Two centuries of biodiversity discovery and loss in Singapore.

There is an urgent need for reliable data on the impacts of deforestation on tropical biodiversity. The city-state of Singapore has one of the most detailed biodiversity records in the tropics, dating back to the turn of the 19th century. In 1819, Singapore was almost entirely covered in primary forest, but this has since been largely cleared. We compiled more than 200 y of records for 10 major taxonomic groups in Singapore (>50,000 individual records; >3,000 species), and we estimated extinction rates using recently developed and novel statistical models that account for "dark extinctions," i.e., extinctions of undiscovered species. The estimated overall extinction rate was 37% (95% CI [31 to 42%]). Extrapolating our Singapore observations to a future business-as-usual deforestation scenario for Southeast Asia suggests that 18% (95% CI [16 to 22%]) of species will be lost regionally by 2100. Our extinction estimates for Singapore and Southeast Asia are a factor of two lower than previous estimates that also attempted to account for dark extinctions. However, we caution that particular groups such as large mammals, forest-dependent birds, orchids, and butterflies are disproportionately vulnerable.

Incidence and Outcomes of Cardiocerebral Infarction: A Cohort Study of 2 National Population-Based Registries.

BACKGROUND: Cardiocerebral infarction (CCI), which is concomitant with acute myocardial infarction (AMI) and acute ischemic stroke (AIS), is a rare but severe presentation. However, there are few data on CCI, and the treatment options are uncertain. We investigated the characteristics and outcomes of CCI compared with AMI or AIS alone. METHODS: We performed a retrospective cohort study of 120 531 patients with AMI and AIS from the national stroke and AMI registries in Singapore. Patients were categorized into AMI only, AIS only, synchronous CCI (same-day), and metachronous CCI (within 1 week). The primary outcome was all-cause mortality, and the secondary outcome was cardiovascular mortality. The mortality risks were compared using Cox regression. Multivariable models were adjusted for baseline demographics, clinical variables, and treatment for AMI or AIS. RESULTS: Of 127 919 patients identified, 120 531 (94.2%) were included; 74 219 (61.6%) patients had AMI only, 44 721 (37.1%) had AIS only, 625 (0.5%) had synchronous CCI, and 966 (0.8%) had metachronous CCI. The mean age was 67.7 (SD, 14.0) years. Synchronous and metachronous CCI had a higher risk of 30-day mortality (synchronous: adjusted HR [aHR], 2.41 [95% CI, 1.77-3.28]; metachronous: aHR, 2.80 [95% CI, 2.11-3.73]) than AMI only and AIS only (synchronous: aHR, 2.90 [95% CI, 1.87-4.51]; metachronous: aHR, 4.36 [95% CI, 3.03-6.27]). The risk of cardiovascular mortality was higher in synchronous and metachronous CCI than AMI (synchronous: aHR, 3.03 [95% CI, 2.15-4.28]; metachronous: aHR, 3.41 [95% CI, 2.50-4.65]) or AIS only (synchronous: aHR, 2.58 [95% CI, 1.52-4.36]; metachronous: aHR, 4.52 [95% CI, 2.95-6.92]). In synchronous CCI, AMI was less likely to be managed with PCI and secondary prevention medications (P<0.001) compared with AMI only. CONCLUSIONS: Synchronous CCI occurred in 1 in 200 cases of AIS and AMI. Synchronous and metachronous CCI had higher mortality than AMI or AIS alone.

Singapore's diverse immunology landscape: interconnected research networks enabling blue sky ideas through to translation.

Singapore stands as a dynamic hub for cutting-edge immunological research and innovation. The country's vibrant research ecosystem is supported by collaborative networks across the many national medical and scientific research institutes, fostering meaningful alliances between academia and industry. In this article, we speak to Assistant Professor Jinmiao Chen from the Agency for Science, Technology, and Research (A*STAR) and Professor Nicholas Gascoigne from the National University of Singapore (NUS), Duke-NUS Medical School and Nanyang Technological University (NTU) about immunology in Singapore. Credit: Kate Forbes.

