INTRODUCTION: Obstructive sleep apnoea (OSA) is common in Singapore, with moderate to severe OSA affecting around 30% of residents. These consensus statements aim to provide scientifically grounded recommendations for the management of OSA, standar-dise the management of OSA in Singapore and promote multidisciplinary collaboration. METHOD: An expert panel, which was convened in 2024, identified several areas of OSA management that require guidance. The expert panel reviewed the current literature and developed consensus statements, which were later independently voted on using a 3-point Likert scale (agree, neutral or disagree). Consensus (total ratings of agree and neutral) was set a priori at ≥80% agreement. Any statement not reaching consensus was excluded. RESULTS: The final consensus included 49 statements that provide guidance on the screening, diagnosis and management of adults with OSA. Additionally, 23 statements on the screening, diagnosis and management of paediatric OSA achieved consensus. These 72 consensus statements considered not only the latest clinical evidence but also the benefits and harms, resource implications, feasibility, acceptability and equity impact of the recommendations. CONCLUSION The statements presented in this paper aim to guide clinicians based on the most updated evidence and collective expert opinion from sleep specialists in Singapore. These recommendations should augment clinical judgement rather than replace it. Management decisions should be individualised, taking into account the patient's clinical characteristics, as well as patient and caregiver concerns and preferences.
Humans ; Sleep Apnea, Obstructive/diagnosis* ; Singapore ; Consensus ; Adult

Problem: Emergency medical teams (EMTs) responding to mass casualty incidents attend to casualties in a chaotic, high-pressure and resource-limited environment that is vastly different from their day-to-day work. The nature of mass casualty incidents and the work environment can impact psychological resilience, but the psychological resilience of members of EMTs has not been evaluated. Context: In Singapore, EMTs are deployed from public hospitals, polyclinics and the Singapore Red Cross to disaster sites, where they triage, stabilize and treat casualties before evacuating them to public hospitals for further management. Action: Twenty-four members of EMTs responded to a cross-sectional survey based on a psychological resilience tool developed for health-care rescuers involved in mass casualty incidents to evaluate their psychological resilience after a full-scale exercise involving an aviation accident. Respondents completed a psychological resilience tool that was developed by experts in disaster work and research using a modified Delphi approach. There were 27 items across eight domains: optimism, altruism, preparations for disaster rescue, social support, perceived control, self-efficacy, coping strategies and positive growth. Outcome: The key observations from the survey were that (i) staff demonstrated a strong sense of altruism and had good social support; (ii) staff were not confident about their preparedness, and this led to a lack of optimism, perceived control and ability to deal with emotions; and (iii) it was necessary for respondents to reflect on their experience to find meaning to support growth after the deployment. Discussion: Optimizing casualty survival and outcomes during mass casualty incidents requires not only excellent procedural training and robust standard operating procedures and work processes but also dedicated efforts to enhance the psychological resilience of members of EMTs.

Problem: Emergency medical teams (EMTs) deployed to mass casualty incidents (MCIs) are required to work outside their usual settings and according to different principles, which may affect their performance and the survival of casualties. Prior to 2013, training offered to domestic EMTs was limited to ad hoc and infrequent simulation exercises. Context: Domestic EMTs are activated from public tertiary hospitals to provide pre-hospital medical support to the Singapore Civil Defence Force and establish a first-aid post (FAP) for triaging, stabilizing and treating casualties. These casualties are then evacuated to public hospitals for further management. Action: Recognizing the need for a more systematic approach to the training of domestic EMTs, the Disaster Medical Responder’s Course (the Course) was developed as a multi-institutional collaboration to equip EMT members attending a MCI with the necessary skills to perform effectively at the FAP. Outcome: The Course was first run in 2013 and is usually offered six to eight times a year. Since June 2019, a total of 414 health-care staff and allied health professionals have participated. There have been numerous revisions of the course content and delivery to reflect the latest concepts in operations and global best practice, as well as developments in educational methodologies. Discussion: Preparedness is crucial to optimize the survival and outcomes of casualties. The Course provides standardized training of domestic EMTs and plays a pivotal role in ensuring operational readiness for MCIs in Singapore.

