Parental use and acceptance of an accessible, commercially available intraoral camera for teledentistry in their children

PURPOSE

The potential of combining teledentistry and engaging parents as underutilised resources to monitor paediatric dental health was emphasised during the COVID-19 pandemic and remains underexplored. This study aims to assess parental acceptance and use of a commercially available intraoral camera (IOC) for effective remote monitoring.

METHODS

47 child-parent dyads, where the parent was the main caregiver and the child was treated under general anaesthesia for early childhood caries, were recruited. Caregivers were trained to image their child's teeth on a commercially available IOC. Subsequently, submitted images were reviewed asynchronously by dentists for image quality, presence of dislodged fillings, abscesses, cavitation, and oral hygiene. Post-surgery monitoring was performed using teledentistry at 1 and 2 months and in-person at 4 months. A modified Telehealth Usability Questionnaire (TUQ) was used to record caregiver acceptance for study procedures.

RESULTS

A mean TUQ of 6.09 out of 7 was scored by caregivers. Caregiver-reported issues were limited to problems with technique and child uncooperativeness. The number of clear images during the second teledentistry review was improved compared to the first (p = 0.007). 68% of children liked having images of their teeth taken.

CONCLUSION

This study supports the feasibility of using an IOC as a clinically appropriate avenue for teledentistry with a high level of caregiver-child acceptance.

The employment of art therapy to develop empathy and foster wellbeing for junior doctors in a palliative medicine rotation - a qualitative exploratory study on acceptability

BACKGROUND

The interdisciplinary realm of medical humanities explores narratives and experiences that can enhance medical education for physicians through perspective-taking and reflective practice. However, there is a gap in comprehension regarding its appropriateness at the postgraduate level, especially when utilising art therapists as faculty. This study aims to assess the acceptability of an innovative art therapy-focused educational initiative among junior doctors during a palliative care rotation, with the goal of cultivating empathy and promoting well-being.

METHODS

A qualitative research project was conducted at the Division of Supportive and Palliative Care (DSPC) in the National Cancer Centre Singapore (NCCS). The study involved the recruitment of junior doctors who had successfully completed a three-month palliative care rotation program, spanning from January 2020 to April 2021. In a single small-group session lasting 1.5 h, with 3 to 4 participants each time, the individuals participated in activities such as collage making, group reflection, and sharing of artistic creations. These sessions were facilitated by an accredited art therapist and a clinical psychologist, focusing on themes related to empathy and wellbeing. To assess the acceptability of the program, two individual interviews were conducted three months apart with each participant. An independent research assistant utilised a semi-structured question guide that considered affective attitude, burden, perceived effectiveness, coherence, and self-efficacy. Thematic analysis of the transcribed data was then employed to scrutinise the participants' experiences.

RESULTS

A total of 20 individual interviews were completed with 11 participants. The three themes identified were lack of pre-existing knowledge of the humanities, promotors, and barriers to program acceptability.

CONCLUSIONS

The participants have mixed perceptions of the program's acceptability. While all completed the program in its entirety, the acceptability of the program is impeded by wider systemic factors such as service and manpower needs. It is vital to address these structural limitations as failing to do so risks skewing current ambivalence towards outright rejection of future endeavours to integrate humanities programs into medical education.

Prevalence and factors associated with sarcopenia among older adults in a post-acute hospital in Singapore

BACKGROUND

Sarcopenia is common in older adults worldwide, but its prevalence varies widely owing to differences in diagnostic criteria, population sampled, and care setting. We aimed to determine the prevalence and factors associated with sarcopenia in patients aged 65 and above admitted to a post-acute hospital in Singapore.

METHODS

This was a cross-sectional study of 400 patients recruited from a community hospital in Singapore. Data including socio-demographics, physical activity, nutritional status, cognition, clinical and functional status, as well as anthropometric measurements were collected. Sarcopenia was defined using the Asian Working Group for Sarcopenia 2019 criteria [AWGS2019].

