Showing papers in "Annals Academy of Medicine Singapore in 2020"

Mental Health Strategies to Combat the Psychological Impact of COVID-19 Beyond Paranoia and Panic

Abstract: 1Department of Psychological Medicine, National University Health System, Singapore 2Department of Psychological Medicine, National University of Singapore, Singapore 3Health Innovation and Technology (iHealthtech), National University of Singapore, Singapore Address for Correspondence: Dr Cyrus Ho Su Hui, Department of Psychological Medicine, National University Health System, Level 9, NUHS Tower Block, 1E Kent Ridge Road, Singapore, 119228. Email: su_hui_ho@nuhs.edu.sg Mental Health Strategies to Combat the Psychological Impact of COVID-19 Beyond Paranoia and Panic

Rapid Progression to Acute Respiratory Distress Syndrome: Review of Current Understanding of Critical Illness from COVID-19 Infection

Abstract: The coronavirus disease 2019 (COVID-19) outbreak that started in Wuhan, Hubei province, China in December 2019 has now extended across the globe with >100,000 cases and 3,000 deaths reported in 93 countries as of 7 March 2020 We report a case of COVID-19 infection in a 64-year-old man who developed rapidly worsening respiratory failure and acute respiratory distress syndrome (ARDS) that required intubation As the clinical spectrum of COVID-19 ranges widely from mild illness to ARDS with a high risk of mortality, there is a need for more research to identify early markers of disease severity Current evidence suggests that patients with advanced age, pre-existing comorbidities or dyspnoea should be closely monitored, especially at 1-2 weeks after symptom onset It remains to be seen if laboratory findings such as lymphopenia or elevated lactate dehydrogenase may serve as early surrogates for critical illness or markers of disease recovery Management of ARDS in COVID-19 remains supportive while we await results of drug trials More studies are needed to understand the incidence and outcomes of ARDS and critical illness from COVID-19, which will be important for critical care management and resource planning

Rapid Progression to Acute Respiratory Distress Syndrome: Review of Current Understanding of Critical Illness from Coronavirus Disease 2019 (COVID-19) Infection

Abstract: The coronavirus disease 2019 (COVID-19) outbreak that started in Wuhan, Hubei province, China in December 2019 has now extended across the globe with >100,000 cases and 3,000 deaths reported in 93 countries as of 7 March 2020. We report a case of COVID-19 infection in a 64-year-old man who developed rapidly worsening respiratory failure and acute respiratory distress syndrome (ARDS) that required intubation. As the clinical spectrum of COVID-19 ranges widely from mild illness to ARDS with a high risk of mortality, there is a need for more research to identify early markers of disease severity. Current evidence suggests that patients with advanced age, pre-existing comorbidities or dyspnoea should be closely monitored, especially at 1-2 weeks after symptom onset. It remains to be seen if laboratory findings such as lymphopenia or elevated lactate dehydrogenase may serve as early surrogates for critical illness or markers of disease recovery. Management of ARDS in COVID-19 remains supportive while we await results of drug trials. More studies are needed to understand the incidence and outcomes of ARDS and critical illness from COVID-19, which will be important for critical care management and resource planning.

Obesity in COVID-19: A Systematic Review and Meta-analysis.

Abstract: OBJECTIVE: Obesity has been shown to be associated with adverse outcomes in viral infections such as influenza, but previous studies on coronavirus disease 2019 (COVID-19) had mixed results. The aim of this systematic review is to investigate the relationship between COVID-19 and obesity. METHODS: We performed a systematic review and meta-analysis. A literature search of MEDLINE, EMBASE, Scopus, Web of Science, CENTRAL, OpenGrey and preprint servers medRxiv and bioRxiv was performed, with no restriction on language or date of publication. Primary outcomes of this study were intensive care unit (ICU) admission or critical disease, severe disease and mortality. Secondary outcome was a positive COVID-19 test. Meta-analysis was performed using OpenMeta-Analyst software, and heterogeneity was tested using Cochran's Q test and I2 statistic. The study protocol was registered on PROSPERO (CRD42020184953). RESULTS: A total of 1,493 articles were identified and 61 studies on 270,241 patients were included. The pooled prevalence of obesity was 27.6% (95% confidence interval [CI] 22.0-33.2) in hospitalised patients. Obesity was not significantly associated with increased ICU admission or critical illness (odds ratio [OR] 1.25, 95% CI 0.99-1.58, P=0.062, I2 =31.0) but was significantly associated with more severe disease (OR 3.13, 95% CI 1.41-6.92, P=0.005, I2 =82.6), mortality (OR 1.36, 95% CI 1.09-1.69, P=0.006, I2=88.5) and a positive COVID-19 test (OR 1.50, 95% CI 1.25-1.81, P<0.001). CONCLUSION: Obesity increased the risk of severe disease, mortality and infection with COVID-19. Higher body mass index was associated with ICU admission and critical disease. Patients who are obese may be more susceptible to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, and infected patients should be monitored closely for adverse outcomes.