Can Timely Outpatient Visits Reduce Readmissions and Mortality Among Heart Failure Patients?

BACKGROUND: Outpatient follow-up after a hospital discharge may reduce the risk of readmissions, but existing evidence has methodological limitations. OBJECTIVES: To assess effect of outpatient follow-up within 7, 14, 21 and 30 days of a hospital discharge on 30-day unplanned readmissions or mortality among heart failure (HF) patients; and whether this varies for patients with different clinical complexities. DESIGN: We analyzed medical records between January 2016 and December 2021 from a prospective cohort study. Using time varying mixed effects parametric survival models, we examined the association between not having an outpatient follow-up and risk of adverse events. We used interaction models to assess if the effect of outpatient follow-up visit on outcomes varies with patients' clinical complexity (comorbidities, grip strength, cognitive impairment and length of inpatient stay). PARTICIPANTS: Two hundred and forty-one patients with advanced HF. MAIN MEASURES: 30-day all-cause (or cardiac) adverse event defined as all cause (or cardiac) unplanned readmissions or death within 30 days of an unplanned all-cause (or cardiac) admission or emergency department visit. KEY RESULTS: We analyzed 1595 all-cause admissions, inclusive of 1266 cardiac admissions. Not having an outpatient follow-up (vs having an outpatient follow-up) significantly increased the risk of 30-day all-cause adverse event. (risk [95% CI] - 14 days: 35.1 [84.5,-1.1]; 21 days: 43.9 [48.2,6.7]; 30 days: 31.1 [48.5, 7.9]) The risk (at 21 days) was higher for those with one co-morbidity (0.25 [0.11,0.58]), mild (0.67 [0.45, 1.00]) and moderate cognitive impairment (0.38 [0.17, 0.84]), normal grip strength (0.57 [0.34, 0.96]) and length of inpatient stay 7-13 days (0.45 [0.23, 0.89]). CONCLUSION: Outpatient follow-up within 30 days after a hospital discharge reduced risk of 30-day adverse events among HF patients, the benefit varying according to clinical complexity. Results suggest the need to prioritize patients who benefit from outpatient follow-up for these visits.

Feeling Alone Together: Loneliness in Older Adults with Cognitive Impairment and Their Family Caregivers with Low Mastery.

INTRODUCTION: Loneliness in older persons with cognitive impairment (PCI) may beget loneliness in their family caregivers, depending on buffering resources caregivers possess. This study examined the association between loneliness in older PCI and loneliness experienced by their family caregivers, and the moderating role of caregiver mastery in this association. METHODS: Dyadic data from 135 PCI and their family caregivers in Singapore were analyzed using multivariable regression. Loneliness was measured using a three-item UCLA loneliness scale. Mastery was assessed using a seven-item Pearlin instrument. RESULTS: Multivariable regression showed that PCI loneliness and caregiver loneliness were weakly associated, taking other covariates into account. Notably, a significant interaction between PCI loneliness and caregiver mastery was observed, indicating that PCI loneliness was associated with caregiver loneliness only when caregivers had low mastery. CONCLUSION: Lonely PCI may share their feelings of loneliness with their caregivers, and this can lead to loneliness among caregivers if they have low mastery. Promoting caregiver mastery may help reduce caregiver loneliness, directly and indirectly as a buffer against PCI loneliness.

Singapore grouper iridovirus VP146 modulates the cGAS-STING signaling pathway to escape the interferon immune response.

