Publications by authors named "Andrew Fu Wah Ho"

80 Publications

Community-level socioeconomic status and the role of the hospital: does where you have an arrest affect receipt ofpost-arrest care?

Resuscitation 2022 May 11. Epub 2022 May 11.

Singapore, Singapore, and the Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore; Prehospital and Emergency Centre Research, Duke-NUS Medical School(5), Singapore, Singapore.

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http://dx.doi.org/10.1016/j.resuscitation.2022.05.003DOI Listing
May 2022

Prevalence of intracranial hemorrhage amongst patients presenting with out-of-hospital cardiac arrest: A systematic review and meta-analysis.

Resuscitation 2022 May 9. Epub 2022 May 9.

Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore. Electronic address:

Introduction: An unknown proportion of out-of-hospital cardiac arrest (OHCA) is caused by intracranial hemorrhage (ICH). There is uncertainty over the role of early head computed tomography (CT) in non-traumatic OHCA due to uncertain diagnostic yield and ways to identify high-risk patients. This study aimed to identify the prevalence of ICH in non-traumatic OHCA and possible predictors.

Methods: PubMed, EMBASE, and the Cochrane library were searched from inception to January 2022. Data extraction and quality assessment were independently reviewed by two authors. Meta-analyses estimated the prevalence of ICH amongst OHCA patients and pre-specified subgroups and geographical settings. Subgroup analysis were used to explore potential clinical predictors.

Results: 23 studies involving 54,349 patients were included. The pooled ICH prevalence was 4.28% (95%CI: 3.31-5.24). Asia had a significantly larger risk ratio (RR= 3.93, P value < 0.0001) than Europe. The ICH subgroup was significantly more likely to be female (OR: 2.16; 95%CI: 1.10-4.26), and less likely to experience shockable rhythms compared with non-shockable rhythms (OR: 0.22; 95% CI: 0.04-1.22), achieve ROSC prior to arrival (OR: 0.27; 95%CI: 0.10-0.77), and survive to discharge compared to those without ICH (OR: 0.26; 95%CI: 0.11-0.59).

Conclusions: One in twenty OHCA have ICH at the time of presentation. An early head CT scan should be strongly considered after return of spontaneous circulation (ROSC), especially in patients who are female, with non-shockable rhythm and did not attain ROSC prior to arrival. These finding should influence clinical protocols to favor routine scans especially in Asia where prevalence is higher.
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http://dx.doi.org/10.1016/j.resuscitation.2022.05.001DOI Listing
May 2022

Implementation of prediction models in the emergency department from an implementation science perspective-Determinants, outcomes and real-world impact: A scoping review protocol.

PLoS One 2022 12;17(5):e0267965. Epub 2022 May 12.

Health Services Research Centre, Singapore Health Services, Singapore, Singapore.

The number of prediction models developed for use in emergency departments (EDs) have been increasing in recent years to complement traditional triage systems. However, most of these models have only reached the development or validation phase, and few have been implemented in clinical practice. There is a gap in knowledge on the real-world performance of prediction models in the ED and how they can be implemented successfully into routine practice. Existing reviews of prediction models in the ED have also mainly focused on model development and validation. The aim of this scoping review is to summarize the current landscape and understanding of implementation of predictions models in the ED. This scoping review follows the Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist. We will include studies that report implementation outcomes and/or contextual determinants according to the RE-AIM/PRISM framework for prediction models used in EDs. We will include outcomes or contextual determinants studied at any point of time in the implementation process except for effectiveness, where only post-implementation results will be included. Conference abstracts, theses and dissertations, letters to editors, commentaries, non-research documents and non-English full-text articles will be excluded. Four databases (MEDLINE (through PubMed), Embase, Scopus and CINAHL) will be searched from their inception using a combination of search terms related to the population, intervention and outcomes. Two reviewers will independently screen articles for inclusion and any discrepancy resolved with a third reviewer. Results from included studies will be summarized narratively according to the RE-AIM/PRISM outcomes and domains. Where appropriate, a simple descriptive summary of quantitative outcomes may be performed.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0267965PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9097992PMC
May 2022

Validation of the CaRdiac Arrest Survival Score (CRASS) for Predicting Good Neurological Outcome After Out-Of-Hospital Cardiac Arrest in An Asian Emergency Medical Service System.

Resuscitation 2022 May 6. Epub 2022 May 6.

Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore; Prehospital Emergency Research Centre, Duke-NUS Medical School, Singapore.

Background: Survival with favorable neurological outcomes is an important indicator of successful resuscitation in out-of-hospital cardiac arrest (OHCA). We sought to validate the CaRdiac Arrest Survival Score (CRASS), derived using data from the German Resuscitation Registry, in predicting the likelihood of good neurological outcomes after OHCA in Singapore.

Methods: We conducted a retrospective population-based validation study among EMS-attended OHCA patients (≥18 years) in Singapore, using data from the prospective Pan-Asian Resuscitation Outcomes Study registry. Good neurological outcome was defined as a cerebral performance category of 1 or 2. To evaluate the CRASS score in light of the difference in patient characteristics, we used the default constant coefficient (0.8) and the adjusted coefficient (0.2) to calculate the probability of good neurological outcomes.

Results: Out of 11,404 analyzed patients recruited between April 2010 and December 2018, 260 had good and 11,144 had poor neurological function. The CRASS score demonstrated good discrimination, with an area under the curve of 0.963 (95% confidence interval: 0.952-0.974). Using the default constant coefficient of 0.8, the CRASS score consistently overestimated the predicted probability of a good outcome. Following adjustment of the coefficient to 0.2, the CRASS score showed improved calibration.

Conclusion: CRASS demonstrated good discrimination and moderate calibration in predicting favorable neurological outcomes in the validation Singapore cohort. Our study established a good foundation for future large-scale, cross-country validations of the CRASS score in diverse sociocultural, geographical, and clinical settings.
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http://dx.doi.org/10.1016/j.resuscitation.2022.04.028DOI Listing
May 2022

Long term risk of recurrence among survivors of sudden cardiac arrest: a systematic review and meta-analysis.

Resuscitation 2022 May 5. Epub 2022 May 5.

Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore. Electronic address:

Aims: With a growing number of survivors of sudden cardiac arrest globally, their natural disease progression is of interest. This systematic review and meta-analysis aimed to determine the risk of recurrence after sudden cardiac arrest and its associated risk factors.

Methods: Medline, Embase, Cochrane Library and Scopus were searched from inception to October 2021. Studies involving survivors of an out-of-hospital sudden cardiac arrest event of any non-traumatic aetiology were included. Meta-analyses of proportions using the random-effects model estimated the primary outcome of first recurrent sudden cardiac arrest incidence as well as secondary outcomes including cumulative incidence of recurrence at 1-year and incidence of second recurrence among survivors of first recurrence. A recurrent episode was defined as a sudden cardiac arrest that occurs 28 or more days after the index event. Subgroup and meta-regression analyses were conducted for predetermined variables. The Newcastle-Ottawa Scale was used to assess risk of bias for most studies.

