Priyanka Khatri

Background: Emergency department (ED) overcrowding and delayed access to care are ongoing challenges in Singapore. The COVID-19 pandemic further underscored the need for scalable virtual care models that go beyond traditional hospital settings, allowing patients to access acute specialist care quickly and efficiently. Objective: This study describes the design, implementation, and early outcomes of the National University Health System (NUHS) Virtual Care Centre (VCC), a clinician-led helpline aimed at reducing unnecessary ED visits and supporting community-based acute care. Methods: In 2020, the NUHS launched the VCC, a helpline at Alexandra Hospital, as a prehospital triage model. The helpline functions as a nurse-led telephone triage with real-time escalation to doctors for urgent medical issues. It ensures the continuity of care for patients recently discharged and diverts nonemergency cases from the ED. A retrospective analysis of call data from 2020 to 2024 was conducted to evaluate utilization patterns, clinical outcomes, and safety. Results: Over 4 years, the VCC managed 4857 calls, of which 59.3% (n=2879) were clinical in nature. Nearly two-thirds (1834/2879, 63.7%) were resolved remotely, preventing in-person ED visits. Only 13.8% (397/2879) required redirection to an ED, and 3.3% (95/2879) were directly admitted to an acute hospital or hospital at home service. Within 72 hours of call resolution, 69.1% (1990/2879) of the callers avoided an ED visit. Undertriage was 4.9% (110/2232) at 72 hours post call resolution, with no high dependency or intensive care unit admissions during this period. Mortality rates were low (1.0% at 14 days; 2.3% at 30 days). Conclusions: The NUHS VCC provides a feasible and safe model for virtual acute care triage within the public health care system. It effectively diverted lower-acuity cases from the ED and ensured continuity of care, offering a scalable approach aligned with national efforts to extend health care beyond hospital walls.

Introduction: Hyperphosphatemia is frequent in hemodialysis (HD) patients and associates with cardiovascular mortality. Parameters of online hemodiafiltration (OL‐HDF) prescription influencing phosphate removal are poorly understood in real‐world clinical settings. Methods: We conducted a prospective observational study including chronic HD patients dialyzed at a single UK university hospital between December 2021 and July 2023. Phosphate removal was quantified from spent dialysate during a midweek session. Results: Dialysate phosphate was measured during 161 dialysis sessions in 128 unique patients (19 on HD and 109 on OL‐HDF), with mean age 63.3 ± 16.2 years and 77 (60.1%) men. Mean intra‐dialytic phosphate removal was 25.6 ± 14.3 mmol per session. In multivariate analysis, pre‐HD serum phosphate concentration, session time, and urea distribution volume ( V ) were positively associated with intradialytic phosphate removal. A significant interaction between session time and pre‐HD serum phosphate concentration indicated that longer sessions provided greater benefit to patients with higher baseline phosphate levels. Conversely, dialysis modality (OL‐HDF vs. HD) and substitution volume were not significantly associated with phosphate removal. Conclusions: OL‐HDF and substitution flow do not demonstrate a measurable beneficial impact on phosphate removal in a real‐world setting. Session time, pre‐HD serum phosphate concentration, and urea distribution volume ( V ) are the most relevant determinants of phosphate clearance in real‐world clinical practice. Session duration emerges as the most effective modifiable factor for controlling phosphate burden in dialysis patients, particularly for those with higher pre‐HD phosphate levels.

Aim: Stroke is a leading cause of death and disability, with substantial healthcare implications. Chronic kidney disease (CKD) is similarly impactful, and emerging evidence links CKD to a higher stroke risk. Despite this, stroke risk assessment in CKD patients remains limited. This study explores the kidney failure risk equation (KFRE) as a predictive tool for ischaemic stroke in CKD patients.Methods: This retrospective cohort study analysed CKD patients from a healthcare registry, excluding those with prior stroke, end‐stage kidney disease, or kidney transplants. Acute ischemic stroke was the primary outcome, with deaths censored. Cox proportional hazards models evaluated associations between the 2‐year and 5‐year 4‐variable KFRE scores and stroke risk.Results: A total of 14,794 consecutive patients were included, with a median follow‐up of 509 days. The median age of the cohort was 73 years (IQR:14 years), with 6251 females(42.3%), and the majority being of Chinese ethnicity (n = 10 759,73.5%). During the follow‐up period, 155 patients (1.05%) experienced an ischemic stroke event, with a median time to stroke of 265 days (IQR:242 days). The 2‐year (HR: 1.38 per 10% increase, 95% CI: [1.17–1.63], p < 0.001) and 5‐year (HR:1.20 per 10% increase, 95% CI: [1.10–1.31], p < 0.001) 4‐variable KFRE scores were significantly associated with an increased risk of ischemic stroke. These associations remained significant after adjusting for patient demographics, comorbidities, advanced CKD stage, glycated haemoglobin and lipid parameters.Conclusion: CKD patients at elevated risk of kidney failure also face a significantly increased risk of acute ischaemic stroke. The KFRE could potentially be integrated into CKD management to assess this risk. Future large prospective cohort studies are necessary to validate these findings.

Introduction: Hyperkalemia is frequently encountered and associated with cardio‐vascular mortality in chronic hemodialysis (HD) patients. While online hemodiafiltration (OL‐HDF) is thought to offer clinical benefit over high‐flux HD, the impact of convective clearance on intra‐dialytic potassium removal is unknown.Methods: Chronic dialysis patients undergoing outpatient HD or OL‐HDF at a single center attached to a university hospital were recruited in a prospective observational study. Spent dialysate along with clinical and biological variables were collected during a single mid‐week session.Results: We included 141 patients, with 21 treated with HD and 120 with OL‐HDF. Mean age was 65.7 ± 15.6 years with 87 (61.7%) men. Mean intra‐dialytic potassium removal was 69.9 ± 34.2 mmol. Patients on OL‐HDF and HD have similar intra‐dialytic potassium removal, with mean values of 69.1 ± 34.2 and 74.3 ± 35.0, respectively. In multivariate analysis, factors associated with intra‐dialytic potassium removal were (decreasing order of effect size): dialysate potassium (β −15.5, p < 0.001), pre‐HD serum potassium (β 9.1, p < 0.001), and session time (β 7.8, p = 0.003). In OL‐HDF patients, substitution flow was not associated with potassium removal.Conclusion: In chronic dialysis patients, convective therapy provided by OL‐HDF does not affect potassium removal when compared with high‐flux HD. Moreover, the importance of convective volume is not associated with potassium clearance in OL‐HDF. Overall, session length and serum‐to‐dialysate potassium gradient are the main determinants of potassium clearance regardless of dialysis modality. Those results should inform clinicians on the optimal therapy in chronic dialysis patients in the era of OL‐HDF.