Multi-ethnic Asian Population Research Articles

Pilot robotic mastectomy in Singapore (PRoMiSing I) study: first safety and feasibility prospective cohort trial in South East Asia.

Robotic mastectomy has been performed worldwide since 2015. The advantages of the robotic approach in nipple-sparing mastectomy have been proven with better visualization and preservation of blood supply to the nipple-areolar complex (NAC), with a lower incidence of necrosis. It also allows smaller incisions for both mastectomy and immediate breast reconstruction. To date, no centers in Singapore and Southeast Asia offer robotic mastectomy. We believe that robotic mastectomy is a feasible and safe technique that can be utilized by our population. This study aimed to ascertain the surgical outcomes and perform a learning curve analysis in patients undergoing robotic mastectomy in a multi-ethnic South East Asian population. A single arm prospective pilot study of eligible patients aged 21-70 years old with early breast cancer or high-risk patients indicated for risk reducing mastectomy who were eligible and consented for robotic mastectomy were enrolled in this trial from 22nd December 2022 to 15th December 2023. A total of 29 consecutive robotic mastectomies were performed. The mean total operative time was 95±10.2 minutes. The average blood loss was 5.7±1.9ml and the average length of stay was 1.05 days. The mean mastectomy specimen weight was 251 g, and there was no conversion to conventional mastectomy in any case. Furthermore, there were no 30-days morbidity or complications in terms of wound infection requiring intervention, flap and nipple-areolar complex (NAC) necrosis, and postoperative hematoma/bleeding requiring intervention. This study contributes to the current evidence that robotic mastectomy is a safe and feasible option, and could prove to be a great alternative to conventional mastectomy. Further prospective trials examining the long-term oncological outcomes of robotic mastectomy will be performed to establish the oncologic safety of this technique in breast cancer treatment.

Associated Demographic Factors for the Recurrence and Prognosis of Stroke Patients within a Multi-Ethnic Asian Population.

There is a paucity of studies investigating the outcomes amongst Asian stroke patients. Identifying subgroups of stroke patients at risk of poorer outcomes could identify patients who would benefit from targeted interventions. Therefore, the aim of this study was to identify which ischemic stroke patients at high risk of recurrent events and mortality. This cohort study adhered to STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) guidelines. We obtained data from the Singapore Stroke Registry (SSR) from 2005 to 2016 and cross referenced to the Death Registry, Myocardial Infarction Registry. Outcome measures included recurrent stroke, acute myocardial infarction (AMI), all-cause and stroke-related deaths. Multivariable Cox proportional hazards regression models were performed to determine risk factors for recurrent stroke, AMI, all-cause and stroke-related deaths. A total of 64,915 patients (6,705 young, and 58,210 older) were included in our analysis. Older stroke patients were found to have an increased risk of recurrent stroke (HR = 1.21, 95%CI: 1.12-1.30), AMI (HR = 1.73, 95%CI: 1.54-1.95), all-cause death (HR = 2.49, 95%CI: 2.34-2.64) and stroke-related death (HR = 176, 95%CI: 1.61-1.92). Amongst young stroke patients, males were at increased risk for recurrent stroke (HR = 1.18, 95%CI: 1.01-1.39) and AMI (HR = 1.41, 95%CI: 1.08-1.83), but at reduced risk for all-cause (HR = 0.78, 95%CI: 0.69-0.89) and stroke-related death (HR = 0.79, 95%CI: 0.67-0.94). Ethnicity appeared to influence outcomes, with Malay patients at increased risk of recurrent stroke (HR = 1.37, 95%CI: 1.14-1.65), AMI (HR = 2.45, 95%CI: 1.87-3.22), all-cause (HR = 1.43, 95%CI: 1.24-1.66) and stroke-related deaths (HR = 1.34, 95%CI: 1.09-1.64). Indian patients were also at increased risk of AMI (HR = 1.96, 95%CI: 1.41-2.72). Similar findings were seen amongst the older stroke patients. This study found that older stroke patients are at risk of poorer outcomes. Within the young stroke population specifically, males were predisposed to recurrent stroke and AMI but were protected against all-cause and stroke-related deaths. Males were also at reduced risk of all-cause and stroke-related deaths in the older stroke population. Additionally, Malay and Indian patients experience poorer outcomes after first stroke. Further optimisation of risk factors targeting these high-priority populations are needed to achieve high quality care.

Development and External Validation of Machine Learning Models for Diabetic Microvascular Complications: Cross-Sectional Study With Metabolites.

