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Traditional bullying typically occurs in schools and has been associated with a myriad of mental health problems. Recent evidence has indicated that cyberbullying may just be traditional bullying that is extended to the online world, but this possibility has received only limited study in Asian countries. This study explored the co-occurrence of traditional and cybervictimization and its association with mental health among 3319 adolescents aged 12 to 17 years in Singapore. Victims of bullying were categorized into mutually exclusive groups: traditional-only victims, cyber-only victims, or combined traditional and cybervictims. Results indicated that there were substantial overlaps between victimization in traditional bullying and cyberbullying and that traditional victimization was more prevalent than cybervictimization. Being a victim of either form of bullying (i.e., traditional-only or cyber-only victims) was associated with higher reports of internalizing and externalizing problems, and combined traditional and cybervictims reported the most internalizing problems. However, there were no significant differences in problem scores between traditional-only victims and cyber-only victims. The findings highlight the need to consider the extensive overlap between traditional and cybervictimization when investigating their differential association with adolescents' mental health. Prevention and intervention efforts by school staff and mental health practitioners need to target both traditional bullying and cyberbullying in an integrated manner, and extra attention should be provided to adolescents who are victims of both forms of bullying.

This article describes a lesson study on the area of a parallelogram for year 7 students. In Singapore, students in secondary schools are streamed into ability bands. Normal (Academic) is the label for the middle band. The teachers were convinced that Lesson Study provided a valuable platform for professional development. The authors followed the key steps of the Lesson Study process as delineated by a number of writers. These steps include: (1) identifying the problem and setting goals; (2) designing the lesson of focus; (3) teaching, observing, and refining; and (4) sharing of results. As a Lesson Study team, the authors focused on the topic of Mensuration and subsequently zoomed-in further to the lesson on "area of parallelogram" as the Lesson of focus. They discuss their experiences in teaching the topic "Area of Parallelogram", especially the difficulties they faced in helping their students understand how to derive the formula "base x height". In the Singapore context, "height" is taken to mean "perpendicular height". The aim of this paper is to share the learning experiences of the team as they underwent the Lesson Study process. (Contains 6 figures.)

Resource partitioning may facilitate the coexistence of sympatric species with similar ecological requirements. Here, we study a colony of unusual echolocating birds called swiftlets, which nest underground on an island off the coast of Singapore. The colony comprises two congeneric swiftlet species, black‐nest swiftlets (Aerodramus maximus) and edible‐nest swiftlets (A. fuciphagus), nesting at high densities and in close proximity. Bioacoustic recordings and monitoring of nesting biology at the site across multiple seasons revealed significant differences in echolocation calls as well as survival rates between the species, with the larger black‐nest swiftlet nesting at locations with the highest fledging rates. We also observe an additional off‐season breeding peak by the smaller species, the edible‐nest swiftlet. Unexpectedly, off‐season egg‐hatching rates were significantly higher compared with the rates during the shared breeding season (mean difference = 14%). Our study on the breeding biology of these echolocating cave‐dwelling birds provides an example of spatial and temporal strategies that animals employ to partition resources within a confined habitat. [ABSTRACT FROM AUTHOR]

Background: Prescription medication labels (PMLs) are central in guiding patients to use their medications appropriately. For PMLs to achieve this purpose, their content must enable medication use as desired and be presented in a clear and legible manner. Aim: This study assesses the extent to which the format and content of PMLs used in Singapore meet national and/or international recommendations, and if the extent varies across public and private healthcare institutions. Method: The format and content variables of 113 PMLs were compared against published recommendations. Variability in the extent to which the format and content of PMLs met the recommendations across public and private institutions was assessed through the Chi‐square test or Fisher's exact test. Results: Less than 50% of the PMLs conformed with the format recommendations of printing instructions in sentence case (35.4%), and the content recommendations for providing drug–food administration instructions (45.3%), using specific dosing intervals for dosing instructions (21.2%), providing an expiry date (17.7%), and generating bilingual labels (5.3%). A higher proportion of private institution PMLs followed the format recommendations of printing instructions in sentence case (p = 0.004) and numeric characters for quantitative values (p = 0.003), and the content recommendations for providing drug indication (p < 0.001). In contrast, a higher proportion of public institution PMLs followed the content recommendations of using specific dosing intervals (p = 0.001), providing side effects/precautions (p = 0.003), and providing drug‐food administration instructions (p = 0.021). Conclusion: There is definite scope for improving the format and content of PMLs in Singapore. Future studies could explore the possible logistical, financial, and administrative reasons that contribute to PML variability across healthcare institutions. [ABSTRACT FROM AUTHOR]

• Influential factors of depressive symptoms were investigated among a representative sample of 976 middle-aged and older adults in Singapore. • Our predictors included demographics, socioeconomics, physical well-being, lifestyle, daily activities and loneliness. • Machine learning models were used to identify impact factors of depressive symptoms. • Along with loneliness and physical health indicators, the amount of time for daily activities also played an important role in contributing to depression risk. This paper aims to investigate the key factors, including demographics, socioeconomics, physical well-being, lifestyle, daily activities and loneliness that can impact depressive symptoms in the middle-aged and elderly population using machine learning techniques. By identifying the most important predictors of depressive symptoms through the analysis, the findings can have important implications for early depression detection and intervention. For our cross-sectional study, we recruited a total of 976 volunteers, with a specific focus on individuals aged 50 and above. Each participant was requested to provide their demographic, socioeconomic information and undergo several physical health tests. Additionally, they were asked to respond to questionnaires that assessed their mental well-being. Furthermore, participants were requested to maintain an activity log for a continuous 14-day period, starting from the day after they signed up. They had the option to use either a provided mobile application or paper to record their activities. We evaluated multiple machine learning models to find the best-performing one. Subsequently, we conducted post-hoc analysis to extract the variable significance from the selected model to gain deeper insights into the factors influencing depression. Logistic Regression was chosen as it exhibited superior performance across other models, with AUC of 0.807 ± 0.038, accuracy of 0.798 ± 0.048, specificity of 0.795 ± 0.061, sensitivity of 0.819 ± 0.097, NPV of 0.972 ± 0.013 and PPV of 0.359 ± 0.064. The top influential predictors identified in the model included loneliness, health indicator (i.e. frailty, eyesight, functional mobility), time spent on activities (i.e. staying home, doing exercises and visiting friends) and perceived income adequacy. These findings have the potential to identify individuals at risk of depression and prioritize interventions based on the influential factors. The amount of time dedicated to daily activities emerges as a significant indicator of depression risk among middle-aged and elderly individuals, along with loneliness, physical health indicators and perceived income adequacy. [ABSTRACT FROM AUTHOR]

