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Tazeen H Jafar,1– 3 Ngiap Chuan Tan,4 Rupesh M Shirore,1 Chandrika Ramakrishnan,1 Sungwon Yoon,1 Christina Chen,5 Amudha Aravindhan5 1Program in Health Services & Systems Research, Duke-NUS Medical School, Singapore, Singapore; 2Department of Renal Medicine, Singapore General Hospital, Singapore, Singapore; 3Global Health, Duke Global Health Institute, Durham, NC, USA; 4Research, SingHealth Polyclinics, Singapore, Singapore; 5PhD Student, Duke-NUS Medical School, Singapore, SingaporeCorrespondence: Tazeen H Jafar, Program in Health Services & Systems Research, Duke NUS Medical School, 8 College Road, Singapore, 169857, Singapore, Tel +65-6601-2582, Fax +65-6534-8632, Email tazeen.jafar@duke-nus.edu.sgBackground: Hypertension is a major public health challenge, globally. Recently, we reported findings from cluster randomized trial in 8 primary care clinics in Singapore and showed that a multicomponent “SingHypertension” intervention comprising 1) motivational conversation by trained nurses, 2) telephone-based follow-ups, 3) standardized algorithm with single-pill combination (SPC) antihypertensive medications, and 4) subsidy on SPC antihypertensive drugs was effective on improving BP control. This paper presents the acceptability of SingHypertension multicomponent intervention among the key stakeholders.Methods: We conducted post-implementation interviews of 38 stakeholders, including 18 patients and 20 healthcare providers (HCPs) in 4 primary care clinics randomized to the multicomponent “SingHypertension” intervention in Singapore. We used Theoretical Framework for Acceptability (TFA) framework with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy to assess stakeholders’ acceptability of the intervention.Results: SingHypertension multicomponent intervention had high perceived effectiveness and a good fit with the value system and ethics of patients and HCPs. Physicians appreciated the guidance from standardized training in hypertension management. Although workload was increased, the nurses felt rewarded for their positive interactions with the patients during motivational conversation sessions and the telephone follow-ups. Most patients reported high self-efficacy levels, improved lifestyles, and adherence to antihypertensive medications. The limited choice of SPC medication, lack of subsidy beyond the trial duration, and shortage of nurses were significant challenges to wide-scale implementation. All HCPs and patients supported scaling up the intervention across primary care clinics.Conclusion: SingHypertension multicomponent intervention is acceptable to the key stakeholders in Singapore. Taken together with the effectiveness of the intervention, our findings make a compelling case for scaling-up SingHypertension in primary care clinics in Singapore and possibly other countries with similar healthcare infrastructure.Keywords: blood pressure, hypertension, cardiovascular risk, multicomponent intervention, cluster-randomized, acceptability

Changwei Liu,1 Chee Wei Tham,2 Jacqueline De Roza,1 Bee Yen Chong,3 Yi Ling Koh,3 Ngiap Chuan Tan3,4 1National Healthcare Group Polyclinics, Singapore; 2Yong Loo Lin School of Medicine, Singapore; 3SingHealth Polyclinics, Singapore; 4SingHealth-Duke-NUS Family Medicine Academic Clinical Programme, SingaporeCorrespondence: Changwei LiuNational Healthcare Group Polyclinics, 21 Geylang East Central 389707, SingaporeEmail Changwei_LIU@nhgp.com.sgBackground: While illness perceptions and medication beliefs have been shown to be associated with inhaled corticosteroid (ICS) adherence in younger adults with asthma, their impact on older adults is less understood. This study aimed to determine the prevalence of ICS adherence among older Asian adults and to assess the association between ICS adherence, illness perceptions and medication beliefs.Methods: A questionnaire survey on older multi-ethnic Asian patients, aged ≥ 60 years, with physician-diagnosed asthma, was conducted in two Singapore public primary care clinics. The scores of the Medication Adherence Report Scale for asthma (MARS) were computed to determine the adherence to ICS alone or in combination with LABA. Illness perceptions and medication beliefs were assessed by the scores from the Brief-Illness Perception Questionnaire (B-IPQ) and Beliefs about Medications Questionnaire (BMQ), respectively. Logistic regression analyses were used to identify factors associated with ICS adherence.Results: Analyses of 323 participants (57% males; Chinese 73.7%, Malay 12.7%, Indian 12.4%; mean age 71.5 years) showed that 40.9% of them had good adherence to ICS (mean MARS score≥ 4.5). Good adherence to ICS was associated with perception of asthma as a chronic illness (OR=1.22; 95% CI=1.10– 1.35; p< 0.001), belief of ICS as an essential medication (2.67; 1.76– 4.06; p< 0.001) and fewer concerns about its use (0.39; 0.26– 0.60; p< 0.001). Patients on combined ICS-LABA therapy had higher adherence (2.50; 1.41– 4.44; p=0.02) than those on ICS monotherapy.Conclusion: Four in ten older patients with asthma were adherent to ICS. Perception of medication necessity, chronicity of illness, concerns and use of ICS-LABA medication were associated with adherence.Keywords: asthma, medication adherence, primary healthcare

