Environmental damage affects many aspects of healthcare, from extreme weather events to evolving population disease. Singapore's healthcare sector has the world's second highest healthcare emissions per capita, hampering the nation's pledge to reduce emissions by 2030 and achieve net zero emissions by 2050. In this review, we provide an overview of the impact environmental damage has on healthcare, including facilities, supply chain and human health, and examine measures to address healthcare's impact on the environment. Utilising the 'R's of sustainability - rethinking, reducing/refusing, reusing/repurposing/reprocessing, repairing, recycling and research - we have summarised the opportunities and challenges across medical disciplines. Awareness and advocacy to adopt strategies at institutional and individual levels is needed to revolutionise our environmental footprint and improve healthcare sustainability. By leveraging evidence from ongoing trials and integrating sustainable practices, our healthcare system can remain resilient against environment-driven challenges and evolving healthcare demands while minimising further impacts of environmental destruction.
Humans ; Climate Change ; Delivery of Health Care ; Singapore ; Conservation of Natural Resources ; Sustainable Development ; Environment

Purpose: This study aimed to evaluate the impact of declining surgical residency program enrollment on patient care and outcomes in colorectal cancer surgeries. Methods: This retrospective observational study included 676 patients (410 males; median age: 69 years) who underwent colorectal cancer surgery at Pusan National University Hospital between January 2018 and June 2024. Patients were divided into Group A (before December 31, 2023; with residents) and Group B (after January 1, 2024; without residents). All surgeries were performed by a single attending surgeon. Results: Preoperative variables were comparable between groups. Group A had more emergency and open surgeries, and a higher proportion of advanced-stage cancers. Overall complication rates were similar, but Group B had a longer hospital stay (9.72 days vs. 11.95 days). Specific complications such as anastomotic leakage and surgical site infections differed significantly. The overall number of surgical procedures declined markedly in 2024 compared to 2018 (77.1% vs. 49.9%). Conclusion The absence of residents did not increase overall complication rates but was associated with longer hospital stays and shifts in clinical practice. Greater reliance on attending surgeons contributed to more defensive decision-making and conservative patient management. Addressing these issues requires systemic reforms, including multidisciplinary collaboration and legal protections to improve surgical care.

Background: Human herpesvirus 6 (HHV-6) encephalitis is a rare but serious complication of allogeneic hematopoietic stem cell transplantation (HSCT). This study investigated the incidence, clinical features, and long-term neurological sequelae of HHV-6 encephalitis in pediatric and adolescent HSCT recipients. Methods: We retrospectively reviewed 92 patients who were younger than 20 years of age at the time of undergoing allogeneic HSCT between January 2015 and December 2024. HHV-6 encephalitis was diagnosed based on neurological symptoms and the detection of HHV-6 DNA in cerebrospinal fluid using multiplex polymerase chain reaction. Patients with HHV-6 encephalitis were followed for a median of six years (range, 4.5-8.5 years) to assess long-term neurological outcomes. Results: Three patients (3.2%) developed HHV-6 encephalitis between 15 and 26 days post-transplantation, coinciding with neutrophil engraftment. Clinical presentation included fever, seizures, altered consciousness, and short-term memory loss.Neuroimaging revealed high signal intensity lesions in the limbic system. Despite prompt antiviral therapy with foscarnet and initial viral clearance, all patients developed significant long-term neurological sequelae, including persistent cognitive impairment, epilepsy (two with refractory seizures), and memory disturbances. One patient continues to require assistance with activities of daily living, while two others face challenges reintegrating into school and society. Conclusion HHV-6 encephalitis following allogeneic HSCT in pediatric and adolescent patients can lead to severe and lasting neurological impairment, despite timely antiviral therapy. These long-term sequelae substantially affect quality of life and impose ongoing healthcare and societal burdens. Multidisciplinary long-term care is essential, and further research is warranted to improve prevention and treatment strategies.