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Bullying through online medium has afflicted many adolescents to cause severe mental health concerns, including self-harm and suicide. The aims of this study are to examine the prevalence of cyberbullying in Singapore adolescents, its associations with psychosocial difficulties, and how do the adolescents seek help after being cybervictimized. A representative sample of 3,319 school students aged between 12 and 17 years responded to a survey with scales measuring cyberbullying, psychosocial difficulties, and help-seeking behaviors. In the present study, 7.3 percent of adolescents reported being cybervictims only, 1.8 percent were cyberbullies only, and 4.8 percent were cyberbully-victims. Compared with the non-involved group, both cybervictim and cyberbully-victim groups were associated with more internalizing problems, but all the three cyberbullying-involved groups were associated with higher externalizing problems. Approximately half of the cybervictimized participants reported that they have sought help, with most of them (81.7 percent) choosing to tell their friends. Our findings are consistent with previous overseas studies showing increased associations of psychosocial difficulties among adolescents who are involved in cyberbullying. Public awareness of the consequences of unhealthy cyber-usage could be raised to aid in the early detection of cyberbullying among school children and adolescents. Moreover, cyberwellness programs should be considered as a component of larger anti-bullying programs in schools and in the community. [ABSTRACT FROM AUTHOR]

This article estimates hedonic prices for different levels of housing space, by exploiting a unique space‐adding project in Singapore that added a uniform amount of space to each existing housing unit regardless of the original size. This space adding program was carried out if sufficient residents vote in favor of space adding. Using a difference‐in‐differences (DiD) strategy after restricting our sample to narrow margins around the voting cutoff, we find that the additional space increased the resale price of a housing unit by 7% on average, and the extent of price appreciation varied significantly across the original size of the units. [ABSTRACT FROM AUTHOR]

Background: Studies on gender differences in attention-deficit/hyperactivity disorder (ADHD) comorbidities in the Asian populations have been limited and previous studies have shown inconclusive findings. Singapore is a city-state country in Southeast Asia with a population of 5.7 million. This study examined gender differences in internalizing and externalizing problems in Singaporean children and adolescents with ADHD. The plausible social factors underlying the gender differences were discussed. Methods: A total of 773 participants (aged 6 to 18, 88% males) newly diagnosed with ADHD were recruited from the largest public child and adolescent psychiatric center in Singapore. Their internalizing and externalizing problems were assessed using the Child Behavioral Checklist and Teacher's Report Form by parents and teachers respectively. Demographics and relevant social factors were collected using parent questionnaires. Results: Females with ADHD were reported to have less delinquent and aggressive behavior but more depressive symptoms than their male counterparts, similar to findings in the Western literature. Gender remained a significant predictor of externalizing problem after controlling for other factors. Lower socioeconomic status and parental use of physical punishment were significant predictors of both internalizing and externalizing problems. Conclusions: Gender differences in ADHD comorbidities do exist in the Asian clinical population. The lack of externalizing symptoms in females with ADHD has made timely referral and diagnosis challenging. More research is needed in understanding the gender differences in ADHD and the biopsychosocial mechanism underlying the differences in order to improve the detection of ADHD in females. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID‐19) is an emerging infectious disease of pandemic proportions. Healthcare workers in Singapore working in high‐risk areas were mandated to wear personal protective equipment (PPE) such as N95 face mask and protective eyewear while attending to patients. Objectives: We sought to determine the risk factors associated with the development of de novo PPE‐associated headaches as well as the perceived impact of these headaches on their personal health and work performance. The impact of COVID‐19 on pre‐existing headache disorders was also investigated. Methods: This is a cross‐sectional study among healthcare workers at our tertiary institution who were working in high‐risk hospital areas during COVID‐19. All respondents completed a self‐administered questionnaire. Results: A total of 158 healthcare workers participated in the study. Majority [126/158 (77.8%)] were aged 21‐35 years. Participants included nurses [102/158 (64.6%)], doctors [51/158 (32.3%)], and paramedical staff [5/158 (3.2%)]. Pre‐existing primary headache diagnosis was present in about a third [46/158 (29.1%)] of respondents. Those based at the emergency department had higher average daily duration of combined PPE exposure compared to those working in isolation wards [7.0 (SD 2.2) vs 5.2 (SD 2.4) hours, P <.0001] or medical ICU [7.0 (SD 2.2) vs 2.2 (SD 0.41) hours, P <.0001]. Out of 158 respondents, 128 (81.0%) respondents developed de novo PPE‐associated headaches. A pre‐existing primary headache diagnosis (OR = 4.20, 95% CI 1.48‐15.40; P =.030) and combined PPE usage for >4 hours per day (OR 3.91, 95% CI 1.35‐11.31; P =.012) were independently associated with de novo PPE‐associated headaches. Since COVID‐19 outbreak, 42/46 (91.3%) of respondents with pre‐existing headache diagnosis either "agreed" or "strongly agreed" that the increased PPE usage had affected the control of their background headaches, which affected their level of work performance. Conclusion: Most healthcare workers develop de novo PPE‐associated headaches or exacerbation of their pre‐existing headache disorders. [ABSTRACT FROM AUTHOR]

Background: Rehospitalizations are common in healthcare. They are costly for hospitals and patients and a substantial percentage are preventable, partly because hospital-to-community transitions are often unmanaged or poorly managed. In this study, we conducted a pragmatic randomized, controlled trial to evaluate the effectiveness of a new nurse–practitioner-led transitional care program called CareHub, piloted in Singapore's National University Hospital. Methods: Study population included all eligible cardiac patients admitted between July 2016 and November 2016. Patients were followed for six months post-discharge. Primary outcomes other than emergency department visits were all cardiac-related: number of readmissions, specialist visits, emergency department visits, and total days readmitted. Secondary outcomes: variables related to quality of life and transitional care. Regression analyses were used to estimate the intent-to-treat effect of CareHub and explore treatment heterogeneity. Results: CareHub reduced the mean number of unplanned readmissions by 0.23 (a 39% reduction relative to control mean of 0.60 unplanned readmissions, p < 0.05), mean number of all readmissions by 0.20 (31% reduction relative to control mean of 0.63 readmissions, p = 0.10), mean number of total unplanned days in hospital by 2.2 (56% reduction relative to control mean of 4.0 days, p < 0.05), mean number of total days in hospital by 2.0 (42% reduction relative to control mean of 4.3 days, p < 0.10). Treatment effects varied by pre-admission health and socio-economic status. Conclusion: A carefully designed protocolized cardiac hospital-to-home transition program can reduce resource utilization while improving quality of life. [ABSTRACT FROM AUTHOR]

