SingHealth Polyclinics

Background: Diabetic foot ulcers (DFUs) and lower-extremity amputations (LEAs) complicating diabetes mellitus are significant contributors to morbidity, mortality, and disease burden. There is insufficient evidence, however, linking podiatric care to mortality and healthcare resource use. There is, concurrently, inadequate access to podiatric care, particularly in Asia. This study evaluated the clinical and healthcare use outcomes of patients with DFUs who received podiatric care. Methods: A longitudinal study involving patients in Diabetic Foot in Primary and Tertiary (DEFINITE) Care followed over a period of 2 years reviewed the effectiveness of podiatric care with regard to 1-year outcomes using multiple logistic and zero-inflated negative binomial regressions, adjusting for covariates. Clinical outcomes were minor and major LEA, mortality, and LEA-free survival rates; healthcare use outcomes were the number of admissions, number of visits to clinics and emergency departments, and length of stay. Results: Eligible patients (n = 2798 [65.5%]) completed at least 12 months of follow-up. Comparisons were made with patients without access to podiatric care. The overall mean ± SD patient age was 65.7 ± 12.7 years. Most patients receiving podiatric follow-up were of Malay or Indian ethnicities and had poor diabetic control and chronic kidney disease. There were more admissions (p < 0.01) and visits to the emergency department (p < 0.01) and hospital outpatient clinics (p < 0.01), but a shorter length of stay (incidence rate ratio, 0.833; p < 0.01), without any reported differences regarding visits to public primary care clinics (p = 0.68). There were more minor LEAs (p < 0.01) but fewer deaths (p < 0.01) and greater LEA-free survival (odds ratio, 1.26; p = 0.02). Conclusions: Podiatric care improved clinical outcomes for patients with DFU, particularly in terms of LEA-free survival, with a positive impact on healthcare utilization. This is a crucial contribution to the limited evidence on podiatric care in diabetic limb salvage in Asian populations.

Protocol (2023): https://doi.org/10.1002/14651858.CD015234.

ObjectiveTo understand the experiences of self‐regulation and health‐promoting behaviours among practising nurses in Singapore.QualitativeTo explore the experiences of self‐regulating health‐promoting behaviours among nurses.QuantitativeTo measure the nurses’ current health‐promoting behaviours and perceived stress levels.BackgroundNursing is a physically and emotionally stressful occupation. While there is existing literature on the influencing factors of self‐care habits among nurses, little is known about the nurses’ self‐regulation facilitators and barriers of maintaining a healthier lifestyle.MethodsA concurrent mixed‐method study was conducted. Twenty‐four full‐time nurses from 15 Singapore healthcare institutions were recruited from August to November 2023 using purposive sampling. In‐depth interviews were conducted online through face‐to‐face virtual platforms using a semistructured interview guide. Thematic analysis was used to identify patterns and themes. Concurrently, 67 full‐time nurses completed questionnaires on their lifestyles and perceived stress. Data were analysed using descriptive statistics and limited statistical analysis and integrated with the qualitative study findings.ResultsFive themes and 13 subthemes emerged. The five themes were (1) conflict between nursing and personal identity; (2) overwhelmed with time constraints; (3) power of intrinsic motivation over extrinsic incentives; (4) influence of close contacts at workplace on nurses’ lifestyle and (5) inadequate support for positive lifestyle change. The mean scores for the Health‐Promoting Lifestyle Profile II and Perceived Stress Scale‐10 were 2.39 (SD = 0.38) and 18.39 (SD = 4.58), respectively, indicating that most of the participants had poor lifestyles and were experiencing moderate stress. Additionally, there was a moderate statistically significant negative relationship between perceived stress and health‐promoting lifestyle behaviours (ρ = −0.461).ConclusionNurses’ healthy lifestyle challenges may stem from inadequate organisational support and low personal health prioritisation. Sustainable interventions should address workplace culture and work‐life integration to empower nurses to take ownership of their well‐being.