Singapore grouper iridovirus (SGIV) is a large double-stranded DNA virus that has caused significant economic losses to the grouper aquaculture industry. So far, the structure and function of SGIV proteins have been successively reported. In the present paper, the protein of SGIV VP146 was cloned and identified. VP146 was whole-cell distributed in GS cells. VP146 promoted SGIV replication and inhibited the transcription of interferon-related genes as well as pro-inflammatory cytokines in GS cells. In addition, VP146 was involved in the regulation of the cGAS-STING signaling pathway, and decreased cGAS-STING induced the promoter of ISRE and NF-κB. VP146 interacted with the proteins of cGAS, STING, TBK1, and IRF3 from grouper, but did not affect the binding of grouper STING to grouper TBK1 and grouper IRF3. Interestingly, grouper STING was able to affect the intracellular localization of VP146. Four segment structural domains of grouper STING were constructed, and grouper STING-CTT could affect the intracellular localization of VP146. VP146 had no effect on the self-binding of EcSITNG, nor on the binding of EcSTING to EcTBK1 and EcIRF3. Together, the results demonstrated that SGIV VP146 modulated the cGAS-STING signaling pathway to escape the interferon immune response.

Burgers, Fast Foods, and Increased Associated Risk for Atopic Dermatitis: A Cross-Sectional Study of Dietary Habits among Young Chinese Adults in Singapore/Malaysia.

BACKGROUND: We see increasing evidence that dietary and nutrients factors play a pivotal role in allergic diseases and recent global findings suggest that dietary habits influence the pathogenesis of atopic dermatitis (AD). Frequent consumption of fast food diets is associated with AD development. Despite the rising prevalence of AD in Asia, efforts in investigating the role of dietary habits and AD in adults are still lacking. METHODS: We evaluated the association between the dietary intake of 16 food types and AD manifestations using our Singapore/Malaysia Cross-sectional Genetics Epidemiology Study (SMCGES) population. Dietary habits profiles of 11,494 young Chinese adults (1,550 AD cases/2,978 non-atopic controls/6,386 atopic controls) were assessed by an investigator-administered questionnaire. AD cases were further evaluated for their chronicity (550 chronic) and severity (628 moderate-to-severe). Additionally, we derived a novel food index, Quality of Diet based on Glycaemic Index Score (QDGIS), to examine the association between dietary intake of glycaemic index (GI) and various AD phenotypes. RESULTS: The majority of AD subjects are distributed in the good (37.1%) and moderate (36.2%) QDGIS classes. From the multivariable analyses for age and gender, a moderate QDGIS class was significantly associated with a lower odds of AD (adjusted odds ratio (AOR): 0.844; 95% confidence interval (CI): 0.719-0.991; p < 0.05) and moderate-to-severe AD (AOR: 0.839; 95% CI: 0.714-0.985; p < 0.05). A good QDGIS class was only significantly associated with a lower odds of chronic AD (AOR: 0.769; 95% CI: 0.606-0.976; p < 0.05). Among high GI foods, frequent consumption of burgers/fast food was strongly associated with an increased risk of chronic and moderate-to-severe AD. Among low GI foods, increased intake frequencies of fruits, vegetables, and pulses decreased the odds of AD. Finally, we identified significant associations between frequent seafood, margarine, butter, and pasta consumption with an increased odds of AD despite them having little GI values. CONCLUSION: While genetic components are well-established in their risks associated with increased AD prevalence, there is still a lack of a focus epidemiology study associating dietary influence with AD. Based on the first allergic epidemiology study conducted here in Singapore and Malaysia, it laid the groundwork to guide potential dietary interventions from changing personal dietary habits.

Cost-effectiveness of sodium zirconium cyclosilicate for advanced chronic kidney patients in Singapore.

