Background: s/Aims: Postoperative pancreatic fistulas (POPF) remain a major cause of morbidity and mortality following pancreatoduodenectomy (PD). Pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) are the two most commonly used reconstruction techniques, yet evidence favoring one over the other is inconclusive. This study evaluates postoperative outcomes following open PD at a single institution that transitioned from PG to PJ as the preferred reconstruction method. Methods: This retrospective comparative study included patients who underwent PD between April 2005 and August 2022. Of 757 patients identified, 522 met the inclusion criteria. Propensity score matching (PSM) was performed to adjust for clinically relevant covariates. Primary endpoints were clinically relevant (CR) POPF (grade B/C) and Clavien–Dindo (CD) grade ≥ 3 POPFs. Secondary outcomes included post-pancreatectomy hemorrhage (PPH), delayed gastric emptying (DGE), systemic complications, length of hospital stay, and mortality. Results: Overall, CR-POPF and CD grade ≥ 3 POPFs occurred in 21.3% and 8.0% of patients, respectively. Thirty-day and in-hospital mortality rates were 3.1% and 4.2%. After PSM, 368 patients (184 PG and 184 PJ) were analyzed. Grade B POPFs were more frequent following PJ than PG (24.5% vs. 15.8%, p < 0.001). Although CR-POPF and CD grade ≥ 3 POPFs were numerically higher in the PJ group, differences were not statistically significant. In contrast, DGE, PPH, and in-hospital mortality were significantly higher following PG (37.0% vs. 25.0%, p = 0.025; 16.3% vs. 8.7%, p = 0.025; and 7.6% vs. 2.7%, p = 0.049, respectively). Conclusions PG was associated with a lower incidence of grade B POPFs but higher rates of DGE, PPH, and in-hospital mortality.

Introduction: Large, rapidly enlarging adrenal masses typically mandate surgical intervention given the high probability of adrenocortical carcinoma (ACC). However, benign processes can mimic these aggressive growth kinetics, creating a diagnostic challenge for clinicians. Case: A 74-year-old male with hypertension, atrial fibrillation on rivaroxaban, and prostate cancer was referred for evaluation of a right adrenal incidentaloma detected on computed tomography imaging performed for prostate cancer staging. The well-defined mass measured 8.9 × 7.8 × 7.5 cm (AP × W × CC) with areas of calcification. Mean attenuation was +40 Hounsfield Unit, with no significant washout. Biochemical evaluation confirmed a non-functioning lesion (24-hour urine metanephrines 756 mcg/24 hours [N 246–753 mcg/24 hours]; serum cortisol 62 nmol/L post overnight dexamethasone suppression test). The patient was otherwise asymptomatic and declined surgical intervention. Repeat imaging 4 months later demonstrated interval enlargement of the mass to 9.8 × 8.8 × 10.7 cm. Due to this rapid growth, which was highly concerning for ACC, the patient underwent laparoscopic right adrenalectomy. Histopathological examination unexpectedly revealed an adrenal hematoma without evidence of an underlying tumor or malignancy. This case illustrates the difficulty in differentiating aggressive cortical tumors from atypical hemorrhagic events. Larger series on adrenal hemorrhage reported trauma and procedural complications as the leading causes, with a median size of 3–4 cm. Idiopathic large adrenal hematomas presenting as rapidly expanding “pseudotumors” are exceptionally rare, with fewer than 20 cases reported in which surgical resection was performed due to high preoperative suspicion of malignancy. Additionally, adrenal hemorrhage attributed to anticoagulant therapy often occurs bilaterally. Unilateral lesion, especially when large, can pose a diagnostic challenge as highlighted in this case. Conclusion In patients on anticoagulation, rapid interval growth of an adrenal mass does not always equate to malignancy. Recognizing this mimicry in the era of widespread Direct Oral Anticoagulant use is essential for refining treatment decision regarding surgical intervention, as most cases exhibited a self-limiting process with spontaneous resolution.

