Mount Elizabeth Novena Hospital

The global cesarean section (CS) rate has increased to 21.1% between 1990 and 2018. In Singapore, the annual CS rate has increased by ~ 0.6%, reaching an overall rate of 37.4%. Almost one-third of all cesarean deliveries are performed for at least one previous CS. Women with two CSs are often denied a "trial of vaginal delivery" due to the increased risk of uterine scar rupture. This study aims to examine maternal and neonatal outcomes of women undergoing trials of labor following two CSs (TOLAC-2). We conducted a retrospective observational study of women with singleton, term pregnancies in cephalic presentation who underwent TOLAC-2 at the National University Hospital, Singapore, between September 2013 and June 2022. Data were obtained through a detailed review of electronic medical records. Among 898 women with two previous CSs, 7.0% (63/898) attempted TOLAC-2, of whom 55.6% (35/63) achieved a successful vaginal birth (VBAC-2). Successful TOLAC-2 was associated with a significantly shorter duration of active labor (5.0 vs. 7.7 h, p = 0.013) and lower estimated blood loss (242mLs vs. 423mLs, p ≤ 0.001) compared with failed TOLAC-2. There were no perinatal complications of uterine rupture, APGAR <7 at 5 minutes, meconium aspiration syndrome or hypoxic-ischemic encephalopathy. We observed a trend toward successful VBAC-2 in women with a history of prior vaginal birth (74.6% vs. 48.9% p = 0.07). In our cohort, more than half of the women attempting TOLAC-2 at term achieved a successful vaginal birth without serious perinatal or maternal complications. TOLAC-2 is a safe and reasonable option for appropriately selected women following adequate counseling, even in the absence of a prior vaginal delivery.

The management of relapsed / refractory myeloma particularly those who are heavily pretreated and penta-refractory has experienced a paradigm change with the advent of bispecific antibodies targeting B-cell maturation antigen (BCMA), offering new hope for these patients. The diverse experiences in the use of bispecific antibodies across Asian countries/regions underscore the complexities of integrating these therapies into clinical practice. With limited availability and varying access through clinical trials, compassionate access programmes and early commercial use, these agents are demonstrating impressive efficacy, yet present unique challenges in widespread adoption of these agents. A roundtable discussion among myeloma experts from Asia has highlighted consistent efficacy but also raised concerns about the durability of response and the management of associated toxicities and infections. These discussions emphasize the need for ongoing research to better understand the nuances of treatment sequencing and patient selection. The insights gained will contribute to developing strategic frameworks and consensus guidelines that can effectively guide clinicians in optimizing outcomes for myeloma patients in diverse healthcare settings.

Introduction: This study aims to evaluate the effect of sensor-based rehabilitation (SR) on chronic knee pain (CKP) outcomes. Materials and Methods: PubMed, Embase, CINAHL, SCOPUS, Cochrane Library, grey literature, and bibliographic references were searched from inception to April 2023. Only randomized controlled trials (RCTs) and cohort studies evaluating the outcomes of SR on CKP were included. Inclusion and exclusion criteria were based on type of study, research subjects, intervention, outcome, language, and availability of data. Out of 937 studies screened, a total of 10 studies with 4347 patients met selection criteria. Comparison of outcomes following intervention was conducted across studies. Meta-analysis of KOOS subscales was also conducted. Literature retrieval and data extraction were conducted by three independent reviewers. Two reviewers performed quantitative data extraction independently before compilation and cross-referencing on Covidence with a third researcher assisting in the cross-referencing process independently to minimise judgment errors. Results: The sensors utilized included wearable sensors, plantar-controlled sensors, embedded sensors, and optical sensors. There was a high degree of variability in the conduct of the intervention programs and timepoint of assessment. There was an improvement in the KOOS aggregate scores from baseline to post intervention with better improvements seen in studies incorporating avatar-based biofeedback. However, meta-analysis of the KOOS subscales did not show clinically significant differences between control and intervention groups. Conclusion: There is insufficient evidence to support the routine use of SR in patients with CKP. However, there is some evidence to suggest that incorporation of SR with avatar-based biofeedback in a multi-faceted treatment approach may yield better outcomes than the use of sensors as merely activity trackers.