Objectives. To evaluate the effectiveness of point-of-care informational interventions in general practitioner clinics to improve influenza and pneumococcal vaccination uptake among elderly patients. Methods. We conducted a pragmatic, cluster-randomized crossover trial in 22 private general practitioner clinics in Singapore, from November 2017 to July 2018. We included all patients aged 65 years or older. Clinics were assigned to a 3-month intervention (flyers and posters encouraging vaccination) plus 1-month washout period, and a 4-month control period (usual care). Primary outcomes were differences in vaccination uptake rates between periods. Secondary outcomes were identification of other factors associated with vaccination uptake. Results. A total of 4378 and 4459 patients were included in the intervention and control periods, respectively. Both influenza (5.9% vs 4.8%; P =.047) and pneumococcal (5.7% vs 3.7%; P =.001) vaccination uptake rates were higher during the intervention period compared with the control period. On multilevel logistic regression analysis, follow-up for hypertension, diabetes mellitus, hyperlipidemia, or any combination of the 3 was associated with uptake of both vaccines. Conclusions. Point-of-care informational interventions likely contributed to increased influenza and pneumococcal vaccination uptake. Patients on follow-up for hypertension, diabetes mellitus, hyperlipidemia, or any combination of the 3 were more likely to receive influenza and pneumococcal vaccination and should be actively engaged by physicians. Trial Registration. ClinicalTrials.gov Identifier: NCT03445117. [ABSTRACT FROM AUTHOR]

Background: The ILD-GAP model was developed and validated in a Western cohort to predict 1-, 2- and 3-year mortality in chronic interstitial lung disease (ILD). Objectives: We aimed to validate the ILD-GAP model and identify predictors of mortality to derive a nomogram to predict mortality in our local Asian population. Methods: Characteristics of patients on follow-up in a tertiary ILD referral center were retrospectively reviewed. Results: There were 181 patients and 48 mortalities. 29.8% had idiopathic pulmonary fibrosis, 2.8% unclassifiable ILD, 33.1% connective tissue disease-associated interstitial lung disease (CTD-ILD), 28.7% idiopathic nonspecific interstitial pneumonia and 5.5% chronic hypersensitivity pneumonitis. Univariable analysis showed that a higher ILD-GAP index, unclassified ILD, males, older age, higher pulmonary artery systolic pressure, lower forced vital capacity percent predicted and carbon monoxide diffusion capacity (DLCO) correlated with increased mortality, and CTD had lower mortality. Multivariable analysis utilizing Akaike's information criterion stopping rule showed males and a lower DLCO predicted increased mortality, while CTD predicted lower mortality. These were used to generate a nomogram which predicted overall mortality better (C index 0.817, adequacy index 99.5%) than ILD-GAP (C index 0.777, adequacy index 60.7%) and provided superior estimates based on likelihood ratio testing. Calibration plots showed the nomogram predicted 1-year mortality better, whilst the ILD-GAP model predicted 2- and 3-year mortality closer to actual mortality rates but underpredicted 1-year mortality. Conclusion: The nomogram performed better than ILD-GAP in predicting overall mortality and 1-year mortality. Both demonstrated good performance in predicting mortality risk. [ABSTRACT FROM AUTHOR]

Background: We aimed to examine the discriminant validity of a brief self-administered cognitive screening test, the Test Your Memory (TYM) and a brief neuropsychological test, the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS), supplemented with executive and language tests (Color Trail Test [CTT] and modified Boston Naming Test [mBNT], respectively), in detecting cognitive impairment (CI) in a one-stop memory clinic in Singapore.Methods: Ninety patients ≥50 years old with a diagnosis of no cognitive impairment, mild cognitive impairment, and mild Alzheimer disease were recruited from memory clinic. They received the TYM, Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), RBANS, CTT, mBNT, and a gold-standard formal neuropsychological test battery.Results: The TYM had a significantly larger area under the curve (AUC) than MMSE (0.96 vs 0.88, P = .03) and was equivalent to MoCA in detecting CI (0.96 vs 0.95, P = .80). At the optimal cutoff points, the TYM (<38) was significantly more sensitive than the MMSE (<24) and MoCA (<20; P < .001). The RBANS had an AUC equivalent to the RBANS supplemented with CTT and mBNT (0.92 vs 0.86, P = .22) in detecting CI. The RBANS supplemented with CTT and mBNT was more sensitive than RBANS alone in detecting CI (sensitivity: 0.98 vs 0.93, P = .016) among patients screened negative using TYM.Conclusion: The self-administered TYM is superior to MMSE and equivalent to MoCA in detecting CI and could be implemented routinely. The RBANS supplemented with CTT and mBNT is more sensitive in detecting CI than RBANS alone therefore could be used for diagnostic purposes. [ABSTRACT FROM AUTHOR]

The potential for marine litter being trapped in biodiverse marine habitats such as mangrove forests, seagrass meadows and coral reefs is poorly understood. This study presents the first comprehensive investigation on the status of macro-litter across four marine habitats in Singapore during the two monsoonal seasons. Overall, litter density did not vary considerably between the southwest and the northeast monsoon. The litter density in terms of count was generally lower in seagrass meadows and coral reefs compared to mangroves and beaches. Plastic was the major type of litter found across most habitat types. Notably, many fishing-related items were found on coral reefs, while drinking straws were abundant at the mangrove strandlines during the southwest monsoon. Foam fragments and cigarette butts were common at the beach strandlines. These results suggest that mangroves among other habitats examined here should be prioritised for clean-up efforts in order to restore these critical coastal habitats. • We compared macro-litter abundance and composition among marine habitats in Singapore. • High litter abundance was trapped in mangroves compared to seagrass and coral reefs. • Plastic was the major type of litter found across most habitat types. • Litter density did not vary between the southwest and the northeast monsoons. [ABSTRACT FROM AUTHOR]