Results: 35 studies of moderate to high quality comprising a total of 7186 survivors were analysed. The pooled incidence of first recurrence was 15.24% (32 studies; 95%CI, 11.01-19.95; mean follow-up time, 41.3±29.3 months) and second recurrence was 35.03% (3 studies; 95%CI, 19.65-51.93; mean follow-up time, 161.1±54.3 months). At 1-year, incidence of recurrence was 10.62% (3 studies; 95%CI, 0.25-30.42). Subgroup analyses found no significant difference (p=0.204) between incidence of first recurrence published from 1975-1992 and 1993-2021, and between studies with mean follow-up time of <24 months, 24-48 months, and >48 months. On meta-regression, initial shockable rhythm increased incidence of first recurrence (p=0.01).

Conclusion: 15.24% of sudden cardiac arrest survivors experienced a recurrence, and of these, 35.03% experienced a second recurrence. Most recurrences occurred in the first year. Initial shockable rhythm increased this risk. Despite the limitations of inter-study heterogeneity, these findings can still guide intervention and follow-up of sudden cardiac arrest survivors.
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http://dx.doi.org/10.1016/j.resuscitation.2022.04.027DOI Listing
May 2022

Development and validation of an interpretable clinical score for early identification of acute kidney injury at the emergency department.

Sci Rep 2022 May 2;12(1):7111. Epub 2022 May 2.

Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.

Acute kidney injury (AKI) in hospitalised patients is a common syndrome associated with poorer patient outcomes. Clinical risk scores can be used for the early identification of patients at risk of AKI. We conducted a retrospective study using electronic health records of Singapore General Hospital emergency department patients who were admitted from 2008 to 2016. The primary outcome was inpatient AKI of any stage within 7 days of admission based on the Kidney Disease Improving Global Outcome (KDIGO) 2012 guidelines. A machine learning-based framework AutoScore was used to generate clinical scores from the study sample which was randomly divided into training, validation and testing cohorts. Model performance was evaluated using area under the curve (AUC). Among the 119,468 admissions, 10,693 (9.0%) developed AKI. 8491 were stage 1 (79.4%), 906 stage 2 (8.5%) and 1296 stage 3 (12.1%). The AKI Risk Score (AKI-RiSc) was a summation of the integer scores of 6 variables: serum creatinine, serum bicarbonate, pulse, systolic blood pressure, diastolic blood pressure, and age. AUC of AKI-RiSc was 0.730 (95% CI 0.714-0.747), outperforming an existing AKI Prediction Score model which achieved AUC of 0.665 (95% CI 0.646-0.679) on the testing cohort. At a cut-off of 4 points, AKI-RiSc had a sensitivity of 82.6% and specificity of 46.7%. AKI-RiSc is a simple clinical score that can be easily implemented on the ground for early identification of AKI and potentially be applied in international settings.
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http://dx.doi.org/10.1038/s41598-022-11129-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9061747PMC
May 2022

Comparison of Mortality Outcomes in Acute Myocardial Infarction Patients With or Without Standard Modifiable Cardiovascular Risk Factors.

Front Cardiovasc Med 2022 14;9:876465. Epub 2022 Apr 14.

Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

Background: Acute myocardial infarction (AMI) cases have decreased in part due to the advent of targeted therapies for standard modifiable cardiovascular disease risk factors (SMuRF). Recent studies have reported that ST-elevation myocardial infarction (STEMI) patients without SMuRF (termed "SMuRF-less") may be increasing in prevalence and have worse outcomes than "SMuRF-positive" patients. As these studies have been limited to STEMI and comprised mainly Caucasian cohorts, we investigated the changes in the prevalence and mortality of both SMuRF-less STEMI and non-STEMI (NSTEMI) patients in a multiethnic Asian population.

Methods: We evaluated 23,922 STEMI and 62,631 NSTEMI patients from a national multiethnic registry. Short-term cardiovascular and all-cause mortalities in SMuRF-less patients were compared to SMuRF-positive patients.

Results: The proportions of SMuRF-less STEMI but not of NSTEMI have increased over the years. In hospitals, all-cause and cardiovascular mortality and 1-year cardiovascular mortality were significantly higher in SMuRF-less STEMI after adjustment for age, creatinine, and hemoglobin. However, this difference did not remain after adjusting for anterior infarction, cardiopulmonary resuscitation (CPR), and Killip class. There were no differences in mortality in SMuRF-less NSTEMI. In contrast to Chinese and Malay patients, SMuRF-less patients of South Asian descent had a two-fold higher risk of in-hospital all-cause mortality even after adjusting for features of increased disease severity.

Conclusion: SMuRF-less patients had an increased risk of mortality with STEMI, suggesting that there may be unidentified nonstandard risk factors predisposing SMuRF-less patients to a worse prognosis. This group of patients may benefit from more intensive secondary prevention strategies to improve clinical outcomes.
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http://dx.doi.org/10.3389/fcvm.2022.876465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9047915PMC
April 2022

Pre-hospital airway management and survival outcomes after paediatric out-of-hospital cardiac arrests.

Resuscitation 2022 Apr 26;176:9-18. Epub 2022 Apr 26.

Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore; Health Services and Systems Research, Duke-NUS Medical School, Singapore.

Background: Paediatric out-of-hospital cardiac arrest (OHCA) results in high mortality and poor neurological outcomes. We conducted this study to describe and compare the effects of pre-hospital airway management on survival outcomes for paediatric OHCA in the Asia-pacific region.

Methods: We performed a retrospective analysis of the Pan Asian Resuscitation Outcomes Study (PAROS) data from January 2009 to June 2018. PAROS is a prospective, observational, multi-centre cohort study from eleven countries. The primary outcomes were one-month survival and survival with favourable neurological status, defined as Cerebral Performance Category1 or 2. We performed multivariate analyses of the unmatched and propensity matched cohort.

Results: We included 3131 patients less than 18 years in the study. 2679 (85.6%) children received bag-valve-mask (BVM) ventilations, 81 (2.6%) endotracheal intubations (ETI) and 371 (11.8%) supraglottic airways (SGA). 792 patients underwent propensity score matching. In the matched cohort, advanced airway management (AAM: SGA and ETI) when compared with BVM group was associated with decreased one-month survival [AAM: 28/396 (7.1%) versus BVM: 55/396 (13.9%); adjusted odds ratio (aOR), 0.46 (95% CI, 0.29 - 0.75); p = 0.002] and survival with favourable neurological status [AAM: 8/396 (2.0%) versus BVM: 31/396 (7.8%); aOR, 0.22 (95% CI, 0.10 - 0.50); p < 0.001]. For SGA group, we observed less 1-month survival [SGA: 24/337 (7.1%) versus BVM: 52/337 (15.4%); aOR, 0.41 (95 %CI, 0.25-0.69), p = 0.001] and survival with favourable neurological status.

Conclusion: In children with OHCA in the Asia-Pacific region, pre-hospital AAM was associated with decreased one-month survival and less favourable neurological status.
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http://dx.doi.org/10.1016/j.resuscitation.2022.04.018DOI Listing
April 2022

Determinants of emergency department utilisation by older adults in Singapore: A systematic review.

Ann Acad Med Singap 2022 03;51(3):170-179

Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

Introduction: Adults aged ≥60 years contribute to disproportionately higher visits to the emergency departments (ED). We performed a systematic review to examine the reasons why older persons visit the ED in Singapore.

Methods: We searched Medline, Embase and Scopus from January 2000 to December 2021 for studies reporting on ED utilisation by older adults in Singapore, and included studies that investigated determinants of ED utilisation. Statistically significant determinants and their effect sizes were extracted. Determinants of ED utilisation were organised using Andersen and Newman's model. Quality of studies was evaluated using Newcastle Ottawa Scale and Critical Appraisal Skills Programme.