INTRODUCTION: Misuse of prescription medicines and the harms associated with such use are growing threats across the world. There is currently, however, limited data on the extent of prescription medicine misuse in Singapore and whether this is a current threat in the country. METHODS: An online survey, limited to 1,000 individuals (aged 21 years and over) who were residents in Singapore, was administered through a survey panel company in September 2015. The survey collected information on participant demographics, and their awareness, self-reported lifetime and past-year misuse of commonly available prescription medicines in Singapore as well as the use of a range of recreational drugs and novel psychoactive substances (NPS). RESULTS: Lifetime (6.7%) and past-year (4.8%) misuse of any prescription medicine was comparable to lifetime (6.0%) and past-year (3.0%) use of any recreational drugs/NPS. The top five prescription medicines for lifetime misuse were: diazepam (2.7%); codeine (2.3%); dhasedyl (promethazine, codeine and ephedrine; 1.6%); panadeine (paracetamol and codeine; 1.5%); and methylphenidate (1.2%). The top five drugs for past-year misuse were: diazepam (1.6%); codeine (0.9%); panadeine (0.7%); alprazolam (0.6%); baclofen (0.6%); and gabapentin (0.6%). CONCLUSION Misuse of prescription medicine in Singapore was common, with prevalence comparable to the use of recreational drugs/NPS. A common source for misused drugs was physicians. Further studies are required to determine whether this is more widespread in Singapore and establish the different forms of drug diversion, so that appropriate prevention strategies can be implemented.
Humans ; Illicit Drugs/adverse effects* ; Public Health ; Singapore/epidemiology* ; Substance-Related Disorders/drug therapy* ; Prescription Drugs/adverse effects* ; Codeine ; Diazepam ; Prescriptions

INTRODUCTIONThis study describes the physician experience relating to the effectiveness of incobotulinumtoxinA and patient satisfaction with its use for the treatment of glabellar frown lines (GFLs).

METHODSA total of 17 patients from six dermatological clinics, aged > 18 years and with mild to very severe GFLs at maximum frown, were included. Patients were excluded if they had treatment with resorbable fillers and botulinum toxins in the preceding six months, or non-resorbable fillers or surgery in the treatment area. Injection sites (range 3-5) were chosen depending on their severity (dose range 12-20 U), covering corrugators and procerus muscles. Physicians assessed improvements to GFLs using the Merz scale on Days 4 and 14 after treatment. Patients completed a self-reported questionnaire on their facial wrinkles on Days 2 and 4 after treatment.

RESULTSMost (76.5%) patients were women. The mean age of the patients was 46.9 ± 10.0 years. Mean severities (on the Merz scale) for at-rest and dynamic (with expression) GFLs at baseline were 1.3 ± 1.10 and 3.4 ± 0.38, respectively, and decreased on Day 14 (p < 0.05). Treatment response rates (> 1-point improvement) for at-rest and dynamic (with expression) GFLs on Day 4 were 40% and 100%, respectively. All patients reported being satisfied or very satisfied, and 64.3%-71.4% indicated that their facial wrinkles had improved on Day 2.

CONCLUSIONIncobotulinumtoxinA was fast acting with visible improvements by Day 4 and all patients expressed satisfaction with their treatment after two days. GFLs saw the most improvement among the facial characteristics measured.

INTRODUCTIONWith the increased use of filler and fat injections for aesthetic purposes, there has been a corresponding increase in the incidence of complications. Vision loss as an uncommon but devastating vascular side effect of filler injections was the focus of this paper.

METHODSA review committee, consisting of plastic surgeons, aesthetic medical practitioners, ophthalmologists and dermatologists from Singapore, was convened by the Society of Aesthetic Medicine (Singapore) to review and recommend methods for the prevention and management of vision loss secondary to filler injections.

RESULTSThe committee agreed that prevention through proper understanding of facial anatomy and good injection techniques was of foremost importance. The committee acknowledged that there is currently no standard management for these cases. Based on existing knowledge, injectors may follow a proposed course of action, which can be divided into immediate, definitive and supportive. The goals were to reduce intraocular pressure, dislodge the embolus to a more peripheral location, remove or reverse central ischaemia, preserve residual retinal function, and prevent the deterioration of vision. Dissolving a hyaluronic acid embolus remains a controversial option. It is proposed that injectors must be trained to recognise symptoms, institute immediate actions and refer patients without delay to dedicated specialists for definitive and supportive management.

CONCLUSIONSSteps to prevent and manage vision loss based on current evidence and best clinical practices are outlined in this paper. Empirical referral to any emergency department or untrained doctors may lead to inordinate delays and poor outcomes for the affected eye.

