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Hepatitis B virus (HBV) infection is the most common cause of liver disease and liver cancer in Singapore, being endemic despite availability of an efficacious vaccine. To assess the factors associated with HBV screening and vaccination. Using mixed methods analysis, focus group discussions were conducted alongside a cross-sectional study amongst 784 Singapore Citizens and Permanent Residents aged 25–69 residing in Housing and Development Board (HDB) flats. Amongst the respondents, 50.6% were screened and 37.8% were vaccinated. The self-reported prevalence of HBV infection was 3.4% and that of HBsAg seropositivity among those screened was 4.3%. Routine health screening was the most common reason cited for screening (32.9%) while doctors’ recommendation was the most common reason for vaccination (42.7%). For both screening and vaccination, knowledge and cost were the top facilitators and barriers respectively. Multivariable regression models revealed the most significant predictors for not undergoing screening to be poor knowledge (p < 0.001), the presence of stigma (p = 0.040) and not being employed in a healthcare sector (p = 0.022), while factors associated with not undergoing vaccination are that of having not undergone screening (p < 0.001) and the lack of importance placed on the knowledge of the possibility of HBV being a silent killer (p = 0.006). Several facilitators and barriers are seen to regulate health-seeking behaviour towards HBV infection. Public initiatives including education and financial relief targeting specific population groups should be considered to increase the uptake of HBV screening and vaccination.

To characterise gout patients at high risk of hospitalisation and to develop a web-based prognostic model to predict the likelihood of gout-related hospital admissions. This was a retrospective single-centre study of 1417 patients presenting to the emergency department (ED) with a gout flare between 2015 and 2017 with a 1-year look-back period. The dataset was randomly divided, with 80% forming the derivation and the remaining forming the validation cohort. A multivariable logistic regression model was used to determine the likelihood of hospitalisation from a gout flare in the derivation cohort. The coefficients for the variables with statistically significant adjusted odds ratios were used for the development of a web-based hospitalisation risk estimator. The performance of this risk estimator model was assessed via the area under the receiver operating characteristic curve (AUROC), calibration plot, and brier score. Patients who were hospitalised with gout tended to be older, less likely male, more likely to have had a previous hospital stay with an inpatient primary diagnosis of gout, or a previous ED visit for gout, less likely to have been prescribed standby acute gout therapy, and had a significant burden of comorbidities. In the multivariable-adjusted analyses, previous hospitalisation for gout was associated with the highest odds of gout-related admission. Early identification of patients with a high likelihood of gout-related hospitalisation using our web-based validated risk estimator model may assist to target resources to the highest risk individuals, reducing the frequency of gout-related admissions and improving the overall health-related quality of life in the long term. Key points •  We reported the characteristics of gout patients visiting a tertiary hospital in Singapore. •  We developed a web-based prognostic model with non-invasive variables to predict the likelihood of gout-related hospital admissions.

Cognitive dysfunction (CD) is a common yet often clinically subtle manifestation that considerably impacts the health-related quality of life in patients with systemic lupus erythaematosus (SLE). Given the inconsistencies in CD assessment and challenges in its attribution to SLE, the reported prevalence of CD differs widely, ranging from 3 to 88%. The clinical presentation of CD in SLE is non-specific and may manifest concurrently with overt neuropsychiatric illness such as psychosis or mood disorders or as isolated impairment of attention, working memory, executive dysfunction or processing speed. Despite the lack of standardized and sensitive neuropsychological tests and validated diagnostic biomarkers of CD in SLE, significant progress has been made in identifying pathogenic neural pathways and neuroimaging. Furthermore, several autoantibodies, cytokines, pro-inflammatory mediators and metabolic factors have been implicated in the pathogenesis of CD in SLE. Abrogation of the integrity of the blood-brain barrier (BBB) and ensuing autoantibody-mediated neurotoxicity, complement and microglial activation remains the widely accepted mechanism of SLE-related CD. Although several functional neuroimaging modalities have consistently demonstrated abnormalities that correlate with CD in SLE patients, a consensus remains to be reached as to their clinical utility in diagnosing CD. Given the multifactorial aetiology of CD, a multi-domain interventional approach that addresses the risk factors and disease mechanisms of CD in a concurrent fashion is the favourable therapeutic direction. While cognitive rehabilitation and exercise training remain important, specific pharmacological agents that target microglial activation and maintain the BBB integrity are potential candidates for the treatment of SLE-related CD.