Background: Singapore remains vulnerable to worldwide epidemics due to high air traffic with other countries This study aims to measure the public's awareness of the Middle East Respiratory Syndrome (MERS) and Avian Influenza A (H7N9), identify population groups who are uninformed or misinformed about the diseases, understand their choice of outbreak information source, and assess the effectiveness of communication channels in Singapore.Methods: A cross-sectional study, comprising of face-to-face interviews, was conducted between June and December 2013 to assess the public's awareness and knowledge of MERS and H7N9, including their choice of information source. Respondents were randomly selected and recruited from 3 existing cohort studies. An opportunistic sampling approach was also used to recruit new participants or members in the same household through referrals from existing participants.Results: Out of 2969 participants, 53.2% and 79.4% were not aware of H7N9 and MERS respectively. Participants who were older and better educated were most likely to hear about the diseases. The mean total knowledge score was 9.2 (S.D ± 2.3) out of 20, and 5.9 (S.D ± 1.2) out of 10 for H7N9 and MERS respectively. Participants who were Chinese, more educated and older had better knowledge of the diseases. Television and radio were the primary sources of outbreak information regardless of socio-demographic factors.Conclusion: Heightening education of infectious outbreaks through appropriate media to the young and less educated could increase awareness. [ABSTRACT FROM AUTHOR]

Abstract: Aim: To provide normative values for the healthy ethnic Chinese Singaporean population and a large sample of patients with schizophrenia for the Continuous Performance Task-Identical Pairs (CPT-IP). Participants Data were collected on 1011 healthy ethnic Chinese and 654 patients diagnosed with schizophrenia, all between 21 and 55years of age. Methods: Data were stratified by age and gender. The effects of age, gender and education were explored in patients and controls. Performance indices were assessed in their ability to predict group inclusion. Controls’ performance was compared with that reported in a US sample. Results: Performance was affected by age, sex, and education, with youth, male sex and higher education providing a performance advantage. Patients’ performance was lower than controls’ by more than 1 standard deviation, with the 3-digit d′ score most significantly discriminating between controls and patients. The effects of socio-demographic factors on performance were in line with those conducted in the US and previously reported in the literature. Conclusions: This is the largest norming study ever conducted on the CPT-IP. It will enable investigators and clinicians to select appropriate indices to assess severity of cognitive decline and/or evaluate cognitive remediation therapy outcomes after taking into account age, gender and education factors. [Copyright &y& Elsevier]

• The work presents a detailed methodology for the creation of virtual tours. • The proposed methodology provides a low-cost solution that requires minimal technical expertise for execution. • Tangible physical structures of the cultural heritage site are documented. • Intangible historical and socio-cultural information of the cultural heritage site is also preserved. • This workflow serves as a template for other cultural heritage sites to replicate. There is a growing use of digital and visualisation technologies in the documentation and preservation of cultural heritage sites. Using the Tampines Chinese Temple in Singapore as a case study, this paper presents a detailed methodological framework to create virtual tours for the preservation of both the physical built environment and intangible historical and sociocultural elements within the space of cultural heritage sites. Tangible data used in the creation of the virtual tour produced for the temple comprise spherical images collected via a 360° camera and two-dimensional (2D) high-resolution images obtained via a digital single-lens reflex camera. The tour also showcases intangible aspects of the temples cultural heritage, derived from references made to multiple sources, namely interviews with personnel involved in the management of heritage sites (e.g. the temple secretary) as well as historical archives (e.g. National Archives of Singapore and publications produced by the temple). In so doing, this paper promotes the importance of incorporating intangible elements of cultural heritage sites into a unified interface. This method is advantageous as the relatively low pricing of the chosen software, and the use of a 360° camera and digital single-lens reflex camera enhances accessibility for heritage practitioners and facilitate future applications. [ABSTRACT FROM AUTHOR]

• This study proposed the first deep learning system to differentiate individuals with ADHD, ADHD+CD, and CD using EEG signals. • The workflow process of our deep learning system is simple and does not require complicated signal processing procedures. • Grad-CAM was also employed to pinpoint crucial ECG characteristics at particular time points that influence the outcome of the prediction. • The proposed deep learning system achieved high performance result with 96.04% accuracy, 95.99% sensitivity, 96.26.% precision, and 96.11% F1-score. • The proposed deep learning system can identify significant ECG features and time-localize them, which may be used as an objective biomarker for more precise diagnosis. Attention Deficit Hyperactivity problem (ADHD) is a common neurodevelopment problem in children and adolescents that can lead to long-term challenges in life outcomes if left untreated. Also, ADHD is frequently associated with Conduct Disorder (CD), and multiple research have found similarities in clinical signs and behavioral symptoms between both diseases, making differentiation between ADHD, ADHD comorbid with CD (ADHD+CD), and CD a subjective diagnosis. Therefore, the goal of this pilot study is to create the first explainable deep learning (DL) model for objective ECG-based ADHD/CD diagnosis as having an objective biomarker may improve diagnostic accuracy. The dataset used in this study consist of ECG data collected from 45 ADHD, 62 ADHD+CD, and 16 CD patients at the Child Guidance Clinic in Singapore. The ECG data were segmented into 2 s epochs and directly used to train our 1-dimensional (1D) convolutional neural network (CNN) model. The proposed model yielded 96.04% classification accuracy, 96.26% precision, 95.99% sensitivity, and 96.11% F1-score. The Gradient-weighted class activation mapping (Grad-CAM) function was also used to highlight the important ECG characteristics at specific time points that most impact the classification score. In addition to achieving model performance results with our suggested DL method, Grad-CAM's implementation also offers vital temporal data that clinicians and other mental healthcare professionals can use to make wise medical judgments. We hope that by conducting this pilot study, we will be able to encourage larger-scale research with a larger biosignal dataset. Hence allowing biosignal-based computer-aided diagnostic (CAD) tools to be implemented in healthcare and ambulatory settings, as ECG can be easily obtained via wearable devices such as smartwatches. [ABSTRACT FROM AUTHOR]

B Learning Objectives: b Tuberculosis (TB) is one of the top 10 causes of death worldwide. This study aimed to identify patient characteristics and risk factors associated with poor outcomes in patients with TB who require intensive care. B Conclusions: b Patients with tuberculosis requiring critical care support have significant risk of mortality. [Extracted from the article]