Diabetic kidney disease (DKD) and diabetic retinopathy (DR) are major diabetic microvascular complications, contributing significantly to morbidity, disability, and mortality worldwide. The kidney and the eye, having similar microvascular structures and physiological and pathogenic features, may experience similar metabolic changes in diabetes. This study aimed to use machine learning (ML) methods integrated with metabolic data to identify biomarkers associated with DKD and DR in a multiethnic Asian population with diabetes, as well as to improve the performance of DKD and DR detection models beyond traditional risk factors. We used ML algorithms (logistic regression [LR] with Least Absolute Shrinkage and Selection Operator and gradient-boosting decision tree) to analyze 2772 adults with diabetes from the Singapore Epidemiology of Eye Diseases study, a population-based cross-sectional study conducted in Singapore (2004-2011). From 220 circulating metabolites and 19 risk factors, we selected the most important variables associated with DKD (defined as an estimated glomerular filtration rate <60 mL/min/1.73 m2) and DR (defined as an Early Treatment Diabetic Retinopathy Study severity level ≥20). DKD and DR detection models were developed based on the variable selection results and externally validated on a sample of 5843 participants with diabetes from the UK biobank (2007-2010). Machine-learned model performance (area under the receiver operating characteristic curve [AUC] with 95% CI, sensitivity, and specificity) was compared to that of traditional LR adjusted for age, sex, diabetes duration, hemoglobin A1c, systolic blood pressure, and BMI. Singapore Epidemiology of Eye Diseases participants had a median age of 61.7 (IQR 53.5-69.4) years, with 49.1% (1361/2772) being women, 20.2% (555/2753) having DKD, and 25.4% (685/2693) having DR. UK biobank participants had a median age of 61.0 (IQR 55.0-65.0) years, with 35.8% (2090/5843) being women, 6.7% (374/5570) having DKD, and 6.1% (355/5843) having DR. The ML algorithms identified diabetes duration, insulin usage, age, and tyrosine as the most important factors of both DKD and DR. DKD was additionally associated with cardiovascular disease history, antihypertensive medication use, and 3 metabolites (lactate, citrate, and cholesterol esters to total lipids ratio in intermediate-density lipoprotein), while DR was additionally associated with hemoglobin A1c, blood glucose, pulse pressure, and alanine. Machine-learned models for DKD and DR detection outperformed traditional LR models in both internal (AUC 0.838 vs 0.743 for DKD and 0.790 vs 0.764 for DR) and external validation (AUC 0.791 vs 0.691 for DKD and 0.778 vs 0.760 for DR). This study highlighted diabetes duration, insulin usage, age, and circulating tyrosine as important factors in detecting DKD and DR. The integration of ML with biomedical big data enables biomarker discovery and improves disease detection beyond traditional risk factors.

The development and validation of a macronutrient and taste preference ranking task in multiethnic Asian population

Understanding how changes in individual food preferences in a dynamic environment translate into dietary choices helps to unravel the aetiology of suboptimal nutrition in the population. To facilitate the measurements of food preferences in a multiethnic Asian population, we aimed to develop and validate the Macronutrient and Taste Preference Ranking Task (MTPRT) in an Asian population. We shortlisted 1770 local food items based on the predominant macronutrient groups (≥50 % macronutrient content is protein or fat or carbohydrates), classified their taste clusters, standard-photographed a final list of 36 food items, and developed an electronic survey through cognitive interviews with 30 participants. We then validated the MTPRT amongst 66 participants (mean (SD) age = 47.4 (11.7) years, 57.6 % male, with Chinese: Malay: Indian ethnicity ratio 3:1:1), through random crossover administration of sweet and savoury standard meals with equivalent macronutrients across 2 study visits over a week. The average duration taken to complete MTPRT was 14.1 (5.3) minutes. The sweet and savoury taste preference scores were inversely correlated (r = -0.9, p < 0.0001). The liking and preference for savoury taste were reduced after consuming savoury meals (p = 0.0009). The intra-person correlations for MTPRT scores were all r > 0.6, p < 0.001. The macronutrient preference scores were all positively associated with the self-reported macronutrient intakes derived from the Food Frequency Questionnaire, independent of sex, age, ethnicity, and BMI. Our study demonstrates the validity and reproducibility of MTPRT in multiethnic Asian populations for future evaluation of food preferences in multiethnic Asian population.

