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1 Department of Infectious Diseases, Tan Tock Seng Hospital, 2 National Centre for Infectious Diseases, 3 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 4 Division of Infectious Diseases, University Medicine Cluster, National University Hospital, 5 Department of Infectious Diseases, Singapore General Hospital, 6 Department of Infectious Diseases, Changi General Hospital, 7 Infectious Diseases Care Pte Ltd, Mount Elizabeth Medical Centre, 8 The Novena Medical Specialists, Mount Elizabeth Novena Specialist Centre, 9 Department of Care and Counselling, Tan Tock Seng Hospital, 10Department of Pharmacy, Tan Tock Seng Hospital, 11Department of Pharmacy, Singapore General Hospital, 12Department of Pharmacy, National University Hospital, Singapore [ABSTRACT FROM AUTHOR]

Introduction: To date, the role of standard asthma care in reducing asthma-related health services use (HSU) during the COVID-19 pandemic remains unclear. This study examined the impact of guideline-based asthma treatment on the use of asthma-related emergency department (ED) visits, polyclinic visits (total visits and urgent visits characterized by nebuliser use) before and during the pandemic.Methods: Data from April 2017 to October 2020 was obtained from the National University Health System, one of the three healthcare clusters in Singapore. Using generalized linear models, we estimated the joint effects of the ratio of preventer to reliever dispensations (PRR) and COVID-19 on asthma-related ED visits per hospital per month, total asthma-related polyclinic visits and asthma-related urgent polyclinic visits per clinic per month.Results: Findings show that before the onset of COVID-19, for every 0.5 unit increase in PRR, the number of asthma-related ED visits and urgent polyclinic visits decreased by 12.9% (95% CI: − 13.0% to − 12.9%) and 6.8% (95% CI: − 6.9% to – 6.7%), respectively, whereas total asthma-related polyclinic visits increased by 1.0% (95% CI: 0.9% to 1.0%). During the pandemic, a 0.5 unit increase of PRR decreased the number of asthma-related ED visits, urgent and total polyclinic visits by 16.9% (95% CI: − 17.0% to – 16.9%), 9.3% (95% CI: − 9.5% to − 9.2%) and 0.7% (95% CI: − 0.8% to − 0.7%), respectively.Discussion: These findings suggest that regardless of the COVID-19 pandemic, an increase in PRR consistently reduced the frequency of asthma-related urgent and emergent care, although it barely influenced routine asthma follow-up visits.Plain Language Summary: In order to understand how guideline-based asthma management affects asthma-related health services use during the COVID-19 pandemic, in this study, we examined the pattern and impact of asthma medication utilisation (ie, the ratio of preventer to reliever dispensations) on asthma-related total polyclinic visits, urgent polyclinic visits and emergency department visits, and compared such effects before and during COVID-19 outbreak.We found a significant reduction in reliever medication dispensations and asthma-related total polyclinic visits, urgent polyclinic visits and emergency department visits in Singapore during the COVID-19 pandemic, as compared to the pre-pandemic period. We also observed a rapid increase in the ratio of preventer to reliever dispensations in Singapore since early 2019 which accelerated during the COVID-19 pandemic. Our finding suggests that this increase could be associated with a significant reduction in asthma-related urgent and emergent care. This effect persisted both before and during the COVID-19 pandemic.These current findings suggest that guideline-based asthma management, which can be delivered through primary care and self-care, is able to reduce asthma-related urgent care even in a global pandemic with restrained healthcare resources. [ABSTRACT FROM AUTHOR]

Background: Despite the promise and popularity of advance care planning, there is insufficient evidence that advance care planning helps patients to meet their end-of-life care preferences, especially in Asian settings. Thus, the proposed study aims to assess whether patients with advanced heart failure who are receiving advance care planning have a greater likelihood of receiving end-of-life care consistent with their preferences compared to patients receiving usual care. Secondary objectives are to compare differences in health care expenditures, quality of life, anxiety and depression, understanding of own illness, participation in decision-making and concordance with their caregiver's preferences for end-of-life care, between patients with advanced heart failure receiving advance care planning and usual care.Methods/design: This is a two-arm randomized controlled trial of advance care planning versus usual care (control) conducted at two institutions in Singapore. Two hundred and eighty-two patients with advanced heart failure (n = 94 in the advance care planning arm; n = 188 in the control arm receiving usual care) will be recruited from these centers and followed for 1 year or until they die, whichever is earlier. Additionally, the study will include up to one caregiver per patient enrolled.Discussion: If advance care planning is proven to be effective, the results will help to promote its uptake among health care providers and patients both within Singapore and in other countries.Trial Registration: NCT02299180 . Registered on 18 November 2014. [ABSTRACT FROM AUTHOR]

