Sengkang 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.

Introduction: In a mass casualty incident, adult medicine-trained emergency physicians and nurses may need to treat pediatric casualties, as part of Field Medical Teams (FMTs) deployed to pre-hospital First Aid Posts. These healthcare professionals are often unaccustomed to managing pediatric patients, who present relatively infrequently to adult general hospital emergency departments in Singapore. A pediatric pre-hospital trauma module was developed to address this gap in knowledge and skills, potentially improving the survival of pediatric casualties in a disaster scenario. Methods: The pediatric module was embedded in the National Disaster Medical Responders’ Course (DMRC) to ensure all emergency medicine medical and nursing staff would progressively benefit from this training. The learning objectives included: 1) effective clinical management of pediatric trauma in a pre-hospital environment with limited medical resources; 2) efficient management of team dynamics in organizing the FMT’s response to pediatric trauma management in a pre-hospital environment; and 3) accurate prioritization during pediatric trauma triaging and evacuation to hospital in a pediatric-predominant mass casualty incident. The curriculum included the following aspects: triage; initial assessment and primary survey; airway, breathing, circulation, and disability considerations focusing on differences between adult and pediatric patients; and team dynamics. Course content was delivered via pre-recorded lectures (given the ongoing COVID-19 pandemic) and hands-on skill stations in small groups. Results: From April 2022-August 2024, 50 courses with 1144 participants from public healthcare institutions were conducted. Of the participants, 246/1144 (21.5%) were doctors, 787/1144 (68.8%) were nurses, 65/1144 (5.7%) were allied health, and 46/1144 (4.0%) were administrative staff. Conclusion: Medical responders in a mass casualty incident need to be prepared for managing pediatric casualties, which are infrequently encountered in daily clinical practice. This module is an important component of Singapore’s disaster medical curriculum and will contribute to disaster preparedness for the vulnerable pediatric population.

Abstract Chronic compartment syndrome (CCS), though often described in athletes, can occur in patients with long-standing lymphedema due to chronic fibrotic changes in the skin, subcutaneous tissue, and deep fascia. We present a unique case of CCS in a patient with advanced secondary lymphedema of the left lower limb. She underwent multiple sittings of vascularized lymph node transfers and lymphovenous anastomoses. Her final lymph node transfer, combined with bariatric surgery, led to dramatic weight loss and a reduction in lower limb girth. Subsequently, she developed persistent exertional pain and neuropathic symptoms in the left calf, raising suspicion for CCS. Intracompartmental pressure (normal range of 0–10 mm Hg) analysis by manometry confirmed CCS with preoperative readings of 22, 25.2, 17.9, and 29.5 mm Hg in anterior, lateral, superficial, and deep compartments of the leg. Surgical decompression and debulking resulted in postdecompression pressures of 6.5, 6, 4.6, and 4.6 mm Hg, respectively, with good symptomatic relief. This case emphasizes the importance of considering CCS in chronic lymphedema with limb pain and neuropathy unexplained by surgical outcomes.

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.

Predicting liver-related events (LREs) in stable cirrhosis is crucial; however, traditional scoring methods perform poorly. Ammonia, due to its pathophysiological integration, may prognosticate LRE. This study tests the hypothesis that hyperammonemia can predict LRE and evaluates the AMMON-OHE score in a prospective cohort. A total of 280 patients with cirrhosis were prospectively enrolled and followed until LRE, liver transplant, or death. Ammonia was measured at enrollment and periodically, along with other parameters. LRE at 1 year was defined as hospitalization for ascites, variceal bleeding, hepatic encephalopathy, or bacterial infection. AMN ≥ULN was calculated by adjusting ammonia to the lab's upper normal limit. Cox regression and time-dependent analyses were performed. AMMON-OHE was validated using TRIPOD+AI and decision curve analysis. Most patients were male (60.7%), with a mean age of 66.1±10.3 years. MASLD was the commonest etiology (43.7%). Median CTP and MELD scores were 6 (IQR: 5-7) and 8 (IQR: 6-11). Overall, 60 (21.4%) developed LRE at 1 year, and 23 (8.2%) died. In multivariable analysis, AMN ≥ULN was an independent predictor of LRE (HR: 4.92; 95% CI: 2.80-8.64). The AMMON-OHE score predicted LRE with a time-dependent AUROC of 0.859 (CI: 0.810-0.907), outperforming MELD (p=0.014) but similar to CTP (p=NS). The AMMON-OHE score underestimated the risk of LRE in our cohort. AMN ≥ULN in stable outpatients with cirrhosis can predict LRE. Although the AMMON-OHE score has a high AUROC, it underestimates the risk of LRE in this cohort.