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Introduction: Melanomas in Asians have different clinicopathological characteristics and prognosis from melanomas in Caucasians. This study reviewed the epidemiology and treatment outcomes of cutaneous melanoma diagnosed at a tertiary referral dermatology centre in Singapore, which has a multiracial population. The study also determined whether Asians had comparable relapse-free and overall survival periods to Caucasians in Singapore. Method: This is a retrospective review of cutaneous melanoma cases in our centre between 1996 and 2015. Results: Sixty-two cases of melanoma were diagnosed in 61 patients: 72.6% occurred in Chinese, 19.4% in Caucasians and 3.2% in Indians, with an over-representation of Caucasians. Superficial spreading melanoma, acral lentiginous melanoma and nodular melanoma comprised 37.1%, 35.5% and 22.6% of the cases, respectively. The median time interval to diagnosis was longer in Asians than Caucasians; median Breslow’s thickness in Asians were significantly thicker than in Caucasians (2.6mm versus 0.9mm, P=0.018) and Asians tend to present at a later stage. The mortality rates for Asians and Caucasians were 52% and 0%, respectively. Conclusion: More physician and patient education on skin cancer awareness is needed in our Asian-predominant population for better outcomes. Keywords: Asian, melanoma, nails, skin neoplasm, survival

Carbapenemase-producing Enterobacteriaceae (CPE) are a group of drug-resistant Gram-negative pathogens that are classified as a critical threat by the World Health Organization (WHO). Conventional methods of detecting antibiotic-resistant pathogens do not assess the resistance mechanism and are often time-consuming and laborious. We have developed a magnetic digital microfluidic (MDM) platform, known as MDM Carba, for the identification of CPE by measuring their ability to hydrolyze carbapenem antibiotics. MDM Carba offers the ability to rapidly test CPE and reduce the amount of reagents used compared with conventional phenotypic testing. On the MDM Carba platform, tests are performed in droplets that function as reaction chambers, and fluidic operations are accomplished by manipulating these droplets with magnetic force. The simple droplet-based magnetic fluidic operation allows easy system automation and simplified hands-on operation. Because of the unique “power-free” operation of MDM technology, the MDM Carba platform can also be operated manually, showing great potential for point-of-care testing in resource-limited settings. We tested 27 bacterial isolates on the MDM Carba platform, and the results showed sensitivity and specificity that were comparable to those of the widely used Carba NP test. MDM Carba may shorten the overall turnaround time for CPE identification, thereby enabling more timely clinical decisions for better clinical outcomes. MDM Carba is a technological platform that can be further developed to improve diagnostics for other types of antibiotic resistance with minor modifications. Ministry of Education (MOE) Nanyang Technological University Published version The authors would like to thank Scott Cunningham and Robin Patel from the Mayo Clinic, Rochester, MN, for sharing the reference isolates used in this study and Lew Wen Siang and Gerard Joseph Lim at Nanyang Technological University, Singapore, for helping with vibrating-sample magnetometer measurements. Yi Zhang and Shawn Vasoo are grateful for the funding support from NTUitive Gap Fund NGF-2020-08-002. Yi Zhang is thankful for funding support from the Singapore Ministry of Education Grant Tier 1 RG39/19 and the Nanyang Technological University Startup Grant.

Background The visual assessment and severity grading of acne vulgaris by physicians can be subjective, resulting in inter- and intra-observer variability. Objective To develop and validate an algorithm for the automated calculation of the Investigator's Global Assessment (IGA) scale, to standardize acne severity and outcome measurements. Materials and methods A total of 472 photographs (retrieved 01/01/2004-04/08/2017) in the frontal view from 416 acne patients were used for training and testing. Photographs were labeled according to the IGA scale in three groups of IGA clear/almost clear (0-1), IGA mild (2), and IGA moderate to severe (3-4). The classification model used a convolutional neural network, and models were separately trained on three image sizes. The photographs were then subjected to analysis by the algorithm, and the generated automated IGA scores were compared to clinical scoring. The prediction accuracy of each IGA grade label and the agreement (Pearson correlation) of the two scores were computed. Results The best classification accuracy was 67%. Pearson correlation between machine-predicted score and human labels (clinical scoring and researcher scoring) for each model and various image input sizes was 0.77. Correlation of predictions with clinical scores was highest when using Inception v4 on the largest image size of 1200 × 1600. Two sets of human labels showed a high correlation of 0.77, verifying the repeatability of the ground truth labels. Confusion matrices show that the models performed sub-optimally on the IGA 2 label. Conclusion Deep learning techniques harnessing high-resolution images and large datasets will continue to improve, demonstrating growing potential for automated clinical image analysis and grading.