Physical activity, sedentary behavior, and sleep across lifespan in adults across European countries: Background and design

Introduction&#x0D; Regular physical activity (PA) has benefits for health throughout the lifespan. PA benefits musculoskeletal, cardio metabolic health, and overall well-being (Kapoor et al., 2022). However, data from 2017 shows that about 55-83% of women and 47-74% of men from European countries (EU) do not meet these guidelines (Lübs et al,. 2018). Moreover, adults at the age of 40-54 (aOR: 0.65, 95% CI: 0.52-0.81) and 55-64 (aOR: 0.61, 95% CI: 0.49-0.77) are less likely to have moderate or high levels of PA in comparison with those 18-24 years of age. (Nikitara et al., 2021). Sedentary behavior (SB) including activities such as watching television, playing computer games, browsing the internet has increased (Wang et al., 2019). Canada has an established track record in the development of 24-hour movement guidelines on PA, SB, and sleep. They have previously release guidelines for all age groups. Following Canada’s lead, several jurisdictions including Australia, New Zealand, South Africa have incorporated the 24-hour movement concepts (Tremblay, 2020). There is a lack of data for 24-hour behavior guideline in the European context. There are no specific recommendations on SB and sleep. Therefore, this project will present the background, methods and design of a 24-hour movement summary of behaviors (PA, SB and sleep) in Europe.&#x0D; Methods&#x0D; We will utilize existing PA, SB and sleep data from the World Health Organization on European adults 18+. Analysis using mean, median, and 95% confidence Intervals, will be complemented by frequency distributions and histograms. These will be stratified by age and sex subgroups for a more comprehensive overview.&#x0D; Results&#x0D; The findings from this research have the potential to inform surveillance efforts, shape policies and public health strategies, improve overall well-being, and contribute to the development of evidence-based guidelines.&#x0D; Discussion/Conclusion&#x0D; Implications of this research may inform researchers on further questions to pursue, policy makers in resource allocation, and practitioners on where to focus intervention efforts.&#x0D; References&#x0D; Kapoor, G., Chauhan, P., Singh, G., Malhotra, N., &amp; Chahal, A. (2022). Physical activity for health and fitness: Past, present and future. Journal of Lifestyle Medicine, 12(1), 9-14. https://doi.org/10.15280/jlm.2022.12.1.9&#x0D; Lübs, L., Peplies, J., Drell, C., &amp; Bammann, K. (2018). Cross-sectional and longitudinal factors influencing physical activity of 65 to 75-year-olds: A pan European cohort study based on the survey of health, ageing and retirement in Europe (SHARE). BMC Geriatrics, 18, Article 94. https://doi.org/10.1186/s12877-018-0781-8&#x0D; Nikitara, K., Odani, S., Demenagas, N., Rachiotis, G., Symvoulakis, E. K., &amp; Vardavas, C. (2021). Prevalence and correlates of physical inactivity in adults across 28 European countries. European Journal of Public Health, 31(4), 840-845. https://doi.org/10.1093/eurpub/ckab067&#x0D; Tremblay, M. S. (2020). Introducing 24-hour movement guidelines for the early years: A new paradigm gaining momentum. Journal of Physical Activity and Health, 17(1), 92-95. https://doi.org/10.1123/jpah.2019-0401&#x0D; Wang, N. X., Chen, J., Wagner, N., Rebello, S. A., Petrunoff, N., Owen, N., &amp; Müller‐Riemenschneider, F. (2019). Understanding and influencing occupational sedentary behavior: A mixed-methods approach in a multiethnic Asian population. Health Education &amp; Behavior, 47(3), 419-429. https://doi.org/10.1177/1090198119885431

A Comparative Study of Three Dementia Screening Instruments (CSI-D, CMMSE, and ECAQ) in a Multi-Ethnic Asian Population

Background—There is no validated dementia screening tool for multi-ethnic Asian populations comprising Chinese, Malays, and Indians. This study aimed to establish the psychometric properties of the Community Screening Instrument for Dementia (CSI-D), Chinese Mini Mental State Examination (CMMSE), and Elderly Cognitive Assessment Questionnaire (ECAQ) in multi-ethnic Singapore. Methods—Participants were randomly drawn from a community-based neurological diseases study of older adults conducted in Singapore, with oversampling to allow similar subject numbers from the three major ethnicities: Chinese, Malay, and Indian. The CSI-D, CMMSE, and ECAQ were administered by trained research nurses using a standardised translated questionnaire in a language the participant was most conversant in. Participants were independently diagnosed as a case/non-case of dementia using the DSM-IV. Results—There were 259 participants (85 Chinese, 85 Malays, and 89 Indians, mean age 70.15 years, 65.4% female, 58.8% had no/minimal formal education); 22.8% (n = 59) had dementia. Correlations between the measures were substantial. All the measures had acceptable overall discriminative abilities. Diagnostic accuracies of the instruments did not differ across the ethnic groups. Effects of education were present in the cognitive screening measures. Conclusions—The CSI-D, CMMSE, and ECAQ are valid dementia instruments in this multi-ethnic Asian setting.