Introduction: The increasing prevalence of diabetes represents a significant global health challenge. Modifiable risk factors, including physical inactivity, unhealthy dietary habits, and obesity contribute substantially to this rising burden. In conjunction with the 2025 World Diabetes Day (WDD) campaign focusing on “diabetes and the workplace,” we assessed diabetes risk among healthcare workers in our hospital using the Modified Asian Finnish Diabetes Risk Score (ModAsian FINDRISC). Methodology: Healthcare workers from various departments were invited to participate in the hospital WDD celebration. A total of 286 attendees underwent anthropometric measurements and completed the ModAsian FINDSRIC questionnaire. Descriptive statistics were used to summarize the prevalence of risk factors and overall diabetes risk. Results: The participants included doctors, nurses, allied healthcare professionals, as well as hospital support and administrative staff. The majority of participants (74.8%) were aged below 45 years. 39.2% were overweight while 30.8% were obese. One-third (37.4%) had increased waist circumference (WC) (≥90 cm for men, ≥80 cm for women). Additionally, 20% of respondents reported being on antihypertensive medication, and 23.8% had previously recorded high blood glucose. A family history of diabetes mellitus (DM) was reported by 62.6% of respondents. Additionally, about onethird were sedentary with less than 30 minutes of daily exercise or physical activity, another one-third did not consume fruits or vegetables on a daily basis. The median ModAsian FINDRISC score was 8, with approximately 30% of them classified as having moderate to very high risk of developing DM (moderate: 17.5%; high: 10.8%; very high: 2.8%). Conclusion These results revealed high metabolic risk in healthcare workers and highlight the need for targeted workplace health promotion strategies to reduce the risk of developing diabetes.
Tertiary Care Centers ; Health Personnel ; Diabetes Mellitus

Introduction: Repaglinide, a meglitinide analogue, has a rapid onset and short duration of action. It offers prandial glucose control while reducing hypoglycemia risk compared to sulfonylureas. We describe its use in our special cohorts of diabetic patients where repaglinide was prescribed to reduce hypoglycemia in vulnerable patients or to optimize glycemic control through pharmacotherapy intensification or deintensification. Cases: Cohort A comprised 12 elderly patients with multiple comorbidities (mean age: 70.3 years; mean DM duration: 18.3 years) characterized by high glucose variability and problematic hypoglycemia. In seven patients, low-dose gliclazide was replaced with repaglinide with reduction in hypoglycemic episodes. One patient on low-dose premixed insulin was successfully switched to preprandial repaglinide. Two patients on basal insulin were able to reduce their insulin requirements and stabilize their glucose levels. A younger patient with autonomic dysfunction had hypoglycemia while on insulin glulisine, while its omission led to severe hyperglycemia. Substituting glulisine with repaglinide resolved the glucose variability. Repaglinide effectively reduced hypoglycemic episodes while maintaining glycemic stability, with a mean hemoglobin A1c (HbA1c) reduction of 0.36% over 3–6 months. Cohort B consisted of six younger patients (mean age: 35.3 years) with focus on optimizing HbA1c and improving treatment adherence. Two patients on basal-bolus regimes success-fully transitioned off bolus insulin to repaglinide, significantly improving compliance. One patient on basal insulin was successfully transitioned to an all-oral regimen. Three patients on existing oral hypoglycemic agents were started on repaglinide to close the glycemic gap. Cohort B achieved a robust mean HbA1c reduction of 2.1% within 3–6 months. Conclusion Repaglinide remains an important armamentarium in personalized diabetes management. Its pharmacokinetics and flexible dosing allow intensification of glycemic control while minimizing the risk of hypoglycemia. It also offers a viable strategy for selected patients struggling with complex insulin regime.
Repaglinide

