Tuberculosis (TB) remains endemic in Asia, with latent TB infection (LTBI) being prevalent, especially among older adults. People with rheumatic diseases (PRD) who are treated with tumour necrosis factor-alpha inhibitors (TNF-I) are at increased risk of TB reactivation, prompting a strong recommendation for screening and treatment of LTBI prior to initiating TNF-I. However, the need for screening before starting non- TNF-I immunosuppressive agents remains unclear. This consensus statement from Chapter of Rheumatologists, College of Physicians, Academy of Medicine, Singapore, offers recommendations on LTBI screening before initiating non-TNF-I immunosuppressive agents, and the need for repeat LTBI testing in patients on TNF-I who initially tested negative. Systematic literature reviews were performed to evaluate published guidelines and recommendations for LTBI screening before starting non-TNF-I immunosuppressive agents, and the need for repeat testing for LTBI during TNF-I use. Recommendations were formulated based on the evidence and expert opinion according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. The consensus comprises 3 overarching principles and 5 recommendations. We conditionally recommend that LTBI screening should be done before starting tocilizumab, Janus kinase inhibitors and moderate-to-high dose glucocorticoids. Conversely, routine screening need not be performed before starting cyclophosphamide. Annual testing for LTBI need not be performed routinely for patients on TNF-I if initial screening is negative. These recommendations provide guidance for LTBI screening in PRD. All recommendations in this consensus are conditional, reflecting a lack of evidence or low-level evidence. These will be updated as new evidence emerges.
This study aimed to investigate the relationship between plasma desialylated low-density lipoprotein (desLDL) levels and the severity of coronary artery disease (CAD), and to evaluate the potential value of desLDL as a biomarker for disease stratification and risk prediction. This study was conducted at Affiliated Nanhua Hospital, University of South China between December 2024 and June 2025. A total of 162 patients undergoing coronary angiography were enrolled and categorised into a CAD group (n=78) and a non-CAD group (n=84) based on the presence of ≥50% coronary stenosis. Plasma desLDL levels were quantified by liquid chromatography-mass spectrometry (LC-MS). Receiver operating characteristic (ROC) analysis compared the diagnostic performance of desLDL with conventional lipid parameters, and multivariable logistic regression was applied to assess the independent predictive value of desLDL. Plasma desLDL levels were significantly higher in the CAD group than in controls. Among CAD patients, those with >2 diseased vessels had higher desLDL levels than those with ≤2 vessels, and both exceeded control values (P<0.001). The ROC area under the curve was 0.836 (95% confidence interval [CI] 0.779-0.893); a threshold of 2.25 mmol/L provided 75.6% sensitivity and 84.2% specificity, outperforming LDL cholesterol and total cholesterol. Multivariable analysis identified desLDL as the strongest independent predictor of CAD (adjusted odds ratio 5.85, 95% CI 2.69-12.69). DesLDL elevations were similar in acute myocardial infarction and stable CAD presentations, while both remained significantly higher than controls. Elevated plasma desLDL levels were significantly associated with the presence of CAD and reflected anatomical disease burden, demonstrating superior predictive performance compared with conventional lipid markers.
Sepsis-induced myopathy (SIM) is a severe complication contributing to long-term morbidity and mortality in sepsis survivors. Emerging evidence highlights the role of pyroptosis in SIM pathogenesis. This study aims to identify pyroptosis-related genes and potential pharmacological targets for SIM and explore their therapeutic implications. The GSE13205 dataset from the Gene Expression Omnibus database was analysed to identify differentially expressed pyroptosis-related genes in SIM. Gene Set Variation Analysis, Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses were performed to investigate the biological functions and associated pathways. Hub genes were identified through protein-protein interaction network analysis. The Connectivity Map (CMap) database was used to predict candidate therapeutic compounds targeting these genes. A total of 39 pyroptosis-related genes were identified as differentially expressed in SIM. These genes were primarily associated with apoptosis, regulation of cell death, p53 signalling, circadian rhythm and responses to hypoxia and chemical stress. KEGG pathway analysis revealed enrichment in apoptosis, p53 signalling, microRNA in cancer and endocrine resistance pathways. Ten potential therapeutic compounds were predicted via CMap based on hub gene profiles. However, experimental validation of these compounds in the context of SIM is needed to assess their therapeutic efficacy. This study identifies key pyroptosis-related genes and potential therapeutic compounds for SIM, providing new insights into its molecular mechanisms and suggesting novel strategies for treatment. Further experimental validation is required to confirm the clinical relevance and therapeutic potential of these findings.