RESULTS

Of the 383 patients with complete datasets, overall prevalence of sarcopenia was 54% while prevalence of severe sarcopenia was 38.9%. Participants with increased age, male gender and a low physical activity level were more likely to be sarcopenic, while those with higher hip circumference and higher BMI of ≥27.5m/kg2 were less likely to be sarcopenic. Other than the above-mentioned variables, cognitive impairment was also associated with severe sarcopenia.

CONCLUSIONS

More than 1 in 2 older adults admitted to a post-acute hospital in Singapore are sarcopenic. There is an urgent need to address this important clinical syndrome burden and to identify patients at risk of sarcopenia in post-acute settings in Singapore for early intervention.

RETINITIS PIGMENTOSA ASSOCIATED WITH THE EYS C2139Y VARIANT : An Important Cause of Blindness in East Asian Populations

PURPOSE

The study aimed to describe the phenotypic features of retinitis pigmentosa (RP) associated with the previously described EYS C2139Y variant in Singaporeans and establish the importance of this variant as a prevalent cause of RP among East Asians.

METHODS

A clinical phenotyping and exome-sequencing study was conducted on consecutive patients with nonsyndromic RP. Epidemiological analysis was performed using Singaporean and global population-based genetic data.

RESULTS

A study of 150 consecutive unrelated individuals with nonsyndromic RP found that 87 (58%) of cases had plausible genotypes. A previously described missense variant in the EYS gene, 6416G>A (C2139Y), occurred heterozygously or homozygously in 17 of 150 families (11.3%), all with autosomal recessive RP. Symptom onset in EYS C2139Y-related RP ranged from 6 to 45 years, with visual acuity ranging from 20/20 at 21 years to no light perception by 48 years. C2139Y-related RP had typical findings, including sectoral RP in cases with EYS E2703X in trans . The median age at presentation was 45 years and visual fields declined to less than 20° (Goldmann V4e isopter) by age 65 years. Intereye correlation for visual acuity, fields, and ellipsoid band width was high (r 2 = 0.77-0.95). Carrier prevalence was 0.66% (allele frequency of 0.33%) in Singaporean Chinese and 0.34% in East Asians, suggesting a global disease burden exceeding 10,000 individuals.

CONCLUSION

The EYS C2139Y variant is common in Singaporean RP patients and other ethnic Chinese populations. Targeted molecular therapy for this single variant could potentially treat a significant proportion of RP cases worldwide.

Smartphone ownership, digital literacy, and the mediating role of social connectedness and loneliness in improving the wellbeing of community-dwelling older adults of low socio-economic status in Singapore

INTRODUCTION

During the COVID-19 pandemic, safe-distancing measures resulted in many community-dwelling older adults being socially isolated and lonely, with its attending negative impact on wellbeing and quality of life. While digital technology may have mitigated this, older adults of low socioeconomic status (SES) are more likely to be digitally excluded and hence susceptible to the adverse effects of social isolation and loneliness. This study aims to understand the factors that affect digital literacy, smartphone ownership, and willingness to participate in a digital literacy program (DLP), and to test the hypothesized relations between digital literacy, social connectedness, loneliness, wellbeing, and quality of life amongst community dwelling older adults of low SES.

MATERIALS AND METHODS

A questionnaire assessing digital literacy, social connectedness, wellbeing and quality of life was administered. Socio-demographic variables, pre-existing internet-enabled, and willingness to participate in a home-based DLP was also collected. Logistic regression was used to identify demographic factors associated with digital literacy, smartphone ownership, and willingness to enroll in a DLP. Serial mediation analysis was also performed using a structural equation model framework.