Background: Differences in disease behaviour and genotypes are described in Asian and Western interstitial lung disease (ILD) cohorts. Short leukocyte telomere length (LTL) correlates with poor outcomes in Western ILD cohorts but its significance in Asian populations is unknown. We aim to characterise the burden and clinical implications of short LTL in Singaporean ILD patients., Methods: Patients diagnosed with ILD at Singapore General Hospital were prospectively recruited and compared against 36 healthy controls. The primary outcome was transplant-free survival. Genomic DNA from peripheral blood was extracted and LTL measured using quantitative polymerase chain reaction assay (qPCR)., Results: Amongst 165 patients, 37% had short LTL. There was a higher proportion of combined pulmonary fibrosis and emphysema (CPFE) patients with short LTL (n = 21, 34.4% vs n = 16, 15.4%; p < 0.001). Short LTL patients had reduced survival at 12-, 24- and 36-months and median survival of 24 months (p < 0.001) which remained significant following adjustment for smoking, GAP Stage and radiological UIP pattern (Hazard Ratio (HR), 2.74; 95%CI:1.46, 5.11; p = 0.002). They had increased respiratory-related mortality and acute exacerbation incidences. Despite similar baseline lung function, short LTL patients had a faster decline in absolute forced vital capacity (FVC) of -105.3 (95% CI: 151.4, -59.1) mL/year compared to -58.2 (95% CI: 82.9, -33.6) mL/year (p < 0.001) in normal LTL patients., Conclusion: Short LTL correlated with increased mortality and faster lung function decline in our Singaporean ILD cohort with a magnitude similar to that in Western ILD cohorts. Further research is needed to integrate LTL assessment into clinical practice., Competing Interests: Declaration of competing interest MLW Kam reports having received research funding from Singapore General Hospital, Singapore and Singapore Health Services (Singhealth), Singapore and having received speaker honorarium from Boehringer Ingelheim, Singapore. YH Tan reports having received speaker honorarium from Boehringer Ingelheim, Singapore. SY Low reports having received research funding, consulting fees, speaker honorarium and support for meetings and travel from Boehringer Ingelheim, Singapore and speaker honorarium from Astra Zeneca, Singapore. JYY Ngeow reports having received research funding from Astra Zeneca, Singapore and the National Medical Research Council Clinician Scientist Award, Singapore. The other authors have no conflicts of interest., (Copyright © 2024 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved.)

Objectives: Artificial intelligence (AI)-driven clinical decision support systems (CDSSs) can augment antibiotic decision-making capabilities, but physicians' hesitancy in adopting them may undermine their utility. We conducted a cross-country comparison of physician perceptions on the barriers and facilitators in accepting an AI-enabled CDSS for antibiotic prescribing., Methods: We conducted in-depth interviews with physicians from the National Centre for Infectious Diseases (NCID), Singapore, and Christian Medical College Vellore (CMCV), India, between April and December 2022. Our semi-structured in-depth interview guides were anchored on Venkatesh's UTAUT model. We used clinical vignettes to illustrate the application of AI in clinical decision support for antibiotic prescribing and explore medico-legal concerns., Results: Most NCID physicians felt that an AI-enabled CDSS could facilitate antibiotic prescribing, while most CMCV physicians were sceptical about the tool's utility. The hesitancy in adopting an AI-enabled CDSS stems from concerns about the lack of validated and successful examples, fear of losing autonomy and clinical skills, difficulty of use, and impediment in work efficiency. Physicians from both sites felt that a user-friendly interface, integration with workflow, transparency of output, a guiding medico-legal framework, and training and technical support would improve the uptake of an AI-enabled CDSS., Conclusion: In conclusion, the acceptance of AI-enabled CDSSs depends on the physician's confidence with the tool's recommendations, perceived ease of use, familiarity with AI, the organisation's digital culture and support, and the presence of medico-legal governance of AI. Progressive implementation and continuous feedback are essential to allay scepticism around the utility of AI-enabled CDSSs., (Copyright © 2023 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Background: Patient preferences for the content and format of prescription medication labels (PMLs, i.e., sticker labels placed on medication bottles/packets at dispensing) have been extensively studied. However, accommodating all preferences on PMLs is impractical due to space limitations. Understanding how patients prioritise the content and format attributes of PMLs can inform improvements while working within PML space constraints., Objectives: We aimed to (1) identify a ranking of medication-related content attributes to be prioritised on PMLs using best-worst scaling (BWS), and (2) determine the relative importance of format attributes when incorporated onto PMLs using discrete choice experiment (DCE), from the perspective of older adult patients in Singapore., Methods: Attributes were informed by our prior qualitative study and PML best practice guidelines. For the BWS component, the assessed content attributes were indication, precautions, interaction or paired medicines, food instructions, side effects, expiry date, and missed dose action, all of which are currently not legally mandated on PMLs in Singapore. A BWS object case was used to rank the content attributes. For the DCE component, in a series of questions, participants were asked to choose between two PML options each time, that varied in the presentation of dosage-frequency instructions, font size, presentation of dosage, presentation of precautions, and font colour of precautions. A mixed logit model estimated the relative utilities of format attribute levels, enabling the calculation of importance scores of the format attributes., Results: The study recruited 280 participants (mean age: 68.8 ± 5.4 years). The three most-preferred content attributes were indication, precautions and interaction or paired medicines. The top three format preferences were tabular style presentation of dosage-frequency instructions, large font size and precautions in red colour., Conclusions: Healthcare institutions should consider improving their PMLs based on the leading content and format preferences voiced by older adult patients. The methodology adopted in the study can also be used for aligning the content and format of other patient education materials with patient preferences., Competing Interests: Declaration of interest statement None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The Retirement and Health Study (RHS) is Singapore's largest nationally representative cohort with over 15,000 participants (aged 45-85 years) followed across five timepoints in 10 years (2014-2024). Accounting for sample weights, the sample represents 1.2 million Singaporeans and permanent residents of a total population of 5.5 million. The RHS sought consent to link survey responses to relevant administrative data, enabling the cross-validation of self-reports with national databases. There are 10 sections in the RHS with over 400 questions, 50% of which are on respondents' physical and mental health, healthcare utilization and insurance; the remaining 50% are about employment history, retirement adequacy, wealth, and household expenditure. The RHS was set up to provide microdata to compliment administrative data for whole-of-government policy making given that Singapore will reach super-aged status by 2026. Sample findings include a need for older adults to balance between immediate financial needs and investments regarding their pension funds. Also, 86% of older adults preferred to transit into partial retirement by reducing workloads. On the health front, existing studies utilising the RHS have revealed latent classes of disabilities, and that intentions to seek employment can mitigate disability developments. Another study reported that physical disability and social isolation was projected to increase, with ethnic disparities in social functioning. Overall, the RHS will be used for evidenced-informed policy agenda setting and evaluation across domains of health, finance, retirement adequacy, social and family development.