Results: The search yielded 138 articles, of which 7 were used for analysis. Among the significant individual determinants were predisposing (staying in public rental housing, religiosity, loneliness, poorer coping), enabling (caregiver distress from behavioural and psychological symptoms of dementia) and health factors (multimorbidity in patients with dementia, frailty, primary care visit in last 6 months, better treatment adherence). The 7 included studies are of moderate quality and none of them employed conceptual frameworks to organise determinants of ED utilisation.

Conclusion: The major determinants of ED utilisation by older adults in Singapore were largely individual factors. Evaluation of societal determinants of ED utilisation was lacking in the included studies. There is a need for a more holistic examination of determinants of ED utilisation locally based on conceptual models of health seeking behaviours.
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March 2022

The Effect of Building-Level Socioeconomic Status on Bystander Cardiopulmonary Resuscitation: A Retrospective Cohort Study.

Prehosp Emerg Care 2022 Apr 28:1-8. Epub 2022 Apr 28.

Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.

Objective: Understanding the social determinants of bystander cardiopulmonary resuscitation (CPR) receipt can inform the design of public health interventions to increase bystander CPR. The association of socioeconomic status with bystander CPR is generally poorly understood. We evaluated the relationship between socioeconomic status and bystander CPR in cases of out-of-hospital cardiac arrest (OHCA).

Methods: This was a retrospective cohort study based on the Singapore cohort of the Pan-Asian Resuscitation Outcomes Study registry between 2010 and 2018. We categorized patients into low, medium, and high Singapore Housing Index (SHI) levels-a building-level index of socioeconomic status. The primary outcome was receipt of bystander CPR. The secondary outcomes were prehospital return of spontaneous circulation and survival to discharge.

Results: A total of 12,730 OHCA cases were included, the median age was 71 years, and 58.9% were male. The bystander CPR rate was 56.7%. Compared to patients in the low SHI category, those in the medium and high SHI categories were more likely to receive bystander CPR (medium SHI: adjusted odds ratio [aOR] 1.48, 95% CI 1.30-1.69; high SHI: aOR 1.93, 95% CI 1.67-2.24). High SHI patients had higher survival compared to low SHI patients on unadjusted analysis (OR 1.79, 95% CI 1.08-2.96), but not adjusted analysis (adjusted for age, sex, race, witness status, arrest time, past medical history of cancer, and first arrest rhythm). When comparing high with low SHI, females had larger increases in bystander CPR rates than males.

Conclusions: Lower building-level socioeconomic status was independently associated with lower rate of bystander CPR, and females were more susceptible to the effect of low socioeconomic status on lower rate of bystander CPR.
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http://dx.doi.org/10.1080/10903127.2022.2061094DOI Listing
April 2022

Leveraging Large-Scale Electronic Health Records and Interpretable Machine Learning for Clinical Decision Making at the Emergency Department: Protocol for System Development and Validation.

JMIR Res Protoc 2022 Mar 25;11(3):e34201. Epub 2022 Mar 25.

Programme in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.

Background: There is a growing demand globally for emergency department (ED) services. An increase in ED visits has resulted in overcrowding and longer waiting times. The triage process plays a crucial role in assessing and stratifying patients' risks and ensuring that the critically ill promptly receive appropriate priority and emergency treatment. A substantial amount of research has been conducted on the use of machine learning tools to construct triage and risk prediction models; however, the black box nature of these models has limited their clinical application and interpretation.

Objective: In this study, we plan to develop an innovative, dynamic, and interpretable System for Emergency Risk Triage (SERT) for risk stratification in the ED by leveraging large-scale electronic health records (EHRs) and machine learning.

Methods: To achieve this objective, we will conduct a retrospective, single-center study based on a large, longitudinal data set obtained from the EHRs of the largest tertiary hospital in Singapore. Study outcomes include adverse events experienced by patients, such as the need for an intensive care unit and inpatient death. With preidentified candidate variables drawn from expert opinions and relevant literature, we will apply an interpretable machine learning-based AutoScore to develop 3 SERT scores. These 3 scores can be used at different times in the ED, that is, on arrival, during ED stay, and at admission. Furthermore, we will compare our novel SERT scores with established clinical scores and previously described black box machine learning models as baselines. Receiver operating characteristic analysis will be conducted on the testing cohorts for performance evaluation.

Results: The study is currently being conducted. The extracted data indicate approximately 1.8 million ED visits by over 810,000 unique patients. Modelling results are expected to be published in 2022.

Conclusions: The SERT scoring system proposed in this study will be unique and innovative because of its dynamic nature and modelling transparency. If successfully validated, our proposed solution will establish a standard for data processing and modelling by taking advantage of large-scale EHRs and interpretable machine learning tools.

International Registered Report Identifier (irrid): DERR1-10.2196/34201.
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http://dx.doi.org/10.2196/34201DOI Listing
March 2022

Development and validation of an interpretable machine learning scoring tool for estimating time to emergency readmissions.

EClinicalMedicine 2022 Mar 6;45:101315. Epub 2022 Mar 6.

Programme in Health Services and Systems Research, Duke-NUS Medical School, 8 College Road, 169857, Singapore.

Background: Emergency readmission poses an additional burden on both patients and healthcare systems. Risk stratification is the first step of transitional care interventions targeted at reducing readmission. To accurately predict the short- and intermediate-term risks of readmission and provide information for further temporal risk stratification, we developed and validated an interpretable machine learning risk scoring system.

Methods: In this retrospective study, all emergency admission episodes from January 1st 2009 to December 31st 2016 at a tertiary hospital in Singapore were assessed. The primary outcome was time to emergency readmission within 90 days post discharge. The Score for Emergency ReAdmission Prediction (SERAP) tool was derived via an interpretable machine learning-based system for time-to-event outcomes. SERAP is six-variable survival score, and takes the number of emergency admissions last year, age, history of malignancy, history of renal diseases, serum creatinine level, and serum albumin level during index admission into consideration.

Findings: A total of 293,589 ED admission episodes were finally included in the whole cohort. Among them, 203,748 episodes were included in the training cohort, 50,937 episodes in the validation cohort, and 38,904 in the testing cohort. Readmission within 90 days was documented in 80,213 (27.3%) episodes, with a median time to emergency readmission of 22 days (Interquartile range: 8-47). For different time points, the readmission rates observed in the whole cohort were 6.7% at 7 days, 10.6% at 14 days, 13.6% at 21 days, 16.4% at 30 days, and 23.0% at 60 days. In the testing cohort, the SERAP achieved an integrated area under the curve of 0.737 (95% confidence interval: 0.730-0.743). For a specific 30-day readmission prediction, SERAP outperformed the LACE index (Length of stay, Acuity of admission, Charlson comorbidity index, and Emergency department visits in past six months) and the HOSPITAL score (Hemoglobin at discharge, discharge from an Oncology service, Sodium level at discharge, Procedure during the index admission, Index Type of admission, number of Admissions during the last 12 months, and Length of stay). Besides 30-day readmission, SERAP can predict readmission rates at any time point during the 90-day period.

Interpretation: Better performance in risk prediction was achieved by the SERAP than other existing scores, and accurate information about time to emergency readmission was generated for further temporal risk stratification and clinical decision-making. In the future, external validation studies are needed to evaluate the SERAP at different settings and assess their real-world performance.

