To determine whether adding compartment specific knee bracing with an adherence intervention to advice, written information, and exercise instruction (AIE+B) is superior to advice, written information, and exercise instruction (AIE) only in improving patient reported outcomes in people with knee osteoarthritis. Multicentre, parallel group, superiority, statistician blinded, randomised (1:1; block; stratified; centralised web based) controlled trial. Recruitment through general practices and the community in Cheshire, Manchester, North Tyneside, and Staffordshire, England; enrolment 25 November 2019 to 16 September 2022. 466 adults aged ≥45 years with symptoms of knee osteoarthritis. AIE was delivered in one in-person consultation by a trained physiotherapist. Individuals randomised to the AIE+B group were also fitted with a patellofemoral, tibiofemoral unloading, or neutral stabilising knee brace, according to their predominant compartmental distribution of knee osteoarthritis, and were offered a two week follow-up consultation. Brief motivational interviewing with targeted text reminders supported brace adherence. The primary outcome was a composite patient reported Knee Osteoarthritis Outcomes Score (KOOS)-5 (0-100) at six months after randomisation. Key secondary outcomes were KOOS-5 at three and 12 months, KOOS-5 subscale scores, and pain on weight bearing activity at three, six, and 12 months. 466 participants (mean age 64 (standard deviation 9) years; 46% female participants) were randomised, with 401 (86%), 394 (85%), and 370 (79%) participants followed up with analysable data at three, six, and 12 months, respectively. At six months, greater improvement in KOOS-5 was seen in the AIE+B group than in the AIE group (adjusted mean difference 3.39, 95% confidence interval (CI) 0.96 to 5.82; effect size 0.24). Secondary outcomes showed the benefits of AIE+B over AIE that diminished over time. The largest effects observed were for pain reduction (KOOS pain (0-100) adjusted mean difference at six months 6.13, 95% CI 3.36 to 8.91; effect size 0.39). Adverse events were minor and expected. Adding compartment specific knee bracing and an adherence intervention to advice, written information, and exercise instruction resulted in small improvements in patient reported outcomes among individuals with knee osteoarthritis. This safe intervention offers a potential treatment option for this common condition. ISRCTN28555470.
Health behaviours and decisions are complex and involve different dimensions of individuals' lives. The current study aimed to investigate considerations and their priorities in health decision and behaviour adoption via a risk-benefit framework unifying elements of mainstream models of health behaviour. We aimed to explore the core dimensions of the outcomes being considered by people and individual differences in perceived importance across dimensions. Two studies were conducted among U.S. adult residents. Study 1 (N = 295) involved eliciting qualitative responses of the health decisions or behaviours that participants encounter in their everyday life, and ratings of the associated dimensions. Study 2 (N = 400) assessed participants' ratings of the importance of outcomes and dimensions across various health decisions and behaviours. Both studies revealed that people considered dimensions beyond health risk and benefit. The dimensions varied their priorities, with health and emotional outcomes being the top considerations. Participants also showed asymmetric considerations of benefit and risk within each dimension. The latent profile analyses in Study 2 also revealed two distinct groups of individuals in risk and benefit considerations across dimensions. The findings highlight that acknowledging individual differences in the weighting and evaluation of outcomes across domains is essential for more tailored health communication and interventions.
Intrinsic capacity (IC) is central to the World Health Organization's life course approach to healthy ageing. Population-level data across the lifespan remain limited. This study aimed to assess the prevalence of IC deficits and to identify sociodemographic, clinical, and lifestyle factors associated with these deficits in a nationally representative community cohort in Singapore. Cross-sectional survey of adults aged ≥21 years in the Queenstown Study. IC was assessed using a modified WHO ICOPE Step 1 screening approach. Sociodemographic and health data were collected. Among 4274 participants, 29.2 % had ≥1 IC deficit; prevalence rose stepwise with age from 10.3 % (20-39 years) to 19.1 % (40-59), 45.0 % (60-79) and 74.5 % (≥80 years). Locomotion (16.8 %) and sensory (11.4 %) deficits were most common. In multivariable analysis, IC deficits were associated with older age (OR 1.05 per year, 95 % CI 1.04-1.06, p < 0.001), female sex (OR 1.19, 95 % CI 1.01-1.40, p = 0.037), underweight (OR 1.61, 95 % CI 1.18-2.20, p = 0.003), and obesity (OR 1.36, 95 % CI 1.07-1.71, p = 0.011), frailty (OR 10.94, 95 % CI 3.57-48.14, p < 0.001), impaired instrumental ADLs (OR 3.93, 95 % CI 2.11-7.84, p < 0.001), low handgrip strength (OR 1.68, 95 % CI 1.43-1.97, p < 0.001), diabetes (OR 1.45, 95 % CI 1.12-1.87, p = 0.004), and social isolation (OR 1.23, 95 % CI 1.04-1.45, p = 0.014). Higher quality of life was protective (OR 0.84, 95 % CI 0.80-0.89, p < 0.001). IC deficits were prevalent even in midlife and linked to modifiable factors. These findings support the need for early, multidomain interventions to preserve function and promote healthy ageing across adulthood.
