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The health-related quality of life (HRQoL) among persons living with HIV (PLWHA) who initiate ART during acute HIV infection (AHI) is not well studied. Participants in the SEARCH010/RV254 cohort initiated ART during AHI. They completed the Thai version of the World Health Organisation Quality of Life instrument-BREF (WHOQOL-BREF) and Patient Health Questionnaire-9 (PHQ-9) prior to ART initiation and 24 weeks later. Of 452 participants, 406 (90%) completed the WHOQOL-BREF. The median age was 26 years (IQR 22-31), and 98% were men. All WHOQOL-BREF domains demonstrated good internal consistency (Cronbach's alpha >0.70). Confirmatory factor analysis validated the WHOQOL-BREF model. 90% of Pearson correlations between domain scores and general facet items were >0.50. HRQoL in all domains was worse among those with at least moderately severe depression (PHQ-9 ≥ 10) (p

ObjectivesChronic wounds are common, costly and impair quality of life, yet epidemiological data are scarce. We aimed to estimate the incidence trend of a multiethnic Asian population.DesignRetrospective cohort study.SettingSingapore’s nationwide claims database.ParticipantsSingaporeans and permanent residents.OutcomesPatients were identified by International Classification of Disease, Ninth Revision, Australian Modification (ICD-9-AM) and ICD-10-AM codes from all admissions between 2000 and 2017, and categorised according to aetiology: venous, arterial, diabetic and pressure. Comorbidities were extracted from a national database of Charlson Comorbidity Index scores.ResultsBetween 2000 and 2017, 124 023 wound-related claims among 86 631 patients were identified. Age-specific rate (ASR) and age-adjusted incidence rates of all wounds increased over 18 years, with greatest increases among those aged ≥80. In 2017, the median age of patients was 74 (IQR 63–84). Half were male (51%). 70% were ethnic Chinese, 15% Malay and 9% Indian. In 2017, the crude incidence rate (CIR) was 15 per 100 000 persons (95% CI 14 to 16) for venous wounds, 56 (95% CI 53 to 58) for arterial, 168 (95% CI 164 to 173) for diabetic and 183 (95% CI 179 to 188) for pressure wounds. The CIR of any chronic wound was 296 (95% CI 291 to 301). ASRs were greatest in patients aged ≥80: 92 (95% CI 74 to 112) for venous, 478 (95% CI 436 to 522) for arterial, 1791 (95% CI 1710 to 1876) for diabetic, 3647 (95% CI 3530 to 3766) for pressure and 4277 (95% CI 4151 to 4407) for any wound. Compared with the Chinese, Indians had thrice the ASRs of venous and arterial wounds and double the ASR of diabetic wounds. Malays had double the ASRs of arterial and diabetic wounds.ConclusionsChronic wounds are common in the elderly with significant ethnic disparities in this Asian cohort. With the incidence expected to rise with ageing populations, it is crucial to address health disparities and evaluate utilisation and cost to inform clinical practice and health policy.

Summary box The COVID-19 outbreak among migrant workers in Singapore has revealed the health disparities of migrant workers due to suboptimal living conditions and poor access to ambulatory healthcare. This has given Singapore the impetus to start discussions on migrant workers’ health concerns so that they will no longer be ignored. We propose consideration of a novel postpandemic health services delivery and financing strategy that aligns the interests of migrant workers and stakeholders, including the government, healthcare providers (HCPs) and the public to bring about a systemic change in Singapore’s health market for migrant workers.1 Migrant workers have existed on the periphery of Singapore society in terms of living conditions and access to Singapore’s high standards of healthcare. Up till March 2020, Singapore was praised internationally for its response to the COVID-19 pandemic.2 The outbreak control measures implemented then were focused on the general population. Subsequently, alarming …