P961 Achieving treatment targets in Ulcerative Colitis and reasons for failing to do so: Real world experience in a multi-ethnic asian population

Abstract Background In ulcerative colitis (UC), endoscopic remission (ER) is recommended as a long-term treatment target as it predicts favourable outcomes. We performed this study to identify the proportion of patients who achieved treatment targets as set out in the Selecting Therapeutic Targets in Inflammatory Bowel disease (STRIDE II) consensus. Secondly, we aim to identify the reasons for failing to meet treatment targets. Methods This is a retrospective analysis of all UC patients who were seen at Changi General Hospital, Singapore from 1 January 2000 to 31 December 2022. Patients were identified from an existing IBD registry. All patients with confirmed diagnosis of UC were included in the analysis. Those with follow up period less than 1 year or no repeat endoscopy were excluded. We collected baseline demographics, disease characteristics, medications, clinical activity scoring, biomarkers, endoscopic findings and histologic reports. We defined biomarker normalization, ER and histological remission as outlined in the STRIDE II consensus. Next, we compared factors associated with ER. We also assessed possible reasons for failure to achieve ER. SPSS version 26 was used for data analysis. Results After excluding 23 patients, a total of 139 patients were analysed with a mean follow-up time of 13.5 years. Figure 1 demonstrates the baseline demographics, disease characteristics, treatment modalities, remission targets and reasons for failure of ER. 96.4% of patients achieved clinical remission with a median time of 8 weeks (IQR: 4). Faecal calprotectin (FC) was not routinely measured at baseline but its use increase significantly after the STRIDE consensus. 53.4% of patients achieved biomarker normalization. ER was achieved in 58.3%. Of the 81 patients who achieved endoscopic remission, 49.4% also achieved histological remission. For patients who had repeat endoscopy within 1 year of diagnosis (35.3%, 49/139), 8.16% had achieved ER with a median time of 34 weeks (IQR: 4). Lower baseline C-reactive protein (CRP), follow-up FC, partial mayo score (PMS) at follow-up and biomarker normalization were associated with ER (Table 1). Interestingly more extensive disease was also associated with ER. The main reason for failing to achieve ER was non-compliance to treatment in 58% of the patients. A smaller proportion of patients refused treatment escalation due to absence of symptoms, cost concerns or repeating endoscopy after treatment escalation. Conclusion More than half of all patients with UC achieve long term target of ER in our population and baseline and follow-up biomarkers and PMS are associated with ER. Patients’ compliance is the key reason for failing to achieve ER. Thus, patient education should be reinforced to improve treatment outcomes.

Complexity of consumer acceptance to alternative protein foods in a multiethnic Asian population: A comparison of plant-based meat alternatives, cultured meat, and insect-based products

Alternative protein foods can be manufactured from various sources, including plants, insects, and cultured meat. Asia is a unique consumer market, with diverse ethnicities and culinary traditions that may impact consumer acceptance of these emerging protein products. Yet, few studies have compared various alternative protein foods within a multi-ethnic Asian population. We examined how sociodemographic factors were associated with alternative protein food acceptance and investigated the attitudes of individuals towards consuming plant-based meat alternatives, cultured meat, and insect-based products. Adult Singaporeans (n = 1224) from the Multi-Ethnic Cohort 2 study (75 % Chinese, 15 % Indian, 10 % Malay) were surveyed. Hierarchical ordinal regression was used to identify the sociodemographic and attitudinal factors of consumption intent and price sensitivity. Consumption intent for plant-based meat alternatives was the highest, followed by cultured meat, and insect-based products. The perception of un-naturalness was the strongest barrier to consumption intent and this perception was strongest for cultured meat, followed by insect-based products, and plant-based meat alternatives. Males and those more familiar with the products were more willing to consume alternative protein foods, whereas ethnic Malays were less willing. Attitudinal factors that were unique to specific types of alternative protein foods were concerns over zoonotic diseases (plant-based meat alternatives), distrust in gene technology (cultured meat), food neophobia and animal welfare (insect-based products). Participants were willing to pay more for alternative protein foods if they had concerns over drug residues in meat. Our findings suggest that differential strategies may be needed to promote acceptance of different types of alternative protein foods.

