The Short Form 36 Health Survey (SF-36) is a popular health-related quality of life (HrQoL) tool. However, few studies have assessed its psychometric properties in patients with spondyloarthritis ...(SpA). We therefore aimed to assess the reliability and validity of the SF-36 in patients with SpA in Singapore. Cross-sectional data from a registry of 196 SpA patients recruited from a dedicated tertiary referral clinic in Singapore from 2011 to 2014 was used. Analyses were guided by the COnsensus-based Standards for the selection of health Measurement INstruments framework. Internal consistency reliability was assessed using Cronbach’s alpha. Construct validity was assessed through 33 a priori hypotheses by correlations of the eight subscales and two summary scores of SF-36 with other health outcomes. Known-group construct validity was assessed by comparison of the means of the subscales and summary scores of the SF-36 of SpA patients and the general population of Singapore using student’s
t
tests. Among 196 patients (155 males (79.0 %), median (range) age: 36 (17–70), 166 Chinese (84.6 %)), SF-36 scales showed high internal consistency ranging from 0.88 to 0.90. Convergent construct validity was supported as shown by fulfillment of all hypotheses. Divergent construct validity was supported, as SF-36 MCS was not associated with PGA, pain and HAQ. Known-group construct validity showed SpA patients had lower scores of 3.8–12.5 when compared to the general population at
p
< 0.001. This study supports the SF-36 as a valid and reliable measure of HrQoL for use in patients with SpA at a single time point.
Background
Near-peer mentoring is a process where a mentor is close to the social, professional, or age level of the mentee. Near-peer mentors are better able to interact with and understand the ...struggles of students.
Objective
The aim of the programme was to increase confidence of students in the final year examination.
Methods
Following a needs analysis of final-year medical students, a near-peer mentoring programme was designed using peer-assisted learning framework. In the programme conducted between November 2019 and March 2020, trained Internal Medicine junior residents were assigned to students grouped according to the examination domains they most needed improvement in. Pre- and post-intervention data on students’ confidence in each of the examination domains using a 5-point Likert scale (1: Not confident at all and 5: Very confident), mock examination scores and feedback on the programme were collected.
Results
Fifty-one students were enrolled. Thirty-one students completed the post-programme survey, of which 71.0% felt more confident in the final year examination. Of the twenty-eight students who completed both the pre- and post-programme survey, 78.6%, 78.6% and 60.7% of them showed an increase in confidence in the communications, physical examination and history component of the examination, respectively. There was no association found between confidence level and examination performance.
Conclusion
A personalized near-peer mentoring programme is effective in increasing confidence of students in examinations and serves as a platform for residents to hone their skills as mentors. Its role as part of the medical school curriculum is worth exploring.
Background
IgG4-related disease (IgG4-RD) is a heterogeneous autoimmune disorder characterised by inflammatory lesions. Diagnostic imaging, such as 2-
18
FFDG PET/CT, is critical in evaluation of the ...disease, especially for potentially lethal cardiovascular manifestations. This retrospective study examines the usefulness of semi-quantitative parameters of 2-
18
FFDG PET/CT in monitoring IgG4-RD in patients with and without cardiovascular manifestations.
Methods
Patients diagnosed with IgG4-RD who underwent a 2-
18
FFDG PET/CT scan were identified and classified based on presence or absence of cardiovascular disease. Clinical and laboratory data were extracted and compared to three 2-
18
FFDG PET/CT semi-quantitative parameters: maximum standardised uptake value (SUVmax), metabolic tumour volume (MTV), and total lesion glycolysis (TLG). Tissue-to-background blood (TBR) values were also evaluated for cardiovascular manifestations. These data were also compared in patients before and after receiving immunosuppressive therapy.
Results
Forty-six patients identified were divided into an eight member subgroup of patients with cardiovascular manifestations, and a thirty-eight member subgroup of patients without. Patients with cardiovascular lesions were most frequently identified incidentally on imaging evaluation for other diseases (37.5%), with none presenting with chest pain or other cardiovascular symptoms. Ten patients with pre-treatment and post-treatment 2-
18
FFDG PET/CT scans demonstrated significant decreases in all semi-quantitative parameters, with no significant decrease in total IgG or ESR. The decrease in SUVmax, MTV, TLG following therapy was replicated in patients with and without cardiovascular manifestations.
Conclusion
2-
18
FFDG PET/CT is an important investigation to determine all sites of involvement in this multisystemic disease and to rule out life-threatening cardiovascular manifestations even in the absence of symptoms. Semi-quantitative parameters such as SUVmax, MTV, TLG, and TBR are useful in assessing treatment response in patients. There are no serological substitutes that can quantify the extent of disease involvement like 2-
18
FFDG PET/CT.
