Stroke remains a leading global cause of death and disability. Primary prevention efforts to reduce the burden of stroke should focus on the management of modifiable risk factors, and 10 such factors were noted to account for approximately 90% of the population-attributable risk of stroke in the INTERSTROKE study.1 These risk factors are often inter-related, with obesity contributing to major cardiovascular risk factors including hypertension, diabetes mellitus, and dyslipidaemia. A meta-analysis of prospective cohorts found that metabolically unhealthy phenotypes carry roughly double the stroke risk at any body weight, whereas metabolically healthy obesity confers only a modest excess (risk ratio of 1.17), suggesting that much of obesity-related stroke risk is transmitted through metabolic intermediaries, with a smaller direct contribution.2 In INTERSTROKE, abdominal obesity defined by waist-to-hip ratio, rather than body mass index (BMI), carried an independent population-attributable risk of 18.6%,1 and central adiposity has been linked to greater stroke severity and poorer early functional outcome in a single-centre prospective cohort,3 which may partly explain the obesity paradox previously described for BMI. This has been attributed to the detrimental effects of visceral fat accumulation in driving systemic inflammation, insulin resistance, and cardiovascular risk. The body roundness index (BRI) was introduced by Thomas et al. in 2013 to quantify abdominal adiposity and overall body fat by integrating the geometric relationship between waist circumference and height, with subsequent research validating its relationship with visceral adiposity and metabolic syndrome.4,5
Modern clinical training is increasingly conducted in technology-rich environments supported by advanced diagnostics, automated systems, and structured workflows. These environments support efficient learning but may offer fewer opportunities for trainees to develop adaptive expertise, particularly when familiar resources, technologies, or processes are unavailable. Resource availability, however, exists on a spectrum, and even well-resourced systems can become stretched during pandemics, supply-chain disruptions, workforce shortages, or service overload. In such situations, clinicians need to prioritise, communicate clearly, reason with incomplete information, and adapt to changing conditions. For this reason, exposure to settings where resources are stretched, variable or constrained can complement modern training by strengthening clinical judgement, observation, teamwork and confidence in core clinical skills. Evidence on elective placements has described self-reported improvements in clinical examination skills, reduced reliance on extensive investigations and greater cultural awareness. However, such experiences must also be ethically and feasibly structured, with attention to host-institution needs, supervision, scope of practice, financing, and equity of access. Since external placements may not be available to all trainees, adaptive expertise should also be cultivated within existing training programmes through history-and-examination-first teaching, no-investigation case discussions, simulation under constraint and structured reflection. The aim is not to privilege 1 training environment over another, but to prepare clinicians to practise safely and thoughtfully across the full spectrum of resource availability by intentionally building adaptive expertise.
Multivariable regression tables are common in observational clinical research, but their coefficients are often over-interpreted. A model built to estimate the effect of 1 exposure may also report coefficients for age, sex, comorbidities, behaviours, and other adjustment variables. These additional rows are frequently read as independent risk factors, even when the analysis was not designed to estimate their effects. This is the Table 2 fallacy. The problem is not the use of adjustment, but the interpretation of adjustment terms as if each were a separate causal estimate. In this commentary, we use a directed acyclic graph and a single worked example to show why the coefficient for the exposure of interest can answer the intended clinical question, while coefficients for adjustment variables may not represent clinically actionable effects. We also show how similar errors arise when interaction terms are interpreted as causal. Authors should specify the target estimand (the causal effect the analysis is designed to estimate) and exposure, choose adjustment variables from the assumed causal structure, interpret only the exposure coefficient, and fit a separate model for each further question. We set out red flags, recurring pitfalls, and questions to ask of any risk-factor table. A regression table is not a menu of modifiable risks. An association is clinically actionable only when the study was designed to support that interpretation.