Hamlet’s ‘To be or not to be’ speech has long been the subject of intense scholarly attention. By situating the speech against the backdrop of classical and Renaissance rhetorical theory, this essay demonstrates that there is still much more to be said about it. The speech ostensibly examines a quaestio infinita or a thesis, and follows the rhetorical rule that the right way to do so is by the invocation of commonplaces. This reading of Hamlet’s speech is not only consistent with Shakespeare’s characterization of the university-educated prince, who frequently invokes commonplaces, but also has significant implications for our understanding of the play and Shakespeare’s own practice as a writer. The book that Hamlet is reading could well be his own commonplace collection, and it is perhaps in looking up his entries under the heading of ‘Death’ that Hamlet finds what he needs in order to examine his quaestio.

Aims Hypertensive left ventricular hypertrophy (LVH) is associated with increased cardiovascular events. We previously developed the remodelling index (RI) that incorporated left ventricular (LV) volume and wall-thickness in a single measure of advanced hypertrophy in hypertensive patients. This study examined the prognostic potential of the RI in reference to contemporary LVH classifications. Methods and results Cardiovascular magnetic resonance was performed in 400 asymptomatic hypertensive patients. The newly derived RI (EDV3t, where EDV is LV end-diastolic volume and t is the maximal wall thickness across 16 myocardial segments) stratified hypertensive patients: no LVH, LVH with normal RI (LVHNormal-RI), and LVH with low RI (LVHLow-RI). The primary outcome was a composite of all-cause mortality, acute coronary syndromes, strokes, and decompensated heart failure. LVHLow-RI was associated with increased LV mass index, fibrosis burden, impaired myocardial function and elevated biochemical markers of myocardial injury (high-sensitive cardiac troponin I), and wall stress. Over 18.3 ± 7.0 months (601.3 patient-years), 14 adverse events occurred (2.2 events/100 patient-years). Patients with LVHLow-RI had more than a five-fold increase in adverse events compared to those with LVHNormal-RI (11.6 events/100 patient-years vs. 2.0 events/100 patient-years, respectively; log-rank P Conclusion The RI provides prognostic value that improves risk stratification of hypertensive LVH.

Introduction: This study aimed to characterise neonatal paediatric emergency department (PED) visits, analyse the main paediatric illnesses and establish associations of these demographics with the readmission rates and severity of their presentation. Methods: A retrospective analysis of neonates (aged

The histological findings in pemphigus vulgaris are suprabasilar acantholysis in the epidermis with the floor of the blister lined with intact keratinocytes. Direct immunofluorescence findings are intercellular IgG and/or C3 in the epidermis Anti-Dsg1 levels decline when moving from active to remission phase of the disease, but anti-Dsg3 levels remain elevated throughout Corticosteroids are the mainstay of treatment for pemphigus vulgaris and work quickly within days by overcoming the effect of anti-desmoglein antibodies Angiotensin converting enzyme inhibitors, such as captorpil, enalapril and ramipril, are the most commonly reported anti-hypertensive drugs to be associated with pemphigus vulgaris Prognostic factors of pemphigus vulgaris include disease severity at time of diagnosis, early response to treatment, and levels of indirect immunofluorescence and ELISA titers

Singapore Hokkien (SH) is the most commonly spoken non-Mandarin Chinese dialect in Singapore. It is an important language for many members of Singapore's pioneer generation, but much less so for the younger generation who prefer English. In recent years, the greying of this demographic has placed an increasing demand on for assistive devices to support them. We report ongoing efforts to build limited-vocabulary speech recognition, with the eventual goal of a conversational voice agent in SH that can support applications in home-automation or in-hospital use case scenarios. This process is challenging as sizeable SH speech corpora do not yet exist, and SH is sufficiently different from existing Mandarin or Minnan such that other corpora cannot be directly used. We document our efforts at building language resources -- audio corpora, pronunciation lexicons -- and present some preliminary findings on multilingual training.