Blindness ; etiology ; prevention & control ; Dermal Fillers ; adverse effects ; Embolism ; Esthetics ; Humans ; Hyaluronic Acid ; adverse effects ; Iatrogenic Disease ; Incidence ; Injections ; adverse effects ; Ophthalmology ; Singapore ; Societies, Medical

Adult ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents ; therapeutic use ; Bacteremia ; drug therapy ; Cefazolin ; therapeutic use ; Drug Resistance, Bacterial ; Female ; Humans ; Klebsiella Infections ; drug therapy ; Klebsiella pneumoniae ; Male ; Microbial Sensitivity Tests ; Middle Aged ; Retrospective Studies ; Young Adult

INTRODUCTIONAntimicrobial stewardship programmes (ASP) can reduce antibiotic use but patient safety concerns exist. We evaluated the safety of prospective carbapenem review and feedback and its impact on carbapenem use and patient outcomes.

MATERIALS AND METHODSAfter 3 months implementation of our ASP, we compared patients with and without acceptance of ASP recommendations on the use of carbapenems. Primary outcome was 30-day mortality. Secondary outcomes included duration of carbapenem use, length of hospitalisation, clinical response, microbiological clearance, 30-day readmission and mortality at discharge.

RESULTSOf 226 recommendations for 183 patients, 59.3% was accepted. De-escalation, switching to oral antibiotics and antibiotic cessation comprised 72% of recommendations. Patients with acceptance of ASP recommendations had lower 30-day mortality and higher end-of-therapy clinical response despite shorter carbapenem duration (P <0.05). Predictors of 30-day mortality were Pitt bacteraemia score (adjusted odds ratio [aOR] 1.39, 95% confidence interval [CI], 1.11 to 1.74; P = 0.004) and non-acceptance of ASP recommendations (aOR 2.84, 95% CI, 1.21 to 6.64; P = 0.016).

CONCLUSIONOur prospective carbapenem review and feedback mainly comprising of reducing carbapenem use is safe.

Carbapenems ; therapeutic use ; Drug Utilization ; standards ; Feedback ; Guideline Adherence ; statistics & numerical data ; Humans ; Patient Safety ; Pharmaceutical Services ; Treatment Outcome

Coxsackievirus A16 (CV-A16) is the leading cause of hand-foot-mouth disease (HFMD), which usually presents as mild and self-limiting symptoms in young children. Rarely, CV-A16 has been reported to cause severe and fatal neurological complications but little is known about these complications. In the present study, 1-day and 7-day old mouse models of CV-A16 were developed using a clinical strain via subcutaneous inoculation. All infected mice exhibited clinical signs of infection, including reduced mobility, limb weakness and paralysis between 3 to 6 days post-infection. Pathologically, the main organs involved were the central nervous system (CNS), skeletal muscles and brown fat. In the CNS, viral antigens as demonstrated by immunohistochemistry, were localized mainly to neurons in the brain stem and spinal cord, suggesting that CV-A16 is neurotropic although inflammation is very mild. The skeletal muscles showed necrosis and myositis due to viral infection as evidenced by the dense viral antigens. Focal viral antigens were also detected in the brown fat. These preliminary pathological findings indicate that our mouse models can be further developed to be useful models for pathogenesis studies, and vaccine and anti-viral drug evaluation.

Coxsackievirus A16 (CV-A16) is the leading cause of hand-foot-mouth disease (HFMD), which usually presents as mild and self-limiting symptoms in young children. Rarely, CV-A16 has been reported to cause severe and fatal neurological complications but little is known about these complications. In the present study, 1-day and 7-day old mouse models of CV-A16 were developed using a clinical strain via subcutaneous inoculation. All infected mice exhibited clinical signs of infection, including reduced mobility, limb weakness and paralysis between 3 to 6 days post-infection. Pathologically, the main organs involved were the central nervous system (CNS), skeletal muscles and brown fat. In the CNS, viral antigens as demonstrated by immunohistochemistry, were localized mainly to neurons in the brain stem and spinal cord, suggesting that CV-A16 is neurotropic although inflammation is very mild. The skeletal muscles showed necrosis and myositis due to viral infection as evidenced by the dense viral antigens. Focal viral antigens were also detected in the brown fat. These preliminary pathological findings indicate that our mouse models can be further developed to be useful models for pathogenesis studies, and vaccine and anti-viral drug evaluation.
Coxsackievirus Infections