Funding: This study was supported by the Singapore National Medical Research Council under the PULSES Center Grant, and Duke-NUS Medical School.
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http://dx.doi.org/10.1016/j.eclinm.2022.101315DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8904223PMC
March 2022

Gender disparities among adult recipients of layperson bystander cardiopulmonary resuscitation by location of cardiac arrest in Pan-Asian communities: A registry-based study.

EClinicalMedicine 2022 Feb 12;44:101293. Epub 2022 Feb 12.

Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.

Background: Bystander cardiopulmonary resuscitation (BCPR) is a critical component of the 'chain of survival' in reducing mortality among out-of-hospital cardiac arrest (OHCA) victims. Inconsistent findings on gender disparities among adult recipients of layperson BCPR have been reported in the literature. We aimed to fill this knowledge gap by investigating the extent of gender disparities in a cross-national setting within Pan-Asian communities.

Methods: We utilised data collected from the Pan-Asian Resuscitation Outcomes Study (PAROS), an international, multicentre, prospective study conducted between 2009 and 2018. We included all OHCA cases with non-traumatic arrest aetiology transported by emergency medical services and excluded study sites that did not consistently collect information about the location of cardiac arrest. Logistic regression was used to analyse the association between gender and BCPR, stratified by location.

Findings: We analysed a cohort of 56,192 OHCA cases with an overall BCPR rate of 36.2% (20,329/56,192). At public locations, the BCPR rate was 31.2% (631/2022) for female and 36.4% (3235/8892) for male OHCA victims; while at home, the rate was 38.3% (6838/17,842) for females and 35.1% (9625/27,436) for males. Controlling for site differences and several factors in multivariable logistic regression, we found females less likely to receive BCPR than males in public locations (odds ratio [OR]=0.89, 95% confidence interval [CI]: 0.70-0.99), but more likely to receive BCPR at home (OR=1.16, 95% CI: 1.11-1.21).

Interpretation: In Pan-Asian communities, gender differences exist in adult recipients of BCPR and differ between home and public locations. Future studies should account for additional information on bystanders and societal factors to identify targets for interventions.

Funding: The study was supported by grants from the National Medical Research Council (NMRC/CSA/0049/2013) and Laerdal Foundation (20040).
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http://dx.doi.org/10.1016/j.eclinm.2022.101293DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8850341PMC
February 2022

Comparative efficacy of anaesthetic methods for closed reduction of paediatric forearm fractures: a systematic review.

Emerg Med J 2022 Feb 17. Epub 2022 Feb 17.

Department of Emergency Medicine, Singapore General Hospital, Singapore.

Background: Forearm fractures in children often require closed reduction in the emergency setting. The choice of anaesthesia influences the degree of pain relief, which determines the success of reduction. Main methods of anaesthesia include procedural sedation and analgesia, haematoma block, intravenous regional anaesthesia (IVRA) and regional nerve blocks. However, their comparative effectiveness is unclear. This study aims to synthesise peer-reviewed evidence and identify the most effective, in terms of pain reduction, and safest anaesthetic method.

Methods: MEDLINE, Embase and the Cochrane Library were searched from inception to 15 June 2021. Randomised controlled trials comparing anaesthetic methods for the closed reduction of paediatric forearm fractures in the emergency setting were included. Two reviewers independently screened, collected data and assessed the risk of bias for the selected outcomes. The primary outcome was pain during reduction. Secondary outcomes included pain after reduction, adverse effects, satisfaction, adequacy of sedation/anaesthesia, success of reduction and resource use.

Results: 1288 records were screened and 9 trials, which studied 936 patients in total, were included. Four trials compared the main methods of anaesthesia. Within the same method of anaesthesia, one compared administrative routes, one compared procedural techniques, one compared different drugs, one compared the use of adjuncts and one compared different doses of the same drug. One study found better pain outcomes with infraclavicular blocks compared with procedural sedation and analgesia. Lidocaine was superior in analgesic effect to prilocaine in IVRA in one study. One study found lower pain scores with moderate-dose than low-dose lidocaine in IVRA.

Conclusion: Few randomised controlled trials compared anaesthetic methods in the closed reduction of paediatric forearm fractures. High heterogeneity precluded meta-analysis. Overall, current data are insufficient to guide the choice of anaesthetic method in emergency settings. More adequately powered trials, conducted using standardised methods, are required.
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http://dx.doi.org/10.1136/emermed-2021-212108DOI Listing
February 2022

Variation in community and ambulance care processes for out-of-hospital cardiac arrest during the COVID-19 pandemic: a systematic review and meta-analysis.

Sci Rep 2022 01 17;12(1):800. Epub 2022 Jan 17.

Department of Emergency Medicine, Singapore General Hospital, C/O Office C, 1 Outram Rd, Singapore, 169608, Singapore.

Bystander cardiopulmonary resuscitation (BCPR), early defibrillation and timely treatment by emergency medical services (EMS) can double the chance of survival from out-of-hospital sudden cardiac arrest (OHCA). We investigated the effect of the COVID-19 pandemic on the pre-hospital chain of survival. We searched five bibliographical databases for articles that compared prehospital OHCA care processes during and before the COVID-19 pandemic. Random effects meta-analyses were conducted, and meta-regression with mixed-effect models and subgroup analyses were conducted where appropriate. The search yielded 966 articles; 20 articles were included in our analysis. OHCA at home was more common during the pandemic (OR 1.38, 95% CI 1.11-1.71, p = 0.0069). BCPR did not differ during and before the COVID-19 pandemic (OR 0.94, 95% CI 0.80-1.11, p = 0.4631), although bystander defibrillation was significantly lower during the COVID-19 pandemic (OR 0.65, 95% CI 0.48-0.88, p = 0.0107). EMS call-to-arrival time was significantly higher during the COVID-19 pandemic (SMD 0.27, 95% CI 0.13-0.40, p = 0.0006). Resuscitation duration did not differ significantly between pandemic and pre-pandemic timeframes. The COVID-19 pandemic significantly affected prehospital processes for OHCA. These findings may inform future interventions, particularly to consider interventions to increase BCPR and improve the pre-hospital chain of survival.
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http://dx.doi.org/10.1038/s41598-021-04749-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8764072PMC
January 2022

Association of ambient air pollution with risk of hemorrhagic stroke: A time-stratified case crossover analysis of the Singapore stroke registry.

Int J Hyg Environ Health 2022 03 30;240:113908. Epub 2021 Dec 30.

Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore.

Background: Haemorrhagic stroke (HS) is a major cause of mortality and disability. Previous studies reported inconsistent associations between ambient air pollutants and HS risk.

Objective: We evaluated the association between air pollutant exposure and the risk of HS in a cosmopolitan city in the tropics.

Methods: We performed a nationwide, population-based, time-stratified case-crossover analysis on all HS cases reported to the Singapore Stroke Registry from 2009 to 2018 (n = 12,636). We estimated the risk of HS across tertiles of air pollutant concentrations in conditional Poisson models, adjusting for meteorological confounders. We stratified our analysis by age, atrial fibrillation and smoking status, and investigated the lagged effects of each pollutant on the risk of HS up to 5 days.

