BackgroundImproving healthcare utilization is essential as health systems around the world grapple with the escalating demands for acute hospital resources. Evidence suggests that transitional care programs are effective to improve utilization of healthcare. However, the evidence for transitional care programs that enhance the home medical care model and provide multi-disciplinary patient-centered care is not well established. We evaluated if a transitional home care program operated by the Singapore General Hospital was effective in reducing acute hospital utilization.MethodsWe performed a quasi-experimental study using a pre-post design to evaluate the effectiveness of a transitional home care program in reducing hospital admissions and emergency department attendances of medically complex patients enrolled into the program in a tertiary hospital in Singapore. Patients received a comprehensive needs assessment performed by the physician and a nurse case manager in the home setting, followed by an individualized care plan that included medical and nursing care, patient education and coordination of care with hospital specialists and community services. Primary study outcomes were emergency department attendances and hospital admissions to all hospitals. These were extracted from hospital administrative data and national health records. Wilcoxon Signed Ranks Test was used for assess differences in pre and post continuous data.ResultsOverall, 262 patients were enrolled into the program and 259 were analyzed. Patients had a 51.6% and 52.8% reduction in hospital admissions in the three-month and six-month post enrollment, respectively. Similarly, a 47.1% and 48.2% reduction was observed for emergency department attendances in the three and six months post enrollment, respectively. The average difference in per patient hospital bed days in the pre- and post-enrollment periods were 12.05 days and 20.03 days at the 3-month and 6-month periods, respectively.ConclusionsPatients enrolled in the transitional home care program had significantly lower acute hospital utilization through the reduction of emergency department attendances and hospital admissions. A comprehensive assessment of patients’ medical and social needs in the home setting and formulation of an individualized care plan optimized post-discharge care for medically complex patients.

BackgroundEmerging evidence from the virtual ward care model showed that multidisciplinary case management are inadequate to reduce readmissions or death for high risk patients. There is consensus that interventions should encompass both pre-hospital discharge and post-discharge transitional care to be effective. Integrated practice units (IPU) had been proposed as an approach of restructuring the organization and work processes of multidisciplinary teams to achieve value in healthcare. Our primary objective is to evaluate if the novel application of the IPU concept to organize a modified virtual ward model incorporating pre-hospital discharge transitional care can reduce readmissions of patients at highest risk for readmission.MethodsWe conducted an open label, assessor blinded randomized controlled trial on patients with one or more unscheduled readmissions in the prior 90 days and LACE score ≥ 10. 840 patients were randomized in 1:1 ratio and blocks of 6 to the intervention program (n = 420) or control (n = 420). Allocation concealment was effected via an off-site telephone service maintained by a hospital administrator. Intervention patients received discharge planning, medication reconciliation, coaching on self-management of chronic diseases using standardized action plans and an individualized care plan complete with written discharge instructions, appointments schedule, medication changes and the contact information of the outpatient VW nurse before discharge. At discharge, care is handed over to the outpatient VW team. Patients were closely monitored in the VW for three months that included a telephone review within 72 hours of discharge, home assessment, regular telephone reviews to identify early complications and early review clinics for patients who destabilize. The VW meet daily to discuss new patients and review care plans for patients. Control patients received standard hospital care that included a standardized patient copy of the hospital discharge summary listing their medical diagnoses and medications; and follow up is arranged with a primary care provider or specialist as considered necessary. The primary outcome was the unplanned readmission rate to any hospital within 30 days of discharge. Secondary outcomes included the unplanned readmission rate, emergency department (ED) attendance rate to any hospital and the probability without readmission or death up to 180 days of discharge. Length of stay and mortality rate at 90-day were compared between the two groups. Outcome data were objectively retrieved from the hospital and National Electronic Health Records by a blinded outcome assessor.FindingsAll patients’ outcomes were included in an intention-to-treat analysis. The characteristics of both study groups were similar. Patients in the intervention group had a significant reduction in the number of 30-day readmissions, IRR 0.67 (95% CI, 0.52 to 0.86, p = 0.001) and the number of 30-day emergency department attendances, IRR 0.60 (95% CI, 0.46 to 0.79, p<0.001) compared to those receiving stan...

Aim: Social oocyte freezing has gained increasing interest worldwide. We conducted a cross-sectional survey on 129 female medical students in Singapore to assess their mindset and attitudes toward fertility and social oocyte freezing. Methods: An anonymous online survey was conducted among female medical students in Singapore. The desired sample size was 100 participants. Their awareness of the existence of social oocyte freezing was first assessed. An information leaflet was provided subsequently, followed by a more detailed questionnaire. The questions focused on their awareness of age-related fertility decline and their intentions for social oocyte freezing if made available. Results: One hundred and twenty-nine female students participated in the electronic survey, of whom 36.4% had heard of social oocyte freezing. Of these, 70% had personally considered taking up this option. However, after reading the information leaflet, only 48.9% would still consider this option. Of the total, 89.9% considered themselves too old for pregnancy after the age of 35 years, 37.2% would delay family planning for their career, 45.7% would consider social oocyte freezing to postpone family planning for their career, 46.5% would consider oocyte freezing if they had no suitable partners yet, 50.4% may consider freezing their eggs after the age of 30 years and 71.3% may be more amenable to oocyte freezing if government subsidy is available. Conclusion: We hypothesize that social oocyte freezing may be a viable option for single young women who wish to delay child-bearing for 'reproductive insurance', so long as this is done with appropriate informed consent with non-directive counseling.

