People with type 2 diabetes mellitus have increased risk of chronic kidney disease and atherosclerotic cardiovascular disease. Improved care delivery and implementation of guideline-directed medical therapy have contributed to the declining incidence of atherosclerotic cardiovascular disease in high-income countries. By contrast, the global incidence of chronic kidney disease and associated mortality is either plateaued or increased, leading to escalating direct and indirect medical costs. Given limited resources, better risk stratification approaches to identify people at risk of rapid progression to end-stage kidney disease can reduce therapeutic inertia, facilitate timely interventions and identify the need for early nephrologist referral. Among people with chronic kidney disease G3a and beyond, the kidney failure risk equations (KFRE) have been externally validated and outperformed other risk prediction models. The KFRE can also guide the timing of preparation for kidney replacement therapy with improved healthcare resources planning and may prevent multiple complications and premature mortality among people with chronic kidney disease with and without type 2 diabetes mellitus. The present review summarizes the evidence of KFRE to date and call for future research to validate and evaluate its impact on cardiovascular and mortality outcomes, as well as healthcare resource utilization in multiethnic populations and different healthcare settings.

BACKGROUND: Tendon and ligament injuries accounted for 30% of all musculoskeletal consultations with 4 million new incidences worldwide each year and thus imposed a significant burden to the society and the economy. Damaged tendon and ligament can severely affect the normal body movement and might lead to many complications if not treated promptly and adequately. Current conventional treatment through surgical repair and tissue graft are ineffective with a high rate of recurrence.METHODS: In this review, we first discussed the anatomy, physiology and pathophysiology of tendon and ligament injuries and its current treatment. Secondly, we explored the current role of tendon and ligament tissue engineering, describing its recent advances. After that, we also described stem cell and cell secreted product approaches in tendon and ligament injuries. Lastly, we examined the role of the bioreactor and mechanical loading in in vitro maturation of engineered tendon and ligament.RESULTS: Tissue engineering offers various alternative ways of treatment from biological tissue constructs to stem cell therapy and cell secreted products. Bioreactor with mechanical stimulation is instrumental in preparing mature engineered tendon and ligament substitutes in vitro.CONCLUSIONS: Tissue engineering showed great promise in replacing the damaged tendon and ligament. However, more study is needed to develop ideal engineered tendon and ligament.
Bioreactors ; Exosomes ; In Vitro Techniques ; Incidence ; Ligaments ; Physiology ; Recurrence ; Referral and Consultation ; Stem Cells ; Tendons ; Tissue Engineering ; Transplants

Increasing prevalence of childhood obesity poses threats to the global health burden. Because this rising prevalence cannot be fully explained by traditional risk factors such as unhealthy diet and physical inactivity, early-life exposure to endocrine disrupting chemicals (EDCs) is recognized as emerging novel risk factors for childhood obesity. EDCs can disrupt the hormone-mediated metabolic pathways, affect children’s growth and mediate the development of childhood obesity. Many organic pollutants are recently classified to be EDCs. In this review, we summarized the epidemiological and laboratory evidence related to EDCs and childhood obesity, and discussed the possible mechanisms underpinning childhood obesity and early-life exposure to non-persistent organic pollutants (phthalates, bisphenol A, triclosan) and persistent organic pollutants (dichlorodiphenyltrichloroethane, polychlorinated biphenyls, polybrominated diphenyl ethers, per- and polyfluoroalkyl substances). Understanding the relationship between EDCs and childhood obesity helps to raise public awareness and formulate public health policy to protect the youth from exposure to the harmful effects of EDCs.
Adolescent ; Diet ; Endocrine Disruptors* ; Global Health ; Halogenated Diphenyl Ethers ; Humans ; Metabolic Networks and Pathways ; Pediatric Obesity* ; Polychlorinated Biphenyls ; Prevalence ; Public Health ; Risk Factors

INTRODUCTION: Despite reports suggesting an association between COVID-19 mRNA vaccination and pericarditis and myocarditis, detailed nationwide population-based data are sparsely available. We describe the incidence of pericarditis and myocarditis by age categories and sex after COVID-19 mRNA vaccination from a nationwide mass vaccination programme in Singapore. METHODS: The incidence of adjudicated cases of pericarditis and myocarditis following COVID-19 mRNA vaccination that were reported to the vaccine safety committee between January to July 2021 was compared with the background incidence of myocarditis in Singapore. RESULTS: As of end July 2021, a total of 34 cases were reported (9 pericarditis only, 14 myocarditis only, and 11 concomitant pericarditis and myocarditis) with 7,183,889 doses of COVID-19 mRNA vaccine administered. Of the 9 cases of pericarditis only, all were male except one. The highest incidence of pericarditis was in males aged 12-19 years with an incidence of 1.11 cases per 100,000 doses. Of the 25 cases of myocarditis, 80% (20 cases) were male and the median age was 23 years (range 12-55 years) with 16 cases after the second dose. A higher-than-expected number of cases were seen in males aged 12-19 and 20-29 years, with incidence rates of 3.72 and 0.98 case per 100,000 doses, respectively. CONCLUSION Data from the national registry in Singapore indicate an increased incidence of pericarditis and myocarditis in younger men after COVID-19 mRNA vaccination.
Adolescent ; Adult ; COVID-19/prevention & control* ; COVID-19 Vaccines/adverse effects* ; Child ; Female ; Humans ; Male ; Middle Aged ; Myocarditis/etiology* ; Pericarditis/etiology* ; RNA, Messenger ; SARS-CoV-2 ; Vaccination/adverse effects* ; Vaccines, Synthetic ; Young Adult ; mRNA Vaccines