Introduction Dolutegravir (DTG)-based antiretroviral therapy (ART) is currently the first-line treatment for people living with HIV. Neuropsychiatric adverse events (NP-AEs) have been reported with DTG but neuropsychiatric symptoms have not been systemically quantified using structured scales. This study examined mood and cognitive parameters before and after a planned transition from non-DTG to DTG-based ART within a longitudinal study of acute HIV infection (AHI). Methods RV254 AHI cohort participants on ≥ 24 weeks of ART initiated at AHI underwent sequential assessments before and after the switch including: (1) Patient Health Questionnaire-9 (PHQ-9), a 9-item survey (scores 0–27) that evaluates somatic and affective/cognitive symptoms of depression; (2) a 2-Questions screening that has been validated locally for depression; (3) Distress Thermometer (scores 0–10); and 4) administration of a 4-test neurocognitive battery sensitive to HIV. Results 254 individuals (95% male, median age 30) switched to a DTG-based regimen after a median 144 weeks of ART. Serial assessments were completed at a median of 19 weeks before and 37 weeks after DTG. There was a modest but statistically significant increase in PHQ-9 scores after DTG (pre-switch: 5 [IQR 1–7] vs. Post-switch: 5 [IQR 2–8], p = 0.009). The percentage of participants with at least moderate depression (PHQ-9 ≥ 10) increased from 10 to 16% (p = 0.006), but the frequency of moderate-severe depression (PHQ-9 ≥ 15) remained unchanged (3%). No volunteer reported NP-AEs within the study period. Somatic symptoms of depression increased more than cognitive/affective symptoms. Plasma viral suppression (HIV-1 RNA Conclusion After a median duration of 37 weeks of DTG use, there was a modest increase in the higher quartile of PHQ-9. This increase was associated with a rise in moderate depression symptoms but not the more severe forms of depression on PHQ-9. No clinically relevant NP-AEs were reported. Pre-existing depression was not associated with subsequent worsening of symptoms after DTG. Cognitive test performance improved post-DTG but could be due to practice effect.

Background: Chronic wounds are common, costly and impair quality of life. Epidemiological data to describe trends and the current situation are scarce. We used Singapore’s nationwide claims database to estimate the incidence trend of a multiethnic Asian population. Methods: Cases were identified by International Classification of Diseases (ICD)-9-AM and ICD-10-AM codes from all inpatient admissions between 2000 and 2017, and categorized according to aetiological subtypes: venous, arterial, diabetic and pressure. Information on co-morbidities was extracted from a national database of Charlson Co-Morbidity Index scores of the general population. Findings: Between 2000 and 2017, 124,023 wound-related claims among 86,631 patients were identified. In 2017, the median age of patients was 74 (IQR 63-84). Half of patients were male (51%) and the majority Chinese (70%) with 15% Malay and 9% Indian. The median CCI score was 6 (IQR 3-9). In 2017, the crude incidence rate (CIR) was 15 per 100,000 persons (95% CI 14-16) for venous wounds, 56 (95% CI 53-58) for arterial, 168 (95% CI 164-173) for diabetic and 183 (95% CI 179-188) for pressure wounds. The CIR of any chronic wound was 296 (95% 291-301). Age-specific rates were greatest in the group aged ≥80: 92 (95% CI 74-112) for venous, 478 (95% CI 436-522) for arterial, 1791 (95% CI 1710-1876) for diabetic, 3647 (95% CI 3530-3766) for pressure and 4277 (95% CI 4151-4407) for any wound. Compared to the Chinese majority, Indians had three-fold higher rates of venous and arterial wounds and a two-fold higher rate of diabetic wounds, and Malays had two-fold higher rates of arterial and diabetic wounds. During this 18-year period, the age-adjusted and age-specific incidence rates of all wounds increased with greatest increases observed among those aged ≥80. Interpretation: Chronic wounds are common in the elderly with significant ethnic disparities in this Asian cohort. With the incidence expected to rise with aging populations, it is crucial to address health disparities and evaluate associated utilization and cost to inform clinical practice and health policy. Funding Statement: None. Declaration of Interests: The authors declare no competing interests. Ethics Approval Statement: As this study was conducted in accordance with national guidelines for the use of administrative databases and personal data protection using anonymized data from the Singapore MOH’s administrative databases, the approval of an ethical committee was not required for this study.