Results: All 12,636 episodes of HS were included. The median (1st-to 3rd-quartile) daily pollutant levels from 22 remote stations deployed across the island were as follows: (PM = 15.9 (12.7-20.5), PM = 27.3 (22.7-33.4), O = 22.5 (17.3-29.8), NO = 23.3 (18.8-28.4), SO = 10.2 (5.6-14.4), CO = 0.5 (0.5-0.6). The median (1st-to 3rd-quartile) temperature (°C) was 27.9 (27.1-28.7), that of relative humidity (%) was 79.4 (75.6-83.2), and that of total rainfall (mm) was 0.0 (0.0-4.2). Higher levels of CO were significantly associated with an increased risk of HS (3rd tertile vs 1st tertile: Incidence Rate Ratio (IRR) = 1.06, 95% CI = 1.01-1.12). The increased risk of HS due to CO persisted for at least 5 days after exposure. Individuals under 65 years old and non-smokers had a higher risk of HS when exposed to CO. O was associated with increased risk of HS up to 5 days (3rd tertile vs 1st tertile: IRR = 1.07, 95% CI = 1.02-1.12; IRR = 1.07, 95% CI = 1.02-1.13).

Conclusion: Short-term exposure to ambient CO levels was associated with an increased risk of HS. A reduction in CO emissions may reduce the burden of HS in the population.
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http://dx.doi.org/10.1016/j.ijheh.2021.113908DOI Listing
March 2022

Long-term outcomes after out-of-hospital cardiac arrest: A systematic review and meta-analysis.

Resuscitation 2022 02 29;171:15-29. Epub 2021 Dec 29.

Department of Emergency Medicine, Singapore General Hospital, Singapore; Saw Swee Hock School of Public Health, National University Singapore, Singapore; Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore. Electronic address:

Aims: Long term outcomes after out-of-hospital cardiac arrest (OHCA) are not well understood. This study aimed to evaluate the long-term (1-year and beyond) survival outcomes, including overall survival and survival with favorable neurological status and the quality-of-life (QOL) outcomes, among patients who survived the initial OHCA event (30 days or till hospital discharge).

Methods: Embase, Medline and PubMed were searched for primary studies (randomized controlled trials, cohort and cross-sectional studies) which reported the long-term survival outcomes of OHCA patients. Data abstraction and quality assessment was conducted, and survival at predetermined timepoints were assessed via single-arm meta-analyses of proportions, using generalized linear mixed models. Comparative meta-analyses were conducted using the Mantel-Haenszel Risk Ratio (RR) estimates, using the DerSimonian and Laird model.

Results: 67 studies were included, and among patients that survived to hospital discharge or 30-days, 77.3% (CI = 71.2-82.4), 69.6% (CI = 54.5-70.3), 62.7% (CI = 54.5-70.3), 46.5% (CI = 32.0-61.6), and 20.8% (CI = 7.8-44.9) survived to 1-, 3-, 5-, 10- and 15-years respectively. Compared to Asia, the probability of 1-year survival was greater in Europe (RR = 2.1, CI = 1.8-2.3), North America (RR = 2.0, CI = 1.7-2.2) and Oceania (RR = 1.9, CI = 1.6-2.1). Males had a higher 1-year survival (RR:1.41, CI = 1.25-1.59), and patients with initial shockable rhythm had improved 1-year (RR = 3.07, CI = 1.78-5.30) and 3-year survival (RR = 1.45, CI = 1.19-1.77). OHCA occurring in residential locations had worse 1-year survival (RR = 0.42, CI = 0.25-0.73).

Conclusion: Our study found that up to 20.8% of OHCA patients survived to 15-years, and survival was lower in Asia compared to the other regions. Further analysis on the differences in survival between the regions are needed to direct future long-term treatment of OHCA patients.
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http://dx.doi.org/10.1016/j.resuscitation.2021.12.026DOI Listing
February 2022

Impact of Cardiac Arrest Centers on the Survival of Patients With Nontraumatic Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

J Am Heart Assoc 2022 01 20;11(1):e023806. Epub 2021 Dec 20.

Department of Emergency Medicine Singapore General Hospital Singapore.

Background The role of cardiac arrest centers (CACs) in out-of-hospital cardiac arrest care systems is continuously evolving. Interpretation of existing literature is limited by heterogeneity in CAC characteristics and types of patients transported to CACs. This study assesses the impact of CACs on survival in out-of-hospital cardiac arrest according to varying definitions of CAC and prespecified subgroups. Methods and Results Electronic databases were searched from inception to March 9, 2021 for relevant studies. Centers were considered CACs if self-declared by study authors and capable of relevant interventions. Main outcomes were survival and neurologically favorable survival at hospital discharge or 30 days. Meta-analyses were performed for adjusted odds ratio (aOR) and crude odds ratios. Thirty-six studies were analyzed. Survival with favorable neurological outcome significantly improved with treatment at CACs (aOR, 1.85 [95% CI, 1.52-2.26]), even when including high-volume centers (aOR, 1.50 [95% CI, 1.18-1.91]) or including improved-care centers (aOR, 2.13 [95% CI, 1.75-2.59]) as CACs. Survival significantly increased with treatment at CACs (aOR, 1.92 [95% CI, 1.59-2.32]), even when including high-volume centers (aOR, 1.74 [95% CI, 1.38-2.18]) or when including improved-care centers (aOR, 1.97 [95% CI, 1.71-2.26]) as CACs. The treatment effect was more pronounced among patients with shockable rhythm (=0.006) and without prehospital return of spontaneous circulation (=0.005). Conclusions were robust to sensitivity analyses, with no publication bias detected. Conclusions Care at CACs was associated with improved survival and neurological outcomes for patients with nontraumatic out-of-hospital cardiac arrest regardless of varying CAC definitions. Patients with shockable rhythms and those without prehospital return of spontaneous circulation benefited more from CACs. Evidence for bypassing hospitals or interhospital transfer remains inconclusive.
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http://dx.doi.org/10.1161/JAHA.121.023806DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9075197PMC
January 2022

Maximum expected survival rate model for public access defibrillator placement.

Resuscitation 2022 01 6;170:213-221. Epub 2021 Dec 6.

Health Services and Systems Research, Duke-NUS Medical School, Singapore; Health Services Research Centre, Singapore Health Services, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore. Electronic address:

Aim: Mathematical optimization of automated external defibrillator (AED) placement has demonstrated potential to improve survival of out-of-hospital cardiac arrest (OHCA). Existing models mostly aim to improve accessibility based on coverage radius and do not account for detailed impact of delayed defibrillation on survival. We aimed to predict OHCA survival based on time to defibrillation and developed an AED placement model to directly maximize the expected survival rate.

Methods: We stratified OHCAs occurring in Singapore (2010-2017) based on time to defibrillation and developed a regression model to predict the Utstein survival rate. We then developed a novel AED placement model, the maximum expected survival rate (MESR) model. We compared the performance of MESR with a maximum coverage model developed for Canada that was shown to be generalizable to other settings (Denmark). The survival gain of MESR was assessed through 10-fold cross-validation for placement of 20 to 1000 new AEDs in Singapore. Statistical analysis was performed using χ and McNemar's tests.

Results: During the study period, 15,345 OHCAs occurred. The power-law approximation with R of 91.33% performed best among investigated models. It predicted a survival of 54.9% with defibrillation within the first two minutes after collapse that was reduced by more than 60% without defibrillation within the first 4 minutes. MESR outperformed the maximum coverage model with P-value < 0.05 (<0.0001 in 22 of 30 experiments).

