INTRODUCTION: Oropharyngeal swabs for diagnosis of COVID-19 often induce violent coughing, which can disperse infectious droplets onto providers. Incorrectly doffing personal protective equipment (PPE) increases the risk of transmission. A cheap, single-use variation of the face shield invented by a Singaporean team, SG Shield, aims to reduce this risk. This manikin study aimed to study the efficacy of the SG Shield in combination with standard PPE. METHODS: A person attired in full PPE whose face and chest was lined with grid paper stood in front of an airway manikin in an enclosed room. A small latex balloon containing ultraviolet fluorescent dye was placed in the oral cavity of the manikin and inflated until explosion to simulate a cough. Three study groups were tested: (a) control (no shield), (b) face shield and (c) SG Shield. The primary outcome was droplet dispersion, determined quantitatively by calculating the proportion of grid paper wall squares stained with fluorescent dye. The secondary outcome was the severity of provider contamination. RESULTS: The SG Shield significantly reduced droplet dispersion to 0% compared to the controls (99.0%, P = 0.001). The face shield also significantly reduced droplet contamination but to a lesser extent (80.0%) compared to the control group (P = 0.001). Although the qualitative severity of droplet contamination was significantly lower in both groups compared to the controls, the face shield group had more contamination of the provider's head and neck. CONCLUSION The manikin study showed that the SG Shield significantly reduces droplet dispersion to the swab provider's face and chest.
Humans ; Infectious Disease Transmission, Patient-to-Professional/prevention & control* ; COVID-19 ; Fluorescent Dyes ; Personal Protective Equipment ; Cough

INTRODUCTION: Hospital-based resuscitation interventions, such as therapeutic temperature management (TTM), emergency percutaneous coronary intervention (PCI) and extracorporeal membrane oxygenation (ECMO) can improve outcomes in out-of-hospital cardiac arrest (OHCA). We investigated post-resuscitation interventions and hospital characteristics on OHCA outcomes across public hospitals in Singapore over a 9-year period. METHODS: This was a prospective cohort study of all OHCA cases that presented to 6 hospitals in Singapore from 2010 to 2018. Data were extracted from the Pan-Asian Resuscitation Outcomes Study Clinical Research Network (PAROS CRN) registry. We excluded patients younger than 18 years or were dead on arrival at the emergency department. The outcomes were 30-day survival post-arrest, survival to admission, and neurological outcome. RESULTS: The study analysed 17,735 cases. There was an increasing rate of provision of TTM, emergency PCI and ECMO (P<0.001) in hospitals, and a positive trend of survival outcomes (P<0.001). Relative to hospital F, hospitals B and C had lower provision rates of TTM (≤5.2%). ECMO rate was consistently <1% in all hospitals except hospital F. Hospitals A, B, C, E had <6.5% rates of provision of emergency PCI. Relative to hospital F, OHCA cases from hospitals A, B and C had lower odds of 30-day survival (adjusted odds ratio [aOR]<1; P<0.05 for hospitals A-C) and lower odds of good neurological outcomes (aOR<1; P<0.05 for hospitals A-C). OHCA cases from academic hospitals had higher odds ratio (OR) of 30-day survival (OR 1.3, 95% CI 1.1-1.5) than cases from hospitals without an academic status. CONCLUSION Post-resuscitation interventions for OHCA increased across all hospitals in Singapore from 2010 to 2018, correlating with survival rates. The academic status of hospitals was associated with improved survival.
Hospitals, Public ; Humans ; Out-of-Hospital Cardiac Arrest/therapy* ; Percutaneous Coronary Intervention ; Prospective Studies ; Singapore/epidemiology*