The aim of this study was to compare the body temperature measurements at tympanic, forehead and temporal sites using infrared thermometers. A total of 1576 consecutive visitors to Singapore General ...Hospital at two entry locations were included in this study. Pearson correlation and Bland–Altman mean difference between sites (95% confidence interval for limits of agreement) were calculated for the relationship between the three different sites of temperatures recorded (i.e. temporal, forehead and tympanic). Of all the visitors, 27 (1.7%) had fever. Moderate positive correlation was found between temporal and forehead temperature readings (r=0.602, mean difference (temporal – forehead), (95% limits of agreement) = 0.1 (−0.8, 0.7)), and there was very weak positive correlation between tympanic and temporal temperature readings (r=0.177, mean difference (temporal – tympanic), (95% limits of agreement) = −0.3 (−1.7, 1.1)). Sensitivity for temporal temperature readings (⩾37.5°C) to detect febrile visitors was 3.7%, specificity was 99.6%, positive predictive value was 14.3% and negative predictive value was 98.3%. Our results demonstrate that tympanic temperature readings should be used for fever screening instead of temporal or forehead readings.
The educational environment (EE) reflects the quality of a residency programme and has an association with burnout. Studying the EE allows for interventions to target specific weaknesses. We aimed to ...measure the EE of an internal medicine residency programme in Singapore, compare the perceptions between genders, residency grades and levels of work experience, and identify specific areas of weaknesses for intervention in hopes of reducing residency burnout rates in Singapore.
This study took place between October and December 2017. We adopted a mixed methods approach, quantitatively using the Postgraduate Hospital Educational Environment Measure (PHEEM), and qualitative exploration using semi-structured focus group discussion.
A total of 136 (88.9%) out of 153 residents responded. Our total PHEEM scores (112.23 ± 16.71), along with the scores for all three subscales, were higher than those of institutions in previous studies. There were no differences in overall PHEEM and subscale scores between genders, residency grades or levels of work experience. However, there were differences for individual questions, which were explored in the focus group discussion. Senior residents juggling heavier workloads, responsibilities and examinations appeared to be most prone to burnout. We identified three recurring themes that contributed to a poor EE in our programme: excessive workload, poor faculty relationships and differing unmet needs.
Although our programme had a good EE, there were also areas of weaknesses revealed by specific questions, possibly contributing to burnout. We hope to implement interventions to these areas and subsequently assess for longitudinal changes in EE and burnout rates.
Cytomegalovirus (CMV) is an opportunistic pathogen causing reactivation and disease in Systemic Lupus Erythematosus (SLE) patients. This study aims to systematically review the literature for risk ...factors associated with CMV disease in SLE patients, in order to identify those more susceptible to CMV infection during their treatment.
A systematic review was conducted on 4 different search engines and via hand search until May 2017. Studies were included after quality assessment via the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (HTA KMET).
Two studies on CMV disease were included. Elevated CMV viral load, higher steroid doses, use of immunosuppressants and disease duration were the most commonly associated risk factors for CMV disease.
High CMV viral loads, longer SLE disease duration and higher steroid doses were associated with CMV disease. Further studies studying the risk of treatment drugs and role of interventions in the development of CMV infection are needed.
Aims
The field of axial spondyloarthritis (axSpA) has undergone significant changes recently in particular with disease classification, assessment of disease activity and increased treatment options ...for biologics. In order to reflect these developments, we aimed to update the local consensus recommendations for subsidization of biologics.
Methods
A modified Delphi approach was used. Six published guidelines from major rheumatology societies and healthcare authorities on axSpA were reviewed. Findings were synthesized and used in formulating updated recommendation statements. Recommendations were rated by 10 practicing rheumatologists in Singapore. Consensus was reached if there was more than 70% agreement or disagreement.
Results
Ten statements achieved consensus. Patients may be considered for subsidization of biologic therapy if they fulfill the Assessment of Spondyloarthritis International Society or modified New York criteria, with persistently active disease (defined either by Ankylosing Spondylitis Disease Activity Score ≥ 2.1 or Bath Spondylitis Disease Activity Index ≥ 4), despite 4 weeks of full‐dose non‐steroidal anti‐inflammatory drugs and regular exercise. Either tumor necrosis factor inhibitors or interleukin 17 inhibitors may be used as first‐line therapy, and should be continued if adequate response is achieved at 6 months.
Conclusion
Recommendation statements were formulated through a formal consensus process by local experts with a view to assist relevant authorities in funding considerations and for use in clinical practice.