Background: A major outbreak of the Zika virus (ZIKV) has been reported in Brazil in 2015. Since then, it spread further to other countries in the Americas and resulted in declaration of the Public Health Emergency of International Concern (PHEIC) by World Health Organization. In 2016, Singapore reported its first minor ZIKV epidemic. Malaysia shares similar ecological environment as Brazil and Singapore which may also favor ZIKV transmission. However, no ZIKV outbreak has been reported in Malaysia to date. This study aimed to discuss all confirmed ZIKV cases captured under Malaysia ZIKV surveillance system after declaration of the PHEIC; and explore why Malaysia did not suffer a similar ZIKV outbreak as the other two countries.Methods: This was an observational study reviewing all confirmed ZIKV cases detected in Malaysia through the ZIKV clinical surveillance and Flavivirus laboratory surveillance between June 2015 and December 2017. All basic demographic characteristics, co-morbidities, clinical, laboratory and outcome data of the confirmed ZIKV cases were collected from the source documents.Results: Only eight out of 4043 cases tested positive for ZIKV infection during that period. The median age of infected patients was 48.6 years and majority was Chinese. Two of the subjects were pregnant. The median interval between the onset of disease and the first detection of ZIKV Ribonucleic Acid (RNA) in body fluid was 3 days. Six cases had ZIKV RNA detected in both serum and urine samples. Phylogenetic analysis suggests that isolates from the 7 cases of ZIKV infection came from two clusters, both of which were local circulating strains.Conclusion: Despite similar ecological background characteristics, Malaysia was not as affected by the recent ZIKV outbreak compared to Brazil and Singapore. This could be related to pre-existing immunity against ZIKV in this population, which developed after the first introduction of the ZIKV in Malaysia decades ago. A serosurvey to determine the seroprevalence of ZIKV in Malaysia was carried out in 2017. The differences in circulating ZIKV strains could be another reason as to why Malaysia seemed to be protected from an outbreak. [ABSTRACT FROM AUTHOR]

Background: Burkholderia pseudomallei is a gram negative bacteria that causes a spectrum of human diseases in the tropics. Although melioidosis is endemic in Southeast Asia, large clinical case series were rarely reported from metropolitan Singapore.Methods: This is a retrospective study of 219 consecutive patients with culture proven infections due to Burkholderia pseudomallei between the years 2001 to 2016 managed in Singapore General Hospital (SGH). We aimed to review local patients' characteristics and identify clinical factors associated with mortality and recurrent melioidosis.Results: Culture proven melioidosis occurred in 219 patients, 83.1% were male with a mean age of 55.7 ± 14.3 years and 63.0% had diabetes mellitus. Most patients (71.7%) present within 4 weeks of symptom onset and the most common symptom was fever. The majority of patients had bacteremia (67.6%) and had infection involving the respiratory system (71.2%), presenting most frequently with multi-lobar pneumonia. Thirty-four (15.5%) deaths occurred during the initial hospitalisation with a median time from presentation to death of 6.0 days (interquartile range: 2.8-16.3). Twelve patients demised before the diagnosis of melioidosis was made. Univariate analysis identified patients with symptom duration of longer than 4 weeks, bacteremia, and disease requiring mechanical ventilation, inotropic support or temporary dialysis as factors that were significantly associated with mortality. Having bacteremia and disease requiring mechanical ventilation remained statistically significant factors in the multivariable analysis. Twenty-one (11.4%) patients developed at least 1 episode of culture proven recurrent infection, with 15 recurring within the first 12 months of their initial infection. Eight patients developed more than 1 episode of culture proven recurrent infection. Patients with multifocal infection were more likely to develop recurrent infection.Conclusion: In metropolitan Singapore, melioidosis was associated with mortality in excess of 15%, where more than a third occurred before diagnosis. This study reminds local physicians that melioidosis is still a serious infection affecting local male diabetic patients and an important differential diagnosis in a patient presenting with severe multi-lobar pneumonia and septic shock. Recurrent infections occurred in 11.4% and the weight-based dosing of oral eradication antibiotics may improve the management of this disease locally. [ABSTRACT FROM AUTHOR]