Introduction: China’s population has aged rapidly in recent decades, accompanied by a steady rise in Alzheimer’s disease and other dementias (ADOD). Understanding long-term national trends is important for anticipating future healthcare needs. Methods: The authors analysed Global Burden of Disease (GBD) 2023 estimates for China from 1990 to 2023, following the Guidelines for Accurate and Transparent Health Estimates Reporting, with STROBE used as a secondary reporting reference. Deaths, disability-adjusted life years (DALYs), incidence, and prevalence were examined together with crude rates, age-standardised rates (ASRs), and average annual percentage changes. Results were evaluated and stratified by sex and broad age group. Modelled risk-attributable burden was assessed for selected GBD risk factors—ambient particulate matter pollution, high fasting plasma glucose, smoking, and household air pollution from solid fuels. Results: Over the study period, the number of people affected increased markedly. Deaths rose from 122,411 in 1990 to 586,002 in 2023, while DALYs and prevalent cases more than tripled. In contrast, ASR showed only modest upward changes. Women had higher ASRs in 2023, although mortality- and DALY-related rates increased more quickly among men. The burden remained concentrated in those aged 75 years and older. Among the selected exposures, ambient particulate matter pollution accounted for the largest attributable share in 2023, whereas household air pollution declined over time. Conclusion: The marked increase in absolute ADOD burden, together with smaller changes in ASR, is consistent with demographic ageing being an important contributor to rising dementia-related service needs in China. The risk-attributable estimates suggest changing population-level patterns for selected environmental and metabolic exposures, but they should not be interpreted as individual-level causal effects.
Introduction:Despite the association between sepsis and carotid-femoral pulse wave velocity, the relationship between estimated pulse wave velocity (ePWV) and sepsis remains unclear. This study investigated the correlation between ePWV and 28-day mortality in patients with sepsis. Method:Using data from the Medical Information Mart for Intensive Care IV database between 2008 and 2019, the association between ePWV and 28-day mortality was analysed with Kaplan-Meier curves, Cox models, and res-tricted cubic splines (RCS). Subgroup analysis was performed to validate the findings. A combined model was constructed by screening variables via Cox-least absolute shrinkage and selection operator (LASSO), with its incremental predictive value evaluated using receiver operating characteristic (ROC) curves and decision curve analysis (DCA). Results:Survival analysis showed an inverse association between ePWV and survival rates (log-rank test P<0.001). Cox analysis demonstrated that each increase in ePWV was associated with a significantly higher risk of 28-day mortality in patients with sepsis (hazard ratio 1.905, 95% confidence interval 1.672-2.169, P<0.001), with linearity confirmed by RCS analysis (P-nonlinear=0.3313). Subgroup analysis indicated significant interaction effects of invasive ventilation (P-interaction <0.001) and a history of malignant tumours (P-interaction =0.005) on mortality. The combined model optimised by LASSO demonstrated the best discriminative performance (ROC=0.823) and an improved net clinical benefit with the inclusion of ePWV, as confirmed by DCA. Conclusion:ePWV was linearly and positively correlated with the risk of 28-day mortality in patients with sepsis.
Introduction:Acute coronary syndrome (ACS) carries a high early risk of recurrent events, yet time-to-target low-density lipoprotein cholesterol (LDL-C) is often prolonged, and goal attainment is suboptimal in real-world practice. The authors aimed to develop expert consensus recommendations for post-ACS lipid management in Singapore, focusing on LDL-C targets, pharmacotherapy, escalation strategies, and implementation tools to improve adherence and reduce therapeutic inertia. Method:A modified Delphi methodology was employed with a panel of 10 members. Evidence was synthesised from guidelines, randomised trials, metaanalyses, and observational studies. Thirty-two statements were drafted across 5 domains (LDL-C targets; timing/ monitoring; pharmacotherapy; special populations; implementation/adherence/health-system strategies) and rated anonymously on a 5-point Likert scale. Consensus thresholds were defined as high (≥75% concordant), moderate (55-74%), and low (<55%). Results:After the final round, 30 of 32 statements achieved high consensus, and 2 received low consensus. Key agreements included measuring lipids within 24 hours of admission and retesting at 4-6 weeks, early initiation of high-intensity statins, and upfront combination therapy with statin + ezetimibe when monotherapy is unlikely to achieve the goals. Consideration of a proprotein convertase subtilisin/kexin type 9 inhibitor at discharge was recommended if LDL-C remained >1.4 mmol/L. Special considerations included older adults, familial hypercholesterolaemia, lower statin adherence among women, and the role of lipoprotein(a). The panel recommended adopting objective metrics, integrating electronic health record prompts, and developing localised pathways to harmonise care transitions. Conclusion:The consensus recommendations provide a tailored approach for Singapore, emphasising early action, proactive escalation, and systems-level interventions to improve post-ACS outcomes.