For buried flaps in the head and neck, direct monitoring of the flap can be extremely difficult. The authors report their experience with 22 patients who underwent pharyngoesophageal reconstruction using an anterolateral thigh (ALT) fasciocutaneous perforator flap with a design that addresses the concerns of buried flap monitoring. This is an observational study of 22 patients, who underwent pharyngoesophageal reconstruction with ALT fasciocutaneous flaps between June 2006 and February 2008. The design of the flap consists of three components: proximal component of flap for pharyngeal reconstruction, mid-component de-epithelized for esophageal-skin flap junction, and distal component either as an external sentinel monitor or for replacing the external neck skin, nourished solely by the suprafascial plexus. The patients' age ranged between 40 and 72years with a mean age of 55.5years. The measurements of the skin paddles of the ALT flaps ranged from 10 to 30cm in length and 6 to 8cm in width. The flap success rate was 95.5% (21/22). The overall sensitivity and specificity rate of this monitoring method is 100% and 94.7% respectively. There were venous congestions found in four skin paddles. One was demonstrated to be false positive after re-exploration. The other three were true positives and two of these were salvaged successfully. The remaining flap could not be salvaged due to severe deep neck infection. Three patients had a small fistula at the distal end of the esophageal-skin flap junction. All healed spontaneously after conservative treatment. This ALT flap design for pharyngoesophageal defect reconstruction is simple and versatile. The distal skin flap can be utilized as an external sentinel monitor for the buried part of the flap, and for resurfacing of the anterior neck skin if required. [ABSTRACT FROM AUTHOR]

BACKGROUND: Low incomes may not provide the minimum requirements for healthy living. We evaluated experiences of food insecurity in relation to income in inner London. METHODS: Subjects attending 10 general medical practices completed a short self-administered questionnaire, including the short form Household Food Security Scale and a short food frequency questionnaire. RESULTS: Responses were obtained from 431/495 (87 per cent) subjects. Overall 87 (20 per cent) of subjects were classified as food insecure. Food insecurity was negatively associated with household income (p = 0.004). University-educated subjects (8 per cent) were less often food insecure than all others (26 per cent). Subjects who were food insecure were less likely to report eating fruit daily (food secure 48 per cent, food insecure 33 per cent, p = 0.017) or vegetables or salads daily (food secure 56 per cent, food insecure 34 per cent, p = 0.002). CONCLUSIONS: Experiences of food insecurity may be common in households with incomes at the level of the UK national minimum wage or lower. [ABSTRACT FROM AUTHOR]

Background: Telehealth, including video consultation (VC), has become prevalent during the COVID-19 pandemic. However, the experience and concern of women using VC for postpartum care has yet to be adequately studied but is crucial for their adoption. The study aimed to assess the experience and attitude of postpartum mothers (PPM) towards using VC as a novel model of care delivery and the factors that could potentially affect their adoption., Method: Data were gathered from PPM participating in VC using Zoom platform for postpartum care using mixed method. In-depth interviews (IDI) of twenty-five PPM were audio-recorded, transcribed verbatim and audited for accuracy. Thematic analysis was conducted to identify themes relating to perceived threat, usefulness, ease of use, and attitudes toward using VC in postpartum care. The themes are reported based on the "Health Information Technology Acceptance Model" framework. Preliminary quantitative data on the acceptability of VC were collected using structured surveys., Results: PPMs valued convenience, accessibility, and personalised care VC offered to address their immediate postpartum concerns. They perceived VC as suitable for seeking medical opinions, improving confidence in parent crafting, and providing better care access. They recognised the lack of physical examination as a major limitation in VC and proposed a hybrid postpartum care model, combining VC and in-person consultation to cater to individual needs and preferences. PPMs alluded to trust in the care providers, flexibility in VC appointment timings and enhanced interface of remote platforms as enablers for VC adoption. Preliminary quantitative data shows that PPMs found VC saved time (100%), energy (98%), and money (90%) and was appropriate (94%), easy to use (96%), acceptable (96%) for postpartum care., Conclusion: PPMs favoured combining VC and in-person consultation to mitigate their concerns and personalise their care needs., Competing Interests: Declarations Ethics approval and consent to participants The study was approved by the SingHealth Centralised Institutional Review Board (CIRB 2021/2732). The research was conducted according to International Conference on Harmonisation Guidelines for Good Clinical Practice. All participants signed written informed consent before study activities. Consent for publication Not applicable. Author information The research team included four female PCP, one male PCP, two female nurses and one female student. The nurses are qualified lactational counselors. ASM and PZ are trained in qualitative and quantitative research. NCT is a trainer and experienced researcher in both qualitative and quantitative research. The PCPs and nurses manage and counsel patients in polyclinics, including mothers, during antenatal and postnatal periods. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Inhaled corticosteroid (ICS) is the mainstay therapy for asthma, but general adherence is low. There is a paucity of real-world inhaler prescribing and adherence data from Asia and at the population level. To address these gaps, we performed a real-world data analysis of inhaler prescribing pattern and adherence in a multi-ethnic Asian asthma cohort and evaluated the association with asthma outcomes. We performed a retrospective analysis of adult asthma patients (aged ≥18 years) treated in the primary and specialist care settings in Singapore between 2015 to 2019. Medication adherence was measured using the medication possession ratio (MPR), and categorised into good adherence (MPR 0.75-1.2), poor adherence (MPR 0.75) or medication oversupply (MPR > 1.2). All statistical analyses were performed using R Studio. 8023 patients, mean age 57 years, were evaluated between 2015 and 2019. Most patients were receiving primary care (70.4%) and on GINA step 1-3 therapies (78.2%). ICS-long-acting beta-2 agonist (ICS-LABA) users increased over the years especially in the primary care, from 33% to 52%. Correspondingly, inpatient admission and ED visit rates decreased over the years. Between 2015 and 2019, the proportion of patients with poor adherence decreased from 12.8% to 10.5% (for ICS) and from 30.0% to 26.8% (for ICS-LABA) respectively. Factors associated with poor adherence included minority ethnic groups (Odds ratio of MPR 0.75-1.2: 0.73-0.93; compared to Chinese), presence of COPD (OR 0.75, 95% CI 0.59-0.96) and GINA step 4 treatment ladder (OR 0.71, 95% CI 0.61-0.85). Factors associated with good adherence were male gender (OR 1.14, 95% CI 1.01-1.28), single site of care (OR 1.22 for primary care and OR 1.76 for specialist care), GINA step 2 treatment ladder (OR 1.28, 95% CI 1.08-1.50). Good adherence was also associated with less frequent inpatient admission (OR 0.91, 95% CI 0.84-0.98), greater SABA overdispensing (OR 1.66, 95% CI 1.47-1.87) and oral corticosteroids use (OR 1.10, 95% CI 1.05-1.14). Inhaled corticosteroid (ICS) adherence has improved generally, however, poor adherence was observed for patients receiving asthma care in both primary and specialist care, and those from the minority ethnicities., (© 2024. The Author(s).)