Conclusion: We developed a novel AED placement model based on the impact of time to defibrillation on OHCA outcomes. Mathematical optimization can improve OHCA survival.
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http://dx.doi.org/10.1016/j.resuscitation.2021.11.039DOI Listing
January 2022

Impact of the COVID-19 pandemic on the epidemiology of out-of-hospital cardiac arrest: a systematic review and meta-analysis.

Ann Intensive Care 2021 Dec 7;11(1):169. Epub 2021 Dec 7.

Office C, Department of Emergency Medicine, Singapore General Hospital, 1 Outram Rd, Singapore, 169608, Singapore.

Background: The coronavirus disease 2019 (COVID-19) pandemic has significantly influenced epidemiology, yet its impact on out-of-hospital cardiac arrest (OHCA) remains unclear. We aimed to evaluate the impact of the pandemic on the incidence and case fatality rate (CFR) of OHCA. We also evaluated the impact on intermediate outcomes and clinical characteristics.

Methods: PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases were searched from inception to May 3, 2021. Studies were included if they compared OHCA processes and outcomes between the pandemic and historical control time periods. Meta-analyses were performed for primary outcomes [annual incidence, mortality, and case fatality rate (CFR)], secondary outcomes [field termination of resuscitation (TOR), return of spontaneous circulation (ROSC), survival to hospital admission, and survival to hospital discharge], and clinical characteristics (shockable rhythm and etiologies). This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42021253879).

Results: The COVID-19 pandemic was associated with a 39.5% increase in pooled annual OHCA incidence (p < 0.001). Pooled CFR was increased by 2.65% (p < 0.001), with a pooled odds ratio (OR) of 1.95 for mortality [95% confidence interval (95%CI) 1.51-2.51]. There was increased field TOR (OR = 2.46, 95%CI 1.62-3.74). There were decreased ROSC (OR = 0.65, 95%CI 0.55-0.77), survival to hospital admission (OR = 0.65, 95%CI 0.48-0.89), and survival to discharge (OR = 0.52, 95%CI 0.40-0.69). There was decreased shockable rhythm (OR = 0.73, 95%CI 0.60-0.88) and increased asphyxial etiology of OHCA (OR = 1.17, 95%CI 1.02-1.33).

Conclusion: Compared to the pre-pandemic period, the COVID-19 pandemic period was significantly associated with increased OHCA incidence and worse outcomes.
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http://dx.doi.org/10.1186/s13613-021-00957-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8649312PMC
December 2021

Development and validation of the SARICA score to predict survival after return of spontaneous circulation in out of hospital cardiac arrest using an interpretable machine learning framework.

Resuscitation 2022 01 26;170:126-133. Epub 2021 Nov 26.

Pre-hospital and Emergency Research Centre, Duke-NUS Medical School, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore. Electronic address:

Background: Accurate and timely prognostication of patients with out-of-hospital cardiac arrest (OHCA) who achieved the return of spontaneous circulation (ROSC) is crucial in clinical decision-making, resource allocation, and communications with next-of-kins. We aimed to develop the Survival After ROSC in Cardiac Arrest (SARICA), a practical clinical decision tool to predict survival in OHCA patients who attained ROSC.

Methods: We utilized real-world Singapore data from the population-based Pan-Asian Resuscitation Outcomes Study between 2010-2018. We excluded patients without ROSC. The dataset was segmented into training (60%), validation (20%) and testing (20%) cohorts. The primary endpoint was survival (to 30-days or hospital discharge). AutoScore, an interpretable machine-learning based clinical score generation algorithm, was used to develop SARICA. Candidate factors were chosen based on objective demographic and clinical factors commonly available at the time of admission. Performance of SARICA was evaluated based on receiver-operating curve (ROC) analyses.

Results: 5970 patients were included, of which 855 (14.3%) survived. A three-variable model was determined to be most parsimonious. Prehospital ROSC, age, and initial heart rhythm were identified for inclusion via random forest selection. Finally, SARICA consisted of these 3 variables and ranged from 0 to 10 points, achieving an area under the ROC (AUC) of 0.87 (95% confidence interval: 0.84-0.90) within the testing cohort.

Conclusion: We developed and internally validated the SARICA score to accurately predict survival of OHCA patients with ROSC at the time of admission. SARICA is clinically practical and developed using an interpretable machine-learning framework. SARICA has unknown generalizability pending external validation studies.
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http://dx.doi.org/10.1016/j.resuscitation.2021.11.029DOI Listing
January 2022

Prevalence of anxiety, depression, and post-traumatic stress disorder after cardiac arrest: A systematic review and meta-analysis.

Resuscitation 2022 01 23;170:82-91. Epub 2021 Nov 23.

Department of Emergency Medicine, Singapore General Hospital, Singapore; Pre-hospital and Emergency Research Centre, 1 Outram Rd, Singapore 169608, Singapore; Duke-NUS Medical School, 8 College Rd, Singapore 169857, Singapore. Electronic address:

Aim: Quality of life after surviving out-of-hospital cardiac arrest (OHCA) is poorly understood, and the risk to mental health is not well understood. We aimed to estimate the prevalence of anxiety, depression, and post-traumatic stress disorder (PTSD) following OHCA.

Methods: In this systematic review and meta-analysis, databases (MEDLINE, EMBASE, and PsycINFO) were searched from inception to July 3, 2021, for studies reporting the prevalence of depression, anxiety, and PTSD among OHCA survivors. Data abstraction and quality assessment were conducted by two authors independently, and a third resolved discrepancies. A single-arm meta-analysis of proportions was conducted to pool the proportion of patients with these conditions at the earliest follow-up time point in each study and at predefined time points. Meta-regression was performed to identify significant moderators that contributed to between-study heterogeneity.

Results: The search yielded 15,366 articles. 13 articles were included for analysis, which comprised 186,160 patients. The pooled overall prevalence at the earliest time point of follow-up was 19.0% (11 studies; 95% confidence interval [CI] = 11.0-30.0%) for depression, 26.0% (nine studies; 95% CI = 16.0-39.0%) for anxiety, and 20.0% (three studies; 95% CI = 3.0-65.0%) for PTSD. Meta-regression showed that the age of patients and proportion of female sex were non-significant moderators.

Conclusion: The burden of mental health disorders is high among survivors of OHCA. There is an urgent need to understand the predisposing risk factors and develop preventive strategies.
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http://dx.doi.org/10.1016/j.resuscitation.2021.11.023DOI Listing
January 2022

Cardiac Arrest Occurring in High-Rise Buildings: A Scoping Review.

J Clin Med 2021 Oct 13;10(20). Epub 2021 Oct 13.

Emergency Medical Services Department, Singapore Civil Defence Force, Singapore 408827, Singapore.