INTRODUCTION: We aimed to assess the attitudes and learner needs of radiology residents and faculty radiologists regarding artificial intelligence (AI) and machine learning (ML) in radiology. METHODS: A web-based questionnaire, designed using SurveyMonkey, was sent out to residents and faculty radiologists in all three radiology residency programmes in Singapore. The questionnaire comprised four sections and aimed to evaluate respondents' current experience, attempts at self-learning, perceptions of career prospects and expectations of an AI/ML curriculum in their residency programme. Respondents' anonymity was ensured. RESULTS: A total of 125 respondents (86 male, 39 female; 70 residents, 55 faculty radiologists) completed the questionnaire. The majority agreed that AI/ML will drastically change radiology practice (88.8%) and makes radiology more exciting (76.0%), and most would still choose to specialise in radiology if given a choice (80.0%). 64.8% viewed themselves as novices in their understanding of AI/ML, 76.0% planned to further advance their AI/ML knowledge and 67.2% were keen to get involved in an AI/ML research project. An overwhelming majority (84.8%) believed that AI/ML knowledge should be taught during residency, and most opined that this was as important as imaging physics and clinical skills/knowledge curricula (80.0% and 72.8%, respectively). More than half thought that their residency programme had not adequately implemented AI/ML teaching (59.2%). In subgroup analyses, male and tech-savvy respondents were more involved in AI/ML activities, leading to better technical understanding. CONCLUSION A growing optimism towards radiology undergoing technological transformation and AI/ML implementation has led to a strong demand for an AI/ML curriculum in residency education.

INTRODUCTION: Treatment of pain is an important component of prehospital care. Inhalational analgesia agents have attractive strengths, but there is a paucity of studies comparing these with more conventional agents. We aimed to compare inhalational methoxyflurane and intramuscular (IM) tramadol as first-contact analgesia in the Singapore national ambulance service. METHODS: Ambulances were randomised to carry either methoxyflurane or IM tramadol for the first six months and crossed over to the other arm after six months. Patients aged ≥ 16 years, with acute pain arising from musculoskeletal trauma with Numerical Rating Scale (NRS) score ≥ 3 were enrolled. Variables included NRS reduction, time variables, adverse effects, Ramsay Sedation Scores, and patient and paramedic satisfaction scores on a Likert scale. RESULTS: A total of 369 patients were enrolled into this study, but 26 patients were excluded due to missing data. The methoxyflurane arm had a shorter median time taken from arrival at the scene to drug administration (9.0 [interquartile range 6.0-14.0] minutes vs. 11.0 [interquartile range 8.0-15.0] minutes). For patients who achieved reduction in NRS ≥ 3 within 20 minutes, those in the methoxyflurane arm took a shorter time. However, the methoxyflurane (46.7%) arm experienced lower proportion of patients not achieving NRS reduction ≥ 3 when compared to the tramadol (71.6%) arm after over 20 minutes. The methoxyflurane arm had significantly higher paramedic and patient satisfaction scores. CONCLUSION For the doses of medication used in this implementation study, methoxyflurane was superior in efficacy, speed of onset and administration, but had more minor adverse effects when compared to IM tramadol.

INTRODUCTION: Epidural steroid injections are an integral part of nonsurgical management of radicular pain from lumbar spine disorders. We studied the effect of dexamethasone 8 mg epidural injections on the hypothalamic-pituitary-adrenal axis and serum glucose control of Asian patients. METHODS: 18 patients were recruited: six diabetics and 12 non-diabetics. Each patient received a total of dexamethasone 8 mg mixed with a local anaesthetic solution of lignocaine or bupivacaine, delivered into the epidural space. Levels of plasma cortisol, adrenocorticotropic hormone (ACTH), serum glucose after an overnight fast and two-hour postprandial glucose, as well as weight, body mass index, blood pressure and heart rate were measured within one week prior to the procedure (baseline) and at one, seven and 21 days after the procedure. RESULTS: Median fasting blood glucose levels were significantly higher on post-procedure Day 1 than at baseline. However, there was no significant change in median two-hour postprandial blood glucose from baseline levels. At seven and 21 days, there was no significant difference in fasting or two-hour postprandial glucose levels. Both ACTH and serum cortisol were significantly reduced on Day 1 compared to baseline in all patients. There was no significant difference in ACTH and serum cortisol levels from baseline at Days 7 and 21. CONCLUSION Our study shows that epidural steroid injections with dexamethasone have a real, albeit limited, side effect on glucose and cortisol homeostasis in an Asian population presenting with lower back pain or sciatica.
Adrenocorticotropic Hormone ; blood ; Adult ; Aged ; Blood Glucose ; analysis ; Body Mass Index ; Dexamethasone ; administration & dosage ; therapeutic use ; Diabetes Mellitus ; therapy ; Endocrine System ; drug effects ; Female ; Glucocorticoids ; administration & dosage ; Humans ; Hydrocortisone ; blood ; Hypothalamo-Hypophyseal System ; drug effects ; Injections, Epidural ; methods ; Male ; Middle Aged ; Pituitary-Adrenal System ; drug effects ; Postprandial Period ; Singapore ; Young Adult