RESULTS

A total of 302 participants were recruited. Female gender, older age, lower education levels were associated with lower digital literacy. Those who owned a smartphone tended to be younger and better educated. Older adults who were better educated, of Chinese descent (the ethnic majority in Singapore), and who had lower digital literacy, were most willing to enroll in the digital literacy education program. Social-use digital literacy had a positive indirect effect on well-being ([Formula: see text]) and Quality of life ([Formula: see text]), mediated by social connectedness and loneliness. In contrast, instrumental-use digital literacy had a negative indirect effect on well-being ([Formula: see text]) and Quality of life ([Formula: see text]), mediated by social connectedness and loneliness.

DISCUSSION

The results suggest there are demographic barriers to participation in DLPs and highlight the benefit of focusing on enhancing social-use digital literacy. Further study is needed to evaluate how well specific interventions to improve social-use digital literacy help to reduce social isolation and loneliness, and ultimately improve wellbeing and quality of life.

Osteoporosis management by primary care physicians in Singapore: a survey on osteoporosis guidelines utilisation and barriers to care

This study seeks to understand the knowledge/utilisation of osteoporosis guidelines among PCPs in Singapore, their confidence in and barriers to osteoporosis management. Knowledge and usage of guidelines was associated with confidence in management. Effective guideline adoption is therefore crucial. PCPs also need systemic support to overcome barriers to osteoporosis care.

PURPOSE

Primary care physicians (PCPs) are at the forefront of offering osteoporosis screening and treatment. However, osteoporosis remains under-treated in primary care, despite the existence of osteoporosis clinical practice guidelines for PCPs. This study aims to determine the self-reported knowledge and utilisation of local osteoporosis guidelines and associated sociodemographic factors and to determine the confidence and barriers to osteoporosis screening and management among PCPs in Singapore.

METHODS

An anonymous web-based survey was conducted. PCPs in public and private practice were invited to participate in the self-administered survey via e-mail and messaging platforms. Chi-square test was performed for bivariate analysis; multivariable logistic regression models were used for factors with p value < 0.2.

RESULTS

Three hundred thirty-four complete survey datasets were processed for analysis. Two hundred fifty-one PCPs (75.1%) had read the osteoporosis guidelines. 70.5% self-reported good knowledge, and 74.9% use the guidelines. PCPs who self-reported good guideline knowledge (OR = 5.84; 2.96-11.49) and utilisation (OR = 4.54; 2.21-9.34) were more likely to perceive confidence in osteoporosis management. PCPs' perception that patients had other medical priorities during the consultation (79.3%) was the commonest barrier to screening. Limited anti-osteoporosis medication (54.1%) in the practice was a hindrance to management. Polyclinic-based PCPs frequently cited the lack of consultation time as a barrier; more systemic barriers were faced by PCPs in private practices.

CONCLUSION

Most PCPs know and use the local osteoporosis guidelines. Knowledge and usage of guidelines was associated with confidence in management. Strategies to address the prevalent barriers to osteoporosis screening and management faced by PCPs are needed.

A novel variant in the tropomyosin 3 gene presenting as an adult-onset distal myopathy - a case report

BACKGROUND

We report a patient with a novel c.737 C > T variant (p.Ser246Leu) of the TPM3 gene presenting with adult-onset distal myopathy.

CASE PRESENTATION

A 35-year-old Chinese male patient presented with a history of progressive finger weakness. Physical examination revealed differential finger extension weakness, together with predominant finger abduction, elbow flexion, ankle dorsiflexion and toe extension weakness. Muscle MRI showed disproportionate fatty infiltration of the glutei, sartorius and extensor digitorum longus muscles without significant wasting. Muscle biopsy and ultrastructural examination showed a non-specific myopathic pattern without nemaline or cap inclusions. Genetic sequencing revealed a novel heterozygous p.Ser246Leu variant (c.737C>T) of the TPM3 gene which is predicted to be pathogenic. This variant is located in the area of the TPM3 gene where the protein product interacts with actin at position Asp25 of actin. Mutations of TPM3 in these loci have been shown to alter the sensitivity of thin filaments to the influx of calcium ions.