Abstract: Since the advent of combination antiretroviral therapy (ART), the mortality attributable to human immunodeficiency virus (HIV) infection has decreased by 80%. Newer antiretroviral agents are highly efficacious, have minimal side effects as compared to older drugs, and can be formulated as combination tablets to reduce patients' pill burden. Despite these advances, 680,000 people worldwide died of acquired immunodeficiency syndrome-related illnesses in 2020. The National ART and Monitoring Recommendations by the National HIV Programme have been created to guide physicians on the prescribing of ART based on the patients' needs. These recommendations are based on international guidelines and tailored to the local context and unique domestic considerations. We hoped that with the publication of these recommendations, the care of people living with HIV can be enhanced, bringing us closer to ending HIV in our lifetime., (Copyright © 2024 Copyright: © 2024 Singapore Medical Journal.)

Background and Objective: Guidelines for chronic obstructive pulmonary disease (COPD) advocate regular influenza vaccination, which has been shown to reduce exacerbations. However, influenza vaccination rates remain low. This quality improvement project was initiated to help improve influenza vaccination rates in a tertiary hospital., Methods: All patients with COPD in the airway program (TAP) in the National University Hospital at the end of 2013 were recruited. The interventions were implemented in 2014; thus, population was stratified into the pre-intervention group and post-intervention group. Those who died in 2014 were excluded. They were (1) patient education posters in the clinics on the need for regular influenza vaccination, (2) direct interventions by physicians, and (3) intervention by the nurses when vaccinations were neglected. Physicians were made aware of previous vaccination rates, vaccination card reminders were placed in the clinics, and a new electronic healthcare record system (EHR) was implemented. The patients were followed up till the end of 2015 or until death. When an influenza vaccination was administered, the patients were asked which of the interventions led to the vaccination. A questionnaire was delivered to the physicians to determine the interventions that led to any change in vaccination prescription practices., Results: The pre-intervention influenza vaccination rate was low at 47.7%. The post-intervention influenza vaccination rate improved to 80.7% with the multi-pronged approach. Physicians initiated the majority of vaccinations (87.9%), while nurses helped intervene in a further 12.1%. Physicians' vaccination prescription practices changed as a result of self-awareness of low vaccination rates, vaccination card reminders, and the new EHR. Patient education made minimal impact., Conclusion: This project demonstrates that with regular audits to track progress and several easy-to-implement interventions, improving influenza vaccination rates is an achievable goal., Competing Interests: The authors declare that there are no conflicts of interest in this work., (© 2019 Li et al.)

Objective: To evaluate the use of the Laryngeal Mask Airway (LMA), the oesophageal-tracheal combitube (ETC) and the tracheal tube (TT) by medical students, with a view to recommend changes to the medical school curriculum., Methods: A prospective cohort study of 93 third-year medical students were taught the use of LMA, ETC and TT on manikins and had their skills tested at 0 and 6 months., Results: Overall, LMA insertion was the fastest technique with a mean time taken for successful insertion of 32.2 s, compared to that for ETC (55.0 s, P = 0.000) and TT (71.5s, P = 0.000). There was a significant delay in the time taken for insertion at 6 months for all three devices: 13.5 s for the LMA (P = 0.000), 29.6 s for the ETC (P = 0.000) and 31.8 s for the TT (P = 0.001). Both the ETC and the TT had a significantly lower first-attempt success rate at 6 months (ETC: 91% versus 63%, P = 0.000 and TT: 80% versus 55%, P = 0.003) but not the LMA (96% versus 92%, P = 0.549). At 6 months, the overall success rate was 99% for the LMA, 100% for the ETC and 93% for the TT. Complication rate was higher for the ETC (9% versus 46%, P = 0.000) and the TT (38% versus 78%, P = 0.005) but not for the LMA (3% versus 10%, P = 0.688)., Conclusions: The use of the TT is difficult and the skills acquired by the medical students deteriorate significantly over time. The LMA and the ETC seem to have an advantage over the TT in that they are more easily learnt and the skills better retained. It is recommended that these alternative devices be included in the medical school curriculum for airway management.