COVID-19 and Singapore: From Early Response to Circuit Breaker.

Abstract: Singapore, an island country with 5.6 million population and a large volume of tourists from mainland China, was one of the first countries to report imported COVID-19 cases and had the highest number of cases outside mainland China for a time in February 2020. The government responded with a series of broadscale public health measures and managed to contain this first wave of infection. Notwithstanding that, an evolving pandemic situation in other countries eventually triggered a second, and much larger, wave of infection. This case study narrates the developments, influencing factors, and outcomes related to events starting from Singapore's first response to COVID-19 and up to the point of its entry into Circuit Breaker. It serves as a reference for the understanding and analysis of developments in an evolving pandemic and a nation's response from a systems level perspective.

Perception and Feelings of Antenatal Women during COVID-19 Pandemic: A Cross-Sectional Survey

Abstract: Introduction To assess the level of anxiety and knowledge regarding COVID-19 amongst antenatal women. Materials and methods This cross-sectional survey was conducted in the antenatal clinics of KK Women's and Children's Hospital, Singapore, from 31 March to 25 April 2020 to assess pregnant women's knowledge of COVID-19, their perceptions of its impact upon pregnancy and psychological impact using the validated Depression, Anxiety, and Stress Scales (DASS-21). Results Of the 324 women who participated in the study, the mean age was 31.8 years (range, 20-45). The majority (53.7%) were multiparous with mean gestational age of 23.4 weeks (SD 10). The commonest sources of information were Internet-based social media platforms. A significant proportion were unaware, or associated COVID-19 infection during pregnancy with fetal distress (82.1%), intrauterine death (71.3%), fetal anomalies (69.8%), miscarriages (64.8%), preterm labour (67.9%) and rupture of membranes (61.4%). A total of 116 (35.8%) women screened positive for anxiety, 59 (18.2%) for depression, and 36 (11.1%) for stress. There was a significant association between household size and stress scores [B = 0.0454 (95% CI, 0.0035-0.0873)]. Women who associated COVID-19 infection with fetal anomalies and intrauterine fetal death had significantly higher anxiety scores [B = -0.395 (95% CI, -0.660 to -0.130) and B = -0.291 (95% CI, -0.562 to -0.021) respectively]. Conclusion Our study highlights that a lack of timely and reliable information on the impact of COVID-19 on pregnancy and its outcomes results in increased levels of depression, anxiety and stress. The healthcare provider must address these issues urgently by providing evidence-based information using Internet-based resources and psychological support.

Counting Coronavirus Disease 2019 (COVID-19) Cases: Case Definitions, Screened Populations and Testing Techniques Matter.

Abstract: While counting cases of disease appears straightforward, there are issues to consider when enumerating disease counts during an epidemic. For example, for Coronavirus Disease-2019 (COVID-19), how is a case defined? Hubei province in China changed its case definition twice in a fortnight-from laboratory-confirmed cases to clinically-confirmed cases without laboratory tests, and back to laboratory-confirmed cases. This caused confusion in the reported number of cases. If a confirmed case requires laboratory testing, what is the population who are laboratory-tested? Due to limited laboratory testing capacity in the early phase of an emerging epidemic, only "suspected cases" are laboratory-tested in most countries. This will result in underdiagnosis of confirmed cases and also raises the question: how is a "suspect case" defined? With the passage of time and increased capability to perform laboratory tests, more people can be screened and the number of confirmed cases will increase. What are the technical considerations of laboratory testing? This includes specimen collection (variable collection methods), samples collected (upper or lower respiratory tract biospecimens), time of collection in relation to course of disease, different laboratory test methods and kits (not all of which may be standardised or approved by authorities such as the Food and Drug Administration). Are approved laboratory facilities and trained manpower available, and how are test results interpreted and false-negatives excluded? These issues will affect the accuracy of disease counts, which in turn will have implications on how we mount an appropriate response to the outbreak.