Diabetic foot ulcers (DFUs) significantly impair health-related quality of life (HRQoL). While clinical predictors are well established, the contribution of psychological factors, particularly in primary care, remains underexplored. To examine the sociodemographic, clinical, and psychological determinants of HRQoL in individuals with DFUs to inform development of psychologically informed interventions. Cross-sectional study conducted between April and October 2022 in primary care settings in Singapore. A total of 186 patients with DFUs completed validated measures, including psychological variables (for example, the Diabetes Distress Scale and Brief Illness Perception Questionnaire) and Wound-QoL, which uses a questionnaire to assess quality of life in body, psyche, and everyday life domains. Hierarchical multiple regression analyses evaluated the contribution of psychological variables to HRQoL. Psychological burden dominated, with psyche HRQoL impaired in 57% of participants (mean = 2.0), outpacing everyday life (38%; mean = 1.3) and body domains (24%; mean = 0.8). In hierarchical models, psychological variables - together with sociodemographic and clinical factors - explained 29.8% of the variance in body HRQoL, with interpersonal distress and threat perceptions emerging as significant predictors. A similar model accounted for 31.8% of the variance in psyche HRQoL, with female sex, emotional burden, and threat perceptions as key predictors. Everyday life HRQoL was significantly associated with HbA1c, independence in daily activities, emotional burden, and threat perceptions, with the full model explaining 33.7% of the variance. Psychological factors significantly contributed to reduced HRQoL in primary care patients with DFUs. Routine screening and targeted, psychologically informed support - particularly for females, those with poor glycaemic control, or limited functional independence - are essential to improve outcomes.

IntroductionRecent hypertension guidelines recommend ambulatory blood pressure monitoring (ABPM) for accurate diagnosis and monitoring. However, patients’ experiences with cuff and wearable ABPM devices in primary care remain unclear. This study compared the acceptance of three devices (oscillometry cuff, tonometry wrist, and photoplethysmography chest devices) among patients with hypertension in primary care.MethodsA multi-method study was conducted. Thirty-five participants with hypertension were recruited from two public primary care clinics in Singapore. All participants used cuff-based and either wrist or chest wearable devices for 24 hours. Structured surveys and in-depth audio-recorded interviews were used to gather feedback on their views, experiences, and challenges using the devices. The interviews were thematically analysed, and the surveys were analysed using descriptive statistics.ResultsAll participants used the cuff (n = 35) device, while the wrist and chest devices were used by two-thirds (n = 22) and a third (n = 11) of the participants, respectively.The device usability questionnaire found that most participants were satisfied with the chest device, which did not disrupt their daily activities. Conversely, cuff arm devices interfered with daily activities (48%) and sleep (26%), were cumbersome (32%), and caused embarrassment (26%). The wrist device was uncomfortable (33%) and painful (22%) for some participants.The qualitative data were categorised into five themes: comfort, convenience, perceived accuracy, and impact on routine and sleep. Participants found the chest device more comfortable and convenient than the cuff and wrist devices. The cuff device was perceived as the most accurate due to its inflation-based BP measurement. All devices minimally affected routines and sleep, though participants expressed safety concerns about the cuff device, particularly while driving.ConclusionWhile wearable ABPM devices offer increased comfort, convenience and reduced impact on patient’s daily activities, concerns regarding their accuracy must be addressed before the widespread adoption of these devices in routine clinical practice.

Background Arterial stiffness (AS) measured by pulse wave velocity (PWV) is a well-recognized marker for increased cardiovascular disease risk in Asian and Western individuals. We evaluated factors in relation to AS using the exposure-wide association study (EWAS) approach within the Health for Life in Singapore (HELIOS) study. Subsequently, two-sample Mendelian randomization (MR) analysis was utilized to examine potential causal associations between identified factors and AS. Methods The HELIOS study is a multi-ethnic prospective cohort study that included adults aged 30-85 years. We analyzed 8,880 subjects of Chinese, Malay, and South Asian ethnicity participating in the HELIOS cohort. PWV was measured by Vicorder. We assessed 54 predictor variables using EWAS approach and correction for multiple comparisons was applied using the false discovery rate (FDR?&lt;?5%) method. Linear regression models were used to assess the association of each predictor variable with PWV. Inverse-variance-weighted MR method was used to estimate causal effects. Results Of the 54 variables, 41 variables were significantly associated with PWV at FDR &lt;5%. We found age, systolic blood pressure (SBP), diastolic blood pressure, and anthropometric, and body composition measurements were positively associated with PWV. Furthermore, insulin, glycated hemoglobin (HbA1c), glucose, triglycerides, albumin, alanine transaminase, gamma-glutamyl transferase, C-reactive protein, and uric acid were positively associated with PWV. Inverse associations were observed for PWV with high-density lipoprotein cholesterol (HDL-C), potassium, vitamin D, bilirubin, handgrip strength and educational level. These associations appear stronger among Chinese participants than among Malay and South Asian participants. In MR analyses, genetically predicted SBP was positively with AS, while genetically predicted HDL-C and HbA1c were inversely associated with AS. Conclusions Our systematic evaluation provides new knowledge on the complex array of anthropometric, body composition, physiological, biochemical, behavioral, and sociodemographic correlates of PWV. Our MR analysis indicates a potential causal association between SBP, HDL-C, HbA1c and AS.