Oesophago-gastro-duodenoscopy (OGD) is the gold standard for evaluating upper gastrointestinal (UGI) symptoms. However, the quality of endoscopic examinations varies widely. This paper, initiated by the Gastroenterological Society of Singapore (GESS), aims to standardise best practices and enhance OGD procedure quality in Singapore. A core group of 6 experienced gastroenterologists conducted a comprehensive literature review, referencing established international guidelines. They developed preliminary statements, which underwent 2 rounds of formal voting by a broader group of consultant-level gastroenterologists. Statements were reviewed, modified and re-evaluated using the Delphi process, and assigned levels of evidence and recommendation using the US Preventive Services Task Force model. The threshold for acceptance of statements was agreed to be 80% or higher. Twenty consensus statements were finalised, covering pre-requisite, pre-procedure, intra-procedure and post-procedure quality indicators. The GESS consensus statements provide recommendations for institutions in Singapore to establish quality standards for white light UGI endoscopy, facilitating high-quality, safe and accurate endoscopic care.
Targeted therapies have significantly transformed the management of chronic lymphocytic leukaemia (CLL), yet most recommendations continue to reflect Western practice patterns. Variations in disease biology, healthcare resources and treatment accessibility across the Asia-Pacific (APAC) necessitate region-specific guidance. The Asia-Pacific Leukaemia Consortium (APLC) therefore developed updated consensus statements to support standardised, context-appropriate care for patients with CLL. A modified Delphi process was conducted with 17 haematology experts from multiple APAC regions. A systematic literature search (i.e. MEDLINE via PubMed) covering publications from 2016 onwards informed the development of 29 statements across 3 domains: diagnosis, treatment and long-term management. Panel members rated each statement using a 5-point Likert scale. Consensus was defined a priori as a mean score ≥3.5. Statistical measures and iterative expert discussions guided refinement of the final recommendations. Twenty-nine statements reached consensus with key recommendations addressing: (1) appropriate use of genetic and prognostic testing, particularly TP53 and immunoglobulin heavy chain (IGHV) status; (2) first-line and relapsed/refractory treatment selection, including the role of Bruton's tyrosine kinase (BTK) inhibitors, B-cell lymphoma 2 inhibitors, combination strategies, cellular therapies and emerging modalities; and (3) long-term monitoring, toxicity surveillance and management of complications such as autoimmune cytopenias. Regionspecific considerations-such as variable access to novel agents and diagnostic platforms-were incorporated throughout. These updated APLC consensus recommendations provide clinicians across the APAC with an evidence-based, pragmatic framework for managing CLL. They aim to support treatment consistency, optimise sequencing strategies and address gaps in diagnostics, access and long-term survivorship care across diverse healthcare settings.
Medical Home (MH) is a hospital-at-home (HaH) service model developed to deliver multidisciplinary acute medical care for patients in their homes. This study evaluated the patient-centred outcomes and cost-effectiveness of the MH service compared with usual care (UC). This quasi-experimental study involved 250 patients recruited from July 2021 to May 2023. Data on costs, healthcare resource utilisation, and patient-centred outcomes were collected at index admission, discharge, and 90 days post-discharge. Regression analyses were employed to estimate the incremental differences in patient-centred outcomes and net monetary benefit (NMB) between MH and UC groups, while adjusting for confounders. A probabilistic sensitivity analysis (PSA) was conducted to evaluate the uncertainty surrounding the data inputs for cost-effectiveness analysis. Subgroups excluding U-turn patients (i.e. patients admitted to the hospital before discharge from MH) and deaths were analysed for patient-centred and cost-effectiveness outcomes. There was no statistically significant difference between the 2 groups in clinical, functional, and experience outcomes, except for length of stay and caregiver's overall experience in which the MH group had significantly better results compared with UC group. Compared to the UC group, the MH group showed a positive incremental NMB of SGD6895 (approximately USD5361; 95% confidence interval SGD1945-11,845) indicating the cost-effectiveness of the MH service. Results from the PSA showed that the MH group was costeffective across a range of willingness-to-pay thresholds. Subgroup analyses were consistent with the base case for patient-centred and cost-effectiveness outcomes. We conclude that an HaH care model like MH is a value-based and cost-effective alternative to admission to hospital for selected frail elderly patients, making it the preferred strategy.