Objectives: The aim of these Clinical Practice Guidelines is to provide evidence-based recommendations to assist healthcare providers in the screening, diagnosis and management of patients with postmenopausal osteoporosis (OP). Methods: A list of key clinical questions on the assessment, diagnosis and treatment of OP was formulated. A literature search using the PubMed, Medline, Cochrane Databases of Systematic Reviews, and OVID electronic databases identified all relevant articles on OP based on the key clinical questions, from 2014 onwards, to update from the 2015 edition. The articles were graded using the SIGN50 format. For each statement, studies with the highest level of evidence were used to frame the recommendation. Results: This article summarizes the diagnostic and treatment pathways for postmenopausal OP. Risk stratification of patients with OP encompasses clinical risk factors, bone mineral density measurements and FRAX risk estimates. Non-pharmacological measures including adequate calcium and vitamin D, regular exercise and falls prevention are recommended. Pharmacological measures depend on patients’ fracture risk status. Very high-risk individuals are recommended for treatment with an anabolic agent, if available, followed by an anti-resorptive agent. Alternatively, parenteral anti-resorptive agents can be used. High-risk individuals should be treated with anti-resorptive agents. In low-risk individuals, menopausal hormone replacement or selective estrogen receptor modulators can be used, if indicated. Patients should be assessed regularly to monitor treatment response and treatment adjusted, as appropriate. Conclusions The pathways for the management of postmenopausal OP in Malaysia have been updated. Incorporation of fracture risk stratification can guide appropriate treatment.

BACKGROUND AND OBJECTIVES: During the transitional period from fetal to neonatal life, there are dramatic changes in the newborn circulation. Among these changes, the left ventricular diastolic function can be easily assessed by Doppler measurement of the mitral inflow. However, there are many physiologic and hemodynamic factors responsible for the mitral inflow. This study was designed to evaluate several parameters that represent the left ventricular function during the transitional circulation period. SUBJECTS AND METHODS: Eighteen normal full-term infants were studied by serial two-dimensional, Doppler and color flow echocardiography within 24 hours before and after birth, between 2 days and 6 days after birth and between 7 days and 30 days after birth). RESULTS: One day after birth, the mitral valve (MV) E velocity and E/A increased (37.9+/-7.5 vs. 60.3+/-9.0 and 0.8+/-0.1 vs. 1.1+/-0.1, p<0.01, respectively), but the MV A velocity, the velocity of propagation (Vp), the LV isovolumic relaxation time (IVRT), the corrected IVRT and the tissue Doppler ventricular septum e' and s' did not change. Although Vp/E and a' decreased (1.2+/-0.3 vs. 0.7+/-0.2 and 8.2+/-1.8 vs. 6.5+/-1.7, p<0.05, respectively), the E/e' and the systolic and diastolic pulmonary venous flow velocities increased after birth (6.3+/-1.9 vs. 11.6+/-2.9, and 26.1+/-6.7 vs. 64.5+/-9.6, and 20.9+/-4.1 vs. 63.5+/-17.2, p<0.05, respectively). CONCLUSION: Increased preload plays a key role for the increased MV E/A ratio after birth. Other unknown factors (and possibly including pericardial restriction) may be also responsible for left ventricular diastolic function.
Echocardiography* ; Echocardiography, Doppler, Color ; Hemodynamics ; Humans ; Infant ; Infant, Newborn ; Mitral Valve ; Parturition ; Relaxation ; Ventricular Function, Left ; Ventricular Septum

INTRODUCTIONThis study aimed to evaluate the efficacy and safety of intra-articular glucocorticoid (IAG) injections in our institution in children with juvenile idiopathic arthritis (JIA).

METHODSThis is a retrospective assessment of IAG injections performed by the Department of Paediatrics, National University Hospital, Singapore, from October 2009 to October 2011. A total of 26 procedures were evaluated for efficacy, considering parameters such as clinical response, changes in systemic medication, length of time between repeat injections, safety, consent-taking, pre- and post-procedural advice, compliance with aseptic technique, and post-procedural complications.