Objectives: Voluntary HIV testing rates are still low in several Asian countries including Singapore. HIV self-testing (HIVST) has the potential to increase testing, leading to earlier diagnosis and better prognosis. However, the views of at-risk individuals, especially heterosexual men (HSM), who are not coming forward for testing are still poorly understood. In this study, we examined the barriers and facilitators to and delivery preferences for HIVST in order to implement an effective intervention in Singapore., Methods: From May 2017 to June 2018, 48 in-depth interviews were conducted with HSM aged 21-66 years and at risk of HIV infection. Participants were purposively sampled based on ethnicity, age and testing behaviour. Recruitment was done mainly at brothels and entertainment establishments in Singapore. Participants gave their views on HIV testing, factors affecting HIVST use and their preferred HIVST service delivery model., Results: Most participants preferred HIVST over conventional testing for its convenience, privacy, anonymity and autonomy, but older men still preferred conventional testing. Low self-perceived risk, low awareness and self-efficacy for HIVST, and non-comprehensive test for other STIs were reported as barriers to HIVST. There were mixed opinions on kit preference. A blood-based kit was favoured for higher accuracy, while the oral-fluid-based kit was favoured for ease of use. Participants wanted a human touch for post-test counselling and linkage to care only if they self-tested positive. Traditional media, internet and social media, and venue-based outreach were potential advertising platforms mentioned., Conclusions: A locally acceptable and feasible HIVST intervention must address the barriers and facilitators of using HIVST in order to improve HIV testing rates among this at-risk population who might otherwise delay or fail to present for testing., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: WHO recommends that low burden countries consider systematic screening and treatment of latent tuberculosis infection (LTBI) in migrants from high incidence countries. We aimed to determine LTBI prevalence and risk factors and evaluate cost-effectiveness of screening and treating LTBI in migrants to Singapore from a government payer perspective., Design: Cross-sectional study and cost-effectiveness analysis., Setting: Migrants in Singapore., Participants: 3618 migrants who were between 20 and 50 years old, have not worked in Singapore previously and stayed in Singapore for less than a year were recruited., Primary and Secondary Outcome Measures: Costs, quality-adjusted life-years (QALYs), threshold length of stay, incremental cost-effectiveness ratios (ICERs), cost per active TB case averted., Results: Of 3584 migrants surveyed, 20.4% had positive interferon-gamma release assay (IGRA) results, with the highest positivity in Filipinos (33.2%). Higher LTBI prevalence was significantly associated with age, marital status and past TB exposure. The cost-effectiveness model projected an ICER of S$57 116 per QALY and S$12 422 per active TB case averted for screening and treating LTBI with 3 months once weekly isoniazid and rifapentine combination regimen treatment compared with no screening over a 50-year time horizon. ICER was most sensitive to the cohort's length of stay in Singapore, yearly disease progression rates from LTBI to active TB, followed by the cost of IGRA testing., Conclusions: For LTBI screening and treatment of migrants to be cost-effective, migrants from high burden countries would have to stay in Singapore for ~50 years. Risk-stratified approaches based on projected length of stay and country of origin and/or age group can be considered., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To evaluate how public perceptions and trust in government communications affected the adoption of protective behaviour in Singapore during the coronavirus disease 2019 (COVID-19) pandemic., Methods: We launched our community-based cohort to assess public perceptions of infectious disease outbreaks in mid-2019. After the first case of COVID-19 was reported in Singapore on 23 January, we launched a series of seven COVID-19 surveys to both existing and regularly enrolled new participants every 2 weeks. As well as sociodemographic properties of the participants, we recorded changing responses to judge awareness of the situation, trust in various information sources and perceived risk. We used multivariable logistic regression models to evaluate associations with perceptions of risk and self-reported adopted frequencies of protective behaviour., Findings: Our cohort of 633 participants provided 2857 unique responses during the seven COVID-19 surveys. Most agreed or strongly agreed that information from official government sources (99.1%; 528/533) and Singapore-based news agencies (97.9%; 522/533) was trustworthy. Trust in government communication was significantly associated with higher perceived threat (odds ratio, OR: 2.2; 95% confidence interval, CI: 1.6-3.0), but inversely associated with perceived risk of infection (OR: 0.6; 95% CI: 0.4-0.8) or risk of death if infected (OR: 0.6; 95% CI: 0.4-0.9). Trust in government communication was also associated with a greater likelihood of adopting protective behaviour., Conclusion: Our findings show that trust is a vital commodity when managing an evolving outbreak. Our repeated surveys provided real-time feedback, allowing an improved understanding of the interplay between perceptions, trust and behaviour., ((c) 2021 The authors; licensee World Health Organization.)

Background and Aims: Studies of hereditary transthyretin amyloidosis (ATTRv amyloidosis) in South-East Asia are underrepresented in the literature. We report the unique phenotypic and genetic characteristics of this disorder in a multiracial South-East Asian cohort., Methods: Patients with genetically proven ATTRv amyloidosis were identified over a 13-year period (2007-2020) at the National Neuroscience Institute, Singapore. Clinical, laboratory, genotypic and electrophysiological features were retrospectively reviewed., Results: 29 patients comprising Chinese, Malay, Burmese, Vietnamese and Indonesians with ATTRv amyloidosis were identified. Somatic neuropathy was the most common initial presentation, followed by carpal tunnel syndrome, autonomic dysfunction and cardiac dysfunction. ATTR-A97S (p.Ala117Ser) was the most common variant found in 14 patients, constituting 66.7%of ethnic Chinese patients and 48.3%of the entire cohort. Five patients had early-onset disease (age < 50 years) with the following variants: ATTR-V30M (p.Val50Met), ATTR-G47A (p.Gly67Ala), ATTR-S50I (p.Ser70Ile) and ATTR-A97S (p.Ala117Ser); one patient with ATTR-A97S (p.Ala117Ser) had isolated unilateral carpal tunnel syndrome with amyloid deposits identified on histological examination of the transverse carpal ligament. All early-onset patients had a positive parental history; two patients, with ATTR-S50I (p.Ser70Ile) and ATTR-Ala97Ser (p.Ala117Ser) respectively, demonstrated anticipation with mother-to-daughter inheritance. Amongst the 24 patients with late-onset disease (age≥50 years), two patients had novel variants, ATTR-G66D (p.Glu86Asp) and ATTR-A81V (p.Ala101Val) that were confirmed to be pathogenic based on the histological identification of transthyretin amyloid. Other identified variants included ATTR-V30M (p.Val50Met), ATTR-R34T (p.Arg54Thr), ATTR-S50I (p.Ser70Ile), ATTR-H88R (p.His108Arg) and ATTR-A97S (p.Ala117Ser)., Conclusion: Our study further expands the genotypic and phenotypic knowledge regarding ATTRv amyloidosis.