CONCLUSION

This report further expands the phenotypic spectrum of myopathies associated with TPM3 mutations, as mutations in TPM3 had not previously been reported with adult-onset distal myopathy. We also discuss the interpretation of variants of unknown significance in patients with TPM3 mutations and summarise the typical muscle MRI findings of patients with TPM3 mutations.

Predictive, preventive, and personalized management of retinal fluid via computer-aided detection app for optical coherence tomography scans

Aims

Computer-aided detection systems for retinal fluid could be beneficial for disease monitoring and management by chronic age-related macular degeneration (AMD) and diabetic retinopathy (DR) patients, to assist in disease prevention via early detection before the disease progresses to a "wet AMD" pathology or diabetic macular edema (DME), requiring treatment. We propose a proof-of-concept AI-based app to help predict fluid via a "fluid score", prevent fluid progression, and provide personalized, serial monitoring, in the context of predictive, preventive, and personalized medicine (PPPM) for patients at risk of retinal fluid complications.

Methods

The app comprises a convolutional neural network-Vision Transformer (CNN-ViT)-based segmentation deep learning (DL) network, trained on a small dataset of 100 training images (augmented to 992 images) from the Singapore Epidemiology of Eye Diseases (SEED) study, together with a CNN-based classification network trained on 8497 images, that can detect fluid vs. non-fluid optical coherence tomography (OCT) scans. Both networks are validated on external datasets.

Results

Internal testing for our segmentation network produced an IoU score of 83.0% (95% CI = 76.7-89.3%) and a DICE score of 90.4% (86.3-94.4%); for external testing, we obtained an IoU score of 66.7% (63.5-70.0%) and a DICE score of 78.7% (76.0-81.4%). Internal testing of our classification network produced an area under the receiver operating characteristics curve (AUC) of 99.18%, and a Youden index threshold of 0.3806; for external testing, we obtained an AUC of 94.55%, and an accuracy of 94.98% and an F1 score of 85.73% with Youden index.

Conclusion

We have developed an AI-based app with an alternative transformer-based segmentation algorithm that could potentially be applied in the clinic with a PPPM approach for serial monitoring, and could allow for the generation of retrospective data to research into the varied use of treatments for AMD and DR. The modular system of our app can be scaled to add more iterative features based on user feedback for more efficient monitoring. Further study and scaling up of the algorithm dataset could potentially boost its usability in a real-world clinical setting.

Supplementary information

The online version contains supplementary material available at 10.1007/s13167-022-00301-5.

Topology of diffusion changes in corpus callosum in Alzheimer's disease: An exploratory case-control study

Aim

This study aims to assess the integrity of white matter in various segments of the corpus callosum in Alzheimer's disease (AD) by using metrics derived from diffusion tensor imaging (DTI), diffusion kurtosis imaging (DKI) and white matter tract integrity model (WMTI) and compare these findings to healthy controls (HC).

Methods

The study was approved by the institutional ethics board. 12 AD patients and 12 HC formed the study population. All AD patients were recruited from a tertiary neurology memory clinic. A standardized battery of neuropsychological assessments was administered to the study participants by a trained rater. MRI scans were performed with a Philips Ingenia 3.0T scanner equipped with a 32-channel head coil. The protocol included a T1-weighted sequence, FLAIR and a dMRI acquisition. The dMRI scan included a total of 71 volumes, 8 at b = 0 s/mm2, 15 at b = 1,000 s/mm2 and 48 at b = 2,000 s/mm2. Diffusion data fit was performed using DKI REKINDLE and WMTI models.

Results and discussion

We detected changes suggesting demyelination and axonal degeneration throughout the corpus callosum of patients with AD, most prominent in the mid-anterior and mid-posterior segments of CC. Axial kurtosis was the most significantly altered metric, being reduced in AD patients in almost all segments of corpus callosum. Reduced axial kurtosis in the CC segments correlated with poor cognition scores in AD patients in the visuospatial, language and attention domains.