Background: Chronic kidney disease (CKD) poses a global health challenge with high morbidity and mortality rates. Early detection and prompt intervention are critical in preventing progression to end-stage kidney disease (ESKD) and cardiovascular complications. Effective CKD management requires comprehensive care packages that integrate both pharmacological and non-pharmacological interventions within collaborative, team-based models, aiming to enhance patient outcomes and overall quality of life. The goal of the Strategies for Kidney Outcomes Prevention and Evaluation (SKOPE) study is to establish effective multicomponent intervention (MCI) strategies for evaluating and preventing kidney outcomes in patients with moderate to advanced CKD within primary care settings in Singapore., Methods: This study is a 3-year randomized controlled trial among 896 participants aged between 40 and 80 years with moderate or advanced CKD in five government-subsidized polyclinics in Singapore. The components of the MCI are (1) nurses/service coordinators trained as health coaches for motivational conversation and CKD-specific lifestyle counseling on diet and exercise, using a hybrid follow-up approach of in-person, telephone, and secure video meetings; (2) training physicians in algorithm-based standardized management of CKD; (3) subsidy on SGLT2i medications for CKD; and (4) regular CKD case review meetings. The primary outcome is the estimated glomerular filtration rate (eGFR) total slope from randomization to final follow-up at 36 months., Discussion: If shown to be effective, cost-effective, and acceptable, SKOPE should be considered for scaling country-wide and in similar regional healthcare systems., Trial Registration: ClinicalTrials.gov NCT05295368. Registered on March 25, 2022., (© 2024. The Author(s).)