Human papillomavirus (HPV) causes over 95% of cervical cancers. The American Society for Colposcopy and Cervical Pathology (ASCCP) guidelines support a risk-based approach using the most informative test, which may include high-risk (HR) or extended genotyping. Most laboratories perform partial genotyping. This study reports findings from the comprehensive genotyping of all 14 HR HPV genotypes in cervical samples from the Singapore population. A total of 2497 cervical specimens collected in ThinPrep PreservCyt vials underwent full HPV genotyping using real-time polymerase chain reaction TOCE technology (Seegene Inc, Seoul, South Korea). Among these, 327 (13.1%) tested positive for HPV. Cytology results were available for 275 (84.1%) of these HPV-positive cases. The authors examined genotype prevalence and cytology correlations, and compared follow-up management under the Society for Colposcopy & Cervical Pathology of Singapore (SCCPS) guidelines versus ASCCP 2019 guidelines. HPV52 and 58 were the most prevalent genotypes, accounting for 32.2% of all detected HPV genotypes. Co-infections were seen in 20.2% of samples. Among 31 (9.5%) HPV16/18 cases, most had normal cytology, though some showed atypical or low-grade changes. Under the ASCCP guidelines for primary screening, 16.8% of cases could defer to repeat HPV testing in 1 year instead of immediate cytology triage under SCCPS. In co-testing, ASCCP-guided management reduced colposcopy referrals by 7.4% since these cases would only require repeat HPV testing in 1 year. Comprehensive HPV genotyping enhances risk stratification and enables more efficient patient management. Compared to SCCPS, the ASCCP guidelines reduce unnecessary procedures while preserving safety, supporting broader adoption of full genotyping and risk-based triage in cervical screening programmes in Singapore.
Atrial septal aneurysm (ASA) is a well-recognised abnormality on the echocardiogram; it is a mobile, localised saccular deformity of the atrial septum and is defined as excursion of the septal tissue of greater than 10 mm from the plane of the atrial septum into either atrium or a combined excursion of 15 mm. Several reports suggest possible links with atrial arrhythmias, increased prevalence of cryptogenic stroke and other embolic events. The authors discussed 3 atypical presentations of ASA that they encountered. Clinicians should be cognisant of these atypical appearances of ASA.
Depressive symptoms represent a major public health concern among middle-aged and older adults. Grip strength, a key indicator of physical frailty and biological ageing, and sleep disturbance, a recognised precursor of depression, have been independently linked to mental health outcomes. However, their combined effect on depressive symptoms remains unexplored. This study aimed to examine the association between grip strength levels, sleep status and their combined effects on the risk of depressive symptoms in middle-aged and older adults. This prospective cohort study included 16,395 participants from the Survey of Health, Ageing and Retirement in Europe, followed from 2006 to 2017. Logistic regression and generalised estimating equations were used to examine associations. During follow-up, 5241 participants (31.97%) developed depressive symptoms, with higher incidence in females (58.98%). After adjusting for covariates, both low grip strength (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.02-1.23) and sleep disturbance (OR 1.66, 95% CI 1.50-1.84) were independently associated with elevated risk of depressive symptoms. A synergistic effect was observed: individuals with both low grip strength and sleep disturbance had 1.87 times higher risk (95% CI 1.60-2.17) compared to those with high grip strength and no sleep disturbance. Sex- and agestratified analyses revealed stronger associations in males and older adults (≥70 years). Low grip strength and sleep disturbance are independently and synergistically associated with risk of depressive symptoms. Screening for both factors may help identify high-risk individuals for targeted preventive interventions.