BackgroundDespite the reported efficacy of overground robotic exoskeleton (ORE) for rehabilitation of mobility post-stroke, its effectiveness in real-world practice is still debated. We analysed prospectively collected data from Improving Mobility Via Exoskeleton (IMOVE), a multicentre clinical implementation programme of ORE enrolling participants with various neurological conditions and were given options to choose between 12 sessions of ORE or conventional therapy (control).MethodsThis is analysis of participants under IMOVE who fulfilled the following criteria (i) primary diagnosis was stroke (ischemic, hemorrhagic; first or recurrent), (ii) onset of stroke was within 9 months and (iii) the intervention was during inpatient stay. They should also fulfill the general IMOVE inclusion and exclusion criteria which were resembling general clinical and manufacturing criteria of ORE. Outcome measures included Functional Ambulatory Category (FAC), Rivermead Mobility Index (RMI), Functional Independence Measure (FIM) and Clinical Outcome Variable Scale (COVS), measured immediately before and after the 12 sessions of therapy, and mean distance walked per session.ResultsOf 149 participants (105 OREs and 44 controls), both groups improved significantly in motor outcomes with no significant between-group differences. Participants with baseline FAC 1 had significantly greater improvement in motor sub-score of FIM (FIM-motor) compared to controls (mean difference 8.4, 95% CI 0.65–16.07, ηp2 = 0.136, p = 0.034). The mean distance walked per session for ORE group was almost three times that of control for those with baseline FAC 0 (121.5 [SD 31.1]m vs 35.0 [SD 41.0]m, 95% CI 62.2–110.9, d = 2.54 p < 0.001) and FAC 1 (145.8 [SD 31.6]m vs 52.2 [SD 42.5]m, 95% CI 61.8–125.2, d = 2.71, p < 0.001). The difference was not observed for FAC 2 to 3 (162.9 [SD 29.2]m vs 134.2 [SD 87.5]m, 95% CI −22.2 to 79.7, d = 0.41, p = 0.252).ConclusionIn a pragmatic setting, use of ORE for gait training enabled patients with lower ambulatory capacity to walk longer distances during therapy sessions. Patients who required continuous assistance during ambulation (FAC 1) had significantly better gains in FIM-motor compared to conventional therapy, suggesting possible benefit of ORE for this group.Trial RegistrationThe trial was registered with clinicaltrials.gov (NCT05659121) on April 14, 2022.

Patients undergoing primary percutaneous coronary intervention (PPCI) for ST-segment-elevation myocardial infarction (STEMI) have a high thrombotic burden and often have a high bleeding risk (HBR). Asian patients have different patterns of thrombotic and bleeding risk from other populations which may be particularly relevant in the setting of PPCI for STEMI. To assess the safety and efficacy of the polymer free biolimus coated coronary stent (PF-BCS, BioFreedomTM, Biosensors International) in Asian STEMI patients. Patients with acute STEMI who received at least one PF-BCS were invited to participate after their index procedure. Follow-up was performed at 1, 4, and 12 months. The primary endpoint was the rate of target lesion failure (TLF) at 1 year. A performance goal was derived from the biolimus eluting stent arm of the COMFORTABLE AMI study which was the only prior dedicated study of biolimus eluting stents in patients with STEMI. A total of 914 patients with STEMI were enrolled. Mean patient age was 60 ± 13 years, diabetes was present in 23.2% and 43% were active smokers. According to the ARC definition, 12.4% of the patients were HBR. TLF rate was 2.54% [95% CI: 1.52-3.56], p-value for non-inferiority <0.0001, p-value for superiority = 0.0004). The rate of definite/probable stent thrombosis was 0.44% [95% CI: 0.16-1.16]. There was a trend toward more BARC 3 to 5 bleeding in ARC-HBR patients (3.69% vs 1.46%, HR = 2.74, [95% CI: 0.87-8.62], p = 0.07). In Asian patients undergoing PPCI for STEMI and treated with variable durations of DAPT, the use of a PF-BCS was associated with low rates of TLF and stent thrombosis (NCT03609346).