Background: This study aimed to investigate changes in gene expression related to matrix synthesis in individuals with fullthickness rotator cuff tears (RCTs) and normal tendon tissues. The study also aimed to examine the differences in gene expression according to 4 distinct tear sizes. Methods: A total of 12 patients with full-thickness RCTs were included in the study, all of whom underwent arthroscopic rotator cuff repair. The RCTs were stratified by size into small, medium, large, and massive. Tendon samples were harvested from the midpoint between the lateral end of the torn tendon and the musculotendinous junction. Subsequent analysis of the tissue samples revealed the mRNA expression levels of 11 collagen types, 6 proteoglycans, and 8 glycoproteins through real-time polymerase chain reaction techniques. For control purposes, supraspinatus tendon tissue was sourced from 3 patients who had proximal humerus fractures but did not present with RCTs. Results: Among the 11 collagens and 14 non-collagenous protein (NCP) genes examined in this study, COL3A1 and COL10A1 showed a significant increase, whereas COL4A1 and COL14A1 showed a tendency to decrease compared to those in the normal group. ACAN significantly increased by 8.92-fold (p < 0.001) compared to that in the normal group, whereas DCN and LUM showed a tendency to decrease. FN1 and TNC increased significantly by 3.47-fold (p = 0.003) and 5.38-fold (p = 0.005), respectively, and the genes ELN, LAMA2, and THBS1 were all significantly reduced compared to those in the normal group. In the NCPs, almost all the genes with increased expression levels had the highest level in small size RCTs, and gene expression decreased as the size increased. The 3 proteoglycans (ACAN, BGN, and FMOD) showed the highest levels of expression in small size RCTs compared to those in the normal group, and 5 glycoproteins (COMP, FBN1, FN1, HAPLN1, and TNC) also showed the highest expression in small size RCTs. Conclusions We confirmed that most of the detected extracellular matrix gene expression changes were related to the size of the full-thickness RCTs. In NCPs, gene expression was increased in small-size tears, and gene expression levels were significantly reduced when the size increased.

Microplastics (MP) are pervasive environmental pollutants with potential adverse effects on human health, particularly concerning neurotoxicity. This study investigates the accumulation and neurotoxic effects of MP in cerebral organoids and mouse brains. Utilizing in vitro cerebral organoids and in vivo mouse models, we examined the penetration of MP, revealing that smaller MP (50 nm) infiltrated deeper into the organoids compared to larger ones (100 nm). Exposure to 50 nm MP resulted in a significant reduction in organoid viability. Furthermore, total RNA sequencing indicated substantial alterations in neurotoxicity-related gene expression.In vivo, MP-treated mice exhibited notable DNA fragmentation in the hippocampus and cortex, alongside elevated levels of inflammatory markers and neurotoxic metabolites, such as kynurenine (KYN) and 3-hydroxykynurenine (3-HK). Our findings suggest that MP may promote neurotoxicity through the kynurenine pathway, leading to heightened levels of neurotoxic compounds like quinolinic acid. This research highlights the potential for MP to induce neuroinflammatory responses and disrupt normal brain function, underscoring the need for further investigation into the long-term effects of MP exposure on neurological health.

Purpose: This study aimed to evaluate the impact of declining surgical residency program enrollment on patient care and outcomes in colorectal cancer surgeries. Methods: This retrospective observational study included 676 patients (410 males; median age: 69 years) who underwent colorectal cancer surgery at Pusan National University Hospital between January 2018 and June 2024. Patients were divided into Group A (before December 31, 2023; with residents) and Group B (after January 1, 2024; without residents). All surgeries were performed by a single attending surgeon. Results: Preoperative variables were comparable between groups. Group A had more emergency and open surgeries, and a higher proportion of advanced-stage cancers. Overall complication rates were similar, but Group B had a longer hospital stay (9.72 days vs. 11.95 days). Specific complications such as anastomotic leakage and surgical site infections differed significantly. The overall number of surgical procedures declined markedly in 2024 compared to 2018 (77.1% vs. 49.9%). Conclusion The absence of residents did not increase overall complication rates but was associated with longer hospital stays and shifts in clinical practice. Greater reliance on attending surgeons contributed to more defensive decision-making and conservative patient management. Addressing these issues requires systemic reforms, including multidisciplinary collaboration and legal protections to improve surgical care.

Background: Chromosomal alterations serve as diagnostic and prognostic markers in acute leukemia. Given the evolving landscape of chromosomal abnormalities in acute leukemia, we previously studied these over two periods. In this study, we investigated the frequency of these abnormalities and clinical trends in acute leukemia in Korea across three time periods. Methods: We retrospectively analyzed data from 1,787 patients with acute leukemia (319 children and 1,468 adults) diagnosed between 2006 and 2020. Conventional cytogenetics, FISH, and multiplex quantitative PCR were used for analysis. The patient groups were divided according to the following three study periods: 2006–2009 (I), 2010–2015 (II), and 2016–2020 (III). Results: Chromosomal aberrations were detected in 92% of patients. The PML::RARA translocation was the most frequent. Over the 15-yr period, chromosomal aberrations showed minimal changes, with specific fusion transcripts being common among patients.ALL was more prevalent in children than in adults and correlated significantly with the ETV6::RUNX1 and RUNX1::RUNX1T1 aberrations. The incidence of ALL increased during the three periods, with PML::RARA remaining common. Conclusions The frequency of chromosomal abnormalities in acute leukemia has changed subtly over time. Notably, the age of onset of adult AML has continuously increased. Our results may help in establishing diagnoses and clinical treatment strategies and developing various molecular diagnostic platforms.