Introduction Dolutegravir (DTG) is recommended as part of first‐line antiretroviral therapy (ART) for people living with HIV(PLHIV). We sought to determine the rate of adverse events (AEs) and discontinuations among Thais treated during acute HIV infection (AHI) and switched to DTG‐based regimens. Methods Thai participants in the SEARCH010/RV254 cohort who initiated ART during AHI and switched to DTG for at least 48 weeks were prospectively observed and included in the analysis. Rates and characteristics of DTG‐related AEs and discontinuations were described. Results A total of 313 Thai participants were included in the analysis. The median age was 29 years, 96% were male, 64% had a Bachelor's degree or higher and 16% had a body mass index (BMI)

INTRODUCTION Although research is widely considered to be a relevant and essential skill to resident development, the actual participation rate of residents in research remains low, and the factors associated with participation are unclear. METHODS We examined the participation rate of junior residents in research, and their attitudes and perceived barriers toward research, via an anonymised survey carried out from October to November 2013. The residents were from an established Accreditation Council for Graduate Medical Education-accredited internal medicine residency training programme in Singapore. RESULTS The overall response rate was 64.1% (82/128 residents). The most frequently cited barrier was lack of time. Only a third of the residents surveyed were actively participating in research. Those with postgraduate qualifications were more likely to be involved in research (odds ratio 4.71, p = 0.015). Among the 82 residents, 40.2% reported an interest in research as part of their career; these were mainly graduates from overseas universities or postgraduates. A belief that research is an intrinsically valuable activity distinguished residents who chose research as a career path from those who were undecided (p = 0.004). The belief that research is a means to better clinical practice also divided those who chose research from those who rejected it (p = 0.02). CONCLUSION Our findings suggest that specific beliefs determine the level of research activity and career interest among residents. Novel strategies may be incorporated in training programmes to improve the interest and participation of residents in research, and to facilitate the development of academic clinicians.

There has been resurgence in the attention placed on pharmacotherapy in atrial fibrillation (AF) recently as specialists in international conferences discuss the utility of novel anticoagulants with caution owing to limited knowledge of the side effect profile in this nascent stage. AF is a well-known risk factor for stroke and has been for more than 20 years, since warfarin was demonstrated to reduce the risk of stroke, with aspirin doing so to a lesser degree.1 Today, there is international variation in the use of warfarin to prevent stroke despite well-established data.2 Singapore finds itself in a peculiar geographical and clinical position.

Editors' Note: In response to the article “The quest to prevent stroke in atrial fibrillation: Fighting the fluttering heart in Singapore,” Dr. Sethi comments on the challenges faced by neurologists in countries where traditional and Western medicines are used in parallel. Authors Goh et al. outline efforts made in Singapore to integrate the 2 spheres. Dr. Svenningsson et al. question several aspects of the article “MS disease activity in RESTORE: A randomized 24-week natalizumab treatment interruption study” on ethical grounds, specifically the …

Background We sought to study the association between carotid stenosis and white-matter hyperintensity (WMH) among patients without intracranial large-vessel stenosis. Methods This was a prospective study of patients with acute lacunar infarcts without concomitant intracranial large-vessel stenosis having undergone carotid ultrasonography. WMH was quantified using the modified Fazekas scale. Patients were grouped into quartiles based on the degree of carotid stenosis. The association among carotid stenosis, vascular risk factors, and WMH were modeled using logistic regression analysis. Results In all, 100 patients with a mean age of 56.2 ± 11.7 years were studied. The quartile with the greatest carotid stenosis had a mean internal/common carotid artery peak systolic velocity ratio of 2.36. Total WMH was 4.64 in the highest quartile and 2.52 in the lowest quartile of carotid stenosis. Periventricular (pv)-WMH was significantly greater between the highest and lowest quartiles (2.80 versus 1.28, P = .025). No significant difference was observed for deep subcortical WMH (1.84 versus 1.24, P = .281). With increasing carotid stenosis, increase in both ipsilateral and contralateral pv-WMH was observed. When patients with significant carotid stenosis were compared to those without significant carotid stenosis, pv-WMH was significantly higher in the group with significant stenosis even after correcting for age and comorbid vascular risk factors (odds ratio 1.24; confidence interval 1.0-1.54). Conclusions Carotid stenosis is an important risk factor for WMH. Volumes of pv-WMH significantly increase with higher grades of carotid stenosis.