Background Diabetes mellitus (DM) is a growing global health problem. In Singapore, the prevalence of Type 2 DM is rising, but comprehensive information about trends in DM-related complications is lacking. Objectives We utilized the Singapore Health Services (SingHealth) diabetes registry (SDR) to assess trends in DM micro and macro-vascular complications at the population level, explore factors influencing these trends. Methods We studied trends for ten DM-related complications: ischemic heart disease (IHD), acute myocardial infarction (AMI), peripheral arterial disease (PAD) and strokes, diabetic eye complications, nephropathy, neuropathy, diabetic foot, major and minor lower extremity amputation (LEA). The complications were determined through clinical coding in hospital (inpatient and outpatient) and primary care settings within the SingHealth cluster. We described event rates for the complications in 4 age-bands. Joinpoint regression was used to identify significant changes in trends. Results Among 222,705 patients studied between 2013 and 2020. 48.6% were female, 70.7% Chinese, 14.7% Malay and 10.6% Indian with a mean (SD) age varying between 64.6 (12.5) years in 2013 and 65.7 (13.2) years in 2020. We observed an increase in event rates in IHD, PAD, stroke, diabetic eye complications nephropathy, and neuropathy. Joinpoints was observed for IHD and PAD between 2016 to 2018, with subsequent plateauing of event rates. Major and minor LEA event rates decreased through the study period. Conclusion We found that DM and its complications represent an important challenge for healthcare in Singapore. Improvements in the trends of DM macrovascular complications were observed. However, trends in DM microvascular complications remain a cause for concern.

Background We investigate the association between mean HbA1c, HbA1c variability, and all-cause mortality and diabetes-related macrovascular complications in patients with diabetes. Methods We performed a retrospective cohort study using patients present in the Singapore Health Services diabetes registry (SDR) during 2013 to 2014. We assessed mean HbA1c using three models: a baseline mean HbA1c for 2013–14, the mean across the whole follow-up period, and a time-varying yearly updated mean. We assessed HbA1c variability at baseline using the patient’s HbA1c variability score (HVS) for 2013–14. The association between mean HbA1c, HVS, and 6 outcomes were assessed using Cox proportional hazard models. Results We included 43,837–53,934 individuals in the analysis; 99.3% had type 2 diabetes mellitus. The data showed a J-shaped distribution in adjusted hazard ratios (HRs) for all-cause mortality, ischemic heart disease, acute myocardial infarction, peripheral arterial disease, and ischemic stroke, with an increased risk of developing these outcomes at HbA1c <6% (42 mmol/mol) and ≥8% (64 mmol/mol). With the addition of HVS, the J-shaped distribution was maintained for the above outcomes, but HRs were greater at HbA1c <6.0% (42 mmol/mol) and reduced at HbA1c ≥8.0% (64 mmol/mol) when compared to models without HVS. The risk for all outcomes increased substantially with increasing glycaemic variability. Conclusion Both low (<6.0% [42 mmol/mol]) and high (≥8.0% [64 mmol/mol]) levels of glycaemic control are associated with increased all-cause mortality and diabetes-related macrovascular complications. Glycaemic variability is independently associated with increased risk for these outcomes. Therefore, patients with stable glycaemic level of 6–8% (42–64mmol/mol) are at lowest risk of all-cause mortality and diabetes-related macrovascular complications.

The 28-joint Disease Activity Score (DAS28) is a composite disease activity measure commonly in use for rheumatoid arthritis (RA) disease activity assessment. 1 It has the following disease activity cutoffs: high disease activity, >5.1; moderate disease activity, 3.2-≤5.1; low disease activity, 2.6-<3.2; remission, <2.6. 1 Despite its popularity as a disease activity measure in RA, DAS28 use is not without limitations. It can overestimate disease activity among RA patients

Swollen joints but not tender joints are associated with significantly greater degree of ultrasound-detected power Doppler joint inflammation among rheumatoid arthritis patients in clinical remission or low disease activityRheumatologists routinely assess joint inflammation in rheumatoid arthritis (RA) by eliciting the presence or absence of joint swelling and tenderness. 1 The swollen joint count (SJC) and tender joint count (TJC) are core components of the American College of Rheumatology (ACR) response criteria and the 28-joint Disease Activity Score (DAS28), both of which are disease activity measures used for RA assessment. 1,2 Recently, there has been an increase in

Background The demand for diagnostic imaging continues to rise. Against the backdrop of rising healthcare costs and finite resources, this has prompted a paradigm shift towards value-driven patient care. Inappropriate imaging is a barrier towards achieving this goal, which runs counter to prevailing evidence-based guidelines and contributes to rising healthcare costs. Our objective was to evaluate the appropriateness of lumbar spine X-rays in a tertiary referral emergency department and assess whether physician specialization and years of experience influence appropriateness. Methods Retrospective review of 1030 lumbar spine radiographs performed in an emergency department of an academic medical centre over a consecutive 3-month period. Referral indications were reviewed for adherence to 2021 American College of Radiology (ACR) appropriateness guidelines for low back pain, and referral pattern evaluated among physician groups based on specialist training and years in practice. Results 63.8% of lumbar spine radiograph were appropriate, with trauma being the most common indication. 36.2% orders were inappropriate, with low back pain of less than 6 weeks duration being the most common indication. Significant differences in inappropriate orders was found (p&lt;0.001) across physician groups: qualified Emergency Medicine specialists (20.9% inappropriate orders), specialists in-training (27.8%) and non-specialists with ≥3 (60.0%) and &lt;3 (36.9%) years in practice, respectively. Conclusion Approximately a third of lumbar spine radiography performed in the emergency room were inappropriately ordered by ACR guidelines; specialist training and years in practice affected referral patterns. Integrating evidence-based appropriateness guidelines into the physician order workflow and targeting older non-specialists may promote more judicious imaging and reduce healthcare costs.