Differences in Social Environmental Characteristics between Intermittent and Daily Smokers in a Multiethnic Asian Population

Objectives: In this study, we assessed potential discrepancies in various social environmental factors between intermittent and daily smokers in Singapore, a multi-ethnic Asian urbanized city-state. Methods: We collected data from the Singapore Smokers Survey 2019 (SSS 2019) (N=2015, ages 19- 69 inclusive), consisting of 434 intermittent (nondaily) smokers and 1581 daily smokers to examine the relationships with social environmental variables including interpersonal communication, media exposure, social participation and social norms. Results: Overall, 22% of the participants self-reported as intermittent smoker. They differed from daily smokers in terms of interpersonal communication, social norms, and social participation. Intermittent smokers were characterized by stronger perceived disapproval of smoking by their family members, lower perceptions of smoking prevalence, and greater involvement in social/community participation. Compared to daily smokers, intermittent smokers were more likely to engage in conversations about quitting but perceived occasional smoking as less harmful.Conclusions: Findings from the study provide useful implications for designing and implementing targeted interventions and tobacco control policies in Singapore and other countries in the region.

Individual and combined associations of sarcopenia, osteoporosis and obesity with frailty in a multi-ethnic asian older adult population

BackgroundWe explored the relationships between sarcopenia (SP), osteoporosis (OP), obesity (OB), (alone and in combination) with physical frailty (PF) in a multi-ethnic, population-based study of Asians aged ≥ 60 years.MethodsParticipants were enrolled from the PopulatION HEalth and Eye Disease PRofile in Elderly Singaporeans Study (PIONEER) study. PF was defined using the modified Fried phenotype; SP using the Asian Working Group for Sarcopenia 2019; OP using bone mineral density scores; and OB using the fat mass index. Modified Poisson regression models investigated the associations between exposures and PF, and the relative excess rates of PF due to interactions (RERI) to determine synergistic or antagonistic interactions.ResultsOf the 2643 participants, 54.8% was female; and 49.8%, 25.1%, 25.0% were Chinese, Indians, and Malays, respectively. 25%, 19.0% and 6.7% participants had OB only, SP only, and OP only, respectively. A total of 356 (17.5%), 151 (7.4%) and 97 (4.8%) had osteosarcopenia (OSP), sarcopenic obesity (SOB) and osteo-obesity (OOB), respectively; while 70 (3.5%) had all 3 morbid conditions (osteosarcopenic obesity, OSO). Both SP only and OB only were strongly associated with increased rates of PF (RR: 2.53, 95% CI: 1.95, 3.29; RR: 2.05, 95% CI: 1.58, 2.66 respectively); but not OP. Those with OSP, OOB and SOB were also associated with high risks of PF (RR: 2.82, 95% CI: 2.16, 3.68; RR: 2.34, 95% CI: 1.69, 3.23; and RR: 2.58, 95% CI: 1.95, 3.41, respectively) compared to robust individuals. Critically, individuals with OSO had the highest relative risk of having PF (RR: 3.06, CI: 2.28, 4.11). Only the sarcopenia-obesity interaction was significant, demonstrating negative synergism (antagonism). The concurrent presence of SP and OB was associated with a 100% lower rate of PF compared to the sum of the relatively rates of SP only and OB only.ConclusionThe prevalence of SP, OB and OP, alone and combined, is substantial in older Asians and their early identification is needed to mitigate the risk of frailty. OB may interact with SP in an antagonistic manner to moderate rates of frailty. Further longitudinal studies are needed to address causality and mechanistic underpinnings our findings.

Risk factors of secondary cardiovascular events in a multi-ethnic Asian population with acute myocardial infarction

Risk factors of secondary cardiovascular events in a multi-ethnic Asian population with acute myocardial infarction

Analysis on epidemiology and influence of hyperkalemia in acute and chronic heart failure patients in a multi-ethnic Asian population

Analysis on epidemiology and influence of hyperkalemia in acute and chronic heart failure patients in a multi-ethnic Asian population

Reference intervals for carotid artery intima-media thickness measurements in the multi-ethnic Asian population: relationship with cardiometabolic risk factors

