Ng Teng Fong General Hospital

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 (>40%) but are much less prominent in the United States (<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.

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.

To evaluate the effect of intraoperative administration of 1g of tranexamic acid (TXA) on perioperative and postoperative outcomes in patients receiving antithrombotic therapy undergoing endoscopic enucleation of the prostate (EEP). This multicenter, prospective, observational study included 932 patients across 30 centers (December 2024-June 2025). Patients were divided into four groups based on TXA use and continuation or discontinuation of blood thinners during EEP. The primary endpoint was bleeding complications within 30 days, defined as a composite of transfusion, clot retention, bleeding requiring restart of continuous bladder washout (CBWO), or surgical reintervention to control hemostasis. Multivariable Logistic regression analysis identified independent predictors of bleeding complications. There were 534 patients in Group 1 (stopped blood thinners, no TXA given), 316 in Group 2 (on blood thinners, no TXA given), 69 in Group 3 (stopped blood thinners, TXA given), and 13 in Group 4 (on blood thinners, TXA given). Median total operative time was longest in Group 2 (88min [IQR 70-127]) and shortest in Group 3 (55min [IQR 39-69]). Hemostasis time was shortest in TXA groups (p < 0.001). Transfusions occurred in 0.6-7.7% and surgical reinterventions in 0.6-7.7% across groups (p < 0.001). At 3 months, urinary symptoms and continence were comparable. On multivariable analysis, TXA reduced the odds of bleeding complications (OR 0.17, p < 0.001), while ongoing anticoagulant therapy (OR 2.93, p = 0.01), dual therapy (OR 4.31, p < 0.001), and longer operative time (OR 1.01, p < 0.001) increased the odds. Intraoperative TXA might mitigate perioperative bleeding and potentially protect patients at higher hemorrhagic risk.

Introduction: Verruca vulgaris, universally recognized as the common wart, represents a benign epithelial proliferation induced by the human papillomavirus (HPV). While these lesions are ubiquitous in the general population, typically manifesting as small hyperkeratotic papules on the acral regions, the occurrence of giant variants exceeding 2 centimeters in diameter on the auricle is an exceptionally rare clinical entity. This unusual presentation creates a significant diagnostic dilemma for the head and neck surgeon, as giant auricular warts frequently mimic the clinical presentation of malignant neoplasms, specifically verrucous carcinoma and squamous cell carcinoma. Case presentation: We document the case of a 36-year-old Indonesian male who presented with a massive, painless, exophytic mass on the posterior aspect of the right auricle. The lesion had persisted for ten years, exhibiting a slow, linear growth trajectory without spontaneous regression. Physical examination revealed a solitary, sessile, papillomatous lesion measuring 3.3 cm × 1.5 cm × 1.0 cm. Despite its alarming size, the mass remained mobile over the underlying perichondrium. Given the giant dimensions and the inability to rule out malignancy via visual inspection, the patient underwent total surgical excision with primary closure under general anesthesia. Histopathological analysis confirmed the diagnosis of verruca vulgaris, characterized by marked hyperkeratosis, papillomatosis, and pathognomonic koilocytosis, with an intact basement membrane ruling out invasive carcinoma. Conclusion: Giant verruca vulgaris of the auricle is a rare pathology that requires a rigorous diagnostic approach. We conclude that auricular verrucous lesions exceeding 2 centimeters should be clinically managed as tumors of uncertain potential. Surgical excision remains the diagnostic and therapeutic gold standard, offering immediate aesthetic restoration and the essential histopathological confirmation required to differentiate benign giant warts from the deceptive pushing border of verrucous carcinoma.

Abstract Background and Objective: Urolithiasis clusters with metabolic and cardiovascular disorders. We estimated nationwide prevalence of urolithiasis in Colombia and quantified its association with cardio-metabolic comorbidities and major cardiovascular events. Methods: Descriptive, cross-sectional analysis of Individual Health Service Provision Records (RIPS), 2010–2024. Urolithiasis identified by ICD-10. Prevalence reported as % and stratified by sex and age. Associations summarized as prevalence ratios (PRs) comparing association with cardio-metabolic comorbidities in individuals with vs without stones; chi-squared tests with 95% CIs. Results and Limitations: Among 65.4 million encounters, 1,838,661 carried a urolithiasis diagnosis (2.8%). Men slightly higher than women (2.9% vs 2.6%). Metabolic disorders were enriched in stone formers: hypertension 6.6% vs 2.2% (PR≈3.0), dyslipidemia 7.3% vs 2.5% (PR≈2.9), obesity 6.3% vs 2.6% (PR≈2.5), diabetes 7.3% vs 2.6% (PR≈2.8). Cardiovascular events were more frequent: ischemic heart disease 7.4% vs 2.7% (PR≈2.7); stroke 5.5% vs 2.8% (PR≈2.0). Renal involvement showed the largest disparity: CKD 8.9% vs 2.7% (PR≈3.3). In children &lt;10 years, CKD occurred in 3.7% with stones. Limitations: reliance on administrative data (selection/misclassification), no verification of diagnoses, cross-sectional design (no temporality/causality), absence of clinical, behavioral, and socioeconomic covariates, no stone type/severity/recurrence or treatment detail; residual confounding likely. Conclusions In Colombia, kidney stones mark a broader cardio-renal-metabolic phenotype. Routine care for stone formers should include blood pressure, glycemia, lipids, adiposity, and kidney-function assessment plus lifestyle counseling. Health systems may consider urolithiasis as a cardiovascular risk-enhancing factor. Longitudinal studies are needed to define causal pathways, risk trajectories, and cost-effective interventions.