Myositis-specific autoantibodies (MSAs) have become pivotal biomarkers for idiopathic inflammatory myopathies and have revolutionized understanding of the heterogeneous disease spectrum that affects both adults and children. The discovery and characterization of MSAs have substantially enhanced patient stratification based on clinical phenotype, thereby facilitating more precise diagnosis and ultimately improving management strategies. Advances in immunoassay technologies in the past 20 years have further propelled the field forward, enabling the detection of a growing repertoire of autoantibodies with high specificity and sensitivity; however, evolving research over the past decade has revealed that even within antibody-defined subsets, considerable clinical diversity exists, suggesting a broader spectrum of disease manifestations than previously acknowledged. Challenges persist, particularly among patients who are seronegative, where the failure to identify certain rare MSAs stems from the use of diverse detection methodologies and inadequate consensus-guided standardization and validation protocols. Bridging these diagnostic gaps is crucial for optimizing patient care and refining prognostic stratification in idiopathic inflammatory myopathies. This Review provides an update on autoantibodies associated with idiopathic inflammatory myopathies in both adults and children. The authors also discuss methods of autoantibody detection and the advantages and limitations of each technique. Key points Autoantibodies, found in over half of adult and paediatric patients with idiopathic inflammatory myopathies (IIMs), correlate with specific clinical phenotypes, aiding in the classification, diagnosis and prognostic assessment of these diseases. The emergence of new myositis autoantibodies, along with a deeper understanding of serological categories in the past 10 years, enriches the diagnostic and prognostic repertoire for IIMs. A more concerted global exploration of ethnic, environmental and genetic diversities is crucial to improve the characterization of subsets within the serological categories already known in IIMs. Numerous new immunoassays for detecting myositis-specific autoantibodies, including line blot techniques, have variable performance and lack standardized protocols, requiring further validation for reliable myositis autoantibody detection.

BackgroundOur review assessed whole body (WB) and dedicated body-part magnetic resonance imaging (DedMRI) techniques, protocols, and inflammatory scoring systems, focusing on their clinimetric properties (reliability, validity, responsiveness) in clinical and research settings of patients with juvenile idiopathic inflammatory myopathies (JIIM).MethodsA comprehensive search of MEDLINE, EMBASE, and Cochrane databases from 2000 to 2024 identified relevant studies.ResultsSixteen studies enrolling JIIM patients with MRI were reviewed, which showed heterogeneity in objectives, methodologies, and scoring systems. Four (25%) studies used quantitative assessments, while 12 (75%) employed semi-quantitative or qualitative methods in scoring MRI. WB-MRI was performed in 3 (18.7%) studies, and DedMRI in 13 (81.2%). Muscle evaluation included assessments of edema [14 (87.5%) studies], fatty infiltration [4 (25%) studies], and atrophy [6 (37.5%) studies]. T1 images were used in 9 (56.2%) studies for measuring chronic changes, with coronal views reported in 6 (37.5%). Fluid-sensitive sequences (T2 with fat saturation, STIR) were employed in all studies and were obtained in the coronal plane in 9 (56.2%). These sequences were crucial for detecting soft tissue edema related to acute/subacute inflammation. One (6%) study included diffusion and T1 post-contrast sequences.ConclusionThere is significant heterogeneity in MRI protocols for evaluating JIIM. Standardized WB-MRI protocols are needed to ensure consistency and comparability across studies and institutions, optimize assessments of disease activity, treatment response, and follow-up in JIIM patients. Standardization should enhance the reliability of MRI for diagnosing and monitoring JIIM in clinical and research settings.Key-points- Heterogenous qualitative, semi-quantitative, quantitative analysis and magnetic resonance imaging (MRI) protocols used to evaluate idiopathic inflammatory myopathies (IIM) in pediatric patients were observed.- Subsequent research efforts should concentrate on establishing uniform protocols and scoring criteria to improve the reproducibility and accuracy of MRI evaluations in pediatric IIM.