Abstract Background Carotid artery intima-media thickness (cIMT) is an intermediate surrogate marker for cardiovascular disease (CVD). It has been reported that although the distribution of cIMT values is very heterogeneous and values vary widely between different ethnicity, geographic location, and ultrasound protocol, the prediction of vascular events with study-specific cIMT values is consistent across all ethnicities and regions (1). Hence, Consensus Statement from the American Society of Echocardiography suggests that cIMT greater than or equal to 75th percentile for the patient’s age, sex, and ethnicity is indicative of increased CVD risk (2). Aims We aimed to establish age, sex, and ethnic-specific reference intervals in the multi-ethnic Asian population comprising Chinese, Malays, and Indians. Methods We analysed data from 8762 healthy individuals who had a 3D carotid ultrasonography done as part of the Health for Life in Singapore study. Carotid ultrasonography measurements were taken from the distal common carotid artery (CCA) at both the lateral and posterior angles bilaterally during the end-diastolic phase. The mean of all 4 measurements were taken as average cIMT (avgcIMT). For this analysis, we excluded individuals on treatment for diabetes, hypertension, hyperlipidemia, and ischemic heart disease to derive a healthy population subset comprising of 6522 individuals (Chinese: 69%, Malays: 14%, Indians: 17%). We then assessed the 75th percentile as a marker of cardiovascular risk in all individuals, by testing associations with Framingham risk scores (locally adapted) and with cardiometabolic risk factors (3). Results Ethnic- and sex-specific 75th percentiles (95% CI) of CIMT for our Asian populations are summarised in Table 1. Compared to reference intervals reported in European and African American populations, the 75th centiles are lower in all Asian ethnic subgroups (p&amp;lt;0.05). Framingham risk score, BMI, LDL-C, HbA1c and systolic blood pressure were higher in Asians with cIMT more than 75th percentile (p&amp;lt;0.001), compared to Asians with normal cIMT. Conclusions We estimated race- and sex-specific 75th percentiles of avgcIMT across age in the multi-ethnic Asian population. The thresholds for Asian populations are substantially lower than reported in European and African populations. The 75th centiles identify people with raised cardiovascular risk factors, supporting the validity of cIMT as marker of vascular risk in the population. The 75th centiles will be useful in interpretation of cIMT measures obtained both in research and clinical settings in different ethnic populations in Asia. Longitudinal evaluation is needed to determine the prediction of our Asian specific thresholds for predicting hard cardiovascular outcomes.

Synergistic Impact of Visual and Cognitive Impairments on Health-Related Quality of Life in a Multiethnic Asian Population

Introduction: The concomitant impact of visual impairment (VI) and cognitive impairment (CI) on health-related quality of life (HRQoL) in older adults is unclear. We aimed to determine the synergistic effect of baseline VI and CI on HRQoL decline at 6 years in multiethnic Asians. Methods: We included Chinese, Malay, and Indian adults aged ≥60 years who participated in baseline (2004–2011) and 6-year (2011–2017) follow-up visits of the Singapore Epidemiology of Eye Diseases Study, a population-based cohort study in Singapore. Visual acuity (VA) was objectively measured at both visits, with VI defined as presenting VA >0.3 LogMAR in the better eye. CI was defined as Abbreviated Mental Test scores of ≤6 and ≤8 for individuals with ≤6 and >6 years of formal education, respectively. HRQoL was measured using the European Quality of Life-5 Dimensions (EQ-5D) questionnaire. HRQoL decline was defined as the difference in the composite EQ-5D scores at baseline and 6-year follow-up and deemed clinically meaningful if the reduction was equal to or larger than the minimal clinically important difference. Multivariable linear regression assessed the independent associations and synergism (β interaction) between baseline VI and CI on EQ-5D decline. Results: Of the 2,433 participants (mean [SD] age: 67.6 [5.5]) at baseline, 559, 120, and 151 had VI only, CI only, and both impairments, respectively. HRQoL decline in individuals with baseline comorbid VI-CI was clinically meaningful and was 2.0 times (β = −0.044, 95% confidence interval: −0.077 to −0.010) and 3.7 times (β = −0.065, 95% confidence interval: −0.11 to −0.022) larger than those with VI only and CI only, respectively. Importantly, there was a significant synergism (β interaction = −0.048, 95% confidence interval: −0.095 to −0.001) between baseline VI and CI as predictors of HRQoL decline, suggesting that individuals having both conditions concurrently had a greater HRQoL reduction than the sum in those with VI alone and CI alone. The affected HRQoL domains included mobility and usual activities. Conclusions: Concomitant VI-CI potentiated HRQoL decline to a greater extent than the sum of individual contributions of VI and CI, suggesting synergism. Our results suggest that rehabilitative interventions such as the use of mobility aids and occupational therapy are needed to maintain HRQoL in older adults with concomitant VI-CI. Moreover, preventive interventions targeting at early detection and management of both VI and CI may also be beneficial.

