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Aims: The performance of circulating soluble urokinase plasminogen activator receptor (suPAR) for predicting the composite endpoint of subsequent heart failure (HF) hospitalisation and/or death at 1 year was assessed in (i) patients with undifferentiated breathlessness, and generalisability was compared in (ii) disparate Western versus Asian sub-cohorts, and in (iii) the sub-cohort adjudicated with HF., Methods and Results: Patients with acute breathlessness were recruited from the emergency departments in New Zealand (NZ, n = 612) and Singapore (n = 483). suPAR measured in the presentation samples was higher in patients incurring the endpoint (n = 281) compared with survivors (5.2 ng/mL vs 3.1 ng/mL, P < 0.0001). The discriminative power of suPAR for endpoint prediction was c-statistic of 0.77 in the combined population, but was superior in Singapore than NZ (c-statistic: 0.83 vs 0.71, P < 0.0001). Although the highest suPAR tertile (>4.37 ng/mL) was associated with risks of >4-fold in NZ, >20-fold in Singapore, and ≥3-fold in HF for incurring the outcome, there was no interaction between country and suPAR levels after adjustment. Multivariable analysis indicated suPAR to be robust in predicting HF/death at 1-year [hazard ratio: 1.9 (95% CI:1.7 to 2.0) per SD increase] and improved risk discrimination for outcome prediction in HF (∆0.06) and for those with NT-proBNP >1000 pg/mL (∆0.02)., Conclusion: suPAR is a strong independent predictor of HF and/or death at 1 year in acutely breathless patients, in both Asian and Western cohorts, and in HF. suPAR may improve stratification of acutely breathless patients, and in acute HF, for risk of later onset of heart failure or mortality., Competing Interests: Declaration of competing interest AMR reports research grant support and speaker's honoraria from Roche Diagnostics, and in-kind support in the form of assay kit reagents from Abbott, Thermo Fisher, and Alere, during the conduct of the study. All other authors report no relationships that could be construed as a conflict of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Aim: For patients who present to the emergency departments (ED) with undifferentiated chest pain, the risk of major adverse cardiac events (MACE) may be underestimated in low-HEART score patients. We aimed to identify characteristics of patients who were classified as low risk by HEART score but subsequently developed MACE at 6 weeks., Methods: We studied a multiethnic cohort of patients who presented with chest pain arousing suspicion of acute coronary syndrome to EDs in the Netherlands and Singapore. Patients were risk-stratified using HEART score and followed up for MACE at 6 weeks. Risk factors of developing MACE despite low HEART scores (scores 0-3) were identified using logistic and Cox regression models., Results: Among 1376 (39.8%) patients with low HEART scores, 63 (4.6%) developed MACE at 6 weeks. More males (53/806, 6.6%) than females (10/570, 2.8%) with low HEART score developed MACE. There was no difference in outcomes between ethnic groups. Among low-HEART score patients with 2 points for history, 21% developed MACE. Among low-HEART score patients with 1 point for troponin, 50% developed MACE, while 100% of those with 2 points for troponin developed MACE. After adjusting for HEART score and potential confounders, male sex was independently associated with increased odds (OR 4.12, 95%CI 2.14-8.78) and hazards (HR 3.93, 95%CI 1.98-7.79) of developing MACE despite low HEART score., Conclusion: Male sex, highly suspicious history and elevated troponin were disproportionately associated with MACE. These characteristics should prompt clinicians to consider further investigation before discharge., (Copyright © 2023 Elsevier B.V. All rights reserved.)