Background Wheat-dependent exercise-induced anaphylaxis (WDEIA) is a specific form of wheat allergy caused by the combination of wheat ingestion and physical exercise and has been reported in other parts of Asia. At present, there are no published reports of WDEIA in Singapore. The objective of this study is to characterise the common local clinical and laboratory manifestations of WDEIA. Methods This was a retrospective descriptive study of all WDEIA who presented to a tertiary Singaporean Hospital over a 5-year-period from 1 January 2009 to 30 June 2013. Results Eight patients aged 9–41 years old were characterised. Six were males and the majority (5) was of Chinese ethnicity. An atopic history was found in four patients. The symptoms of anaphylaxis included cutaneous manifestations such as urticaria (n=7), angioedema (n=6), respiratory symptoms of dyspnoea and wheezing (n=5) and hypotension (n=5). The symptoms occurred 20–75 min after consumption of wheat-based products, often upon cessation of exercise [running (n=3), walking (n=4) and swimming (n=1)]. The WDEIA was recurrent in seven patients. The skin prick tests were positive to wheat in seven patients, and ω-5 gliadin test to wheat was positive in five patients. Conclusions With the emergence of wheat allergy in East Asian countries, WDEIA has become an important condition for physicians and Singapore is no exception. Under-recognition combined with life-threatening symptoms warrants better public awareness measures. In addition, further studies are necessary to identify possible unique genetic and environmental exposures that could explain the inter-regional differences of WDEIA.

Abstract Capturing disease activity in SLE remains challenging. The binary nature of global score indices such as the SLEDAI 2000 (SLEDAI-2K) poses limitations, while the complexity of the BILAG-2004 index requires training and more time investment. Recent efforts to improve SLE activity indices include the SLE Disease Activity Score (SLE-DAS) and Easy-BILAG system. This review analyses the main indices used to assess SLE activity, examines their progressive refinements, evaluates their advantages and limitations and aims to identify the optimal index. The SLE-DAS offers greater sensitivity than the SLEDAI-2K and the Easy-BILAG simplifies scoring while maintaining the comprehensiveness of the BILAG-2004. Composite indices like the SLE Responder Index and BILAG-based Composite Lupus Assessment integrate the SLEDAI-2K and BILAG-2004 but are mainly used in clinical trials due to their complexity. This review emphasizes the importance of balancing sensitivity, specificity, simplicity and comprehensiveness in lupus activity measurement. The search for the optimal index remains ongoing. Lay Summary What does this mean for patients? Capturing disease activity accurately and completely in lupus patients is difficult because the disease causes many clinical problems. Some problems may be hard to distinguish from other factors, including concomitant diseases and drug side effects. Global score systems offer a simplistic way to capture disease activity (‘awarding’ points if a feature is present). The best-known example of this approach, the Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) system, has been criticized, as it misses some features altogether (e.g. gastrointestinal involvement) and the logic for the ‘weighting’ of some features (e.g. a lupus headache—considered rare—gets 8 points) is hard to justify. However, it is very easy to calculate. In contrast, the British Isles Lupus Assessment Group (BILAG) system is more comprehensive and (unlike the SLEDAI) distinguishes partial improvement in features from those that remain unchanged and those that have gotten worse. However, it takes longer to complete. In this review we compared some ‘new kids on the block’, focusing in particular on the SLE Disease Activity Score system, which is more comprehensive than the SLEDAI index, and the Easy-BILAG, which uses a colour-coding approach to help get to the final score much faster. Time will tell if either, or both, of these new instruments will become more widely used.