INTRODUCTION: Hyperkalaemia (HK) is prevalent among patients with chronic kidney disease (CKD) and chronic heart failure, especially if they are treated with renin-angiotensin-aldosterone system inhibitors (RAASi). This study evaluated the cost-effectiveness of a newly developed anti-HK therapy, sodium zirconium cyclosilicate (SZC), to the current standard of care for treating HK in advanced CKD patients from the Singapore health system perspective. METHODS: We adapted a global microsimulation model to simulate individual patients' potassium level trajectories with baseline potassium ≥5.5 mmol/L, CKD progression, changes in treatment, and other fatal and non-fatal events. Effectiveness data was derived from ZS-004 and ZS-005 trials. Model parameters were localised using CKD patients' administrative and medical records at the Singapore General Hospital Department of Renal Medicine. We estimated the lifetime cost and quality-adjusted life years (QALYs) of each HK treatment, and the incremental cost-effectiveness ratio of SZC. RESULTS: SZC demonstrated cost-effectiveness with an incremental cost-effectiveness ratsio of SGD 45 068 per QALY over a lifetime horizon, below the willingness-to-pay threshold of SGD 90 000 per QALY. Notably, SZC proved most cost-effective for patients with less severe CKD who were concurrently using RAASi. Sensitivity analyses confirmed the robustness of the findings, accounting for alternative parameter values and statistical uncertainty. CONCLUSION: This study establishes the cost-effectiveness of SZC as a treatment for HK, highlighting its potential to mitigate the risk of hyperkalaemia and optimise RAASi therapy. These findings emphasise the value of integrating SZC into the Singapore health system for improved patient outcomes and resource allocation.

Comparisons between Caucasian-validated photo-numeric scales and Korean-validated photo-numeric scales for photo-ageing. Insights from the Singapore/Malaysia cross-sectional genetics epidemiology study (SMCGES) cohort.

BACKGROUND: Photo-ageing is a form of skin ageing which affects the entire face. A photo-aged skin has a diverse variety of wrinkles and dyspigmentation all over the face. Here, we discuss photo-ageing on the Chinese skin evaluated using a photo-numeric scale developed and validated on Caucasian skin (i.e., Caucasian scale) and evaluated using a photo-numeric scale developed and validated on Korean skin (i.e., Korean scale). The Korean scale can be subdivided into two scales that separately address the wrinkling and dyspigmentation constituents of photo-ageing. AIM: As there are currently no photo-ageing scales for Chinese skin, the main objective of this study is to adapt existing photo-ageing photo-numeric scales for use on ethnic Chinese skin. METHOD: Three trained assessors studied facial photo-ageing on 1,081 ethnic Chinese young adults from the Singapore/Malaysia Cross-sectional Genetics Epidemiology Study (SMCGES) cohort. RESULTS: All assessors are highly internally consistent (Weighted Kappa (κw) values≥0.952). We found that the Caucasian scale and Korean scale give nearly synonymous results for the wrinkling constituent of photo-ageing (R2 = 0.9386). The two scales are strongly concordant (Spearman's Rank Correlation (ρ) value: 0.62 ± 0.06, p = 1.31×10-84). A weak-to-moderate inter-scalar level of agreement (Cohen's Kappa (κ) values: 0.38 ± 0.05, p = 8.87×10-53) persists and is statistically significant after accounting for agreements due to chance. When tested on ethnic Chinese skin, both scales detect photo-ageing consistently (Area under curve [AUC] values: 0.76-0.84). Additionally, the Korean scale for the dyspigmentation constituent of photo-ageing is concordant with both the Caucasian scale (R2 = 0.7888) and the Korean scale for the wrinkling constituent of photo-ageing (R2 = 0.7734). CONCLUSION: Our results show that the Caucasian scale is suitable for capturing photo-ageing on Chinese skin, especially wrinkle variations. The Korean dyspigmentation scale supplements the Caucasian scale to capture dyspigmentation patterns on Chinese skin that may be absent on Caucasian skin. Currently, photo-ageing scales for Chinese skin are absent. When developed, these photo-ageing scales must be properly validated for their ability to capture photo-ageing of the entire face.

A comparison of word humor ratings across speakers of North American, British, and Singapore English.