The COVID-19 pandemic has exerted a huge emotional strain on mental health professionals (MHP) in Singapore. As Singapore transited into an endemic status, it is unclear whether the psychological strain has likewise lessened. The aims of this study were to investigate the levels of stress and burnout experienced by MHP working in a tertiary psychiatric hospital in Singapore during this phase of COVID-19 endemicity (2022) in comparison to the earlier pandemic years (2020 and 2021) and to identify factors which contribute to as well as ameliorate stress and burnout. A total of 282 MHP participated in an online survey in 2022, which included 2 validated measures, namely the Perceived Stress Scale and the Oldenburg Burnout Inventory (OLBI). Participants were also asked to rank factors that contributed the most to their stress and burnout. Between-group comparisons were conducted regarding stress and burnout levels among MHP across different demographic groupings and working contexts. In addition, OLBI data completed by MHP in 2020 and 2021 were extracted from 2 published studies, and trend analysis was conducted for the proportion of MHP meeting burnout threshold across 3 time points. We found that the proportion of MHP meeting burnout threshold in 2020, 2021 and 2022 were 76.9%, 87.6% and 77.9% respectively. Professional groups, age, years of experience and income groups were associated with stress and/or burnout. High clinical workload was ranked as the top factor that contributed to stress and burnout while flexible working arrangement was ranked as the top area for improvement so as to reduce stress and burnout. As such, policy makers and hospital management may want to focus on setting clear mental health targets and facilitate manageable clinical workload, build manpower resiliency, optimize resources and provide flexible work arrangements to alleviate stress and burnout among MHP., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Yang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Objectives: In dyspneic patients with atrial fibrillation (AF) or obesity, the diagnostic performance of NT-proBNP for acute heart failure is reduced. We evaluated the erythroblast derived protein erythroferrone (ERFE) as an ancillary biomarker for the diagnosis of acute decompensated heart failure (ADHF) in these comorbid subgroups in both Western and Asian populations., Methods: The diagnostic performance of ERFE (Intrinsic Lifesciences) and NT-proBNP (Roche Cobas e411) for ADHF was assessed in 479 New Zealand (NZ) and 475 Singapore (SG) patients presenting with breathlessness., Results: Plasma ERFE was higher in ADHF, compared with breathlessness from other causes, in both countries (NZ; 4.9 vs. 1.4 ng/ml, p  < 0.001) and (SG; 4.2 vs. 0.4 ng/ml, p  = 0.021). The receiver operating characteristic (ROC) areas under the curve (AUCs) for discrimination of ADHF were reduced in the NZ cohort compared to SG for ERFE (0.75 and 0.84, p  = 0.007) and NT-proBNP (0.86 and 0.92, p  = 0.004). Optimal cut-off points for ERFE yielded comparable sensitivity and positive predictive values in both cohorts, but slightly better specificity, negative predictive values and accuracy in SG compared with NZ. In patients with AF, the AUC decreased for ERFE in each cohort (NZ: 0.71, n  = 105, SG: 0.61, n  = 44) but increased in patients with obesity (NZ: 0.79, n  = 150, SG: 0.87, n  = 164)., Conclusions: Circulating ERFE is higher in patients with ADHF than in other causes of new onset breathlessness with fair diagnostic utility, performing better in Asian than in Western patients. The diagnostic performance of ERFE is impaired in patients with AF but not patients with obesity., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Appleby, Frampton, Holdaway, Chew-Harris, Liew, Chong, Lewis, Troughton, Ooi, Kuan, Ibrahim, Chan, Richards and Pemberton.)

Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Competing Interests: None

Competing Interests: None

Objectives: A major surge in COVID-19 cases despite Singapore's high vaccination has strained the health care system in October 2021. Our aim was to assess and compare Healthcare Worker (HCW) mental well-being in 2021 against a previously published cohort in 2020., Design: Cross-sectional survey study., Setting and Participants: HCWs from 4 public hospitals and a primary health care system over a 4-week duration in 2021 coinciding with a major surge compared with a similar period in 2020., Methods: A survey comprising of the Oldenburg Burnout Inventory (OLBI), Hospital Anxiety and Depression Scale (HADS), and Safety Attitudes Questionnaire (SAQ) was distributed via email. Primary endpoints were the proportion meeting OLBI thresholds for both disengagement and exhaustion and being at risk for both Anxiety and Depression using HADS. Multivariate analysis identified significant predictors among demographic, workplace, and SAQ data. Subgroup analysis of overseas HCWs was performed., Results: We surveyed 1475 HCWs. Significantly more HCWs met primary outcomes using OLBI and HADS than in 2020 (84.1% and 39.6% vs 68.2% and 23.3%, respectively; P < .001). Burnout levels were uniformly high. A HADS score ≥8 in either subscale was significantly associated with meeting burnout thresholds (P < .001). Overseas HCWs (P = .002), South Asian ethnicity (P = .004), preuniversity educational qualifications (P = .026), and longer shift workhours of 8 to <12 (P = .015) and ≥12 (P = .001) were significantly associated with meeting HADS thresholds. Among overseas HCWs (n=407), seeing family more than a year ago was significantly associated with worse OLBI disengagement scores and a greater proportion meeting HADS thresholds vs seeing them within a year or being local HCWs (47.2% vs 37.2% and 35.6%, respectively; P = .001)., Conclusions and Implications: HCW mental health has objectively worsened between 2020 and 2021 in the pandemic's second year. Avoiding prolonged shifts, adopting preventive mental health strategies, improving patient safety, and attention to HCWs of minority ethnicity, from overseas, and with preuniversity education may help., (Copyright © 2022 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: The strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs., Design: Cross-sectional survey study., Setting and Participants: Doctors, nurses, allied health professionals, administrative, and support staff in 4 public hospitals and 1 primary care service in Singapore 3 months after COVID-19 was declared a global pandemic., Methods: Study questionnaire captured demographic and workplace environment information and comprised 3 validated instruments, namely the Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were used to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs., Results: Among 11,286 invited HCWs, 3075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion, respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents, respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours, and being redeployed were significantly associated with higher OLBI mean scores, whereas high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared with those redeployed onsite., Conclusions and Implications: Every level of the health care workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours, and promoting safe working environments. Mitigating strategies should target every level of the health care workforce, including frontline and nonfrontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Aims: Extracellular vesicles (EVs) are small double-membrane plasma vesicles that play key roles in cellular crosstalk and mechanisms such as inflammation. The role of EVs in combined organ failure such as cardiorenal syndrome has not been investigated. The aim of this study is to identify EV proteins that are associated with renal dysfunction, heart failure, and their combination in dyspnoeic patients., Methods and Results: Blood samples were prospectively collected in 404 patients presenting with breathlessness at the emergency department at National University Hospital, Singapore. Renal dysfunction was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m 2 . The presence of heart failure was independently adjudicated by two clinicians on the basis of the criteria of the European Society of Cardiology guidelines. Protein levels of SerpinG1, SerpinF2, Cystatin C, and CD14 were measured with a quantitative immune assay within three EV sub-fractions and in plasma and were tested for their associations with renal dysfunction, heart failure, and the concurrence of both conditions using multinomial regression analysis, thereby correcting for confounders such as age, gender, ethnicity, and co-morbidities. Renal dysfunction was found in 92 patients (23%), while heart failure was present in 141 (35%). In total, 58 patients (14%) were diagnosed with both renal dysfunction and heart failure. Regression analysis showed that Cystatin C was associated with renal dysfunction, heart failure, and their combination in all three EV sub-fractions and in plasma. CD14 was associated with both renal dysfunction and the combined renal dysfunction and heart failure in all EV sub-fractions, and with presence of heart failure in the high density lipoprotein sub-fraction. SerpinG1 and SerpinF2 were associated with heart failure in, respectively, two and one out of three EV sub-fractions and in plasma, but not with renal dysfunction., Conclusions: We provide the first data showing that Cystatin C and CD14 in circulating EVs are associated with both renal dysfunction and heart failure in patients presenting with acute dyspnoea. This suggests that EV proteins may be involved in the combined organ failure of the cardiorenal syndrome and may represent possible targets for prevention or treatment., (© 2020 The Authors. ESC Heart Failure published by John Wiley & Sons Ltd on behalf of the European Society of Cardiology.)

The ongoing coronavirus disease 2019 (COVID-19) crisis has hit Singapore hard. As of February 25, 2020, Singapore had the fourth highest number of confirmed COVID-19 infections outside of China, only trailing behind South Korea, Italy, and Japan. This has had reverberating effects on Singapore's health care system, and has, consequently, also affected medical education all the way from the undergraduate to the postgraduate level. While efforts are underway to contain disease spread and transmission, the authors believe that this is an opportune time to examine and reflect on the impact that medical crises like COVID-19 can have on medical training and education and to evaluate "business continuity plans" to ensure quality medical education even in the face of constant disruptions from pandemic outbreaks. Medical training is as important a mandate as patient care and service. The authors believe that even in trying times like this, rich and precious lessons can be sought and taught, which will immensely benefit medical students and residents-the health care leaders of tomorrow. In this Perspective, the authors discuss the various ways in which the COVID-19 crisis has affected medical instruction in Singapore and explore pertinent practical and creative solutions for the continuity of medical training in these trying times, drawing on their previous experience with the Severe Acute Respiratory Syndrome outbreak in 2003 as well as the current ongoing COVID-19 crisis.