Background: Long-term management of patients with hypothyroidism on thyroxine replacement requires thyroid function test (TFT) monitoring once every six-12 months as recommended by clinical practice guidelines. This study determined their thyroid function status during two-year follow-up visits in primary care, and the factors influencing their thyroid status, and assessed the optimal interval for TFTs., Methods: A retrospective cohort study was conducted on adults with a clinical diagnosis code for hypothyroidism in their electronic health records taken from a group of polyclinics in Singapore between July 2017 and June 2020. The follow-up thyroid status was categorized as under-replacement (TSH ≥ 3.70mIU/L), over-replacement (TSH ≤ 0.65mIU/L) or euthyroid (TSH 0.65-3.70mIU/L). The patients' demographic, clinical and TFT data were analyzed using appropriate statistical tests during the two-year follow-up. Stepwise logistic regression analysis identified the factors associated with suboptimal thyroid control. Kaplan-Meier analysis was used to compare their thyroid function status in association with the interval between TFT monitoring., Results: Data from 5,749 eligible subjects (mean age 62.1 ± 13.29 years; 79% female; 79.7% Chinese) were analyzed. After a two-year follow-up, 61.9% (n = 3558) of all subjects were euthyroid, with 29.5% (n = 1694) being under-replaced and 8.6% (n = 497) over-replaced. However, thyroid status did not differ significantly with the various dose regimen (daily, segmented, or alternate days) (p = 0.193). Stepwise logistic regression showed that thyroxine under-replacement was significantly associated with the male gender (AOR = 1.25,95%CI = 1.03-1.51,p = 0.02) and obesity (AOR = 1.34,95%CI = 1.08-1.66,p = 0.008). Every unit (μg/kg body weight) increase in the mean daily thyroxine dose was associated with 2.72 times greater odds of over-replacement. When comparing thyroid function monitoring at intervals of 13-24 months, monitoring at shorter intervals (≤ 12 months) was less likely to detect thyroxine under-replacement (AOR = 0.57,95%CI = 0.44-0.74,p < 0.001) and over-replacement (AOR = 0.62,95%CI = 0.41-0.97,p = 0.033). Among the 3,312 adults who were euthyroid at baseline, 22.2%, 41.7% and 59.6% had suboptimal thyroid control at 6, 12 and 24 months respectively (Kaplan-Meier analysis)., Conclusion: Around six in ten patients were euthyroid with thyroxine replacement for hypothyroidism in primary care over two years. Thyroxine under-replacement was associated with male gender and obesity. The proportion of euthyroid patients developing abnormal thyroid function doubled with TFTs at six, 12 and 24-month intervals., (© 2024. The Author(s).)

Introduction: Meta-analysis shows that home tele-monitoring (HTM) improves glycaemic control in patients with type-2 diabetes mellitus (T2DM) up to 12 months, but their health outcomes after HTM cessation remains unclear. This study aimed to determine the health outcomes of these patients 18 months after completing 6 months of HTM, compared to standard care., Methods: Patients with T2DM were enrolled in an open-labelled randomised controlled trial, aged 26 to 65 years, and suboptimal glycaemic control (HbA1c = 7.5%-10%). Patients in the intervention group ( n  = 165) undertook HTM using the OPTIMUM (Optimising care of Patients via Telemedicine In Monitoring and aUgmenting their control of diabetes Mellitus) HTM system for 6 months followed by usual care for another 18 months, while control group ( n  = 165) had usual care for 24 months. The OPTIMUM HTM system includes in-app video-based tele-education, tele-monitoring of the blood pressure (BP), capillary glucose and weight via Bluetooth devices and mobile applications, followed by algorithm-based telecare by the investigators. They were assessed using the Self-Care Inventory Scale (SCIR) and medication adherence (Medication Adherence Report Scale 5) at baseline, 6-month and 24-month time-points., Results: The data from 146 (intervention) and 152 (control) patients, with comparable baseline demographic profiles were eventually analysed. The decrease in HbA1c over 24 months was comparable between intervention and control group. Those in the intervention group were more likely to maintain their glycemic control (HbA1c ≤ 8%) (adjusted odds ratio (AOR) = 1.9, 95%confidence interval (CI) = 1.1-3.2; p  = 0.028), had higher SCIR score ( p  = 0.004), and less likely to "never forget" ( p  = 0.022), or "stop medications" ( p  = 0.048), at 24-month time-point as compared to subjects in the control group., Conclusion: The glycaemic control of patients with T2DM continued to be maintained for another 18 months after 6 months of HTM, which were attributed to sustained self-care behaviour and medication adherence., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study investigated osteoporosis risk factors among older Asian men with type-2 diabetes mellitus, hypertension, or hyperlipidaemia in primary care. Advanced age, dementia, depression, and polypharmacy were associated with higher risks for osteoporosis. Screening strategies targeting these factors are crucial for improving bone health as part of comprehensive preventive care., Purpose: Asian patients with type-2 diabetes mellitus (T2DM), hypertension, or hyperlipidaemia (DHL) are predominantly managed in primary care. They are also at risk of osteoporosis, but men are often under-screened and under-treated for this preventable bone disorder. This study aimed to identify the clinical characteristics and risk factors of osteoporosis among older men with DHL in primary care for early intervention., Methods: This retrospective study included men aged 65 years and older managed in public primary care clinics for their DHL between 1st July 2017 and 30th June 2018. Demographic, clinical, laboratory, and imaging data were extracted from their electronic medical records based on their International Classification of Diseases-10 (ICD-10) diagnosis codes. Descriptive statistical analyses, with statistical significance set at p < 0.05, were conducted, followed by generalized estimating equation (GEE) modelling., Results: Medical records of 17,644 men (83.1% Chinese, 16.9% minority ethnic groups, median age 71 years) were analysed. 2.3% of them had diagnosis of osteoporosis, 0.15% had fragility fracture, and 26.0% of those diagnosed with osteoporosis were treated with bisphosphonates. Their mean HbA1c was 6.9%; mean systolic and diastolic blood pressure were 133 and 69 mmHg. The GEE model showed that age (OR = 1.07, 95%CI = 1.05-1.09, p < 0.001), dementia (OR = 2.24, 95%CI = 1.33-3.77, p = 0.002), depression (OR = 2.38, 95%CI = 1.03-5.50, p = 0.043), and polypharmacy (OR = 6.85, 95%CI = 3.07-15.26, p < 0.001) were significantly associated with higher risks for osteoporosis., Conclusion: Age, dementia, depression, and polypharmacy are associated with osteoporosis risks in men with DHL. Strategies to incorporate osteoporosis screening among older men with these risk factors are needed to improve their bone health., (© 2024. The Author(s).)