Introduction: Severe hypercalcemia is most commonly caused by primary hyperparathyroidism (PHPT) and malignancy. While standard therapies are effective in most cases, a subset of patients have persistent or refractory hypercalcemia. We present a retrospective case series detailing the clinical characteristics, biochemistry, and outcomes of patients treated with denosumab for hypercalcemia. Cases: Seven patients with severe hypercalcemia were identified, comprising five with PHPT and two with malignancyassociated hypercalcemia. The mean age was 70.4 years (range 55–86), with 71% female (n = 5) and 29% male (n = 2). Baseline corrected calcium ranged from 2.92 to 4.59 mmol/L, with a mean of 3.26 mmol/L. In the PHPT cohort, parathyroid hormone (PTH) levels were significantly elevated (16.7–168 pmol/L), while malignancy patients had suppressed PTH (0.6 and 0.9 pmol/L). Prior to denosumab, 4/7 patients (57%) received bisphosphonates, 3/7 (43%) received calcitonin, and 1/7 (14%) was treated with cinacalcet. Denosumab resulted in a mean reduction in corrected calcium of 0.22 mmol/L from 3.26 to 3.03 mmol/L. Biochemical response was observed in 5/7 patients (71%). Of these, 3 patients (43%) achieved normocalcemia, while 2 patients (29%) demonstrated a partial response. The remaining 2/7 patients (29%) showed no significant improvement in calcium levels. Among responders, the mean time to calcium reduction to <3.0 mmol/L was 27 days (range 7–47). Repeat dosing was required in the majority of patients, with a mean of 1.7 doses per patient (range 1–4), indicating variability in both onset and durability of response. Among patients with PHPT, four underwent parathyroidectomy, and one declined surgery. Both patients with malignancy were managed nonsurgically. Conclusion Denosumab achieved normocalcemia in 43% of patients, with additional partial responses. Its effects were variable, with delayed response and frequent need for repeat dosing, supporting its role as an adjunctive or bridging therapy rather than as a definitive treatment.
Denosumab ; Hypercalcemia ; Retrospective Studies

Introduction: Hypercalcemic crisis, a decompensated state characterized by multiorgan dysfunction and a corrected serum calcium (CCa) level typically >3.5 mmol/L, is a rare but lifethreatening endocrine emergency that requires prompt recognition and aggressive multimodal management. We report a fatal case of hypercalcemic crisis secondary to primary hyperparathyroidism, which was refractory to multiple lines of medical therapy. Case: A 55-year-old female with diabetes mellitus, hypertension, and chronic kidney disease (creatinine 159 umol/L; estimated glomerular filtration rate 33 mL/min) presented with 3 days of confusion, profound fatigue, and constipation, preceded by a 1-month history of polyuria and polydipsia. Her Glasgow Coma Scale (GCS) was E4V3M5. Physical examination was unremarkable, with no palpable neck swelling. Significant laboratory findings included severe hypercalcemia with markedly elevated serum intact parathyroid hormone (iPTH) (CCa 4.49 mmol/L; phosphate 1.01 mmol/L; iPTH 60.1 pmol/L [N 1.6–6.0]; creatinine 149 umol/L). Saline diuresis was initiated together with subcutaneous calcitonin, resulting in an initial biochemical response, with CCa decreasing to a nadir of 3.61 mmol/L. However, the CCa subsequently rebounded to 5.00 mmol/L. Hemodialysis was performed, followed by administration of subcutaneous denosumab 60 mg. Nonetheless, the CCa decreased only modestly to 4.28 mmol/L. She became increasingly drowsy, and her clinical course was further complicated by aspiration pneumonia and lung collapse, leading to respiratory failure requiring intubation and inotropic support. Despite intensive care, additional sessions of hemodialysis and continuous renal replacement therapy, her CCa remained persistently above 4.0 mmol/L, peaking at 5.35 mmol/L. Due to her critical condition, imaging for lesion localization could not be performed. She eventually succumbed to her illness on day 10 of admission, before definitive surgery could be undertaken. Conclusion This case highlights the potentially fatal course of hypercalcemic crisis secondary to primary hyperparathyroidism. The reported mortality rate is high, at around 60%. Early recognition and intensive management, including emergency parathyroidectomy in resistant cases, have been shown to be crucial in improving outcomes.
Hyperparathyroidism, Primary

