LOS, respectively.

CONCLUSIONThe DRG model is able to explain 21% of the variation in the cost of hospitalisation and actual LOS in older patients. Other factors that determined the variation in the cost of hospitalisation and LOS include the degree of illness severity, the number of referral to therapists and referral to medical social worker.

Age Factors ; Aged ; Confidence Intervals ; Diagnosis-Related Groups ; Female ; Frail Elderly ; statistics & numerical data ; Health Resources ; economics ; statistics & numerical data ; Health Status Indicators ; Hospitalization ; economics ; statistics & numerical data ; Humans ; Length of Stay ; statistics & numerical data ; trends ; Linear Models ; Male ; Prospective Studies ; Psychometrics ; Referral and Consultation ; Reproducibility of Results ; Severity of Illness Index ; Singapore ; Statistics, Nonparametric