Introduction: Telehealth increases care accessibility to patients with type-2 diabetes mellitus but the duration of its implementation to sustain optimal glycaemic control remains unclear. This study aimed to assess the health outcomes of these patients using the Optimizing care of Patients via Telemedicine In Monitoring and aUgmenting their control of diabetes Mellitus (OPTIMUM) home tele-monitoring (HTM) system 6 months post-intervention, compared to standard care., Methods: An open-labelled randomized controlled trial involving 330 participants with type-2 diabetes mellitus, aged 26-65 years, and suboptimal glycaemic control (HbA1c = 7.5%-10%) was conducted. Intervention group received OPTIMUM HTM for 6 months followed by usual care for another 6 months, while control group received usual care for 12 months. OPTIMUM HTM includes in-app video-based tele-education, tele-monitoring of the blood pressure, capillary glucose and weight via Bluetooth devices and mobile applications, followed by algorithm-based tele-management by the OPTIMUM HTM team. Assessments using self-care inventory scale and medication adherence were administered for both groups at baseline, 6-month, and 12-month timepoints., Results: Complete data from 156 (intervention) and 159 (control) participants, with comparable demographic profiles, were analysed. Both groups showed a significant reduction in HbA1c from baseline ( p  < 0.001). From 6-month to 12-month time-points, the intervention group was twice as likely to maintain their HbA1c ≤ 8% (adjusted odds ratio = 2.02, 95%CI = 1.18-3.49; p  < 0.011). The intervention group demonstrated higher scores for self-care behaviours (adjusted odds ratio = 3.83 [95%CI = 1.68-5.97], p  = 0.001) and not skipping medications (adjusted odds ratio = 2.32 [95%CI = 1.09-4.97], p  = 0.030) at 12 months., Discussion: The OPTIMUM HTM system enabled patients to maintain their glycaemic control beyond the intervention period. The favourable outcomes could be the effect of telehealth in sustaining self-care behaviour and medication adherence., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Telemonitoring programs have been found to be effective in improving diabetic control by promoting patients' self-management of diabetes through medication adherence, dietary modifications, and exercise. Nonetheless, few studies have assessed the cost-effectiveness of telemonitoring for the self-management of diabetes based on real-world data. Methods: A randomized controlled trial entitled Optimizing care of Patients via Telehealth In Monitoring and Augmenting their control of Diabetes Mellitus was conducted among adults with Type 2 Diabetes Mellitus in Singapore. Individuals in the intervention group ( n = 159) underwent a telemonitoring program comprising of remote patient monitoring, education, individualized health coaching, and teleconsultations, whereas individuals in the control group ( n = 160) received regular care. Economic evaluation was conducted from health care system and societal perspectives in 2020 in Singapore dollars, using health outcomes and costs documented at baseline and at 6 month follow-up. One-way sensitivity analyses and bootstrapping to generate scatter plot on cost-effectiveness planes were done. Results: The adjusted reduction in HbA1c scores was greater in the intervention group by -0.41 (95% confidence interval [CI], -0.65 to -0.17), while the change in utility scores was higher in the intervention group by 0.011 (95% CI, -0.016 to 0.0378). From a health care perspective, the incremental cost-effectiveness ratio (ICER) of the telemonitoring program per unit improvement in HbA1c, per additional case of well-controlled diabetes, and per unit improvement in quality adjusted life years was SGD 580.44, SGD 9100.15, and SGD 21,476.36, respectively. From a societal perspective, the ICERs were SGD 817.20, SGD 12,812.02, and SGD 30,236.36, respectively. Conclusions: The Optimizing care of Patients via Telehealth In Monitoring and Augmenting their control of Diabetes Mellitus telemonitoring program was effective and potentially cost-effective for the management and control of diabetes among patients in primary care.