Large-scale collection of lexical-semantic norms for words in a given language has been instrumental in the progress of psycholinguistic research. However, such norms tend to be collected from speakers of the dominant variant or dialect. This research aims to determine if there may be differences across speakers of various dialects of English in the humor of individual words. Engelthaler and Hills (2018, Behavior Research Methods, 50[3], 1116-1124) observed that their humor ratings were most strongly correlated with inverse word frequency: Less frequent words tended to be rated as more humorous. We hypothesized that words that are less frequently occurring in a given English dialect should be perceived as more humorous by speakers of the same dialect. We selected words of relatively higher and lower frequencies across various corpora of North American, British, or Singapore English, and presented these words to participants who were native English speakers of North American, British, or Singapore English. Study 1 compared humor ratings of North Americans and Singaporeans; Study 2 compared humor ratings of North Americans and the British. Analyses of participants' random slope coefficients of frequency extracted from cumulative link mixed-effects models indicated that humor ratings were more strongly (and inversely) associated with the word's frequency in the corpora that aligned with the rater's English dialect. These results provide evidence that people are sensitive to the statistics of their specific language environment, and importantly suggest that creators of lexical-semantic norm databases should consider how the cultural, historical, or sociopolitical context of raters might influence the nature of their ratings.

Assertive community treatment for high-utilizing alcohol misuse patients: a before-and-after cohort study protocol.

BACKGROUND: The challenge posed by Alcohol-Related Frequent Attenders (ARFAs) in Emergency Departments (EDs) is growing in Singapore, marked by limited engagement with conventional addiction treatment pathways. Recognizing this gap, this study aims to explore the potential benefits of Assertive Community Treatment (ACT) - an innovative, community-centered, harm-reduction strategy-in mitigating the frequency of ED visits, curbing Emergency Medical Services (EMS) calls, and uplifting health outcomes across a quartet of Singaporean healthcare institutions. METHODS: Employing a prospective before-and-after cohort design, this investigation targeted ARFAs aged 21 years and above, fluent in English or Mandarin. Eligibility was determined by a history of at least five ED visits in the preceding year, with no fewer than two due to alcohol-related issues. The study contrasted health outcomes of patients integrated into the ACT care model versus their experiences under the exclusive provision of standard emergency care across Hospitals A, B, C and D. Following participants for half a year post-initial assessment, the evaluation metrics encompassed socio-demographic factors, ED, and EMS engagement frequencies, along with validated health assessment tools, namely Christo Inventory for Substance-misuse Services (CISS) scores, University of California, Los Angeles (UCLA) Loneliness scores, and Centre for Epidemiologic Studies Depression Scale Revised (CESD-R-10) scores. DISCUSSION: Confronted with intricate socio-economic and medical challenges, the ARFA cohort often grapples with heightened vulnerabilities in relation to alcohol misuse. Pioneering the exploration of ACT's efficacy with ARFAs in a Singaporean context, our research is anchored in a patient-centered approach, designed to comprehensively address these multifaceted clinical profiles. While challenges, like potential high attrition rates and sporadic data collection, are anticipated, the model's prospective contribution towards enhancing patient well-being and driving healthcare efficiencies in Singapore is substantial. Our findings have the potential to reshape healthcare strategies and policy recommendations. TRIAL REGISTRATION: ClinicalTrials.gov, NCT04447079. Initiated on 25 June 2020.

First report of Hibiscus latent Singapore virus and Hibiscus latent Fort Pierce virus infecting Lantana camara in China.