Introduction: Ectopic ACTH secretion (EAS) is a rare cause of Cushing’s syndrome, accounting for 5–15% of cases. Pulmonary neuroendocrine tumors are the most frequent cause. However, primary tumor localization remains a significant diagnostic challenge, delaying effective treatment. Case: A 59-year-old female with diabetes mellitus presented with refractory hypertension and hypokalemia. Initial laboratory findings revealed a baseline cortisol of 1,164 nmol/L and morning adrenocorticotropic hormone (ACTH) of 19.5 pmol/L (normal <10.2 pmol/L), with an overnight dexamethasone suppression test cortisol of 624 nmol/L. Pituitary magnetic resonance imaging (MRI) and computed tomography (CT) scans of the thorax, abdomen, and pelvis were initially unremarkable. A PET scan identified mild hypermetabolism in the left adrenal gland and gastrointestinal tract, though colonoscopy revealed only chronic colitis. An intravenous desmopressin stimulation test demonstrated a 181% rise in ACTH and a 35% rise in cortisol, pointing toward pituitary Cushing’s. However, repeat pituitary MRI remained normal. A high-dose dexamethasone suppression test showed approximately 34% cortisol suppression (cortisol 1,128 nmol/L to 745 nmol/L), suggesting ectopic Cushing’s syndrome. Bilateral inferior petrosal sinus sampling demonstrated a peak central-to-peripheral ACTH ratio of 1.8 on the right and 1.6 on the left, pointing toward ectopic Cushing’s. Localization with DOTATATE PET-CT identified a 7 × 9 × 8 mm nodule in the right middle lobe. A wedge resection was performed. Histopathology confirmed a typical carcinoid tumor with clear resection margins. Immunohistochemistry revealed tumor cells positive for CK AE1/ AE3, synaptophysin, chromogranin, and INSM-1, with weak positivity for ACTH. The latest 8 am cortisol was 117 nmol/L and ACTH 1.74 pmol/L, confirming biochemical cure. Hypokalemia resolved, with improvement in her metabolic profile. Conclusion This case highlights the diagnostic complexities of EAS, particularly when initial imaging is inconclusive and biochemical tests yield conflicting results. Timely, precise localization of the causative tumor is crucial for successful surgical intervention and to prevent severe complications of hypercortisolism, thereby improving patient outcomes.
ACTH Syndrome, Ectopic

Introduction: Electrolyte imbalance is common in central nervous system infections. Arginine vasopressin deficiency (AVP-D), Cerebral Salt Wasting (CSW), and Syndrome of Inappropriate Antidiuretic Hormone secretion (SIADH) are important etiologies that can cause opposing extremes of serum sodium, posing diagnostic and therapeutic challenges. We report a rare case of transient central AVP-D followed by CSW secondary to tuberculous meningitis (TBM). Case: An 18-year-old female presented with a 1-month history of fever, reduced responsiveness, and visual hallucinations. Her Glasgow Coma Scale was E4V1M4 with neck stiffness and upper motor neuron signs. Initial investigations revealed severe hyponatremia (119 mmol/L) and communicating hydrocephalus with third ventricle ballooning on brain imaging. Coupled with a positive tuberculosis contact, anti-tuberculous therapy was initiated for probable TBM alongside 3% saline correction prior to insertion of external ventricular drain (EVD). Her condition deteriorated on day 5, requiring intubation for aspiration pneumonia. Repeated imaging showed worsening hydrocephalus, necessitating EVD revision. She subsequently developed polyuria (urine output [UO] 150–300 mLs/hour), with biochemical findings consistent with AVP-D (serum sodium 154 mmol/L; urine osmolality 96 mOsm/kg; urine sodium <20 mmol/L). Intravenous desmopressin 1 mcg was administered, and UO reduced to 30 mLs/hour. However, polyuria recurred on Day 9, accompanied by tachycardia, hypotension, and a rapid decline in serum sodium to 120 mmol/L. Diagnosis of CSW was established (urine sodium 204 mmol/L; urine osmolality 470 mOsm/kg). Oral fludrocortisone was initiated and titrated to 0.4 mg daily to maintain serum sodium >130 mmol/L. Due to persistent hydrocephalus, right ventriculoperitoneal shunt was inserted on Day 22, after which her UO gradually decreased, allowing tapering of fludrocortisone. She remains on fludrocortisone 0.1 mg daily with ongoing rehabilitation. Conclusion TBM can be complicated by SIADH, AVP-D, or CSW. Concurrent AVP-D and CSW have not been reported. This case highlights the dynamic electrolyte disturbances in TBM which may lead to diagnostic confusion and therapeutic error. Early recognition and tailored therapy, alongside definitive management to reduce intracranial pressure, are essential for optimal outcomes.
Hypernatremia ; Hyponatremia ; Tuberculosis, Meningeal