This study aimed to determine the association between diabetes mellitus (DM) medication use and glycaemic control. This was a retrospective diabetes registry-based cohort study. Singapore. Patients aged 18 and above with incident DM in the SingHealth Diabetes Registry from 2013 to 2020 were included. The entire study period included a 1 year baseline period, a 1 year observation period and a 3 month outcome period. Drug use was measured using the proportion of days covered (PDC), and the changes in glycated haemoglobin (HbA1c) between the outcome and baseline periods were assessed. The associations between baseline HbA1c and PDC ≥0.80 and between PDC and change in HbA1c were analysed using logistic regression and the Kruskal-Wallis test, respectively. Of 184 646 unique patients in the registry from 2013 to 2020, 36 314 met the inclusion and exclusion criteria and were included in the analysis. The median PDC for any DM drug, oral DM drugs and insulin during the observation period was 20.3%, 16.8% and 0%, respectively. Those who had good glycaemic control at baseline were less likely to receive DM drugs and those with poor baseline glycaemic control or missing baseline HbA1c were more likely to be consistent users (PDC >80%) (p<2.2 × 10-16). The relationship between DM drug use and glycaemic control is complex and non-monotonic. Higher PDC for any DM drug and oral DM drugs during the observation period was significantly associated with clinically relevant HbA1c improvements.

The inertia to adopt protective health behaviours by patients with diabetes is contributed by underestimation of their risks of diabetes complications. Risk communication, using social comparison of glycaemic control and disease trajectory to other patients of similar clinicodemographic profiles, has potential to increase patients' risk perceptions and motivate protective health behaviours. A digital tool named PERDICT.AI was designed to support primary care physicians (PCPs) in patient similarity-based risk communication to patients with type 2 diabetes mellitus (T2DM). This study explored the perspectives of patients with uncontrolled T2DM on how their diabetes-related risks were communicated to them by a PCP using PERDICT.AI. A qualitative design was used. Eighteen participants aged 40-79 with T2DM with ≥1 HBA1c reading ≥8.0% within the last 6 months were recruited from a primary care clinic in Singapore. Each participant went through the risk communication session followed by an in-depth interview. The transcripts were coded and analysed to identify emerging themes. Five themes emerged representing participants' risk perceptions post-session and social comparison tendencies. These are: 1) 'I am myself', 2) motivation to be like the majority, 3) avoiding similar negative outcomes, 4) low risk does not equate to zero risk, and 5) motivation to replicate how others achieve positive outcomes. Themes 1 and 4 were concurrently represented among some participants; zero risk tolerance for diabetes complications was expressed despite not being motivated by their HBA1c cohort ranking. This study provided insights into the acceptability of using a social comparison approach in communicating risk to patients with uncontrolled T2DM. It highlights the importance of identifying and selecting patients who are receptive to social comparison, clarifying patients' perceptions of risks, including zero risk, and providing tailored and socially comparable strategies to mitigate these risks.

Growth differentiation factor-15 (GDF-15) is a stress-reactive cytokine which is implicated in the pathogenesis of several diabetic complications. GDF-15 may induce endothelial dysfunction which is a determinant of arterial stiffness. We aimed to study the association between GDF-15 with pulse wave velocity (PWV) and endothelial function in patients with T2D, and the potential mediating role of albuminuria. This was a prospective cohort study of 1784 patients with T2D. Baseline plasma GDF-15 was measured using multiplex immunoassay. Carotid-femoral PWV was measured using applanation method. We used laser Doppler imaging with iontophoresis to measure forearm endothelium-independent vasodilation (EIV) and endothelium-dependent vasodilation (EDV). The mean age of patients was 57.0 ± 10.8 years. Cross-sectionally, GDF-15 was associated with higher PWV and lower EDV at baseline. Baseline GDF-15 was also associated with higher PWV and lower EIV at follow-up with adjusted coefficients 0.33 (95%CI 0.15-0.52; p < 0.001) and -2.09 (95%CI -4.14--0.05; p = 0.045) respectively. Albuminuria mediated 29.5% and 44.9% of the association between baseline GDF-15 with follow-up PWV and EDV respectively. Baseline GDF-15 was independently associated with higher PWV and lower EDV over time, with mediation by albuminuria in patients with T2D. GDF-15 is a potential biomarker of arterial stiffness and impaired endothelial function in T2D.