Positive psychological functions are associated with various health and life outcomes. This study examined the construct of psychological well-being in the multi-ethnic Singaporean population and evaluated the Comprehensive Inventory of Thriving (CIT) scale that captures 18 aspects of psychological well-being. A two-wave survey study was carried out with 1349 community-dwelling Singaporean adults, of whom 562 completed the second wave. We compared factor structures that have been reported in other populations. The factor model was further tested for replicability in a subsequent household survey sample (N = 1756). A new higher-order factor model emerged in the Singaporean sample consisting of three dimensions: interpersonal well-being, individual well-being, and resistance to threats. The new structure demonstrated gender and age measurement invariance. CIT and the three dimensions had expected associations with mental health symptoms, work/study stress, and participants’ actual social support. The new higher-order factor model was replicated in the subsequent household survey sample. Finally, both CIT and its short form, the Brief Inventory of Thriving (BIT), showed convergent validity, reliability and test-retest reliability in the Singaporean population. CIT demonstrated some evidence of construct validity and reliability in the current large samples of Singaporean community-dwelling adults. BIT can be an efficient tool to assess and monitor population general well-being. The online version contains supplementary material available at 10.1186/s12955-026-02484-1.
The prevalence of food allergy is growing among children in the UK. There is increasing evidence suggesting a link between epicutaneous exposure to food proteins and subsequent sensitisation, particularly in those with atopic dermatitis. Skincare products including creams and emollients, widely-used in paediatric populations, may inadvertently contribute to allergen exposure when containing food-derived ingredients. This study investigates the prevalence of food protein allergens in paediatric leave-on skincare products available in the UK. A cross-sectional review was conducted on 130 skincare products marketed for children across three major online retailers: Amazon, Boots, and Lloyds Pharmacy. Ingredient lists were screened for the presence of food allergens, including the 4 major food allergens as defined by UK legislation. Allergenic components were classified by type (e.g. oils, extracts), and descriptive statistical analysis was performed. Of the 130 products assessed, 68 (52.3%) contained at least one food-derived allergen. A total of 102 allergenic ingredients were identified, with almond oil (Prunus Amygdalus Dulcis) and oat flour (Avena Sativa) being the most common. Oil-based allergens accounted for the majority (49%) of identified ingredients. Notably, products sold through Amazon had a higher prevalence of allergens compared to those sold by Lloyds Pharmacy. A significant proportion of paediatric skincare products in the UK contain food allergens, posing potential risks of epicutaneous sensitisation in children, particularly those with compromised skin barriers such as atopic dermatitis. These findings underscore the need for stricter ingredient scrutiny when recommending skincare products to reduce allergen exposure during early life.