Hibiscus latent Singapore virus (HLSV) and Hibiscus latent Fort Pierce virus (HLFPV) both belong to the genus Tobamovirus in the family Virgaviridae. The genomes of both HLSV and HLFPV consist of a linear positive sense single-stranded RNA of about 6.3 kb. HLSV is the causal agent of hibiscus leaf crinkle disease. Infections of HLSV in hibiscus (Hibiscus rosa-sinensis) have so far only been reported in Singapore, Japan and Malaysia (Srinivasan et al., 2002; Yoshida et al., 2018; Yusop et al., 2021). In 2017, leaf curling and chlorosis symptoms of lantana (Lantana camara) plants were found in Chenshan Botanical Garden, Shanghai, China. To detect potential virus(es) in these lantana samples, leaves from one lantana plant were collected and total RNA was extracted with RNAiso Plus (TaKaRa). A cDNA library was prepared by TruSeq RNA Sample Prep Kit (Illumina) after removing ribosomal RNA by Ribo-ZeroTM rRNA Removal Kit (Epicentre). The paired-end sequencing was then performed on an Illumina NovaSeq 6000. A total of 61,085,018 high quality reads were obtained and de novo assembly by StringTie revealed 124,516 contigs (greater than 50 bp, N50=719 bp) with an average length of 537 bp. BLASTx analyses in the National Center for Biotechnology Information (NCBI) database showed that 1 long contig of 6,305 bp, assembled of 1794 clean reads, shared significant nucleotide similarities with the genomic sequence of HLSV, and 1 contig of 6,271 bp, assembled of 3174 clean reads, shared significant similarities with the genomic sequence of HLFPV, yielding an average coverage of the whole genome at 42.65 and 75.83 per million reads, respectively. To obtain the complete genome of the viral RNA in this lantana sample, eleven overlapping regions covering the entire HLSV viral genome, and nine overlapping regions covering the entire HLFPV viral genome were amplified by reverse transcription-PCR (RT-PCR) and sequenced. In addition, the exact 5' and 3' ends of the genomic RNA of each virus were determined by rapid amplification of the cDNA ends (RACE) (Wang et al. 2020). The complete genome of the identified HLSV, deposited in GenBank: MZ020960, is 6,486 nt in length and shows 98.4% nucleotide sequence identity with HLSV Singapore isolate (GenBank: AF395898). Similar to other HLSV isolates, this virus isolate possesses an internal poly(A) tract of 87 nucleotides, which is crucial to virus replication (Niu et al., 2015). The complete genome of the Lantana HLFPV isolate is 6,463 nt (GenBank MZ020961) including a 73 nt internal poly(A) tract, and has 98.4% nt identity to HLFPV-Japan (AB917427). In two other lantana plants from the same site, the presence of HLSV and HLFPV was confirmed by RT-PCR using the primer pairs (5'-GCATCTGCATAACACGGTTG-3'/5'-ACGTTGTAGTAGACGTTGTTGTAG-3' and 5'-GGACCTTGCTAATCCGCTAAAGTTG-3'/5'-GGTCCATGTCCATCCAGATGCAATC-3'). In addition to the HLSV and HLFPV genomes, BLASTx analysis of three contigs of 3,006 bp, 2,845 bp and 2,200 bp, assembled of 1328, 352 and 2280 clean reads respectively, showed high identity to RNAs 1 (MG182148), 2 (DQ412731) and 3 (KY794710) of cucumber mosaic virus. To the best of our knowledge, this is the first report of L. camara as a new natural host of HLSV and HLFPV, and first identification of a mixed infection of HLSV and HLFPV.

Challenges of care coordination for complex patients among family medicine residents in a community ambulatory clinic: a qualitative study.

BACKGROUND: Care coordination has been identified as one of five focuses of HealthierSG. Family medicine residents are expected to collaborate with other healthcare professionals for complex patients by the end of residency. However, many residents felt that it was challenging to coordinate care effectively among healthcare stakeholders. However, to date, no qualitative studies have explored these challenges. Therefore, this study aimed to understand the challenges encountered by family medicine residents when coordinating care for complex patients. METHODS: This was a qualitative descriptive study in which semi structured in-depth interviews were conducted and guided by a topic guide. Total population sampling of 15 third-year family medicine residents in the National Healthcare Group Polyclinics was performed. The interviews were performed over Zoom and were transcribed. Thematic analysis was subsequently performed to analyse the transcripts. Coding was performed iteratively by two independent researchers. Disagreements were adjudicated by a third coder. A coding framework was agreed upon. Potential themes were then independently developed based on the coding framework. RESULTS: Six themes emerged from the data, namely, interprofessional communications, accessibility, personal knowledge, time constraints, patient factors and caregiver dissent. CONCLUSION: Challenges faced by family medicine residents are multifaceted. While a few are systemic and pertain to the broader healthcare framework, others, such as issues of unfamiliarity with institutional workflows, community resources, and confidentiality, pertain to the microcosm of residency itself. These are reversible areas for improvement. These challenges can be addressed during planning of residency curricula to better equip family medicine residents with coordinating care for complex patients in the future.