Malnutrition may result in abnormal biochemical and hematological indices. This planned prespecified analysis investigated the effects of a specialized oral nutritional supplement (ONS) on biochemical and hematological indices in community-dwelling older adults at risk of malnutrition. In the Strengthening Health in ELDerly through nutrition (SHIELD) study, 811 older adults aged 65 years and above took part in this randomized, double-blind, placebo-controlled, multi-center study. Participants were randomly allocated to either a complete and balanced specialized ONS (each serving provides 262 kcal, 10.5 g protein, 7.75 µg vitamin D 3 , and 0.74 g calcium β-hydroxy-β-methylbutyrate) and dietary counselling (intervention group) or a placebo and dietary counselling (placebo group). Both groups consumed study products twice a day for 180 days. Data were collected at baseline, day 90, and day 180. Blood analysis results at follow-up visits were analyzed using repeated measures analysis of covariance with adjustments for confounders. Overall, when compared with the placebo group, the intervention group showed significantly greater urea (6.0 mmol/L vs. 5.4 mmol/L, p < 0.001), urea to creatinine ratio (4.39 vs. 4.26, p < 0.001), prealbumin (24.9 mg/dL vs. 24.0 mg/dL, p < 0.001), vitamin B 12 (480.0 pmol/L vs. 420.1 pmol/L, p < 0.001), and globulin levels (26.8 g/L vs. 26.5 g/L, p = 0.032). The intervention group also had a significantly higher absolute reticulocyte count (62.0 × 10 3 /µL vs. 58.2 × 10 3 /µL, overall p < 0.001) and mean platelet volume (10.0 fL vs. 9.9 fL, overall p = 0.003). Furthermore, significant improvements were seen in total protein at day 90 (71.7 g/L vs. 71.1 g/L, p = 0.017) and in absolute monocyte count at day 90 (0.50 × 10 3 /µL vs. 0.47 × 10 3 /µL, p = 0.009) in the intervention group. In conclusion, daily consumption of a specialized ONS for six months led to significant improvements in biochemical and hematological indices in community-dwelling older adults at risk of malnutrition.

Objectives: Early smoking initiation has been associated with a higher risk of developing long-term smoking habit. There is a growing global consensus that demands raising the minimum legal age (MLA) for smoking as an approach to address this problem. Singapore successfully raised the MLA from 18 to 21 years in 2021. This study aimed to evaluate the awareness and attitude of multi-ethnic Asian youth (aged 15-24) on raising MLA to 21 and passive smoking., Methods: A cross-sectional survey comprising of 23 items was circulated via a secure internet-based platform, FORMSG between September and November 2022. Data were analyzed for descriptive statistics. Categorical variables were compared for association with receptivity toward change in MLA using Chi-Squared test and multivariable logistic regression analysis using Rstudio. Post-hoc Bonferroni correction were further utilized for pairwise comparison., Results: Majority (80.3%) of the 608 participants expressed their support for MLA 21 implementation. Participants' age was a significant variable as those aged 15-17 years old (OR = 2.1, 95%CI = 1.01-4.32, p  = 0.048) showed a higher likelihood of supporting MLA implementation compared to those aged 21 and above. In addition, majority (89.8%) of them were also aware of the harmful effects of passive smoking. When it came to discouraging smoking among youth, family influence (64%) and school education (55.6%) emerged as the top strategies., Conclusion: Most of the youth express strong support for raising the MLA to 21, with over 80% in favor of such change, reflects a significant harmony among youth in favor of tobacco-free environment., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Gunasekaran, Singh, Ng, Koh, Lee, Tan, Wang and Tan.)

Aims: To evaluate the effectiveness of glaucoma screening using glaucoma suspect (GS) referral criteria assessed on colour fundus photographs in Singapore's Integrated Diabetic Retinopathy Programme (SiDRP)., Methods: A case-control study. This study included diabetic subjects who were referred from SiDRP with and without GS between January 2017 and December 2018 and reviewed at Singapore National Eye Centre. The GS referral criteria were based on the presence of a vertical cup-to-disc ratio (VCDR) of ≥0.65 and other GS features. The final glaucoma diagnosis confirmed from electronic medical records was retrospectively matched with GS status. The sensitivity, specificity and positive predictive value (PPV) of the test were evaluated., Results: Of 5023 patients (2625 with GS and 2398 without GS) reviewed for glaucoma, 451 (9.0%, 95% CI 8.2% to 9.8%) were confirmed as glaucoma. The average follow-up time was 21.5±10.2 months. Using our current GS referral criteria, the sensitivity, specificity and PPV were 81.6% (95% CI 77.7% to 85.1%), 50.6% (95% CI 49.2% to 52.1%) and 14.0% (95% CI 13.4% to 14.7%), respectively, resulting in 2257 false positive cases. Increasing the VCDR cut-off for referral to ≥0.80, the specificity increased to 93.9% (95% CI 93.1% to 94.5%) but the sensitivity decreased to 11.3% (95% CI 8.5% to 14.6%), with a PPV of 15.4% (95% CI 12.0% to 19.4%)., Conclusions: Opportunistic screening for glaucoma in a lower VCDR group could result in a high number of unnecessary referrals. If healthcare infrastructures are limited, targeting case findings on a larger VCDR group with high specificity will still be beneficial., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: There is an unmet need for precise biomarkers for early non-invasive breast cancer detection. Here, we aimed to identify blood-based DNA methylation biomarkers that are associated with breast cancer., Methods: DNA methylation profiling was performed for 524 Asian Chinese individuals, comprising 256 breast cancer patients and 268 age-matched healthy controls, using the Infinium MethylationEPIC array. Feature selection was applied to 649,688 CpG sites in the training set. Predictive models were built by training three machine learning models, with performance evaluated on an independent test set. Enrichment analysis to identify transcription factors binding to regions associated with the selected CpG sites and pathway analysis for genes located nearby were conducted., Results: A methylation profile comprising 51 CpGs was identified that effectively distinguishes breast cancer patients from healthy controls achieving an AUC of 0.823 on an independent test set. Notably, it outperformed all four previously reported breast cancer-associated methylation profiles. Enrichment analysis revealed enrichment of genomic loci associated with the binding of immune modulating AP-1 transcription factors, while pathway analysis of nearby genes showed an overrepresentation of immune-related pathways., Conclusion: This study has identified a breast cancer-associated methylation profile that is immune-related to potential for early cancer detection., (© 2024. The Author(s).)