The Brain Care Score (BCS) is a recently developed tool that measures modifiable risk factors for brain health. This study evaluated the association between BCS and cognitive performance in a community-based cohort from Singapore. Data were drawn from the Health District @ Queenstown baseline study, a representative multiethnic community cohort. The BCS (range 0-21; higher scores = healthier profiles) was derived from baseline questionnaires across physical, lifestyle, and socioemotional domains. Cognitive recall was assessed with the five-item word recall test, and executive function with the Eriksen flanker task. A total of 5224 participants (mean age 52.8 ± 17.5 years; 53.1% women) were surveyed between September 2023 and May 2024. Participants with impairment had lower mean BCS than those without (14.9 ± 3.1 vs. 16.2 ± 2.8; p < 0.001). Each one-point BCS increase was linked to 5% lower odds of impaired recall (odds ratios [OR] 0.95; 95% confidence intervals [CI] 0.92-0.98; p = 0.002), whereas per five-point higher BCS corresponded to 23% lower odds (OR 0.77; 95% CI 0.66-0.91; p = 0.002). Each one-point BCS increase was also associated with a 0.03-point higher executive function score (β 0.03; 95% CI 0.01-0.05; p = 0.02), with per five-point higher BCS yielding a 0.15-point higher score (β 0.15; 95% CI 0.03-0.27; p = 0.02). Associations were stronger among younger, Chinese, and higher income participants. Higher BCS was associated with better cognitive performance. These findings support its use as a potential community-based tool for brain health risk assessment in Asian populations.
Obtaining consent in antibiotic trials targeting patients with severe infections can be challenging due to time sensitivity and the frequent lack of decision-making capacity among these patients. This study reviews (1) the current common informed consent procedures and (2) recruitment loss due to consent failures in randomized controlled trials (RCTs) that involve critically ill patients with severe infections. We conducted a scoping review of RCTs published between 2010 and 2023. Antibiotic RCTs involving patients with severe infections were identified in databases including PubMed, Embase, CINAHL, PsycINFO, Cochrane Central, Web of Science, and Scopus. Title and abstract screening and full-text review were performed by 2 independent reviewers. Information relating to consent procedures and enrolled participants was extracted and summarized in a tabulated format. A total of 926 records were identified, and 112 eligible RCTs were included. Of these, 107 RCTs stated that consent was required, and the majority reported obtaining consent before study procedures (74.8%), requiring written consent (82%), and allowing for surrogate consent (85%). Substantial underreporting of consent rate information was observed, with only 58% of the RCTs reporting details of consent failure before randomization. Substantial heterogeneity in consent failure rates among these studies was also observed, with the rate being up to 66% and a median of 13%. There is substantial heterogeneity in consent failure rates across antibiotic RCTs involving critically ill patients. Understanding and addressing barriers in recruitment and consent in those trials requires more standardized reporting of consent rate information.
Quality mental health services are pivotal in addressing mental health issues worldwide. Despite this importance, many countries face challenges in providing accessible, high-quality mental health care. This study examines the nexus between mental health services and worry about mental health issues across different countries. This study used data from the Lloyd's Register Foundation 2021 World Risk Poll, the OECD, the World Health Organization, and Our World in Data. The variables include worry about the personal harm that mental health issues could cause, mental health services (i.e. service facilities, service availability, and service utilisation), and estimated prevalences of major mental disorders. The results revealed that structural components - specifically the availability of mental health outpatient facilities - were associated with less worry about mental health issues across countries. However, no significant association was observed between process components - such as service utilisation - and worry about mental health issues. Additionally, the association between the prevalence of various mental disorders and worry about mental health issues showed mixed results. The findings emphasise the importance of increasing the availability of these facilities to ensure universal access to essential mental health care, thereby improving mental well-being across both low-income and high-income countries.
The social norms that guide emotional expression are critical for successful interpersonal interaction. However, the intricate emotional architecture underpinning these norms has remained largely unexplored. Our study is the first to rigorously investigate "display rules" or expressive norms for a comprehensive set of 64 theory-based emotions, utilizing a representative sample from the United Kingdom. The sample reflected national census demographics based on age, sex, and ethnicity. We measured expressive norms ranging from suppression to amplification in four social situations, combining two settings (public vs. private) and interactant types (close relations vs. distant others). Using a theory-building subsample (n = 507), we employed ant colony optimization (AOC) algorithms and a suite of factor analytical techniques to distill the emotions into three domains: affiliative, vulnerable, and disruptive. Subsequent validation in a separate confirmatory subsample (n = 506) supported this structure in all four situations (conditions), providing evidence these domains were robust. Notably, this new Expression Regulation Scale (ERS) demonstrated scalar invariance across all situations using repeated measures confirmatory factor analysis. We introduce scoring metrics and norms to aid researchers and practitioners in their analytical endeavors and highlight potential avenues for future research aimed at enriching our understanding of expression regulation.