Low molecular weight heparin use and thrombotic complications in upper gastrointestinal resection for malignancy in a multi-ethnic Asian population

ObjectiveEpidemiological studies showed substantially lower venous thromboembolic event risk among Asians compared to Caucasians. Yet no Asian guidelines addresses thromboprophylaxis following major surgery for upper gastrointestinal (UGI) malignancy. We aim to evaluate effects of LMWH on thromboembolic and bleeding events in our population. MethodsA retrospective study of all UGI resections for malignancy performed in a tertiary institution in Singapore between 2008 and 2018 was performed. Demographics, clinicopathological data and treatment outcome data were collected and analyzed. ResultsA total of 399 patients were included in the study. 210 (52.6%) received postoperative LMWH. Basic demographics-age, gender, BMI, smoking status were comparable. Most patients had cancers stage III or above (42.5% vs 34.6%) cancers. Patients who had open surgery were more likely to receive postoperative LMWH (81.8% vs 67.2%, p = 0.002).Postoperative mortality (3.2% vs 2.9%) and venous thromboembolic events (1.6% vs 1.4%) were similar. However, LMWH use was associated with increased blood transfusion (29.0% vs 12.7%, p < 0.001). ConclusionIncidence of venous thromboembolism was low and similar irrespective of postoperative LMWH use. However, LMWH use was associated with increased postoperative bleeding. Hence, we do not support routine LMWH for Asian patients undergoing UGI resection for malignancy.

Educators’ roles and challenges in supporting tertiary education students’ mental health: a qualitative study in Malaysia

PurposeEducators play a vital role in supporting tertiary education students’ mental health, as they have frequent interactions with their students. However, information on the strategies and difficulties educators face in this area is scarce, particularly within the multi-ethnic Asian population. Therefore, this study aims to explore Malaysian educators’ roles and challenges in handling students with mental health issues.Design/methodology/approachSemi-structured interviews were conducted with a sample of 12 educators from tertiary education in Malaysia. All interviews were recorded, transcribed and analysed using thematic analysis.FindingsFour themes were emerged: perceived factors contributing to mental health issues among students, educators’ strategies in supporting students’ mental health, difficulties in supporting students’ mental health and training to support students’ mental health.Originality/valueTo the best of the authors’ knowledge, this is the first study exploring the roles and challenges educators face in supporting tertiary education students’ mental health in Malaysia.

Cardiovascular disease and thinning of retinal nerve fiber layer in a multi-ethnic Asian population: the Singapore epidemiology of eye diseases study.

Our study aimed to examine the relationship between cardiovascular diseases (CVD) with peripapillary retinal fiber layer (RNFL) and macular ganglion cell-inner plexiform layer (GCIPL) thickness profiles in a large multi-ethnic Asian population study. 6,024 Asian subjects were analyzed in this study. All participants underwent standardized examinations, including spectral domain OCT imaging (Cirrus HD-OCT; Carl Zeiss Meditec). In total, 9,188 eyes were included for peripapillary RNFL analysis (2,417 Malays; 3,240 Indians; 3,531 Chinese), and 9,270 eyes (2,449 Malays, 3,271 Indians, 3,550 Chinese) for GCIPL analysis. History of CVD was defined as a self-reported clinical history of stroke, myocardial infarction, or angina. Multivariable linear regression models with generalized estimating equations were performed, adjusting for age, gender, ethnicity, diabetes, hypertension, hyperlipidaemia, chronic kidney disease, body mass index, current smoking status, and intraocular pressure. We observed a significant association between CVD history and thinner average RNFL (β = -1.63; 95% CI, -2.70 to -0.56; p = 0.003). This association was consistent for superior (β = -1.79, 95% CI, -3.48 to -0.10; p = 0.038) and inferior RNFL quadrant (β = -2.14, 95% CI, -3.96 to -0.32; p = 0.021). Of the CVD types, myocardial infarction particularly showed significant association with average (β = -1.75, 95% CI, -3.08 to -0.42; p = 0.010), superior (β = -2.22, 95% CI, -4.36 to -0.09; p = 0.041) and inferior (β = -2.42, 95% CI, -4.64 to -0.20; p = 0.033) RNFL thinning. Among ethnic groups, the association between CVD and average RNFL was particularly prominent in Indian eyes (β = -1.92, 95% CI, -3.52 to -0.33; p = 0.018). CVD was not significantly associated with average GCIPL thickness, albeit a consistent negative direction of association was observed (β = -0.22, 95% CI, -1.15 to 0.71; p = 0.641). In this large multi-ethnic Asian population study, we observed significant association between CVD history and RNFL thinning. This finding further validates the impact of impaired systemic circulation on RNFL thickness.

Trends in hemorrhagic stroke incidence and mortality in a National Stroke Registry of a multi-ethnic Asian population.