ObjectiveTo investigate the mechanism by which Feixin decoction treats hypoxic pulmonary hypertension （HPH） by regulating the peroxisome proliferator-activated receptor gamma （PPARγ）/nuclear factor-kappa B （NF-κB）/NOD-like receptor pyrin domain containing 3 （NLRP3） signaling pathway. MethodsForty-eight male SD rats were randomly allocated into normal， hypoxia， and low-， medium- and high-dose （5.85， 11.7， 23.4 g·kg^-1， respectively） Feixin decoction groups， with 8 rats in each group. Except the normal group， the remaining five groups were placed in a hypoxia chamber with an oxygen concentration of （10.0±0.5）% for 8 h per day， 28 days， and administrated with corresponding drugs during the modeling process. After 4 weeks of treatment， echocardiographic parameters ［pulmonary artery acceleration time （PAT）， pulmonary artery ejection time （PET）， right ventricular anterior wall thickness （RVAWd）， and tricuspid annular plane systolic excursion （TAPSE）］ were measured for each group. The right ventricular systolic pressure （RVSP） was measured by the right heart catheterization method， and the right ventricular hypertrophy index （RVHI） was calculated by weighing the heart. The pathological changes in pulmonary arterioles were observed by hematoxylin-eosin staining. The co-localization of α-smooth muscle actin （α-SMA） with NLRP3， N-terminal gasdermin D （N-GSDMD）， and cysteinyl aspartate-specific proteinase-1 （Caspase-1） in pulmonary arteries was detected by immunofluorescence. The protein levels of PPARγ， NF-κB， NLRP3， apoptosis-associated speck-like protein containing a CARD （ASC）， N-GSDMD， interleukin-1β （IL-1β）， interleukin-18（IL-18）， and cleaved Caspase-1 in the lung tissue was determined by Western blot. The ultrastructural changes in pulmonary artery smooth muscle cells （PASMCs） were observed by transmission electron microscopy. ResultsCompared with the normal group， the hypoxia group showed increased RVSP and RVHI （P<0.01）， decreased right heart function （P<0.01）， increased pulmonary vascular remodeling （P<0.01）， increased co-localization of α-SMA with NLRP3， N-GSDMD， and Caspase-1 in pulmonary arterioles （P<0.01）， up-regulated protein levels of NF-κB， NLRP3， ASC， N-GSDMD， IL-1β， IL-18， and cleaved Caspase-1 in the lung tissue （P<0.05， P<0.01）， a down-regulated protein level of PPARγ （P<0.05， P<0.01）， and pyroptosis in PASMCs. Compared with the hypoxia group， Feixin decoction reduced RVSP and RVHI， improved the right heart function and ameliorated pulmonary vascular remodeling （P<0.05， P<0.01）， decreased the co-localization of α-SMA with NLRP3， N-GSDMD， and Caspase-1 （P<0.05， P<0.01）， down-regulated the protein levels of NF-κB， NLRP3， ASC， N-GSDMD， IL-1β， IL-18， and cleaved Caspase-1 in the lung tissue （P<0.05， P<0.01）， up-regulated the protein level of PPARγ （P<0.05， P<0.01）， and alleviated pyroptosis in PASMCs. ConclusionFeixin decoction can ameliorate pulmonary vascular remodeling and right heart dysfunction in chronically induced HPH rats by regulating pyroptosis in PASMCs through the PPARγ/NF-κB/NLRP3 pathway.

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