The clinical value and cost-effectiveness of treatments for patients with coronary artery disease

BACKGROUND

The clinical value and cost-effectiveness of invasive treatments for patients with coronary artery disease is unclear. Invasive treatments such as coronary artery bypass grafting and percutaneous coronary intervention are frequently used as a starting treatment, yet they are much more costly than optimal medical therapy. While patients may transition into other treatments over time, the choices of starting treatments are likely important determinants of costs and health outcomes. The aim is to predict by how much costs and health outcomes will change from a decision to use different starting treatments for patients with coronary artery disease in an Asian setting.

METHODS

A cost-effectiveness study using a Markov model informed by data from Singapore General Hospital was done. All patients with initial presentations of stable coronary disease and no acute coronary syndromes who received medical treatments and interventional therapies were included. We compare existing practice, where the starting treatment can be medical therapy or stent percutaneous coronary interventions or coronary artery bypass grafting, with alternate starting treatment strategies.

RESULTS

When compared to 'existing practice' a policy of starting 14% of patients with coronary artery bypass grafting and 86% with optimal medical therapy showed savings of $1,743 per patient and 0.23 additional quality adjusted life years. A change to policy nationwide would save $10 million and generate 1,380 quality adjusted life years.

CONCLUSIONS

Increasing coronary artery bypass grafting and use of medical therapy in the setting of coronary artery disease is likely to saves costs and improve health outcomes. A definitive study to address the question we investigate would be very difficult to undertake and so using existing data to model the expected outcomes is a useful tool. There are likely to be large and complex barriers to the implementation of any policy change based on the findings of this study.

Prediction of subclinical atherosclerosis in low Framingham risk score individuals by using the metabolic syndrome criteria and insulin sensitivity index

Background

Subclinical atherosclerosis can be present in individuals with an optimal cardiovascular risk factor profile. Traditional risk scores such as the Framingham risk score do not adequately capture risk stratification in low-risk individuals. The aim of this study was to determine if markers of metabolic syndrome and insulin resistance can better stratify low-risk individuals.

Methods

A cross-sectional study of 101 healthy participants with a low Framingham risk score and no prior morbidities was performed to assess prevalence of subclinical atherosclerosis using computed tomography (CT) and ultrasound. Participants were compared between groups based on Metabolic Syndrome (MetS) and Insulin-Sensitivity Index (ISI-cal) scores.

Results

Twenty three individuals (23%) had subclinical atherosclerosis with elevated CT Agatston score ≥1. Presence of both insulin resistance (ISI-cal <9.23) and fulfillment of at least one metabolic syndrome criterion denoted high risk, resulting in significantly improved AUC (0.706 95%CI 0.588–0.822) over the Framingham risk score in predicting elevated CT Agatston score ≥1, with net reclassification index of 50.9 ± 23.7%. High-risk patients by the new classification also exhibited significantly increased carotid intima thickness.

Conclusions

The overlap of insulin resistance and presence of ≥1 criterion for metabolic syndrome may play an instrumental role in identifying traditionally low-risk individuals predisposed to future risk of atherosclerosis and its sequelae.

Chronic sequelae complicate convalescence from both dengue and acute viral respiratory illness

Long Covid has raised awareness of the potentially disabling chronic sequelae that afflicts patients after acute viral infection. Similar syndromes of post-infectious sequelae have also been observed after other viral infections such as dengue, but their true prevalence and functional impact remain poorly defined. We prospectively enrolled 209 patients with acute dengue (n = 48; one with severe dengue) and other acute viral respiratory infections (ARI) (n = 161), and followed them up for chronic sequelae up to one year post-enrolment, prior to the onset of the Covid-19 pandemic. Baseline demographics and co-morbidities were balanced between both groups except for gender, with more males in the dengue cohort (63% vs 29%, p<0.001). Except for the first visit, data on symptoms were collected remotely using a purpose-built mobile phone application. Mental health outcomes were evaluated using the validated SF-12v2 Health Survey. Almost all patients (95.8% of dengue and 94.4% of ARI patients) experienced at least one symptom of fatigue, somnolence, headache, concentration impairment or memory impairment within the first week of enrolment. Amongst patients with at least 3-months of follow-up, 18.0% in the dengue cohort and 14.6% in the ARI cohort experienced persistent symptoms. The median month-3 SF-12v2 Mental Component Summary Score was lower in patients who remained symptomatic at 3 months and beyond, compared to those whose symptoms fully resolved (47.7 vs. 56.0, p<0.001), indicating that patients who self-reported persistence of symptoms also experienced functionally worse mental health. No statistically significant difference in age, gender distribution or hospitalisation status was observed between those with and without chronic sequelae. Our findings reveal an under-appreciated burden of post-infection chronic sequelae in dengue and ARI patients. They call for studies to define the pathophysiology of this condition, and determine the efficacy of both vaccines as well as antiviral drugs in preventing such sequelae.