Comparative Analysis of Symptomatic and Asymptomatic SARS-CoV-2 Infection in Children

Abstract: Introduction In this study, a comparison of clinical, epidemiological and laboratory parameters between symptomatic and asymptomatic children with SARS-CoV-2 infection was performed. Materials and methods Data from all children with laboratory confirmed SARS-CoV-2 infection admitted to KK Women's and Children's Hospital (KKH), Singapore, from January to May 2020 were analysed. Results Of the 39 COVID-19 children included, 38.5% were asymptomatic. Household transmission accounted for 95% of cases. The presenting symptoms of symptomatic children were low-grade fever (54.2%), rhinorrhoea (45.8%), sore throat (25%), diarrhoea (12.5%) and acute olfactory dysfunction (5.4%). Children of Chinese ethnicity (37.5% vs 6.7%), complete blood count (45.8% vs 6.7%) and liver enzyme abnormalities (25% vs 7.7%) were more common in symptomatic versus asymptomatic children. All children had a mild disease course and none required oxygen supplementation or intensive care. Conclusions The high proportion of asymptomatic infected children coupled with household transmission as the main source of paediatric COVID-19 infection underscores the importance of early screening and isolation of children upon detection of an index case of COVID-19 in a household. Symptomatic children were more likely to have abnormal laboratory parameters but they did not have a poorer outcome compared to asymptomatic cases.

Coronavirus Disease 2019 (COVID-19): The Singapore Experience. A Review of the First Eight Months

Abstract: As of 27 October 2020, there have been 57,980 confirmed cases of COVID-19 in Singapore, with 28 fatalities. To summarise the Singapore experience in managing and containing COVID-19 based on available published data and from relevant sources, a review of literature using research databases such as PubMed and OVID Medline, along with non-peer-reviewed articles and other sources, was conducted with the search terms 'COVID-19' and 'Singapore'. Research conducted in Singapore has provided insight into the clinical manifestations and period of infectivity of COVID-19, demonstrated evidence of pre-symptomatic transmission, linked infection clusters using serological tools, and highlighted aspects of hospital-based environmental contamination. It has also provided guidance for diagnostic testing and has described immune and virologic correlates with disease severity. Evidence of effectiveness of containment measures such as early border control, rigorous contact training, and calibrated social distancing measures have also been demonstrated. Singapore's multipronged strategy has been largely successful at containing COVID-19 and minimising fatalities, but the risk of re-emergence is high.

Characteristics and Outcomes of COVID-19 Patients with Respiratory Failure Admitted to a "Pandemic Ready" Intensive Care Unit - Lessons from Singapore

Abstract: Introduction Singapore was one of the first countries affected by the coronavirus disease 2019 (COVID-19) pandemic but has been able to prevent its healthcare system and intensive care units (ICU) from being overwhelmed. We describe the clinical features, management and outcomes of COVID-19 patients with respiratory failure admitted to our ICU. Materials and methods A case series of COVID-19 patients admitted to our ICU for respiratory failure from 7 February, with data censoring at 30 June 2020, was performed from a review of medical records. Results Twenty-two COVID-19 patients were admitted to our ICU for respiratory failure. The median age was 54.5 years (IQR 30-45.5), 72.7% were male and had at least one comorbidity. The Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 2.5 (IQR 1.25-7) and 10 (8.25-12) respectively. Thirteen patients required invasive mechanical ventilation (IMV) and had a median PaO2/FiO2 ratio of 194 mmHg (IQR 173-213) after intubation. The 28-day survival was 100%, with 2 patients demising subsequently. The overall ICU mortality rate was 9.1% at the time of data censoring. In IMV survivors, length of IMV and ICU stay were 11 days (IQR 9-17.75) and 16 days (IQR 12-32) respectively. Conclusion Low COVID-19 ICU mortality was observed in our "pandemic-ready" ICU. This was achieved by having adequate surge capacity to facilitate early ICU admission and IMV, lung protective ventilation, and slow weaning. Being able to maintain clinical standards and evidence-based practices without having to resort to rationing contributed to better outcomes.

Pregnancy Outcomes in COVID-19: A Prospective Cohort Study in Singapore.