Background: With growing elderly populations, management of patients with acute stroke is increasingly important. In South Korea, the Acute Stroke Quality Assessment Program (ASQAP) has contributed to improving the quality of stroke care and practice behavior in healthcare institutions. While the mortality of hemorrhagic stroke remains high, there are only a few assessment indices associated with hemorrhagic stroke. Considering the need to develop assessment indices to improve the actual quality of care in the field of acute stroke treatment, this study aims to investigate the current status of human resources and practices related to the treatment of patients with acute stroke through a nationwide survey. Methods: For the healthcare institutions included in the Ninth ASQAP of the Health Insurance Review and Assessment Service (HIRA), data from January 2022 to December 2022 were collected through a survey on the current status and practice of healthcare providers related to the treatment of patients with acute stroke. The questionnaire consisted of 19 items, including six items on healthcare providers involved in stroke care and 10 items on the care of patients with acute stroke. Results: In the treatment of patients with hemorrhagic stroke among patients with acute stroke, neurosurgeons were the most common providers. The contribution of neurosurgeons in the treatment of ischemic stroke has also been found to be equivalent to that of neurologists. However, a number of institutions were found to be devoid of healthcare providers who perform definitive treatments, such as intra-arterial thrombectomy for patients with ischemic stroke or cerebral aneurysm clipping for subarachnoid hemorrhage. The intensity of the workload of healthcare providers involved in the care of patients with acute stroke, especially those involved in definitive treatment, was also found to be quite high. Conclusion Currently, there are almost no assessment indices specific to hemorrhagic stroke in the ASQAP for acute stroke. Furthermore, it does not reflect the reality of the healthcare providers and practices that provide definitive treatment for acute stroke. The findings of this study suggest the need for the development of appropriate assessment indices that reflect the realities of acute stroke care.

Background: Dementia is a multifaceted disorder that affects cognitive function, necessitating accurate diagnosis for effective management and treatment. Although the Mini-Mental State Examination (MMSE) is widely used to assess cognitive impairment, its standalone efficacy is debated. This study examined the effectiveness of the MMSE alone versus in combination with other cognitive assessments in predicting dementia diagnosis, with the aim of refining the diagnostic accuracy for dementia. Methods: A total of 2,863 participants with subjective cognitive complaints who underwent comprehensive neuropsychological assessments were included. We developed two random forest models: one using only the MMSE and another incorporating additional cognitive tests.These models were evaluated based on their accuracy, precision, recall, F1-score, and area under the receiver operating characteristic curve (AUC) on a 70:30 training-to-testing split. Results: The MMSE-alone model predicted dementia with an accuracy of 86% and AUC of 0.872. The expanded model demonstrated increased accuracy (88%) and an AUC of 0.934.Notably, 17.46% of the cases were reclassified from dementia to non-dementia category upon including additional tests. Higher educational level and younger age were associated with these shifts. Conclusion The findings suggest that although the MMSE is a valuable screening tool, it should not be used in isolation to determine dementia severity. The addition of diverse cognitive assessments can significantly enhance diagnostic precision, particularly in younger and more educated populations. Future diagnostic protocols should integrate multifaceted cognitive evaluations to reflect the complexity of dementia accurately.

Background: With growing elderly populations, management of patients with acute stroke is increasingly important. In South Korea, the Acute Stroke Quality Assessment Program (ASQAP) has contributed to improving the quality of stroke care and practice behavior in healthcare institutions. While the mortality of hemorrhagic stroke remains high, there are only a few assessment indices associated with hemorrhagic stroke. Considering the need to develop assessment indices to improve the actual quality of care in the field of acute stroke treatment, this study aims to investigate the current status of human resources and practices related to the treatment of patients with acute stroke through a nationwide survey. Methods: For the healthcare institutions included in the Ninth ASQAP of the Health Insurance Review and Assessment Service (HIRA), data from January 2022 to December 2022 were collected through a survey on the current status and practice of healthcare providers related to the treatment of patients with acute stroke. The questionnaire consisted of 19 items, including six items on healthcare providers involved in stroke care and 10 items on the care of patients with acute stroke. Results: In the treatment of patients with hemorrhagic stroke among patients with acute stroke, neurosurgeons were the most common providers. The contribution of neurosurgeons in the treatment of ischemic stroke has also been found to be equivalent to that of neurologists. However, a number of institutions were found to be devoid of healthcare providers who perform definitive treatments, such as intra-arterial thrombectomy for patients with ischemic stroke or cerebral aneurysm clipping for subarachnoid hemorrhage. The intensity of the workload of healthcare providers involved in the care of patients with acute stroke, especially those involved in definitive treatment, was also found to be quite high. Conclusion Currently, there are almost no assessment indices specific to hemorrhagic stroke in the ASQAP for acute stroke. Furthermore, it does not reflect the reality of the healthcare providers and practices that provide definitive treatment for acute stroke. The findings of this study suggest the need for the development of appropriate assessment indices that reflect the realities of acute stroke care.