National University Hospital

Women with pre-existing diabetes remain at increased risks of adverse pregnancy complications. Optimising glycaemic control before and during pregnancy could reduce risk but data from Asian countries are limited. This study evaluates maternal glycaemia, management strategies and pregnancy outcomes in women with diabetes in a multiethnic cohort. We retrospectively studied pregnancies with pre-existing diabetes or prediabetes at a Singapore tertiary hospital from 01/01/2022 to 31/12/2024. Maternal data and pregnancy outcomes were analysed by diabetes subtype. Multivariate logistic regression identified factors linked to adverse outcomes, including fetal overgrowth (macrosomia and large-for-gestational-age [LGA]) using local birthweight standards. Of 289 pregnancies (75.8% Type 2 diabetes mellitus [T2DM], 19.0% prediabetes, 5.2% Type 1 diabetes mellitus [T1DM]), median maternal age was 33 years and pre-pregnancy body mass index (BMI) was 29.3 kg/m2. HbA1c improved from 7.0% to 6.1% across trimesters (p < 0.00). Macrosomia (≥ 4 kg) occurred in 4.2% of infants, while preterm birth was more frequent in T1DM (33.3%) than in T2DM (5.0%) or prediabetes (1.8%). Retinopathy screening was completed in 67.6% of patients and continuous glucose monitoring (CGM) or pump devices were not utilised. Using Singapore LGA reference, third trimester HbA1c < 6.5% was associated with lower odds of LGA. Multidisciplinary care enhanced glycaemic control and reduced macrosomia, but women with T1DM remain at increased risk of preterm delivery and neonatal morbidity. Enhanced preconception care, retinopathy screening and adoption of real-time CGM may improve outcomes in Asian women with pre-existing diabetes in pregnancy.

Conduction abnormalities are common long-term sequelae after the Senning procedure for dextro-transposition of the great arteries (d-TGA), often requiring permanent pacing. Infection or lead malfunction may necessitate system extraction. Leadless pacemakers offer a promising alternative option. We present a 30-year-old man with d-TGA who previously underwent a Senning procedure. He had an infected pacemaker with lead extrusion. A combined procedure was performed, including complete system extraction and implantation of a leadless VDD pacemaker (Micra AV2). The procedure achieved atrioventricular (AV) synchrony and rapid recovery. This case highlights the viability of integrating leadless VDD pacemaker implantation with lead extraction in post-Senning d-TGA patients for efficient AV synchrony. It supports leadless pacing as practical solution for complex congenital cardiac anatomy. Leadless pacemakers represent a promising alternative pacing strategy for patients with d-TGA post-Senning procedure. Micra VDD pacing with AV synchrony represents an innovative and effective approach in this setting.

Standard modifiable risk factors (SMuRFs) are associated with increased risk of acute myocardial infarction (AMI). Patients with AMI in the absence of standard modifiable risk factors (SMuRF-less) have demonstrated excess mortality. The study aims to forecast trends in prevalence and case fatality of SMuRF-less AMI in Singapore and United Kingdom. Data from the Singapore Myocardial Infarction Registry and the UK Myocardial Ischemia National Audit Project were used to construct Poisson regression models to predict the prevalence and case fatality rate of SMuRF-less AMI from 2025 to 2040. From 2025 to 2040, SMuRF-less AMI cases are expected to contribute to larger proportions of total AMI cases in Singapore (5.8% [95% CI: 5.2%-6.4%] to 8.5% [95% CI: 6.2%-10.8%]) and United Kingdom (13.8% [95% CI: 13.0%-14.6%] to 16.9% [95% CI: 15.1%-18.7%]). The proportion of SMuRF-less AMI mortality of the total AMI mortality is set to decrease in the United Kingdom (11.3% [95% CI: 10.5%-12.1%] to 9.5% [95% CI: 7.7%-11.4%]), but increase in Singapore (6.3% [95% CI: 5.7%-6.9%] to 13.3% [95% CI: 10.9%-15.6%]). Men continue to bear the majority of SMuRF-less AMI prevalence, with the most rapid rise in young adults in Singapore (8.1%; 95% CI: 7.5%-8.7%) and middle-aged adults in the United Kingdom (2.3%; 95% CI: 1.5%-3.1%). The increase in SMuRF-less AMI prevalence is set to be more rapid in the overweight/obesity population (3.9%; 95% CI: 3.3%-4.5%). By 2040, SMuRF-less AMI will expand to a larger proportion of the AMI census in Western and Eastern populations. SMuRF-less AMI vulnerability will shift toward a younger, male-dominant demographic, with overweight/obesity as a dominant risk factor.