Attributes of the clinical learning environment (CLE) are a measure of quality in postgraduate medical education, and assessing the CLE is a component of the New Accreditation System being introduced ...in Singapore by the Accreditation Council for Graduate Medical Education International. There is a dearth of published studies of CLE quality in Singapore.
Our study had 3 aims: (1) to measure the CLE in 1 Singaporean residency program; (2) to compare trainee perceptions by sex, training level, and experience; and (3) to identify areas for improvement.
Between October and December 2017, we conducted a mixed assessment of the CLE in an internal medicine program in Singapore, using the Postgraduate Hospital Educational Environment Measure (PHEEM) and qualitative exploration using a focus group.
Of 153 IM residents, 136 (89%) provided PHEEM responses and 8 participated in the focus group. Total PHEEM scores and scores for the 3 subscales were higher than published data on the use of the PHEEM in international settings. Exploration of selected PHEEM responses via a focus group identified attributes associated with negative perceptions of the CLE: excessive workload, inadequate faculty presence in the CLE, and unmet trainee needs. It also suggested senior residents' clinical workloads, greater responsibilities, and pending examinations may contribute to their less positive perceptions of the CLE.
Our analysis using the PHEEM showed overall positive perceptions of the CLE, along with areas for improvement amenable to interventions. Our approach has relevance to an accreditation model with ongoing evaluation of the CLE.
Introduction
Approximately 30% of patients with rheumatoid arthritis (RA) respond inadequately to conventional‐synthetic disease‐modifying anti‐rheumatic drugs (csDMARDs). However, widespread use of ...biologic DMARDs (bDMARDs) and targeted‐synthetic (tsDMARDs) is limited by cost. We formulated updated recommendations for eligibility criteria for government‐assisted funding of bDMARDs/tsDMARDs for RA patients in Singapore.
Materials and Methods
Published guidelines regarding use of bDMARD and tsDMARDs were reviewed. We excluded those without a systematic literature review, formal consensus process or evidence grading. Separately, unpublished national reimbursement guidelines were included.
Results
Eleven recommendations regarding choice of disease activity measure, initiation, order of selection and continuation of bDMARD/tsDMARDs were formulated. A bDMARD/tsDMARD is indicated if a patient has: (a) at least moderately active RA with a Disease Activity Score in 28 joints/erythrocyte sedimentation rate (DAS28‐ESR) score of ≥3.2; (b) failed ≥2 csDMARD strategies, 1 of which must be a combination; (c) received an adequate dose regimen of ≥3 months for each strategy. For the first‐line bDMARD/tsDMARD, either tumor necrosis factor inhibitors (TNFi), non‐TNFi (abatacept, tocilizumab, rituximab), or tsDMARDs, may be considered. If a first‐line TNFi fails, options include another TNFi, non‐TNFi biologic or tsDMARDs. If a first‐line non‐TNFi biologic or tsDMARD fails, options include TNFi or another non‐TNF biologic or tsDMARD. For continued bDMARD/tsDMARD subsidization, a patient must have a documented DAS28‐ESR every 3 months and at least a moderate European League Against Rheumatism response by 6 months.
Conclusion
These recommendations are useful for guiding funding decisions, making bDMARD/tsDMARDs usage accessible and equitable in RA patients who fail csDMARDs.
Aim
There have been major advances in biologic treatment options for psoriatic arthritis (PsA) since the publication of the 2015 consensus recommendations by the Chapter of Rheumatologists, College ...of Physicians, Academy of Medicine, Singapore, for government‐assisted funding, thus warranting a revision of this guideline.
Methods
Recent trials and nine published guidelines on the use of biologic therapy for PsA were reviewed. Based on the synthesized evidence, a task force panel (TFP), consisting of 10 practicing rheumatologists in Singapore, rated the statements pertaining to the use of biologic therapy, using a modified Delphi approach. Consensus was obtained if >70% agreed on a statement.
Results
The TFP agreed on 10 recommendations pertaining to the initiation, choice and continuation of biologic therapy. A biologic is indicated in patients with PsA: (a) with at least three swollen and tender joints, digits or entheses; and (b) who have failed at least two conventional synthetic disease‐modifying anti‐rheumatic drug (csDMARD) strategies for a minimum of 3 months each. Any approved drug class including tumor necrosis factor inhibitors, interleukin‐17 inhibitors (IL‐17i), IL‐12/23i or targeted synthetic DMARDs may be considered as first‐line treatment, and continued only if a response is achieved by 6 months.
Conclusion
These recommendations developed through a formal consensus method may be useful to guide funding considerations for appropriate and equitable use of biologic therapy for eligible patients with PsA.
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