Aortic regurgitation (AR) is a common valvular heart disease, with a cohort study reporting an approximate prevalence of 13% in men and 8.5% in women.1 Severe AR portends significant mortality and morbidity if untreated.2 Aortic valve surgery remains the gold standard for management.3 However, a significant proportion are treated conservatively because of high surgical risks, significant comorbidities, or the patient’s refusal of surgery.4 Despite the success of transcatheter aortic valve implantation (TAVI) for the management of aortic stenosis (AS), existing devices have not been designed for the treatment of AR. In patients with limited surgical options, these devices have been used off-label with higher associated risks.5 The recent development of dedicated devices has changed the landscape.6,7 In particular, the ALIGN-AR study demonstrated the safety and efficacy of the use of the Trilogy transcatheter heart valve (THV) (JenaValve Technology, Irvine, CA, US) in treating patients with severe tricuspid AR.7 The Trilogy valve is a porcine pericardial THV composed of 3 leaflets within a self-expanding nitinol stent scaffold. It has 3 locators which are centred on the native aortic cusps, limiting implant depth and allowing clipping to the native leaflets for secure anchoring.7 To the authors’ knowledge, this is the first case series in Southeast Asia (SEA) to describe the initial experience with the Trilogy THV for the treatment of severe tricuspid AR.
Introduction:Although monocyte and albumin levels have been associated with survival in various malignant tumours, their specific prognostic significance in nasopharyngeal carcinoma (NPC) remains under-explored. This study seeks to examine the relationship between the monocyte-to-albumin ratio (MAR) and overall survival (OS) in NPC patients to create a precise prediction model. Method:The authors retrospectively analysed data from 860 NPC patients who underwent concurrent chemoradiotherapy. The optimal cut-off for MAR was determined using the maximum selection log-rank method. Univariate and multivariate Cox proportional hazards models were applied to identify factors significantly related to OS. A predictive nomogram was then developed and rigorously validated for its accuracy. Results:The optimal MAR threshold was determined to be 11.63, effectively categorising the 860 NPC patients into 2 prognostic subgroups (hazard ratio 0.56; 95% confidence interval [CI] 0.41-0.77, P<0.001). The predictive nomogram exhibited strong predictive capability for OS, factoring in T stage, N stage, MAR value, body mass index, and age over 45 years. The concordance index (C-index) of the traditional tumour- node-metastasis staging system was found to be 0.64 (95% CI 0.57-0.70), which was less than the C-index of the nomogram (0.68; 95% CI 0.64-0.72) for OS. Conclusion:MAR was identified as an innovative and independent prognostic factor in NPC patients, presenting a potential biomarker for personalised treatment strategies.