INTRODUCTION: Our study aimed to identify the factors associated with successful first-time radioactive iodine (RAI) treatment in patients with Graves' disease (GD). MATERIALS AND METHODS: This is a restrospective study of patients with GD who were treated with RAI. Treatment success was defined as onset of permanent hypothyroidism or euthyroidism after 1 dose of RAI at 1-year follow-up. RESULTS: There were 388 GD patients who underwent RAI treatment between January 2014 and December 2015. Of these, 74% achieved treatment success. Median time to achieve permanent hypothyroidism was 2 months. Male gender, smoking, higher antithyroid drug dosage, lower thyroid stimulating hormone (TSH) level, large goitre size and TSH receptor antibody (TRAb) titre at time of RAI were significantly associated with treatment failure. Multivariate analysis showed that larger goitre size and higher TRAb titre were associated with lower first-time RAI success. CONCLUSION Larger goitre size and higher TRAb titre predict lower success of RAI therapy in GD patients. Treatment decisions and strategies should be customised for patients who present with these characteristics.

INTRODUCTIONTinea unguium is a common nail infection. We conducted a retrospective ten-year study of the patient demographics and species distribution of dermatophytes causing tinea unguium in a tertiary hospital from Singapore.

METHODSResults of fungal nail cultures were retrieved from our hospital's microbiology department. Samples from nail scrapings and clippings were inoculated onto agar plates (Sabouraud dextrose agar with chloramphenicol and Mycosel agar). Nail specimens that grew dermatophytes were included in the study.

RESULTSOverall, 229 (male: n = 164, 71.6%; female: n = 65, 28.4%) nail specimens grew dermatophytes. Mean patient age was 58 (range 18-93) years. A majority of specimens came from patients aged over 50 years (n = 162, 70.7%) and 60-79 years (n = 100, 43.7%). Ethnically, 160 (69.9%) patients were Chinese, 36 (15.7%) Indian, 18 (7.9%) Malay and 15 (6.6%) of other ethnicities. Among dermatophytes isolated were Trichophyton rubrum (n = 93, 40.6%), Trichophyton mentagrophytes (n = 60, 26.2%), unidentified Trichophyton spp. (n = 57, 24.9%), Trichophyton tonsurans (n = 10, 4.4%), Epidermophyton floccosum (n = 5, 2.2%), Trichophyton verrucosum (n = 2, 0.9%), Trichophyton soudanense (n = 1, 0.4%) and Trichophyton violaceum (n = 1, 0.4%).

CONCLUSIONA majority of isolates were from elderly patients. Compared to Singapore's general population, patients of Indian and other ethnicities were over-represented for tinea unguium when compared to Chinese and Malay patients. Trichophyton rubrum was the most common dermatophyte isolated, while Trichophyton verrucosum, Trichophyton violaceum and Trichophyton soudanense were rare causes of tinea unguium.

INTRODUCTIONVictims of out-of-hospital cardiac arrests require timely cardiopulmonary resuscitation (CPR) and early defibrillation. Callers to emergency medical services are asked to provide dispatcher-guided responses until an ambulance arrives. Knowing what to expect in such circumstances should reduce both delay and confusion.

METHODSThis study was conducted among schoolchildren aged 11-17 years using ten-item pre- and post-training surveys. We aimed to observe any knowledge and attitude shifts regarding CPR and automated external defibrillator (AED) use subsequent to the training.