Abstract Vibrios are important aquatic human pathogens, causing gastroenteritis, wound infections, and cholera. Vibriosis (non-cholera infection) has been increasing in temperate climates due to correlation between Vibrio abundance and water temperature. However, how warming oceans differentially influence various Vibrio species, and whether incidence is higher in tropical regions, remains understudied. We assembled the first comprehensive dataset of culture-confirmed vibriosis cases outside a temperate climate from equatorial Singapore. Comparison to cases from the detailed United States (US) CDC COVIS system revealed that vibriosis incidence is over two times higher in Singapore than the United States. Causative species also differ markedly, with Vibrio fluvialis and non-toxigenic Vibrio cholerae dominating in Singapore (&gt;40%) but are much less prominent in the United States (&lt;15%). Singapore cases have remained stable in the last decade, while US incidence is rising rapidly, especially for V. fluvialis and V. cholerae (13% and 17% per year). Differences in causative species in Singapore and the United States suggest ecological factors may shape infection dynamics, with some species benefitting more from warming oceans, raising their equatorial prominence. Incidence is stable in Singapore, likely due to slower warming of waters near the equator. In contrast, vibriosis in the United States will likely continue to increase steadily, with changing species composition, likely becoming tropicalized.

Acute generalized exanthematous pustulosis (AGEP) is a rare severe cutaneous adverse reaction in children. In this systematic review of 47 cases, a male predominance was observed, and medications remained the most common trigger for AGEP, with a higher contribution from infectious etiologies compared with frequencies reported in adult studies. Management primarily involved cessation of the inciting drug, topical corticosteroids, and supportive care. These findings provide practical guidance for early recognition and evaluation of pediatric AGEP.

BACKGROUNDTuberculous meningitis (TBM) is a severe extrapulmonary complication of tuberculosis. Early diagnosis is crucial in improving patient outcomes, albeit difficult given the non-specific clinical presentation of early stage TBM. Numerical diagnostic scoring systems may be useful diagnostic tools for clinicians, particularly in resource-constrained settings.AIMTo describe existing TBM diagnostic scores with the primary focus being on scores with external validation.METHODSPubMed and EMBASE were searched from inception to 21 March 2024. Cross-sectional studies with numerical TBM scoring systems were included. Literature pertaining to non-human, non-live subjects, single diagnostic tests, papers with no gold standard diagnosis, and non-English papers were excluded.RESULTSWe reviewed 21 unique scoring systems, of which 4 have been externally validated. Key features of the scores (clinical, laboratory, microbiological, histopathological and radiological criteria, interpretation), outcomes (sensitivity, specificity) and study population (location, demographics, subgroups) were described.CONCLUSIONWe suggest Thwaites (2002) and Marais (2010) as first-line TBM screening tests due to high sensitivities and extensive external validation, however clinicians should consider scores specific to their patient population.

Elizabethkingia species are rare but increasingly recognised Gram-negative pathogens linked to healthcare-associated transmission, intrinsic multidrug resistance, and severe infection in vulnerable hosts. We performed a comprehensive review of human Elizabethkingia infections by systematically searching PubMed on 18 October 2025 and included English-language case reports, case series, and outbreak investigations; species were analysed as reported (legacy nomenclature retained), and adults were defined as ≥18 years. In total, 374 studies were included (300 case reports, 41 case series, 33 outbreak investigations). Adult infections were predominantly healthcare-related, affected older adults with substantial comorbidities and most often presented as bacteraemia or sepsis and pneumonia; crude mortality in adult case reports was 32.8%. Paediatric disease was concentrated in neonates and Neonatal Intensive Care Unit (NICU) settings, with meningitis and bloodstream infection predominating; crude mortality in paediatric case reports was 23.3%, and neurological sequelae were frequently reported among survivors. Across studies, isolates showed broad resistance to β-lactams and near-universal resistance to carbapenems, with variable activity to fluoroquinolones and trimethoprim-sulfamethoxazole and more consistent in vitro activity to minocycline. Species misidentification (notably Elizabethkingia anophelis as Elizabethkingia meningoseptica) and heterogeneous susceptibility testing limited comparability. Outbreak investigations repeatedly implicated water-associated reservoirs and reusable equipment, underscoring the need for improved diagnostics, susceptibility-guided therapy and water-focused infection prevention.