Objective: To assess the effectiveness of a telemedicine service for ureteric colic patients in reducing the number of unnecessary face-to-face consultations and shortening waiting time for appointments., Methods: A telemedicine workflow was implemented as a quality improvement study using the Plan-Do-Study-Act method. All patients presenting with ureteric colic without high-risk features of fever, severe pain, and hydronephrosis, were recruited, and face-to-face appointments to review scan results were replaced with phone consultations. Data were prospectively collected over 3 years (January 2017 to December 2019). Patient outcomes including the reduction in face-to-face review visits, time to review, reattendance and intervention rates, were tracked in an interrupted time-series analysis, and qualitative feedback was obtained from patients and clinicians., Results: Around 53.2% of patients presenting with ureteric colic were recruited into the telemedicine workflow. A total of 465 patients (46.2%) had normal scan results and 250 patients (24.9%) did not attend their scan appointments, hence reducing the number of face-to-face consultations by 71.1%. A total of 230 patients (22.9%) required subsequent follow-up with urology, while 61 patients (6.1%) were referred to other specialties. Mean (SD) time to review was 30.0 (6.2) days, 6-month intervention rate was 3.4% (n = 34) and unplanned reattendance rate was 3.2% (n = 32). Around 93.1% of patients reported satisfaction with the service., Conclusion: The ureteric colic telemedicine service successfully and sustainably reduced the number of face-to-face consultations and time to review without compromising on patient safety. The availability of this telemedicine service has become even more important in helping us provide care to patients with ureteric colic in the current COVID-19 pandemic., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Existing studies have suggested that internet-based participatory surveillance systems are a valid sentinel for influenza-like illness (ILI) surveillance. However, there is limited scientific knowledge on the effectiveness of mobile-based ILI surveillance systems. Previous studies also adopted a passive surveillance approach and have not fully investigated the effectiveness of the systems and their determinants., Objective: The aim of this study was to assess the efficiency of a mobile-based surveillance system of ILI, termed FluMob, among health care workers using a targeted surveillance approach. Specifically, this study evaluated the effectiveness of the system for ILI surveillance pertaining to its participation engagement and surveillance power. In addition, we aimed to identify the factors that can moderate the effectiveness of the system., Methods: The FluMob system was launched in two large hospitals in Singapore from April 2016 to March 2018. A total of 690 clinical and nonclinical hospital staff participated in the study for 18 months and were prompted via app notifications to submit a survey listing 18 acute respiratory symptoms (eg, fever, cough, sore throat) on a weekly basis. There was a period of study disruption due to maintenance of the system and the end of the participation incentive between May and July of 2017., Results: On average, the individual submission rate was 41.4% (SD 24.3%), with a rate of 51.8% (SD 26.4%) before the study disruption and of 21.5% (SD 30.6%) after the disruption. Multivariable regression analysis showed that the adjusted individual submission rates were higher for participants who were older (<30 years, 31.4% vs 31-40 years, 40.2% [P<.001]; 41-50 years, 46.0% [P<.001]; >50 years, 39.9% [P=.01]), ethnic Chinese (Chinese, 44.4% vs non-Chinese, 34.7%; P<.001), and vaccinated against flu in the past year (vaccinated, 44.6% vs nonvaccinated, 34.4%; P<.001). In addition, the weekly ILI incidence was 1.07% on average. The Pearson correlation coefficient between ILI incidence estimated by FluMob and that reported by Singapore Ministry of Health was 0.04 (P=.75) with all data and was 0.38 (P=.006) including only data collected before the study disruption. Health care workers with higher risks of ILI and influenza such as women, non-Chinese, allied health staff, those who had children in their households, not vaccinated against influenza, and reported allergy demonstrated higher surveillance correlations., Conclusions: Mobile-based ILI surveillance systems among health care workers can be effective. However, proper operation of the mobile system without major disruptions is vital for the engagement of participants and the persistence of surveillance power. Moreover, the effectiveness of the mobile surveillance system can be moderated by participants' characteristics, which highlights the importance of targeted disease surveillance that can reduce the cost of recruitment and engagement., (©May Oo Lwin, Jiahui Lu, Anita Sheldenkar, Chitra Panchapakesan, Yi-Roe Tan, Peiling Yap, Mark I Chen, Vincent TK Chow, Koh Cheng Thoon, Chee Fu Yung, Li Wei Ang, Brenda SP Ang. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 07.12.2020.)

The convergence of carbapenem-resistance and hypervirulence genes in Klebsiella pneumoniae has led to the emergence of highly drug-resistant superbugs capable of causing invasive disease. We analyzed 556 carbapenem-resistant K. pneumoniae isolates from patients in Singapore hospitals during 2010-2015 and discovered 18 isolates from 7 patients also harbored hypervirulence features. All isolates contained a closely related plasmid (pKPC2) harboring bla KPC-2 , a K. pneumoniae carbapenemase gene, and had a hypervirulent background of capsular serotypes K1, K2, and K20. In total, 5 of 7 first patient isolates were hypermucoviscous, and 6 were virulent in mice. The pKPC2 was highly transmissible and remarkably stable, maintained in bacteria within a patient with few changes for months in the absence of antimicrobial drug selection pressure. Intrapatient isolates were also able to acquire additional antimicrobial drug resistance genes when inside human bodies. Our results highlight the potential spread of carbapenem-resistant hypervirulent K. pneumoniae in Singapore.

Introduction: A successful arteriovenous fistula is essential for effective haemodialysis. We aim to validate the existing failure to maturation equation and to propose a new clinical scoring system by evaluating arteriovenous fistula success predictors., Methods: Data of end-stage renal disease patients initiated on haemodialysis from January 2010 to December 2012 were retrospectively obtained from medical records with follow-up until 1 January 2014. Application of the failure to maturation equation was evaluated. A nomogram was developed using arteriovenous fistula success predictors and was calibrated with a bootstrapping technique., Results: A total of 694 patients were included with mean duration of follow-up of 2.3 years. Arteriovenous fistula maturation was achieved by 542 patients (78%). Comparing our cohort with the failure to maturation cohort, there were statistically significant differences in mean age, ethnicity and presence of diabetes mellitus. The failure to maturation equation failed to predict arteriovenous fistula outcomes with area under the curve performance of 0.519 on a receiver operating characteristic curve. Multivariate logistic regression showed that Malay patients (odds ratio = 0.628; 95% confidence interval = 0.403-0.978; p < 0.05) and patients requiring preoperative vein mapping (odds ratio = 0.601; 95% confidence interval = 0.410-0.883; p < 0.01) had a lower chance of arteriovenous fistula success, whereas male gender (odds ratio = 1.526; 95% confidence interval = 1.040-2.241; p < 0.05) and presence of postoperative good thrill (odds ratio = 3.137; 95% confidence interval = 2.127-4.625; p < 0.0001) had a higher chance of arteriovenous fistula success. The derived nomogram predicted arteriovenous fistula success (odds ratio = 1.030; 95% confidence interval = 1.022-1.038; p < 0.0001) with the area under the curve of 0.695 on a receiver operating characteristic curve and an adequacy index of 99.86% ( p < 0.0001)., Conclusion: The failure to maturation equation was not validated in our cohort. The clinical utility of our proposed arteriovenous fistula scoring system requires external validation in larger studies.