The Pulse of Singapore: Short-Term HRV Norms.

Short-term heart rate variability (HRV) is increasingly used to assess autonomic nervous system activity and found to be useful for monitoring and providing care due to its quick measurement. With evidence of low HRV associated with chronic diseases, mental disorders, and an increased risk of cardiovascular disease, having normative data of HRV across the age spectrum would be useful for monitoring health and well-being of a population. This study examines HRV of healthy Singapore sample, with ages ranging from 10 to 89 years. Short-term HRV of five minutes was measured from 2,143 participants. 974 males and 1,169 females, and overall HRV was found to be 42.4ms (RMSSD) and 52.0 ms (SDNN) with a further breakdown of HRV by age and gender. Overall HRV declined with age and gender, although gender differences dissipated in the 60s age range onwards, with the 50s age range having the sharpest decline in HRV. Short-term HRV norms were similar to Nunan et al.'s (2010) systematic review in various populations and less similar to Choi et al.'s (2020) study on Koreans.

The Telemedicine Demand Index and its Utility in Managing COVID-19 Case Surges.

Introduction: Telemedicine was an integral component in Singapore's COVID-19 management strategy, having been deployed at a national level in a centrally-administered program whereby patients at higher risk of developing severe COVID-19 disease were proactively assigned tele-consultations, whereas those at lower risk and seen by primary care physicians could request ad hoc tele-consultations. To better plan for fluctuations in telemedicine demand during the pandemic, the Telemedicine Demand Index (TDI) was developed. Methods: Three main factors influencing telemedicine demand were considered-characteristics of the Variant of Concern, prevailing health care policies, and the population's healthcare-seeking behaviour-from which 11 coefficients were derived for the TDI formula. The number of tele-consultations demanded is the product of the TDI and the total number of new COVID-19 cases for a given period. Results: Real-world data from January 31 to March 27, 2022 were compared with TDI estimates. A total of 148,485 tele-consultations were conducted against a backdrop of 723,675 new COVID-19 cases for the period. The TDI overestimated demand by an average 11.4%. Data from March 28 to May 1, 2022 were then used to derive new TDI values and applied to a 3-week period starting May 9, 2022, following a policy change. A total of 5,560 tele-consultations were conducted against a backdrop of 77,998 new COVID-19 cases. The TDI underestimated demand by an average of 7.2%. Conclusion: The TDI shows initial promise for quickly estimating telemedicine demand at a population level. By leveraging historical data and applying some informed assumptions, it allows for the estimation of current capabilities and future requirements. There remains scope for more research to refine the TDI's constituent components, as well as its applicability in different population contexts.

A Constructivist Grounded Theory Study on Mental Health Recovery from a Lived Experience Perspective in Singapore.

More contemporary personal recovery conceptualisation of mental health recovery emphasize the need to consider the perspectives of people who experience mental ill-health. Most lived experience research has been done in Western cultures with relatively few studies in Asian ones, creating a gap that needs to be addressed due to differences in cultural worldviews. This study explores the notion of recovery from the lens of people experiencing mental health challenges in Singapore. We adopted a constructivist grounded theory perspective to evaluate qualitative data from 21 participants. The core category which best represented what recovery meant was "reconciling and living with experiences of mental ill-health". Our findings suggest that a variety of societal aspects greatly influence perceptions of mental health recovery in Singapore, as participants often shared their desire to live a meaningful life within society but could only do so if they found a way to manage their symptoms more effectively.

Impact of climate change on dengue incidence in Singapore: time-series seasonal analysis.