Objective: We evaluated the impact of intermittently scanned continuous glucose monitoring(is-CGM)over self-monitoring of blood glucose(SMBG) in the context of diabetes self-management education (DSME) in sub-optimally controlled type 2 diabetes(T2D) in a multi-ethnicsetting., Research Design and Method: Randomized-controlled, open-label trial (NCT04564911), of T2D with HbA1c ≥ 7.5-≤10 %, on oral agents with/without basal insulin was carried out. Intervention arm received 6 weeks(w) continuous is-CGM, followed by one is-CGM/month till 24w. Control arm was advised to perform 4 SMBG/day. Educationwas delivered at weeks 0, 2, 8, 16., Primary Outcome: Change in HbA1c from baseline at 24w. Modified intention-to-treat (mITT) analysis with linear mixed-effect model for repeated measurementswas performed., Results: 176 subjects, age 55 ± 10.7 years(y), DM duration 11 ± 7.3y, BMI 27.8 ± 5.9 kg/m 2 , 58 % Male, 29.5 % basal insulin users were analysed. Within each arm,from baseline to 24w, mean HbA1c decreasedby -0.6 % (-6.6.mmol/mol, p-value < 0.01)and weight decreased(isCGM: -1.44 kg; SMBG: -1.25 kg, both p < 0.01). These changes were sustained to one year. However, there wasno significant difference in these parameters between arms (p-value > 0.05)., Conclusion: In the context of DSME, use of either SMBG or is-CGM led to improved glycaemia and reduced weight over a period of 24 weeks, sustained to one year., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: [The study used Abbott glucose meters, is-CGM devices and the Freestyle Libre Pro sensors which were procured at cost for the purpose of carrying out the study. Abbott Diabetes Care did not have any influence over the study protocol, insight into data or analysis. SRC has participated on speaker bureaus with Abbott, Medtronic, Sanofi and Dexcom. DSLG has participated on speaker bureaus with Medtronic, Embecta, Dexcom, Sanofi and Roche. DSLG has been paid consultation fees from Dexcom and Embecta]., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: The SingHypertension primary care clinic intervention, which consisted of clinician training in hypertension management, subsidized single-pill combination medications, nurse-delivered motivational conversations and telephone follow-ups, improved blood pressure control and cardiovascular disease (CVD) risk scores relative to usual care among patients with uncontrolled hypertension in Singapore. This study quantified the incremental cost-effectiveness, in terms of incremental cost per unit reduction disability-adjusted life years, of SingHypertension relative to usual care for patients with hypertension from the health system perspective., Methods and Results: We developed a Markov model to simulate CVD events and associated outcomes for a hypothetical cohort of patients over a 10-year period. Costs were measured in US dollars, and effectiveness was measured in disability-adjusted life years averted. We present base-case results and conducted deterministic and probabilistic sensitivity analyses. Based on a willingness-to-pay threshold of US $55 500 per DALY averted, SingHypertension was cost-effective for patients with hypertension (incremental cost-effectiveness ratio: US $24 765 per disability-adjusted life year averted) relative to usual care. This result held even if risk reduction was assumed to decline linearly to 0 over 10 years but not sooner than 7 years. Incremental cost-effectiveness ratios were most sensitive to the magnitude of the reduction in CVD risk; at least a 0.13% to 0.16% point reduction in 10-year CVD risk is required for cost-effectiveness. Probabilistic sensitivity analysis indicates that SingHypertension has a 78% chance of being cost-effective at the willingness-to-pay threshold., Conclusions: SingHypertension represents good value for the money for reducing CVD incidence, morbidity, and mortality and should be considered for wide-scale implementation in Singapore and possibly other countries., Registration Information: REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02972619.