Introduction: Family history of psychopathology is a risk factor for mood and anxiety disorders in children, but little is known about rates of parental psychopathology among treatment-seeking youth with affective disorders in the Asia Pacific region. This study examined patterns of emotional and behavioural problems in parents of clinically-referred youth in Singapore. We hypothesised that parents would have higher rates of affective disorders compared to the Singapore national prevalence rate of 12%., Materials and Methods: In this cross-sectional study, 47 families were recruited from affective disorders and community-based psychiatry programmes run by a tertiary child psychiatry clinic. All children had a confirmed primary clinical diagnosis of depression or an anxiety disorder. Parents completed the Mini International Neuropsychiatric Interview (MINI) to assess for lifetime mood and anxiety disorders. They also completed the Adult Self Report (ASR) and Adult Behavior Checklist (ABCL) to assess current internalising and externalising symptoms., Results: Consistent with our hypothesis, 38.5% of mothers and 10.5% of fathers reported a lifetime mood and anxiety disorder. Nearly 1/3 of mothers had clinical/subclinical scores on current internalising and externalising problems. A similar pattern was found for internalising problems among fathers, with a slightly lower rate of clinical/subclinical externalising problems., Conclusion: Our findings are consistent with previous overseas studies showing elevated rates of affective disorders among parents - particularly mothers - of children seeking outpatient psychiatric care. Routine screening in this population may help to close the current treatment gap for adults with mood and anxiety disorders.

Introduction:: Hemodialysis is the main modality of renal replacement therapy in Singapore. However, a majority of the patients in Singapore are initiated on hemodialysis via a catheter. This study examines the complication rates and factors predicting catheter-related bloodstream infections and mortality rates in patients who were initiated on hemodialysis at our institution., Methods:: This is a single-center retrospective analysis of incident hemodialysis patients who were initiated on renal replacement therapy between 1 January 2010 and 31 December 2012. Catheter-related bloodstream infection risk factors, organisms, and associated mortality were analyzed., Results:: The catheter-related bloodstream infection and exit site infection incidence rates were 0.75 and 0.50 per 1000 catheter days, respectively. The mean duration to first catheter-related bloodstream infection episode was 182.47 ± 144.04 catheter days. Prolonged catheter duration was found to be a risk factor for catheter-related bloodstream infection. Compared to patients initiated on dialysis via arteriovenous fistula, initiation of dialysis via catheter is strongly associated with increased mortality (6.0% vs 14.5%; p = 0.02). In particular, the presence of diabetes mellitus and development of catheter-related bloodstream infection was associated with increased mortality ( p = 0.04 and 0.05, respectively). In addition, patients who began hemodialysis before being seen by a nephrologist were associated with decreased mortality (3.4% vs 13.0%; p = 0.03)., Conclusion:: In conclusion, prolonged duration of catheter insertion is found to be a risk factor for catheter-related bloodstream infection in hemodialysis patients, and its development is associated with increased mortality. Early referral to a nephrologist and creation of arteriovenous fistula in pre-end-stage renal disease patients are pivotal in improving the outcomes of patients.

Background: Singapore remains vulnerable to worldwide epidemics due to high air traffic with other countries This study aims to measure the public's awareness of the Middle East Respiratory Syndrome (MERS) and Avian Influenza A (H7N9), identify population groups who are uninformed or misinformed about the diseases, understand their choice of outbreak information source, and assess the effectiveness of communication channels in Singapore., Methods: A cross-sectional study, comprising of face-to-face interviews, was conducted between June and December 2013 to assess the public's awareness and knowledge of MERS and H7N9, including their choice of information source. Respondents were randomly selected and recruited from 3 existing cohort studies. An opportunistic sampling approach was also used to recruit new participants or members in the same household through referrals from existing participants., Results: Out of 2969 participants, 53.2% and 79.4% were not aware of H7N9 and MERS respectively. Participants who were older and better educated were most likely to hear about the diseases. The mean total knowledge score was 9.2 (S.D ± 2.3) out of 20, and 5.9 (S.D ± 1.2) out of 10 for H7N9 and MERS respectively. Participants who were Chinese, more educated and older had better knowledge of the diseases. Television and radio were the primary sources of outbreak information regardless of socio-demographic factors., Conclusion: Heightening education of infectious outbreaks through appropriate media to the young and less educated could increase awareness.

Aim: Capsule endoscopy has demonstrated its clinical utility in the evaluation of small bowel pathology in several Western studies. In this prospective study, we aimed to determine the clinical utility, safety and tolerability of capsule endoscopy in the evaluation of suspected small bowel disease in an urban Southeast Asian population., Methods: We used the given (M2A) capsule endoscopy system in 16 consecutive patients with suspected small bowel pathology. In 9 patients the indication was obscure gastrointestinal bleeding, while in 6 patients it was to determine the extent of small bowel involvement in Crohn's disease. One patient underwent capsule endoscopy for evaluation of chronic abdominal pain. Patient's tolerability to the procedure was evaluated by standardized questionnaires and all patients were reviewed at one week to ensure that the capsule had been excreted without any adverse events., Results: Abnormal findings were present in 8 patients (50%). The cause of obscure gastrointestinal bleeding was determined in 5 out of 9 patients. Findings included 2 cases of angiodysplasia, 2 cases of jejunal ulcers and 1 case of both angiodysplasia and jejunal ulcer. One patient had small bowel erosions and foci of erythema of doubtful significance. Ileal lesions were diagnosed in 2 out of 6 patients with Crohn's disease. Capsule endoscopy was well tolerated by all patients. One patient with Crohn's disease had a complication of capsule retention due to terminal ileum stricture. The capsule eventually passed out spontaneously after 1 month., Conclusion: Our study, which represented the first Asian series, further confirms the diagnostic utility, safety and tolerability of wireless capsule endoscopy.