Introduction:Nursing home (NH) residents are vulnerable to infections and avoidable hospital transfers. The Infectious Diseases Community Program was developed as a multicomponent intervention to strengthen infection prevention and control (IPC), improve vaccination uptake, and support clinical decisionmaking in NHs. Method:The authors conducted a retrospective cohort study in 6 NHs in western Singapore with pre- and post-implementation data, in collaboration with an acute hospital. A total of 4801 admissions were screened, of which 2045 fever-related admissions were included. The intervention comprised IPC training, policy and process reviews, vaccination support, antimicrobial guidance, and implementation of a structured fever and desaturation pathway to standardise hospital transfer decisions. Results:New methicillin-resistant Staphylococcus aureus (MRSA) acquisitions declined from 14.6% to 9.7% (relative reduction 33.6%, 95% confidence interval [CI] -6.8 to -3.1, P<0.001). Inappropriate fever-related transfers decreased from 12.0% (108/898) to 7.3% (61/839), a relative reduction of 39.2% (absolute reduction 4.8%, 95% CI -7.5 to -2.0, P<0.001). Influenza vaccination coverage exceeded 90% by 2022. Staff surveys indicated sustained adoption, with 84% reporting regular use of the pathway. Conclusion:A collaborative model integrating acute hospital expertise with NH teams was associated with improved IPC outcomes, increased vaccination coverage, and reduced inappropriate transfers, supporting safer care delivery in long-term care.
Introduction: Osteoporosis is a progressive disease characterised by changes in bone structure leading to fragility fractures. In Singapore, it is a significant health concern with a high prevalence, and is expected to increase as the population ages. These consensus statements aim to provide scientifically grounded recommendations for the management of osteoporosis, to standardise its management in Singapore and promote multidisciplinary collaboration. Methods: An expert panel comprising 18 representatives from 10 Singapore medical bodies developed consensus statements based on current evidence and through multiple online meetings. Each panellist voted on each statement independently using a 3-point Likert scale (Agree, Neutral, Disagree). Consensus (total ratings of “Agree”) was set a priori at ≥80%, with statements not reaching this threshold excluded for lacking consensus. Results: The expert panel reached consensus on 80 consensus statements. These include 10 statements on screening, risk factors, and fracture risk assessment; 7 statements on initial bone mineral density testing; 5 on the indications for pharmacotherapy; 20 on osteoporosis pharmacotherapy; 24 on treatment targets, treatment monitoring, and follow-up bone mineral density testing; and 14 statements on the prevention and management of medication-related osteonecrosis of the jaw. Conclusion: The consensus statements in this paper guide clinicians in using the latest evidence and expert opinion to inform appropriate diagnostic and therapeutic approaches for the management of osteoporosis. These statements are not intended to replace current guidelines, but rather to support clinical decision-making and help develop individualised, patient-centred management plans based on the patient’s demographics, clinical characteristics, and preferences.
Introduction: 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). Methods: 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. Results: 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 with 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 cost-effective across a range of willingness-to-pay thresholds. Subgroup analyses were consistent with the base case for patient-centred and cost-effectiveness outcomes. Conclusions: 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.
The readers writing this letter read with interest Hwang et al.’s article on augmented intelligence in healthcare,1 and agree that it would be most responsible for artificial intelligence (AI) to enhance, rather than replace clinical judgment. The more urgent question for Singapore’s clinicians today is therefore not whether to use AI, but where to prioritise its deployment for responsible, meaningful impact.
Introduction: Chronic myeloid leukaemia (CML) patients on tyrosine kinase inhibitors (TKIs) show adequate antibody responses to SARS-CoV-2 vaccination, but T-cell responses remain unclear. This study investigates the overall immune responses in these patients after vaccination. Methods: In this longitudinal study, CML patients on TKIs who received at least 3 doses of the SARS-CoV-2 vaccine were assessed for neutralisation activity against the wild-type (WT) and Omicron variants at multiple time points: baseline (D0), week 4 (D28), month 6 (M6), and after the booster dose at months 3 (B3), 6 (B6), and 12 (B12). T-cell responses were evaluated at B6 and B12, with comparisons made to healthy controls (HC). Results: Twenty-seven CML patients and 113 HC were included. Neutralising activity against WT was similar across groups at all time points. Fewer CML patients exhibited positive neutralisation against Omicron at B6 (50.0% versus 88.9%, P=0.003), with higher antibody levels in CML patients at D28 and M6, but lower levels at B6 (P<0.05). T-cell responses were similar between groups at B6 and B12. Conclusion: Neutralising activity against WT and Omicron was similar, with a decline at B6, while T-cell responses were comparable across groups. These findings highlight the importance of continued vaccination in CML patients.