High-quality epidemiological data on hemorrhagic stroke (HS) and its subtypes, intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), remains limited in Asian ethnicities. We investigated the trends in HS incidence and 30-day mortality from 2005 to 2019 in a multi-ethnic Asian population from a national registry. Data on all stroke cases from the Singapore Stroke Registry from 2005 to 2019 were collected. Cases were defined using centrally adjudicated review of diagnosis codes. Death outcomes were obtained by linkage with the national death registry. Incidence (per 100,000 people) and 30-day mortality (per 100 people) were measured as crude and age-standardized rates. Trends were analyzed using linear regression. We analyzed 19,017 cases of HS (83.9% ICH; 16.1% SAH). From 2005 to 2019, age-standardized incidence rates (ASIR) for HS remained stable from 34.4 to 34.5. However, age-standardized mortality rates (ASMR) decreased significantly from 29.5 to 21.4 (p < 0.001). For ICH, ASIR remained stable while ASMR decreased from 30.4 to 21.3 (p < 0.001); for SAH, ASIR increased from 2.7 to 6.0 (p = 0.006) while ASMR remained stable. In subgroup analyses, HS incidence increased significantly in persons <65 years (from 18.1 to 19.6) and Malays (from 39.5 to 49.7). From 2005 to 2019, ASIR of HS remained stable while ASMR decreased. Decreasing ASMR reflects improvements in the overall management of HS, consistent with global trends. Population health efforts to address modifiable risk factors for HS in specific demographic subgroups may be warranted to reduce incidence and mortality of HS.

Predictors of real-world adherence to prescribed home exercise in older patients with a risk of falling: A prospective observational study.

Using a multi-ethnic Asian population, this study assessed adherence to prescribed home exercise programs, explored factors predicting adherence, and evaluated whether home exercise adherence was associated with physical activity. A prospective cohort study was conducted in 68 older adults (aged ≥65 years) from two geriatric outpatient clinics in Singapore, who were receiving tailored home exercises while undergoing 6 weeks of outpatient physical therapy for falls prevention. Adherence was measured as the percentage of prescribed sessions completed. Predictor variables included sociodemographic factors, clinical characteristics, intervention-specific factors, and physical and psychosocial measures. Multivariable linear regressions were performed to develop a model that best predicted adherence to prescribed exercise. Physical activity levels, measured by accelerometry, were analyzed by cross-sectional univariate analysis at 6 weeks. The mean adherence rate was 65% (SD 34.3%). In the regression model, the number of medications [B = 0.360, 95% CI (0.098-0.630)], social support for exercising [B = 0.080, 95% CI (0.015-0.145)], and self-efficacy for exercising [B = -0.034, 95% CI (-0.068-0.000)] significantly explained 31% (R 2 = 0.312) of the variance in exercise adherence. Older adults with better adherence took more steps/day at 6 weeks [B = 0.001, 95% CI (0.000-0.001)]. Low adherence to home exercise programs among older adults in Singapore, emphasizing the need for improvement. Counterintuitively, older adults with more medications, lower exercise self-efficacy, but with greater social support demonstrated higher adherence. Addressing unmet social support needs is crucial for enhancing adherence rates and reducing fall risks.

Mediating effect of symptom severity on the relationship between aggression, impulsivity and quality of life outcomes among patients with schizophrenia and related psychoses.

Aggression and impulsivity among individuals with schizophrenia have been associated with poor clinical outcomes including worsening of symptoms and substance abuse which have been linked to a lower quality of life (QoL). The current study aimed to look at the mediating effect of symptom severity on the relationship between aggression, impulsivity and QoL among outpatients with schizophrenia and related psychoses in a multi-ethnic Asian population. Data (n = 397) were collected from outpatients seeking treatment at the Institute of Mental Health. The World Health Organization quality of life-BREF (WHOQOL-BREF) scale, the symptoms checklist-90 revised (SCL-90-R), Buss Perry aggression questionnaire (BPAQ), and the Barratt impulsiveness scales (BIS) were used to assess subjective well-being, symptom severity, aggression, and impulsivity, respectively. Mediation analysis was performed using the PROCESS macro to understand the mediating effect of symptom severity. Motor impulsivity (MI) was indirectly associated with both the physical and psychological health domains of QoL while self-control was indirectly associated with the physical, psychological, and environmental health QoL domains through increased symptom severity. The significant indirect effect of symptom severity in our study highlights one potential pathway through which impulsivity impacts the QoL of individuals with schizophrenia and related psychoses. Elucidating other factors besides symptom severity that have an indirect effect on the QoL of individuals provides alternative approaches for treatment through which better clinical outcomes can be achieved.