Asia faces significant barriers to accessing newer antibiotics despite a high burden of antimicrobial resistance. We conducted a literature review to identify key gaps and challenges in access to newer antibiotics in Asian countries. Peer-reviewed and gray literature from January 2010 to October 2024 were searched for articles discussing access to Food and Drug Administration (FDA)-approved antibiotics post-2010 with an Asian perspective. A total of 134 articles were reviewed. Key challenges spanned 7 main stakeholders: pharmaceutical industries, drug regulatory agencies, health technology assessment agencies, funders/nongovernmental organizations, healthcare practitioners, patient advocates, and ministries of health/policymakers. These challenges included limited and fragmented epidemiological data, insufficient health economic assessments, manufacturing constraints, complex regulatory frameworks, inefficient distribution systems, poor affordability in low-resource settings, and weak governance structures. These findings underscore the urgent need for a deeper understanding of stakeholder- and context-specific perspectives to address critical gaps and improve antibiotic access in the region.
We aimed to develop and test a scale that assesses knowledge of medical and health research for the Singaporean general adult population and examine the implications of 'don't know' (DK) responses from participants in the knowledge assessment. Two studies were conducted among Singaporean community adults. Items in the scale were selected via exploratory factor analysis in a pilot study (N = 223) and evaluated via confirmatory factor analysis and item response modelling in a larger population survey study (N = 999). We also explored characteristics of DK responses. A two-factor structure emerged and reflected two pathways of knowledge formation, including acknowledgement of facts and resistance of myths in medical and health research. The scale showed satisfactory structure validity, reliability, item-level properties, and criterion validity. The two subscales (Facts and Myths) also achieved measurement invariance across genders. Treating DK responses as missing reduced the psychometric quality. DK response tendency in both Facts and Myths subscales was primarily and significantly associated with lower trust in research, suggesting that DK and incorrect answer might not be results of the same response process. DK responses were non-ignorable in the scoring in assessing knowledge of medical research and carried implications separate from incorrect answers. Individuals answering DK may entail both those who truly lack knowledge and those who do not wish to disclose their views. Patient and community engagement strategies for improving the public knowledge of medical and health research should not only consider communicating facts but also strategies to correct misinformation. Assessing knowledge in health should consider the implications of patients' DK responses.
Peripheral intravenous catheter (PIVC) insertion is a critical component of patient care in out-of-hospital settings, with its use becoming routine for a wide array of therapies. However, repeated failed attempts at catheter insertion are both a source of patient distress and a contributing factor to suboptimal clinical and economic outcomes. This study examined the challenges associated with PIVC placement in out-of-hospital settings, specifically within the Lloyds Clinical service, where a diverse group of patients receives intravenous therapies, including oncology medications, antibiotics, and treatments for rare disorders. The study retrospectively analysed 16 241 nursing visits, identifying cases of failed initial PIVC insertion and exploring the causes behind these instances. Findings suggest that patient-related anatomical and physiological factors, such as vein visibility and previous medical interventions, account for the majority of failed insertions. A review of current literature highlighted the importance of addressing variability in nursing practices, enhancing educational frameworks, and adopting evidence-based guidelines to optimise PIVC insertion and management. Strategies such as patient education, localised warming techniques, and targeted nurse retraining were identified as potential ways to improve outcomes. The implementation of these strategies aims to enhance the overall patient experience and ensure optimal venous access success rates in out-of-hospital settings.