This study aimed to identify the meteorological factors that contribute to dengue epidemics. The monthly incidence of dengue was used as the outcome variable, while maximum temperature, humidity, precipitation, and sunshine hours were used as independent variables. The results showed a consistent increase in monthly dengue cases from 2013 to 2021, with seasonal patterns observed in stationary time-series data. The ARIMA (2, 1, 3) × seasonal (0, 1, 2)12 model was used based on its lowest Akaike Information Criterion (AIC) values. The analysis revealed that a 1-unit increase in rainfall was positively correlated with a small 0.062-unit increase in dengue cases, whereas a 1-unit increase in humidity was negatively associated, leading to a substantial reduction of approximately 16.34 cases. This study highlights the importance of incorporating weather data into national dengue prevention programs to enhance public awareness and to promote recommended safety measures.

The effect of Covid-19 emergence on religiosity: Evidence from Singapore.

How do people deal with events they cannot control? Religious beliefs and practices are common responses to uncontrollable situations. We analyzed the responses of Singaporeans surveyed between November 2019 and March 2020-just before and just after Covid-19 hit the region-to understand how the beliefs and actions of both religious and non-religious people were affected by the emergence of the previously unknown virus. We find that after the emergence of Covid-19, religious respondents reported significantly higher levels of belief and service attendance frequency, while prayer frequency was not affected. We argue that the decrease in perceived controllability over people's lives explains these results. We discuss the implications of our findings for understanding the dynamics of religious beliefs and practices during times of uncertainty.

Examining the role of moral foundations in promoting intergroup contact willingness.

Improving people's motivation to seek meaningful intergroup contact is considered key to facilitating intergroup harmony. Based on moral foundations theory, this study examines how moral foundations as individual traits predict contact willingness with three minority groups (foreign domestic helpers, LGBT, and Chinese expats) and how moral emotions mediate such associations. We tested our hypotheses based on survey data across Hong Kong and Singapore. We found that care/harm foundation positively predicted contact willingness with foreign domestic helpers and LGBT people, mediated by compassion. Sanctity/degradation foundation negatively predicted contact willingness with LGBT people only in Singapore. Loyalty/betrayal foundation served as a positive predictor of willingness to contact Chinese expats. We also found care/harm foundation to be exclusively associated with compassion and promoted willingness to contact with helpers and LGBT people. Our findings highlight the influence of moral foundations, and possibly norms and intergroup dynamics at the societal level in predicting willingness to contact outgroups.

Commercial milk formula marketing following increased restrictions in Singapore: A qualitative study.

The promotion of commercial milk formula (CMF) negatively impacts breastfeeding outcomes. In 2019, Singapore updated its 1979 Code of Ethics of the Sale of Infant Foods Ethics Committee Singapore (SIFECS) to increase marketing restrictions on CMF for infants 0-12 months. However, little is known about industry tactics to undermine these restrictions. This qualitative study explores health workers' and mothers' experiences with CMF marketing in Singapore following the 2019 restrictions. We conducted a qualitative study, using semistructured interviews with 14 mothers of infants aged less than 5 months and 20 health workers with expertise in antenatal, maternity, or paediatric care. We analysed data thematically using inductive coding. Five themes were identified. Mothers and health workers reported digital marketing, product line extensions with toddlers' milk and milk for mothers, and CMF sponsorships in the healthcare setting. Expert endorsement, competitive price, nutritional claims, and brand reputation influenced mothers' infant formula choices, yet both mothers and health workers appeared to be unaware of the impact of CMF marketing tactics on their own perceptions. The restriction of CMF marketing and infant feeding practices varied widely between hospitals, with private hospitals and practices having less strict controls on CMF marketing. Despite the updated SIFECS restrictions, CMF companies continue to target mothers and health workers in Singapore. SIFECS restrictions should be tightened to align with international guidelines, by increasing their scope to include toddlers' milk and prohibiting cross-promotion, digital marketing, and any sponsorships of events targeting health workers that may create a conflict of interest.