To compare the performance and safety of six LLM-based scribing tools in generating ophthalmological clinical notes from simulated physician-patient encounters. This cross-sectional comparative study involved seven ophthalmic encounters, transcribed by six scribing tools (Heidi AI, Whisper GPT-4o, Whisper Gemini 1.5 Pro, i-scribe, Lyrebird, Twofold). Scribing tools were prompted to generate notes using Subjective, Objective, Assessment, and Plan (SOAP) format. Consultant-level ophthalmologists evaluated note quality using the Physician Documentation Quality Instrument (PDQI-9), which evaluates eight dimensions: "accurate", "thorough", "useful", "organized", "comprehensive", "succinct", "synthesized", "internally consistent" on a 5-point scale (with a maximum sum of 40). Text-generation metrics (ROUGE-L, BERTScore, BARTScore, AlignScore) were also used. Safety analysis was conducted to identify documentation errors categorised as omissions, incorrect information, and extraneous content. Heidi AI achieved the highest overall documentation quality (PDQI-9: 38.524, 95%CI: 37.815-39.233), followed by Whisper GPT-4o (38.048, 95%CI: 36.747-39.349). It scored highest in accuracy, usefulness, organisation, comprehensiveness, and succinctness, and led in ROUGE-L (0.326, 95%CI: 0.276-0.374), BERTScore (0.727, 95%CI: 0.707-0.747), and AlignScore (0.704, 95%CI: 0.650-0.758). All tools, however, exhibited errors. The most common were omissions of clinically relevant details, including disease severity, coexisting ocular conditions, systemic comorbidities, and management specifics. Some tools also generated incorrect or extraneous content, such as hallucinated patient requests or incorrect patient names. Among the evaluated LLM based scribing tools, Heidi AI demonstrated the highest performance and shows promise for supporting ophthalmology documentation. However, persistent errors, particularly omissions of critical details, were observed across all tools and could compromise patient care. Human oversight and rigorous verification processes remain essential before clinical integration.

Introduction: Pre-positioning and maintaining additional critical equipment to manage sudden surges during mass casualty incidents (MCI) is crucial. While specialized equipment carts tailored for critical patients in logistically challenging situations have been shown to improve patient care, such carts have yet to be customized for MCI. This study aims to develop a customized MCI equipment cart (MCI-EC) for use in the emergency department (ED). Methods: The development of the MCI-EC followed a systematic approach. We focused on road traffic accidents (RTA) with ten casualties based on a study conducted in a similar urban setting, which identified this to be the most common MCI type. The anticipated injury profile was derived from a study on RTA-type MCI, followed by consensus between study members, which specified four airway or facial injuries, four head or cervical spine injuries, three chest injuries, two abdominal injuries, seven extremity injuries, and two thoracolumbar spine injuries. The equipment list was generated regarding published checklists and two rounds of voting by the study members. Finally, the dimensions and arrangement of the MCI-EC were prototyped to prioritize mobility, compactness, and ergonomics within the study ED to ensure practicality in the intended setting. Results: The MCI-EC was stainless steel and measured 180cm (H) x 47cm (D) x 95cm(W) on 6-inch diameter wheels. Equipment was arranged by treatment tasks comprising monitoring, airway and breathing interventions like intubation, and circulatory interventions like hemostatic dressings, intravenous volume delivery, and chest decompression. A photograph of the MCI-EC and the equipment list are provided as supplementary material. Conclusion: The MCI-EC was customized for treatment of MCI patients. This study is the first template for MCI-EC in similar settings, and a novel example for further customization in other settings.

Background and Aims:Emergency laparotomy is associated with substantial morbidity and mortality. This study assessed the impact of the structured intraoperative component of Singapore’s Emergency Laparotomy Audit (EMLA), inspired by the National Emergency Laparotomy Audit (NELA) conducted in the United Kingdom, in patients undergoing emergency laparotomy in an Asian context.Methods:This prospective, single-centre quality improvement study was conducted at a 700-bed tertiary hospital using iterative Plan–Do–Study–Act cycles. Adult patients (aged 18 years or older) who underwent emergency laparotomy between August 2020 and August 2024 were included (n = 586). The intraoperative bundle consisted of three components: consultant-delivered anaesthesia and surgical care, goal-directed haemodynamic therapy (GDHT) for high-risk patients (NELA score greater than 10), and maintenance of normothermia. Primary measures included consultant presence, GDHT adherence, and intraoperative normothermia. Secondary outcomes were complications, intensive care unit (ICU) admission, length of stay (LOS), and 30-day mortality.Results:The presence of a consultant anaesthesiologist increased from 89.6% to 98.8% (P < 0.0001). Adherence to GDHT remained high across all phases (94.6%, 88%, and 86.7%). Hypothermia persisted in 11–16% of cases and was independently associated with longer LOS and higher ICU admission rates. No significant change in 30-day mortality was observed.Conclusion:Implementation of the structured intraoperative EMLA bundle improved consultant coverage and maintained high adherence to GDHT. Consultant presence was associated with a 42% relative reduction in medical complications; however, causality cannot be established in this quality improvement project. Persistent hypothermia highlights the need for enhanced temperature management strategies.