RESULTSA total of 26 IAG injections of triamcinolone hexacetonide were administered over 17 occasions (i.e. patient encounters) to ten patients with JIA during the study period. After the injections, clinical scoring by a paediatric rheumatologist showed overall improvement by an average of 2.62 points out of 15. Besides six patient encounters that had an increase in systemic medication on the day of the injection, five required an increase within six months post injection, two required no adjustments, and one resulted in a decrease in medications. In all, 21 injections did not require subsequent injections. The mean interval between repeat injections was 7.8 months. Cutaneous side effects were noted in three anatomically difficult joints. Medical documentation with regard to patient progress was found to be lacking.

CONCLUSIONAs per the recommendations of the American College of Rheumatology, we safely used IAG injections as the first-line therapy in our group of patients with oligoarticular JIA, and/or as an adjunct to systemic therapy in our patients with JIA.

Adolescent ; Anti-Inflammatory Agents ; administration & dosage ; Arthritis, Juvenile ; drug therapy ; Child ; Child, Preschool ; Female ; Glucocorticoids ; administration & dosage ; Humans ; Injections, Intra-Articular ; Male ; Pediatrics ; methods ; Retrospective Studies ; Singapore ; Skin ; drug effects ; Treatment Outcome ; Triamcinolone Acetonide ; administration & dosage ; analogs & derivatives

Introduction: Human papillomavirus (HPV) testing is used as a means of triaging cervico-vaginalsmears with low grade squamous abnormalities or as part of co-testing with cytology. While HPVtesting has a high sensitivity, it has a low specificity in detecting cervical intraepithelial neoplasiagrade 2 and above (CIN 2+) leading to unnecessary colposcopy referrals. We investigate the accuracyof the p16/Ki-67 dual immunocytochemical stain in determining the presence of CIN 2+ lesions onhistology and its potential as a superior biomarker for triage. Methods: Liquid based cervico-vaginalcytology specimens with squamous abnormalities and corresponding histology from 97 women withsubsequent colposcopy and biopsy were included. The specimens were then subjected to the dual stainand Roche Cobas 4800 multiplex real time PCR HPV DNA testing. The sensitivity and specificity ofthe dual stain and HPV testing were calculated using CIN 2+ on histology as a reference standard.Results: The sensitivity and specificity of the dual stain in detecting histology proven CIN 2+ was93.7% and 76.5% while HPV testing was 85.7% and 14.7% respectively. Of the 44 women withASCUS or LSIL on cytology, the dual stain also reduced the number of unnecessary colposcopyreferrals from 27 to 7 when used as a triage marker compared to HPV testing. Conclusion: p16/Ki-67dual stain was more sensitive and specific than HPV testing in determining the presence of CIN 2+on histology. It could triage low grade cervico-vaginal specimens more effectively and potentiallyhelp women avoid unnecessary colposcopies. Future studies are needed to further evaluate its rolein cervical cancer screening programmes.

INTRODUCTION: General anaesthesia is associated with higher maternal morbidity and mortality when compared with regional anaesthesia, related mainly to failure of intubation, hypoxia and aspiration. The aim of this retrospective review was to define the incidence of failed and difficult intubation in parturients undergoing general anaesthesia for Caesarean delivery at a high-volume obstetric hospital in Singapore. METHODS: All parturients who underwent Caesarean delivery under general anaesthesia from 2013 to 2016 were identified and their medical records were reviewed to extract pertinent data. Difficult intubation was defined as 'requiring more than one attempt at intubation or documented as such, based on the opinion of the anaesthetist'. A failed intubation was defined as 'inability to intubate the trachea, with subsequent abandonment of intubation as a means of airway management'. RESULTS: Records of 660 Caesarean sections under general anaesthesia were extracted. The mean age of the parturients was 32.1 ± 5.5 years and the median body mass index was 27.5 (interquartile range 24.6-31.1) kg/m². Rapid sequence induction with cricoid pressure was employed for all patients, with thiopentone and succinylcholine being administered for 91.2% and 98.1% of patients, respectively. There were 33 difficult intubations among 660 patients, yielding an incidence of 5.0%. Junior trainees performed about 90% of all intubations and 28 (84.8%) out of 33 difficult intubations. Repeat intubations were performed by senior residents/fellows (57.1%) and consultants (14.3%). No instance of failed intubation was reported. CONCLUSION The local incidence of difficult obstetric intubation was one in 20. No failure of intubation was observed.
Adult ; Airway Management ; Anesthesia, General ; Cesarean Section ; Female ; Humans ; Intubation, Intratracheal ; Pregnancy ; Retrospective Studies