Immunodeficient mouse-human chimeras provide a powerful approach to study host-specific pathogens, such as Plasmodium falciparum that causes human malaria. Supplementation of immunodeficient mice with human RBCs supports infection by human Plasmodium parasites, but these mice lack the human immune system. By combining human RBC supplementation and humanized mice that are optimized for human immune cell reconstitution, we have developed RBC-supplemented, immune cell-optimized humanized (RICH) mice that support multiple cycles of P. falciparum infection. Depletion of human natural killer (NK) cells, but not macrophages, in RICH mice results in a significant increase in parasitemia. Further studies in vitro show that NK cells preferentially interact with infected RBCs (iRBCs), resulting in the activation of NK cells and the elimination of iRBCs in a contact-dependent manner. We show that the adhesion molecule lymphocyte-associated antigen 1 is required for NK cell interaction with and elimination of iRBCs. Development of RICH mice and validation of P. falciparum infection should facilitate the dissection of human immune responses to malaria parasite infection and the evaluation of therapeutics and vaccines. malaria infection | humanized mouse model | LFA-1 | NK killing

BackgroundResidence in public rental housing is an area-level measure of socioeconomic status, but its impact as a social determinant of health in Singapore has not been studied. We therefore aimed to examine the association of public rental housing with readmission risk and increased utilization of hospital services in Singapore.MethodsWe conducted a retrospective cohort study using retrospective 2014 data from Singapore General Hospital’s electronic health records. Variables known to affect readmission risk and health-care utilization were identified a priori and include patient demographics, comorbidities, health-care utilization in the preceding 1 year and clinical variables from the index admission in 2014. Multivariate logistic regression was used to evaluate public rental housing as an independent risk factor for admission risk, emergency department (ED), and specialist outpatient clinic attendances.ResultsA total of 14,457 unique patients were analyzed, and 2,163 patients (15.0%) were rental housing residents. Rental housing patients were significantly more likely to be male; required financial assistance; have chronic obstructive pulmonary disease; usage of anti-depressant and anti-psychotic medications; longer length of hospital stay during the index admission; and higher Charlson Comorbidity Index scores. After adjusting for demographics and clinical variables, staying in public rental housing remained an independent risk factor for readmission within 15 and 30 days, frequent hospital admissions and ED attendances in Singapore.ConclusionOur study showed an association between public rental housing with readmission risk and increased utilization of hospital services in Singapore. A deeper understanding of the residents’ social circumstances and health seeking behavior would be insightful.

The LACE index (length of stay, acuity of admission, Charlson comorbidity index, CCI, and number of emergency department visits in preceding 6 months) derived in Canada is simple and may have clinical utility in Singapore to predict readmission risk. We compared the performance of the LACE index with a derived model in identifying 30-day readmissions from a population of general medicine patients in Singapore. Additional variables include patient demographics, comorbidities, clinical and laboratory variables during the index admission, and prior healthcare utilization in the preceding year. 5,862 patients were analysed and 572 patients (9.8%) were readmitted in the 30 days following discharge. Age, CCI, count of surgical procedures during index admission, white cell count, serum albumin, and number of emergency department visits in previous 6 months were significantly associated with 30-day readmission risk. The final logistic regression model had fair discriminative ability c-statistic of 0.650 while the LACE index achieved c-statistic of 0.628 in predicting 30-day readmissions. Our derived model has the advantage of being available early in the admission to identify patients at high risk of readmission for interventions. Additional factors predicting readmission risk and machine learning techniques should be considered to improve model performance.

Semantic segmentation generates comprehensive understanding of scenes through densely predicting the category for each pixel. High-level features from Deep Convolutional Neural Networks already demonstrate their effectiveness in semantic segmentation tasks, however the coarse resolution of high-level features often leads to inferior results for small/thin objects where detailed information is important. It is natural to consider importing low level features to compensate for the lost detailed information in high-level features. Unfortunately, simply combining multi-level features suffers from the semantic gap among them. In this paper, we propose a new architecture, named Gated Fully Fusion(GFF), to selectively fuse features from multiple levels using gates in a fully connected way. Specifically, features at each level are enhanced by higher-level features with stronger semantics and lower-level features with more details, and gates are used to control the propagation of useful information which significantly reduces the noises during fusion. We achieve the state of the art results on four challenging scene parsing datasets including Cityscapes, Pascal Context, COCO-stuff and ADE20K.

BackgroundInterventions to prevent readmissions of patients at highest risk have not been rigorously evaluated. We conducted a randomised controlled trial to determine if a post-discharge transitional care programme can reduce readmissions of such patients in Singapore.MethodsWe randomised 840 patients with two or more unscheduled readmissions in the prior 90 days and Length of stay, Acuity of admission, Comorbidity of patient, Emergency department utilisation score ≥10 to the intervention programme (n = 419) or control (n = 421). Patients allocated to the intervention group received post-discharge surveillance by a multidisciplinary integrated care team and early review in the clinic. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge.ResultsWe found no statistically significant reduction in readmissions or emergency department visits in patients on the intervention group compared to usual care. However, patients in the intervention group reported greater patient satisfaction (p < 0.001).ConclusionAny beneficial effect of interventions initiated after discharge is small for high-risk patients with multiple comorbidity and complex care needs. Future transitional care interventions should focus on providing the entire cycle of care for such patients starting from time of admission to final transition to the primary care setting.Trial RegistrationClinicaltrials.gov, no NCT02325752