Chronic sequelae after viral infections such dengue have been observed, but their true prevalence and impact remain undefined. We prospectively enrolled a cohort of 209 patients with dengue and acute viral respiratory infections (ARI) and followed them up chronic sequelae for up to one year. 18% of patients in the dengue cohort and 14.6% of patients in the ARI cohort experienced chronic sequelae such as fatigue, somnolence, headache, concentration impairment and memory impairment. Patients who experienced chronic sequelae also had lower month-3 SF-12v2 Mental Component Summary Scores, suggesting that such those who self-reported persistence of symptoms experienced functionally worse mental health. Overall our findings reveal an under-appreciated burden of chronic sequelae in dengue and ARI patients and call for further studies to define the pathophysiology and potential therapeutic options for this condition.

Assessing the validity of a data driven segmentation approach: A 4 year longitudinal study of healthcare utilization and mortality

BACKGROUND

Segmentation of heterogeneous patient populations into parsimonious and relatively homogenous groups with similar healthcare needs can facilitate healthcare resource planning and development of effective integrated healthcare interventions for each segment. We aimed to apply a data-driven, healthcare utilization-based clustering analysis to segment a regional health system patient population and validate its discriminative ability on 4-year longitudinal healthcare utilization and mortality data.

METHODS

We extracted data from the Singapore Health Services Electronic Health Intelligence System, an electronic medical record database that included healthcare utilization (inpatient admissions, specialist outpatient clinic visits, emergency department visits, and primary care clinic visits), mortality, diseases, and demographics for all adult Singapore residents who resided in and had a healthcare encounter with our regional health system in 2012. Hierarchical clustering analysis (Ward's linkage) and K-means cluster analysis using age and healthcare utilization data in 2012 were applied to segment the selected population. These segments were compared using their demographics (other than age) and morbidities in 2012, and longitudinal healthcare utilization and mortality from 2013-2016.

RESULTS

Among 146,999 subjects, five distinct patient segments "Young, healthy"; "Middle age, healthy"; "Stable, chronic disease"; "Complicated chronic disease" and "Frequent admitters" were identified. Healthcare utilization patterns in 2012, morbidity patterns and demographics differed significantly across all segments. The "Frequent admitters" segment had the smallest number of patients (1.79% of the population) but consumed 69% of inpatient admissions, 77% of specialist outpatient visits, 54% of emergency department visits, and 23% of primary care clinic visits in 2012. 11.5% and 31.2% of this segment has end stage renal failure and malignancy respectively. The validity of cluster-analysis derived segments is supported by discriminative ability for longitudinal healthcare utilization and mortality from 2013-2016. Incident rate ratios for healthcare utilization and Cox hazards ratio for mortality increased as patient segments increased in complexity. Patients in the "Frequent admitters" segment accounted for a disproportionate healthcare utilization and 8.16 times higher mortality rate.

CONCLUSION

Our data-driven clustering analysis on a general patient population in Singapore identified five patient segments with distinct longitudinal healthcare utilization patterns and mortality risk to provide an evidence-based segmentation of a regional health system's healthcare needs.