Many conditions, including neurodegenerative diseases and psychiatric disorders, can impair financial decision-making in older age. Although banking data offer rich insights, they have not yet been leveraged to understand how the loss of financial capacity is associated with financial behaviors. To describe the behavioral indicators of financial capacity loss and the association of financial capacity loss with financial vulnerability. In this case-control study, banking data recorded by a major UK bank between January 1, 2009, and April 21, 2023, were used to compare the financial outcomes of a group of 16 742 donors of power of attorney (PoA) registrations with a "loss of financial capacity" marker and a control group of 50 226 individuals with no reported financial capacity loss that matched the demographic and socioeconomic characteristics of the donor group 10 years prior to their PoA registration. Group differences in financial outcomes were examined in the 10-year period leading up to the PoA registration. Analysis took place between December 2023 and December 2024. Bank registrations of PoAs recorded between 2019 and 2023 for which the attorney reported that the donor lost financial capacity. A broad range of 344 financial measures capturing day-to-day transactional activity (eg, spending on travel and hobbies) and other financial behaviors (eg, online banking logins). The group of donors of PoA registrations with a "loss of financial capacity" marker comprised 16 742 individuals (mean [SD] age, 72.8 [8.5] years; 10 285 women [61.4%]), and the control group comprised 50 226 individuals (mean [SD] age, 72.7 [8.2] years; 30 657 women [61.0%]). During the 5 years prior to PoA registration, compared with the control group, donors were increasingly less likely to spend on everyday activities (clothing [difference, -9.1 percentage points (pp); 95% CI, -10.0 to -8.3 pp], travel [eg, hotels; difference, -9.6 pp; 95% CI, -10.5 to -8.8 pp], hobbies [eg, gardening; difference, -7.9 pp; 95% CI, -8.8 to -7.1 pp]) and more likely to spend on items associated with increased time at home (eg, household gas and electricity bills [difference, 5.1 pp; 95% CI, 4.6-5.7 pp]). Signs of heightened financial vulnerability in the donor group compared with the control group included an increase in the frequencies of PIN (personal identification number) reset requests (difference, 0.002 [95% CI, 0.002-0.003]), fraud cases (eg, animal charity difference, 0.0003 [95% CI, 0.0002-0.0003]), and lost or stolen credit or debit cards reported (difference, 0.005 [95% CI, 0.004-0.006]) and increased spending on charity (difference, 1.1 pp [95% CI, 0.5-1.7 pp]). In addition, the donor group exhibited reduced attention to finances compared with the control group via decreased online banking activity (difference in number of monthly online banking logins, -1.0 [95% CI, -1.1 to -0.8]). This study highlighted the financial behaviors and vulnerabilities associated with declining financial capacity, such as a decrease in activity across multiple domains of daily life. These findings illustrate how banking data can reveal early behavioral signs and financial harms associated with financial capacity loss.
Multiple treatment options frequently exist for a single medical condition with no single standard of care (SoC), rendering a classic randomised trial comparing a specific treatment to a control treatment infeasible. A novel design, the personalised randomised controlled trial (PRACTical), allows individualised randomisation lists and borrows information across patient subpopulations to rank treatments against each other without comparison to a SoC. We evaluated standard frequentist analysis with Bayesian analyses, and developed a novel performance measure, utilising the precision in treatment coefficient estimates, for treatment ranking. We simulated trial data to compare four targeted antibiotic treatments for multidrug resistant bloodstream infections as an example. Four patient subgroups were simulated based on different combinations of patient and bacteria characteristics, which required four different randomisation lists with some overlapping treatments. The primary outcome was binary, using 60-day mortality. Treatment effects were derived using frequentist and Bayesian analytical approaches, with logistic multivariable regression. The performance measures were: probability of predicting the true best treatment, and novel proxy variables for power (probability of interval separation) and type I error (probability of incorrect interval separation). Several scenarios with varying treatment effects and sample sizes were compared. The Frequentist model and Bayesian model using a strong informative prior, were both likely to predict the true best treatment ( P best ≥ 80 % ) and gave a large probability of interval separation (reaching a maximum of P IS = 96 % ), at a given sample size. Both methods had a low probability of incorrect interval separation ( P IIS < 0.05 ), for all sample sizes ( N = 500 - 5000 ) in the null scenarios considered. The sample size required for probability of interval separation to reach 80% ( N = 1500 - 3000 ), was larger than the sample size required for the probability of predicting the true best treatment to reach 80% ( N ≤ 500 ). Utilising uncertainty intervals on the treatment coefficient estimates are highly conservative, limiting applicability to large pragmatic trials. Bayesian analysis performed similarly to the frequentist approach in terms of predicting the true best treatment.