Background Thromboembolic events (TEs) are frequent after mechanical mitral valve replacement (MVR), but their association to anticoagulation quality is unclear and has never been studied in a population-based setting with patients who have a complete anticoagulation record. Methods We compiled a complete record of all residents of Olmsted County, MN, who underwent mechanical MVR between 1981 and 2004, for all TE, bleeding episodes, and international normalized ratios (INRs) measured from prosthesis implantation. Results In the 112 residents (mean [± SD] age, 57 ± 16 years; 60% female residents) who underwent mechanical MVR, 19,647 INR samples were obtained. While INR averaged 3.02 ± 0.57, almost 40% of INRs were 4.5. Thirty-four TEs and 28 bleeding episodes occurred during a mean duration of 8.2 ± 6.1 years of follow-up. There was no trend of association of INR (average, SD, growth variance rate, or intensity-specific incidence of events) with TE. Previous cardiac surgery (p = 0.014) and ball prosthesis (hazard ratio [HR], 2.92; 95% CI, 1.43 to 5.94; p = 0.003) independently determined TE. With MVR using a ball prosthesis, despite higher anticoagulation intensity (p = 0.002), the 8-year rate of freedom from TE was considerably lower (50 ± 9% vs 81 ± 5%, respectively; p Conclusion This population-based comprehensive study of anticoagulation and TE post-MVR shows that, in these closely anticoagulated patients, anticoagulation intensity was highly variable and not associated with TE incidence post-MVR. Higher anticoagulation intensity is linked to higher variability and, thus, to bleeding. The MVR-ball prosthesis design is associated with higher TE rates notwithstanding higher anticoagulation intensity, and its use should be retired worldwide.

In this case report, we detail the response of a 37-year-old Caucasian man with an overlap of erythematotelangiectatic rosacea and telangiectatic photoaging to brimonidine tartrate gel. With the application of brimonidine only on half of his face, skin analysis images, clinician's and patient's assessment showed that there was significant improvement in the erythema. This case has lent insight into how brimonidine can be used to assess the extent of photoaging by eliminating the erythema of rosacea to some degree. We propose that it can be used as a non-invasive test to differentiate between the two conditions, sparing patients from skin biopsies and molecular analysis.

Hidradenitis suppurativa is a chronic inflammatory skin condition associated with an increased prevalence of individual metabolic conditions such as insulin resistance, obesity, hyperlipidemia, hypertension, and with the metabolic syndrome, as a constellation of these risk factors. This places affected patients at an increased risk of early cardiovascular morbidity and mortality. Moreover, many of the therapeutic options, including the newer biologics, used in the treatment of hidradenitis suppurativa have both beneficial and adverse metabolic effects. Therefore, it is critical for physicians to consider the complex interactions between the disease process and the treatment options in the holistic management of these patients with an intrinsically higher risk of metabolic consequences. Other chronic systemic inflammatory diseases such as psoriasis and rheumatoid arthritis have been studied more extensively with regard to their associations and share an underlying link with the metabolic syndrome; we can draw upon the existing knowledge in our understanding and management of hidradenitis suppurativa.

BackgroundThrombo-embolic events (TE) are frequent after mechanical mitral valve replacement (MVR) but their association to anticoagulation quality is unclear and was never studied in a population-based setting with complete anticoagulation record.MethodsWe compiled complete record of all residents of Olmsted County, MN, who underwent mechanical MVR between 1981 and 2004, for all TE, bleedings and international normalized ratios (INR) measured from prosthesis implantation.ResultsIn the 112 residents (57±16 years, female 60%) who underwent mechanical MVR, 19,647 INR samples were obtained. While INR averaged 3.02±0.57, almost 40% of INR were below 2 or above 4.5. Thirty-four TE and 28 bleedings occurred during 8.2±6.1 years follow-up. There was no trend of association of INR (average, standard deviation-SD, growth variance rate or intensity specific incidence of events) with TE. Previous cardiac surgery (P=0.014), and ball prosthesis (2.92[1.43–5.94], P=0.003) independently determined TE. With MVR-ball, despite higher anticoagulation intensity (p=0.002), 8-year freedom from TE was considerably lower (50±9 vs. 81±5%, p