Out-of-hospital cardiac arrests (OHCAs) occurring in high-rise buildings are a challenge to Emergency Medical Services (EMS). Contemporary EMS guidelines lack specific recommendations for systems and practitioners regarding the approach to these patients. This scoping review aimed to map the body of literature pertaining to OHCAs in high-rise settings in order to clarify concepts and understanding and to identify knowledge gaps. Databases were searched from inception through to 6 May 2021 including OVID Medline, PubMed, Embase, CINAHL, and Scopus. Twenty-three articles were reviewed, comprising 8 manikin trials, 14 observational studies, and 1 mathematical modelling study. High-rise settings commonly have lower availability of bystanders and automatic external defibrillators (AEDs), while height constraints often lead to delays in EMS interventions and suboptimal cardiopulmonary resuscitation (CPR), scene access, and extrication. Four studies found return of spontaneous circulation (ROSC) rates to be significantly poorer, while seven studies found rates of survival-to-hospital discharge ( = 3) and neurologically favourable survival ( = 4) to be significantly lower in multistorey settings. Mechanical chest compression devices, transfer sheets, and strategic defibrillator placement were suggested as approaches to high-rise OHCA management. A shift to maximising on-scene treatment time, along with bundling novel prehospital interventions, could ameliorate some of these difficulties and improve clinical outcomes for patients.
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http://dx.doi.org/10.3390/jcm10204684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8539960PMC
October 2021

Optimal glucose, HbA1c, glucose-HbA1c ratio and stress-hyperglycaemia ratio cut-off values for predicting 1-year mortality in diabetic and non-diabetic acute myocardial infarction patients.

Cardiovasc Diabetol 2021 10 19;20(1):211. Epub 2021 Oct 19.

Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.

Background: Stress-induced hyperglycaemia at time of hospital admission has been linked to worse prognosis following acute myocardial infarction (AMI). In addition to glucose, other glucose-related indices, such as HbA1c, glucose-HbA1c ratio (GHR), and stress-hyperglycaemia ratio (SHR) are potential predictors of clinical outcomes following AMI. However, the optimal blood glucose, HbA1c, GHR, and SHR cut-off values for predicting adverse outcomes post-AMI are unknown. As such, we determined the optimal blood glucose, HbA1c, GHR, and SHR cut-off values for predicting 1-year all cause mortality in diabetic and non-diabetic ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients.

Methods: We undertook a national, registry-based study of patients with AMI from January 2008 to December 2015. We determined the optimal blood glucose, HbA1c, GHR, and SHR cut-off values using the Youden's formula for 1-year all-cause mortality. We subsequently analyzed the sensitivity, specificity, positive and negative predictive values of the cut-off values in the diabetic and non-diabetic subgroups, stratified by the type of AMI.

Results: There were 5841 STEMI and 4105 NSTEMI in the study. In STEMI patients, glucose, GHR, and SHR were independent predictors of 1-year all-cause mortality [glucose: OR 2.19 (95% CI 1.74-2.76); GHR: OR 2.28 (95% CI 1.80-2.89); SHR: OR 2.20 (95% CI 1.73-2.79)]. However, in NSTEMI patients, glucose and HbA1c were independently associated with 1-year all-cause mortality [glucose: OR 1.38 (95% CI 1.01-1.90); HbA1c: OR 2.11 (95% CI 1.15-3.88)]. In diabetic STEMI patients, SHR performed the best in terms of area-under-the-curve (AUC) analysis (glucose: AUC 63.3%, 95% CI 59.5-67.2; GHR 68.8% 95% CI 64.8-72.8; SHR: AUC 69.3%, 95% CI 65.4-73.2). However, in non-diabetic STEMI patients, glucose, GHR, and SHR performed equally well (glucose: AUC 72.0%, 95% CI 67.7-76.3; GHR 71.9% 95% CI 67.7-76.2; SHR: AUC 71.7%, 95% CI 67.4-76.0). In NSTEMI patients, glucose performed better than HbA1c for both diabetic and non-diabetic patients in AUC analysis (For diabetic, glucose: AUC 52.8%, 95% CI 48.1-57.6; HbA1c: AUC 42.5%, 95% CI 37.6-47. For non-diabetic, glucose: AUC 62.0%, 95% CI 54.1-70.0; HbA1c: AUC 51.1%, 95% CI 43.3-58.9). The optimal cut-off values for glucose, GHR, and SHR in STEMI patients were 15.0 mmol/L, 2.11, and 1.68 for diabetic and 10.6 mmol/L, 1.72, and 1.51 for non-diabetic patients respectively. For NSTEMI patients, the optimal glucose values were 10.7 mmol/L for diabetic and 8.1 mmol/L for non-diabetic patients.

Conclusions: SHR was the most consistent independent predictor of 1-year all-cause mortality in both diabetic and non-diabetic STEMI, whereas glucose was the best predictor in NSTEMI patients.
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http://dx.doi.org/10.1186/s12933-021-01395-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8524932PMC
October 2021

Incidence, characteristics and complications of dispatcher-assisted cardiopulmonary resuscitation initiated in patients not in cardiac arrest.

Resuscitation 2022 01 6;170:266-273. Epub 2021 Oct 6.

Pre-hospital & Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore; National Heart Research Institute Singapore, National Heart Centre Singapore, Singapore. Electronic address:

Aim: Dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) can increase bystander CPR rates and improve outcomes in out-of-hospital cardiac arrest (OHCA). Despite the use of protocols, dispatchers may falsely recognise some cases to be in cardiac arrest. Hence, this study aimed to find the incidence of DA-CPR initiated for non-OHCA cases, its characteristics and clinical outcomes in the Singapore population.

Methods: This was a multi-centre, observational study of all dispatcher-recognised cardiac arrests cases between January to December 2017 involving three tertiary hospitals in Singapore. Data was obtained from the Pan-Asian Resuscitation Outcomes Study cohort. Audio review of dispatch calls from the national emergency ambulance service were conducted and information about patients' clinical outcomes were prospectively collected from health records. Univariate analysis was performed to determine factors associated with in-hospital mortality among non-OHCA patients who received DA-CPR.

Results: Of the 821 patients recognised as having OHCA 328 (40.0%) were not in cardiac arrest and 173 (52.7%) of these received DA-CPR. No complications from chest compressions were found from hospital records. The top diagnoses of non-OHCA patients were cerebrovascular accidents (CVA), syncope and infection. Only final diagnoses of CVA (aOR 20.68), infection (aOR 17.34) and myocardial infarction (aOR 32.19) were significantly associated with in-hospital mortality.

Conclusion: In this study, chest compressions initiated on patients not in cardiac arrest by dispatchers did not result in any reported complications and was not associated with in-hospital mortality. This provides reassurance for the continued implementation of DA-CPR.
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http://dx.doi.org/10.1016/j.resuscitation.2021.09.022DOI Listing
January 2022

Leveraging open data to reconstruct the Singapore Housing Index and other building-level markers of socioeconomic status for health services research.

Int J Equity Health 2021 10 3;20(1):218. Epub 2021 Oct 3.

Pre-hospital and Emergency Research Centre, Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore.

Background: Socioeconomic status (SES) is an important determinant of health, and SES data is an important confounder to control for in epidemiology and health services research. Individual level SES measures are cumbersome to collect and susceptible to biases, while area level SES measures may have insufficient granularity. The 'Singapore Housing Index' (SHI) is a validated, building level SES measure that bridges individual and area level measures. However, determination of the SHI has previously required periodic data purchase and manual parsing. In this study, we describe a means of SHI determination for public housing buildings with open government data, and validate this against the previous SHI determination method.

Methods: Government open data sources (e.g.

Data: gov.sg, Singapore Land Authority OneMAP API, Urban Redevelopment Authority API) were queried using custom Python scripts. Data on residential public housing block address and composition from the HDB Property Information dataset (data.gov.sg) was matched to postal code and geographical coordinates via OneMAP API calls. The SHI was calculated from open data, and compared to the original SHI dataset that was curated from non-open data sources in 2018.