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Financial regulation requires the submission of diverse and often highly granular data from financial institutions to regulators. In turn, regulators face the challenge of condensing this data into a comprehensive map that captures the mutual similarity or distance between different institutions and identifies clusters or outliers based on features like size, credit portfolio, or business model. Additionally, missing data due to varying regulatory requirements for different types of institutions, can further complicate this task. To address these challenges, we interpret the credit data of financial institutions as probability distributions whose respective distances can be assessed through optimal transport theory. Specifically, we propose a variant of Lloyd's algorithm that applies to probability distributions and uses generalized Wasserstein barycenters to construct a metric space. Our approach provides a solution for the mapping of the banking landscape, enabling regulators to identify clusters of financial institutions and assess their relative similarity or distance. The online version contains supplementary material available at 10.1007/s11579-025-00394-2.
Despite being established public health practice for >80 y, community water fluoridation continues to attract assertions of harm, and continued scrutiny of the evidence is required to inform policy. A rapid systematic literature review was conducted to examine human nondental health outcomes from fluoride exposure through drinking water. A protocol was developed a priori and registered on the Open Science Framework. Literature searches were conducted in Medline, CINAHL, Web of Science, Embase, PubMed, Campbell Collaboration, Cochrane Library, and Scopus databases. Gray literature and citation searches were also undertaken. Quality assessment was performed using the Mixed Methods Appraisal Tool (MMAT). Meta-analysis was judged not feasible due to the heterogeneous nature of the included studies. A total of 1143 unique records were identified, of which 130 full-text studies were reviewed and 58 were selected for final inclusion. Among these, 37 were cross-sectional studies, 15 were cohort studies, 4 were case-control studies, and 2 were ecological studies. Most studies were judged to be of acceptable quality using MMAT. The most common risk of bias was insufficient control of confounders. Health outcomes studied included blood pressure, neurological outcomes, bone cancers, thyroid function, skeletal outcomes, low birth weight/preterm birth, and metabolic outcomes. In children, some evidence of adverse effects on neurological outcomes and thyroid function was observed. In adults, some evidence was identified of adverse effects on blood pressure, thyroid function, and skeletal structure. In general, these effects occurred at drinking water fluoride concentrations >1.5 mg/L. No evidence of adverse effects was found at concentrations <1.0 mg/L in both children and adults. The nature of study designs and methodological limitations precluded causal inference. No convincing evidence of harm was identified from community water fluoridation at concentrations between 0.7 and 1.0 mg/L, whereas uncertainty remains at higher concentrations. Significant methodological limitations highlight the need for more rigorous future studies. A protocol was developed a priori and registered on the Open Science Framework (Registration DOI: https://doi.org/10.17605/OSF.IO/JH245).
Singapore occupies a curious societal grey-area: a digitally savvy country with a colonial-remnant law against homosexuality (penal code 377A), widely acknowledged as non-proactively enforced, existing to placate a conservative society; hotly contested for years and finally repealed in Parliament in 2022. Within a national context of state-upheld heteronormativity, yet with homosexuality not entirely condemned, Singapore occupies a liminal space where subtle resistance is carefully negotiated, especially in online spaces. This study investigated LGBT-adjacent discussions across social media over a decade (2011-2021) for salient topics, sentiment distribution, emotional intensity frames and nuanced topics. Historical Twitter data containing LGBT keywords (N = 15,659) were collected and analyzed using bi-term topic modelling, sentiment score modelling, and emotional intensity modelling. Qualitative thematic analysis was conducted on highest-scoring emotion tiers. Sentiment was distributed over a range: Very Positive (6%), Positive (33%), Neutral (11%), Negative (42%), Very Negative (7%). Predominant emotions were Joy (39%), Anger (32%), Sadness (11%), Fear (11%). Of themes from highest-scoring emotional-intensity tweets, Anger included: 'gay' used derogatorily; heated debates over ideological-often religious-differences; dissent within the community, condemning exclusionary views. Fear and Sadness included distress over violence (mass shootings, harassment, bullying); lack of acceptance (criminalization, protests over local pride event 'Pinkdot'; lack of familial support). Joy stemmed from the celebration of pride month. Our findings highlight nuanced emotional intensities, profiles undertones of LGBT dissent and support, fractured along a schism of differing views and contrasting opinions-a societal microcosm of a divisive topic. Practically, this presents a decade-long barometer of dominant trigger points that may help facilitate conversations on the affective concerns of the local population.