The authors aim to determine tuberculosis (TB) incidence and ascertain risk factors for TB in patients with stage 5 chronic kidney disease (CKD5) in the Singapore population. A retrospective cohort study of all stage CKD5 patients registered in Singapore's renal registry who developed active pulmonary and extra-pulmonary TB between 2012 and 2021, after their CKD5 diagnosis. TB incidence among CKD5 patients was significantly higher compared to the general Singapore population, ranging from 279 to 630 per 100,000 CKD5 population over the period from 2012 to 2021, versus 32.6 to 41.1 per 100,000 general population during the same period. In univariable comparisons, statistically significant risk factors for development of TB disease in CKD5 patients were: male sex (odds ratio [OR] 1.66, 95% confidence interval [CI] 1.3-2.12, P<0.001), Malay ethnicity (OR 1.33, 95% CI 1.02-1.72, P=0.03) and reported history of "ever smoking" (OR 2.93, 95% CI 2.15-4.03, P<0.001). CKD5 patients who were on any type of dialysis were also observed to have a significantly higher risk of developing TB disease, haemodialysis (OR 2.31, 95% CI 1.69-3.23, P<0.001), peritoneal dialysis (OR 2.53, 95% CI 1.46-4.23, P=0.001) or a combination of haemodialysis and peritoneal dialysis (OR 2.55, 95% CI 1.63-3.95, P<0.001), compared to those who had not been initiated on dialysis. These factors remained significant in the multivariable models except ethnicity. CKD5 patients have an increased risk of developing TB, particularly when certain risk factors are present, such as male sex or receiving dialysis. Clinicians should maintain a high degree of suspicion for TB in CKD5 patients with compatible clinical symptoms.
Enhancing the understanding of mental health of migrant workers (MWs) and migrant domestic workers (MDWs) is both economically and morally important. This study aimed to examine the prevalence and correlates of depressive and anxiety symptoms among MWs and MDWs in Singapore. This cross-sectional study recruited 1465 MWs from August 2022 to July 2023, and 1462 MDWs from March 2023 to November 2023 through convenience sampling. Depressive symptoms were assessed using Patient Health Questionnaire-9, whereas anxiety symptoms were evaluated using the Generalized Anxiety Disorder-7. Both scales were dichotomised at a cut-off score of 10. Covariates included in the analysis were sociodemographic characteristics, stress level, insomnia, social support and resilience. Correlates were examined using multivariable logistic regression models. Among MWs, 0.83% had moderate-to-severe depressive symptoms and 1.25% had mild-to-severe anxiety symptoms. Among MDWs, 4.05% had moderate-to-severe depressive symptoms and 4.23% had moderate-to-severe anxiety symptoms. MWs were more likely to develop anxiety symptoms if they had low resilience (adjusted prevalence ratio [APR] 2.41), and less likely to develop anxiety symptoms if they had high resilience (APR 0.71). MDWs were more likely to develop depressive symptoms if they worked >14 hours per day (APR 1.42), and less likely to develop depressive symptoms if they had high resilience (APR 0.55). Enhancing resilience among both groups is vital for protection against depressive and anxiety symptoms. The findings also highlight the detrimental effects of overworking on the mental health of MWs and MDWs.
Sarcopenia is the progressive loss of muscle strength and mass that is commonly, though not exclusively, associated with increasing age. It has been well established to be associated with increased risk of adverse health outcomes and is a growing public health challenge. Reported prevalence varies widely by setting and diagnostic criteria, complicating surveillance and cross-study comparisons. The recent development of the conceptual definition of sarcopenia by the Global Leadership Initiative in Sarcopenia marks a critical step towards harmonisation. There have been significant advances in our understanding of the pathophysiological basis, biomarkers, assessment, diagnosis and interventions in sarcopenia. Novel biomarkers (including creatinine–cystatin C indices, myokines and composite multi-marker panels) and artificial intelligence-enabled radiomics from computed tomography, magnetic resonance imaging and ultrasound show promise for scalable, opportunistic case-finding, but currently remain research tools requiring large-scale validation and cost-effectiveness assessments. Management remains grounded in resistance exercise and nutrition, although there is ongoing debate on the optimal type of protein as well as the most effective timing of protein intake in relation to exercise and the amount required. Pharmacological and regenerative approaches are under active investigation but have yet to deliver proven, generalisable clinical benefits. Translation into practice hinges on standardised definitions, validated assessment tools and integrated care pathways that embed sarcopenia screening into chronic disease management and public health programmes. Singapore’s first national sarcopenia consortium aims to accelerate translation into clinical practice and community care by advancing mechanistic research, validating novel biomarkers and developing scalable interventions to enhance muscle health and promote healthy ageing.