Background: Despite the potential advantages of Internet-based diabetes self-management education, its adoption was not widespread among Singapore's public primary care clinics (polyclinics). An interactive online tool was thus developed to help educate patients with Type 2 diabetes mellitus (T2DM), and was now ready for user testing before implementation., Aim: To explore the perceived utility and usability of the educational tool in patients with suboptimally-controlled T2DM in a Singapore primary care setting., Methods: In-depth interviews were used to gather qualitative data from multi-ethnic Asian adults who had suboptimally-controlled T2DM. A total of 17 IDIs were conducted between April 2022 to March 2023, audio-recorded, transcribed, and analyzed to identify emergent themes via thematic analysis., Results: Regarding utility, users found the educational tool useful because it provided them with information that was comprehensive, accessible, reliable, and manageable. Regarding usability, the majority of users reported that the educational tool was easy to use, and suggested ways to improve navigational cues, visual clarity, readability and user engagement., Conclusion: Participants generally found the educational tool useful and easy to use. A revised educational tool will be developed based on their feedback and implemented in clinical practice., (© 2024. The Author(s).)

Background: The Diabetic Retinopathy Extended Screening Study (DRESS) aims to develop and validate a new DR/diabetic macular edema (DME) risk stratification model in patients with Type 2 diabetes (DM) to identify low-risk groups who can be safely assigned to biennial or triennial screening intervals. We describe the study methodology, participants' baseline characteristics, and preliminary DR progression rates at the first annual follow-up., Methods: DRESS is a 3-year ongoing longitudinal study of patients with T2DM and no or mild non-proliferative DR (NPDR, non-referable) who underwent teleophthalmic screening under the Singapore integrated Diabetic Retinopathy Programme (SiDRP) at four SingHealth Polyclinics. Patients with referable DR/DME (> mild NPDR) or ungradable fundus images were excluded. Sociodemographic, lifestyle, medical and clinical information was obtained from medical records and interviewer-administered questionnaires at baseline. These data are extracted from medical records at 12, 24 and 36 months post-enrollment. Baseline descriptive characteristics stratified by DR severity at baseline and rates of progression to referable DR at 12-month follow-up were calculated., Results: Of 5,840 eligible patients, 78.3% (n = 4,570, median [interquartile range [IQR] age 61.0 [55-67] years; 54.7% male; 68.0% Chinese) completed the baseline assessment. At baseline, 97.4% and 2.6% had none and mild NPDR (worse eye), respectively. Most participants had hypertension (79.2%) and dyslipidemia (92.8%); and almost half were obese (43.4%, BMI ≥ 27.5 kg/m 2 ). Participants without DR (vs mild DR) reported shorter DM duration, and had lower haemoglobin A1c, triglycerides and urine albumin/creatinine ratio (all p < 0.05). To date, we have extracted 41.8% (n = 1909) of the 12-month follow-up data. Of these, 99.7% (n = 1,904) did not progress to referable DR. Those who progressed to referable DR status (0.3%) had no DR at baseline., Conclusions: In our prospective study of patients with T2DM and non-referable DR attending polyclinics, we found extremely low annual DR progression rates. These preliminary results suggest that extending screening intervals beyond 12 months may be viable and safe for most participants, although our 3-year follow up data are needed to substantiate this claim and develop the risk stratification model to identify low-risk patients with T2DM who can be assigned biennial or triennial screening intervals., (© 2024. The Author(s).)

Background: Over the past few decades, the incidence of dengue fever has considerably increased. Effective vector control strategies and specific protection using dengue vaccine are thought to be the key elements to combat dengue. The dengue incidence among the Singapore youths (15-24 years) was second only to that of adults (25-44 years). This study evaluated the knowledge and attitude of Singapore youths on dengue and its preventive measures., Methods: A cross-sectional study using online-based questionnaire survey was conducted among Singapore youths from September to November 2022. Data were analyzed for descriptive statistics whereas Chi-squared test, linear regression analysis and Pearson correlation were used to determine the association between demographic factors and youth's attitude on dengue prevention using Rstudio., Results: A total of 624 respondents completed the survey out of 1822 surveys distributed nation-wide, with a response rate of 34.2% (mean age 17.4 years ± 1.84; 59.3% female; 89.9% Chinese). The mean dengue knowledge scores of participants were 14.1 ± 2.8. Univariate analysis showed that teenagers (15-19 years) had significantly higher knowledge score than the young adults (20-24 years) ( β =0.82,95%CI = 0.13-1.51, p  = 0.021). Majority of them were aware of the Mozzie Wipeout campaign (90.2%) followed by the release of Wolbachia mosquitos (69.1%). Two-thirds of the youths who were aware of Wolbachia and Gravitrap considered that it was effective in reducing dengue infection rates. Participants suggested information about the current dengue infection rate (71.9%) as the most effective of the five proposed strategies to improve uptake of dengue preventive measures. In comparison to young adults, teenagers were more likely to uptake dengue preventive measures if widespread mosquito control practices were implemented (69.1% vs. 42.3%)., Conclusion: The overall knowledge of the youths on dengue and its prevention was satisfactory. Future health promotion campaigns targeting the youths should focus on transforming the knowledge into practice., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Soo, Gunasekaran, Ng, Kwek and Tan.)