The COVID-19 pandemic has affected healthcare systems worldwide. The disruption to hospital routines has affected continuing medical education (CME) for specialty trainees (STs). We share our academic institution's experience in mitigating the disruption on the CME programme amidst the pandemic. Most specialty training programmes had switched to videoconferencing to maintain teaching. Some programmes also utilized small group teachings with precautions and e-learning modules. Surgical residencies were disproportionately affected due to reductions in elective procedures but some ways to provide continued surgical exposure include going through archived surgical videos with technical pointers from experienced faculty and usage of surgical simulators . We should adapt CME sessions to keep trainees up to date with core clinical competencies as they will continue to manage both COVID-19 and non-COVID-19 cases and this pandemic may last until year's end., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Aims: The performance of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in diagnosing acute decompensated heart failure (ADHF) among patients presenting with breathlessness is markedly impaired in the presence of atrial fibrillation (AF). We evaluated the diagnostic performance of mid-regional pro-adrenomedullin (MR-proADM) and cardiac troponin T as possible alternative markers for discrimination of ADHF in this setting., Methods and Results: Breathless patients (n = 1107) were prospectively and contemporaneously recruited in emergency departments in Singapore and New Zealand. The diagnoses of ADHF and presence of AF were adjudicated by two clinician specialists, blinded to MR-proADM, NT-proBNP and high-sensitivity cardiac troponin T (hs-cTnT) results. MR-proADM exhibited strong discrimination of ADHF with little change in performance irrespective of the presence of AF (area under the curve 0.83 in non-AF vs. 0.76 in AF) compared to NT-proBNP (0.91 vs. 0.71) and hs-cTnT (0.83 vs. 0.62), respectively. The accuracy of MR-proADM (73.3%) for diagnosing ADHF among patients with AF was superior to both NT-proBNP (61.6%) and hs-cTnT (64.6%). The superior performance of MR-proADM remained apparent when data from Singapore and New Zealand were analysed separately., Conclusion: In the presence of AF, MR-proADM showed greater discrimination and accuracy, and less impairment in performance compared to that in non-AF cases, for the diagnosis of ADHF, compared to the guideline-endorsed NT-proBNP., (© 2019 European Society of Cardiology.)

Long duty hours have been associated with significant medical errors, adverse events, and physician "burn-out". An innovative night float (NF) system has been implemented in our internal medicine program to reduce the negative effects of long duty hours associated with conventional full-call systems. However, concerns remain if this would result in inadequate training for interns. We developed a structured questionnaire to assess junior doctors' perceptions of the NF system compared to full calls, in areas of patient safety, medical training, and well-being. Ninety-seven (71%) of the 137 doctors polled responded. Ninety-one (94%) felt the NF system was superior to the full call system. A strong majority felt NF was beneficial for patient safety compared to full call (94% vs. 2%, p&lt;0.001). The NF system was also perceived to reduce medical errors (94% vs. 2%, p&lt;0.001) and reduce physician "burn-out" (95% vs. 5%, p&lt;0.001). Beyond being a practical solution to duty-hour limitations, there was a significant perceived benefit of the NF system compared to the full call in terms of overall satisfaction, patient safety, reducing medical errors and physician "burn-out".

Background: The decision to perform a blood culture is influenced by factors, such as the pretest probability of bacteremia, resource availability and individual clinician's preference. The lack of formal guidelines results in inconsistencies in practices and an inappropriate or overuse of blood cultures. The primary aim of this study is to compare the rate of positive blood cultures in the emergency department (ED) and general ward. The secondary aim of this study is to analyze factors associated with a positive blood culture., Methods: We compared 200 consecutive patients in the ED with 200 consecutive patients with first blood cultures done within 24 h of admission from ED to the general ward. We analyzed the clinical characteristics, proportion of positive blood cultures, and variables associated with a positive blood culture., Results: The percentage of positive blood cultures was 13.5% (n = 27) in the ED group, compared with 6.0% (n = 12) in the general ward group. Contamination rates were higher in the ED compared to general ward (4% vs 0.5%). Heart rate and rigors were independently associated with a positive blood culture in a multivariate logistic regression model., Conclusion: There was a lower rate of positive blood cultures in the general ward group. Reasons may include a lower threshold for performing blood cultures in the general ward, and prior antibiotics in the ED reducing the sensitivity of blood cultures taken in the general ward. Adherence to clinical decision rules and education of junior staff are needed to improve the efficiency of blood culture taking practices., (Copyright © 2018 Australasian College for Infection Prevention and Control. Published by Elsevier B.V. All rights reserved.)