RESULTSA total of 1,196 students across five schools completed the pre- and post-training surveys. Survey questions tested basic CPR knowledge and attitudes towards CPR and AED use. The overall response rate was 80.8% and 81.5% in the pre- and post-training surveys, respectively. There was a statistically significant improvement in the students' CPR knowledge. The number of students who selected all the correct answers for the knowledge-based questions in the post-training survey increased by 64.7% (95% confidence interval 61.9%-67.5%; p < 0.001). There was also an improvement in their willingness to administer CPR (likely/very likely to administer CPR pre-training vs. post-training: 13.0% vs. 71.0%; p < 0.001) and use AED (likely/very likely to administer AED pre-training vs. post-training: 11.7% vs. 78.0%; p < 0.001) after training.

CONCLUSIONThe training programme imparted new information and skills, and improved attitudes towards providing CPR and using AED. However, some concerns persisted about hurting the victim while performing CPR.

INTRODUCTIONThere is a need for a simple-to-use and easy-to-carry CPR feedback device for laypersons. We aimed to determine if a novel CPRcard™ feedback device improved the quality of chest compressions.

METHODSWe compared participants' chest compression rate and depth with and without feedback. Compression data was captured through the CPRcard™ or Resusci Anne's SimPad® SkillReporter™. Compression quality was defined based on 2010 international guidelines for rate, depth and flow fraction.

RESULTSOverall, the CPRcard group achieved a better median compression rate (CPRcard 117 vs. control 122, p = 0.001) and proportion of compressions within the adequate rate range (CPRcard 83% vs. control 47%, p < 0.001). Compared to the no-card and blinded-card groups, the CPRcard group had a higher proportion of adequate compression rate (CPRcard 88% vs. no-card 46.8%, p = 0.037; CPRcard 73% vs. blinded-card 43%, p = 0.003). Proportion of compressions with adequate depth was similar in all groups (CPRcard 52% vs. control 48%, p = 0.957). The CPRcard group more often met targets for compression rate of 100-120/min and depth of at least 5 cm (CPRcard 36% vs. control 4%, p = 0.022). Chest compression flow fraction rate was similar but not statistically significant in all groups (92%, p = 1.0). Respondents using the CPRcard expressed higher confidence (mean 2.7 ± 2.4; 1 = very confident, 10 = not confident).

CONCLUSIONUse of the CPRcard by non-healthcare workers in simulated resuscitation improved the quality of chest compressions, thus boosting user confidence in performing compressions.

INTRODUCTION72-hour emergency department (ED) reattendance is a widely-used quality indicator for quality of care and patient safety. It is generally assumed that patients who return within 72 hours of ED discharge (72-hour re-attendees) received inadequate treatment or evaluation. The current literature also suggests considerable variation in probable causes of 72-hour ED reattendances internationally. This study aimed to understand the characteristics of these patients at the ED of a Singapore tertiary hospital.

METHODSWe conducted a retrospective cohort study on all ED visits between 1 January 2013 and 31 December 2013. 72-hour re-attendees were compared against non-re-attendees based on patient demographics, mode of arrival, patient acuity category status (i.e. P1/P2/P3/P4), seniority ranking of doctor-in-charge and medical diagnoses. Multivariate analysis using the generalised linear model was conducted on variables associated with 72-hour ED re-attendance.

RESULTSAmong 104,751 unique patients, 3,065 (2.93%) were in the 72-hour re-attendees group. Multivariate analysis showed that the following risk factors were associated with higher risk of returning within 72 hours: male gender, older age, arrival by ambulance, triaged as P2, diagnoses of heart problems, abdominal pain or viral infection (all p < 0.001), and Chinese ethnicity (p = 0.006). There was no significant difference in the seniority ranking of the doctor-in-charge between both groups (p = 0.419).

CONCLUSIONSeveral patient and event factors were associated with higher risk of being a 72-hour re-attendee. This study forms the basis for hypothesis generation and further studies to explore reasons behind reattendances so that interventions can be developed to target high-risk groups.

Abdominal Pain ; Adult ; Aged ; Aged, 80 and over ; China ; Data Mining ; Electronic Health Records ; Emergency Medicine ; methods ; statistics & numerical data ; Emergency Service, Hospital ; statistics & numerical data ; Female ; Humans ; Male ; Middle Aged ; Multivariate Analysis ; Patient Discharge ; Patient Readmission ; Patient Safety ; Quality of Health Care ; Retrospective Studies ; Risk ; Singapore ; Tertiary Care Centers ; Triage ; methods ; Young Adult