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Generative artificial intelligence (AI) is a recent technological advancement that has become increasingly ubiquitous in its usage. Conversational AI, powered by large language models (LLMs) in particular, has opened many possibilities in psychiatry for providing psychoeducation, mental health support and even evidencebased therapy for people with mental health concerns. Despite its possible benefits, there are inherent limitations and dangers to this technology. In this commentary, the authors explore the possible link between psychosis and conversational AI with the use of a case illustration. The authors show how the sycophantic and excessively agreeable nature of LLMs, combined with its use of human-like language and capacity to generate inaccurate information, might collude with and reinforce delusional beliefs of a user with psychosis. Further research on the interaction between conversational AI and psychopathology would be essential in the process of incorporating such a powerful tool into clinical practice, and would aid in developing the necessary guidelines and safeguards to optimise its inevitable use, and minimise its abuse and untoward effects.
Neurofilament light chain (NfL) is a blood biomarker of neuronal injury in inflammatory and neurodegenerative disorders. The red cell distribution width-to-albumin ratio (RAR) reflects systemic inflammation and nutritional status. This study investigated whether higher RAR is associated with higher serum NfL (sNfL) in a general adult population. Data from 1750 adults who participated in the 2013-2014 National Health and Nutrition Examination Survey were analysed. RAR was calculated as red cell distribution width (%) divided by serum albumin (g/dL). sNfL was measured using an automated Atellica chemiluminescent immunoassay. Participants were grouped into RAR quartiles. Survey-weighted multivariable linear regression and restricted cubic spline (RCS) models assessed associations between RAR and log-transformed sNfL, adjusting for demographic, socioeconomic, lifestyle and clinical factors. Each unit increase in RAR was associated with higher sNfL in unadjusted analysis, and this association remained significant in partially and fully adjusted models. Compared with participants in the lowest quartile, those in the highest RAR quartile had higher sNfL, with a significant trend across quartiles. RCS analysis showed a non-linear but monotonic increase in log-transformed sNfL with higher RAR (P for non-linearity = 0.020). Associations varied by race/ethnicity, body mass index and diabetes status. Higher RAR is associated with higher sNfL in US adults. This epidemiological association suggests that inflammation/nutritional status may relate to neuroaxonal injury. Longitudinal studies are needed to establish temporality and assess prognostic value before any clinical application.
Menopause is a universal life transition with lived experiences shaped by biological, psychological, sociocultural and systemic factors. In Singapore, where diverse cultural norms intersect with a high-pressure professional environment, little is known about how these influences converge to shape symptom recognition, coping and care. This qualitative study formed part of the multicountry MARIE project on menopause and midlife health. Eighteen participants with different menopausal stages were purposively sampled ensuring variation in age, ethnicity, socio-economic status and health status. Semi-structured interviews explored symptom profiles, psychosocial well-being, family and workplace dynamics, and healthcare experiences. Data were analysed using the Delanerolle and Phiri framework, integrating biological, psychological, sociocultural and health system domains. Participants described heterogeneous symptom trajectories, with vasomotor, genitourinary and cognitive symptoms as most prominent. Multimorbidity and surgical menopause intensified symptom burden and narrowed treatment options. Anxiety, low mood and brain fog impaired work, particularly without workplace support. Sociocultural silences and misinformation reinforced selfmanagement and delayed care-seeking. Resilience rooted in peer and family support, and culturally familiar coping strategies buffered distress for some. Health system gaps included inconsistent general practitioner's knowledge, reluctance to prescribe hormone therapy and private care costs. Study participation itself triggered symptom recognition and help-seeking in some, underscoring menopause invisibility in routine care. Findings highlight that menopause in Singapore is navigated through intersecting clinical, cultural and structural determinants. Addressing inequities requires embedding women's voices into clinical pathways, training clinicians in culturally competent care, and implementing workplace and public health policies that legitimise menopause as a health and occupational issue.
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