Results: Ten thousand seventy-seven unique residential buildings were identified from open data. OneMAP API calls generated valid geographical coordinates for all (100%) buildings, and valid postal code for 10,012 (99.36%) buildings. There was an overlap of 10,011 buildings between the open dataset and the original SHI dataset. Intraclass correlation coefficient was 0.999 for the two sources of SHI, indicating almost perfect agreement. A Bland-Altman plot analysis identified a small number of outliers, and this revealed 5 properties that had an incorrect SHI assigned by the original dataset. Information on recently transacted property prices was also obtained for 8599 (85.3%) of buildings.

Conclusion: SHI, a useful tool for health services research, can be accurately reconstructed using open datasets at no cost. This method is a convenient means for future researchers to obtain updated building-level markers of socioeconomic status for policy and research.
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http://dx.doi.org/10.1186/s12939-021-01554-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8489093PMC
October 2021

Heart rate n-variability (HRnV) measures for prediction of mortality in sepsis patients presenting at the emergency department.

PLoS One 2021 30;16(8):e0249868. Epub 2021 Aug 30.

Duke-NUS Medical School, National University of Singapore, Singapore, Singapore.

Sepsis is a potentially life-threatening condition that requires prompt recognition and treatment. Recently, heart rate variability (HRV), a measure of the cardiac autonomic regulation derived from short electrocardiogram tracings, has been found to correlate with sepsis mortality. This paper presents using novel heart rate n-variability (HRnV) measures for sepsis mortality risk prediction and comparing against current mortality prediction scores. This study was a retrospective cohort study on patients presenting to the emergency department of a tertiary hospital in Singapore between September 2014 to April 2017. Patients were included if they were above 21 years old and were suspected of having sepsis by their attending physician. The primary outcome was 30-day in-hospital mortality. Stepwise multivariable logistic regression model was built to predict the outcome, and the results based on 10-fold cross-validation were presented using receiver operating curve analysis. The final predictive model comprised 21 variables, including four vital signs, two HRV parameters, and 15 HRnV parameters. The area under the curve of the model was 0.77 (95% confidence interval 0.70-0.84), outperforming several established clinical scores. The HRnV measures may have the potential to allow for a rapid, objective, and accurate means of patient risk stratification for sepsis severity and mortality. Our exploration of the use of wealthy inherent information obtained from novel HRnV measures could also create a new perspective for data scientists to develop innovative approaches for ECG analysis and risk monitoring.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249868PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8405012PMC
November 2021

Development and Assessment of an Interpretable Machine Learning Triage Tool for Estimating Mortality After Emergency Admissions.

JAMA Netw Open 2021 08 2;4(8):e2118467. Epub 2021 Aug 2.

Programme in Health Services and Systems Research, Duke-National University of Singapore Medical School, Singapore.

Importance: Triage in the emergency department (ED) is a complex clinical judgment based on the tacit understanding of the patient's likelihood of survival, availability of medical resources, and local practices. Although a scoring tool could be valuable in risk stratification, currently available scores have demonstrated limitations.

Objectives: To develop an interpretable machine learning tool based on a parsimonious list of variables available at ED triage; provide a simple, early, and accurate estimate of patients' risk of death; and evaluate the tool's predictive accuracy compared with several established clinical scores.

Design, Setting, And Participants: This single-site, retrospective cohort study assessed all ED patients between January 1, 2009, and December 31, 2016, who were subsequently admitted to a tertiary hospital in Singapore. The Score for Emergency Risk Prediction (SERP) tool was derived using a machine learning framework. To estimate mortality outcomes after emergency admissions, SERP was compared with several triage systems, including Patient Acuity Category Scale, Modified Early Warning Score, National Early Warning Score, Cardiac Arrest Risk Triage, Rapid Acute Physiology Score, and Rapid Emergency Medicine Score. The initial analyses were completed in October 2020, and additional analyses were conducted in May 2021.

Main Outcomes And Measures: Three SERP scores, namely SERP-2d, SERP-7d, and SERP-30d, were developed using the primary outcomes of interest of 2-, 7-, and 30-day mortality, respectively. Secondary outcomes included 3-day mortality and inpatient mortality. The SERP's predictive power was measured using the area under the curve in the receiver operating characteristic analysis.

Results: The study included 224 666 ED episodes in the model training cohort (mean [SD] patient age, 63.60 [16.90] years; 113 426 [50.5%] female), 56 167 episodes in the validation cohort (mean [SD] patient age, 63.58 [16.87] years; 28 427 [50.6%] female), and 42 676 episodes in the testing cohort (mean [SD] patient age, 64.85 [16.80] years; 21 556 [50.5%] female). The mortality rates in the training cohort were 0.8% at 2 days, 2.2% at 7 days, and 5.9% at 30 days. In the testing cohort, the areas under the curve of SERP-30d were 0.821 (95% CI, 0.796-0.847) for 2-day mortality, 0.826 (95% CI, 0.811-0.841) for 7-day mortality, and 0.823 (95% CI, 0.814-0.832) for 30-day mortality and outperformed several benchmark scores.

Conclusions And Relevance: In this retrospective cohort study, SERP had better prediction performance than existing triage scores while maintaining easy implementation and ease of ascertainment in the ED. It has the potential to be widely applied and validated in different circumstances and health care settings.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.18467DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8397930PMC
August 2021

Assessing unrealised potential for organ donation after out-of-hospital cardiac arrest.

Scand J Trauma Resusc Emerg Med 2021 Jul 28;29(1):105. Epub 2021 Jul 28.

Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.

Background: Organ donation after brain death is the standard practice in many countries. Rates are low globally. This study explores the potential national number of candidates for uncontrolled donations after cardiac death (uDCD) amongst out-of-hospital cardiac arrest (OHCA) patients and the influence of extracorporeal cardiopulmonary resuscitation (ECPR) on the candidacy of these potential organ donors using Singapore as a case study.

Methods: Using Singapore data from the Pan-Asian Resuscitation Outcomes Study, we identified all non-traumatic OHCA cases from 2010 to 2016. Four established criteria for identifying uDCD candidates (Madrid, San Carlos Madrid, Maastricht and Paris) were retrospectively applied onto the population. Within these four groups, a condensed ECPR eligibility criteria was employed and thereafter, an estimated ECPR survival rate was applied, extrapolating for possible neurologically intact survivors had ECPR been administered.

Results: 12,546 OHCA cases (64.8% male, mean age 65.2 years old) qualified for analysis. The estimated number of OHCA patients who were eligible for uDCD ranged from 4.3 to 19.6%. The final projected percentage of potential uDCD donors readjusted for ECPR survivors was 4.2% (Paris criteria worst-case scenario, n = 532) to 19.4% of all OHCA cases (Maastricht criteria best-case scenario, n = 2428), for an estimated 14.3 to 65.4 uDCD donors per million population per year (pmp/year).

Conclusions: In Singapore case study, we demonstrated the potential numbers of candidates for uDCD among resuscitated OHCA cases. This sizeable pool of potential donors demonstrates the potential for an uDCD program to expand the organ donor pool. A small proportion of these patients might however survive had they been administered ECPR. Further research into the factors influencing local organ and patient outcomes following uDCD and ECPR is indicated.
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http://dx.doi.org/10.1186/s13049-021-00924-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8317313PMC
July 2021
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