Abstract: Introduction Pregnant women are reported to be at increased risk of severe coronavirus disease 2019 (COVID-19) due to underlying immunosuppression during pregnancy. However, the clinical course of COVID-19 in pregnancy and risk of vertical and horizontal transmission remain relatively unknown. We aim to describe and evaluate outcomes in pregnant women with COVID-19 in Singapore. Methods Prospective observational study of 16 pregnant patients admitted for COVID-19 to 4 tertiary hospitals in Singapore. Outcomes included severe disease, pregnancy loss, and vertical and horizontal transmission. Results Of the 16 patients, 37.5%, 43.8% and 18.7% were infected in the first, second and third trimesters, respectively. Two gravidas aged ≥35 years (12.5%) developed severe pneumonia; one patient (body mass index 32.9kg/m2) required transfer to intensive care. The median duration of acute infection was 19 days; one patient remained reverse transcription polymerase chain reaction (RT-PCR) positive >11 weeks from diagnosis. There were no maternal mortalities. Five pregnancies produced term live-births while 2 spontaneous miscarriages occurred at 11 and 23 weeks. RT-PCR of breast milk and maternal and neonatal samples taken at birth were negative; placenta and cord histology showed non-specific inflammation; and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-specific immunoglobulins were elevated in paired maternal and umbilical cord blood (n=5). Conclusion The majority of COVID-19 infected pregnant women had mild disease and only 2 women with risk factors (obesity, older age) had severe infection; this represents a slightly higher incidence than observed in age-matched non-pregnant women. Among the women who delivered, there was no definitive evidence of mother-to-child transmission via breast milk or placenta.

Obsessive-Compulsive Disorder in Singapore: Prevalence, Comorbidity, Quality of Life and Social Support.

Abstract: Introduction Using data from Singapore Mental Health Study 2016 (SMHS 2016), we examined the prevalence of lifetime and 12-month obsessive-compulsive disorder (OCD), its sociodemographic correlates and association with comorbid psychiatric disorders and physical conditions, perceived social support and quality of life. Materials and methods The World Mental Health Composite International Diagnostic Interview (version 3.0) was administered by trained interviewers to 6126 residents aged ≥18 years old to assess OCD prevalence and that of other select psychiatric disorders. Details on sociodemographics, perceived social support and health-related quality of life were obtained. Results Lifetime and 12-month prevalence of OCD was 3.6% and 2.9%, respectively. Adjusted regression analysis showed that those with OCD had significantly higher odds of major depressive disorder (odds ratio [OR], 5.4), bipolar disorder (OR, 8.9), generalised anxiety disorder (OR, 7.3) and alcohol abuse (OR, 2.7). OCD was significantly associated with suicidal ideation and suicidality (OR, 5.1). OCD subjects also had higher odds of chronic pain (OR, 2.4) and diabetes (OR, 3.1). Finally, OCD subjects had lower mean mental composite summary scores than controls (respondents without any of the psychiatric disorders and physical conditions included in SMHS 2016) and those with other lifetime psychiatric disorders and physical conditions. Conclusion OCD prevalence in Singapore is high. Most people with OCD do not seek treatment despite experiencing significant comorbidity and loss of quality of life.

The Role of Hope to Alleviate Anxiety in COVID-19 Outbreak among Community Dwellers: An Online Cross-sectional Survey

Abstract: Introduction: The worldwide emergence of COVID-19 has been associated with diverse consequences, including anxiety Hope is believed to act as a motivation to enable one to cope with the anxiety This study was conducted to identify the role of hope in alleviating anxiety due to the COVID-19 outbreak during the primary phase among community dwellers in Iran Methods: This cross-sectional study recruited 3,565 subjects with the convenience sampling method Data collection tools used included the COVID-19 knowledge checklist, Generalised Anxiety Disorder (GAD-7) questionnaires and Snyder Hope Scale Participants were asked to fill in the questionnaires online The data were analysed using descriptive and inferential statistics (multivariate linear regression analysis) Results: Participants' mean scores of anxiety and hope were 6 064 52 and 31 27 +/- 4 52, respectively The results indicated that 27 1% of the changes in the anxiety scores were predictable with some of the variables examined in this study A high score of hope was directly associated with a lower level of anxiety In addition, the number of hours spent following news and information on COVID-19 was significantly related to anxiety level Moreover, female gender, urban residence, and having relatives suffering from COVID-19 were significantly related to a higher level of anxiety (P<0 05) Conclusion: The morbidity and mortality associated with the COVID-19 outbreak had brought a lot of anxiety among community dwellers Hope, potentially, can contribute to overcoming anxiety Therefore, health policymakers can introduce appropriate social interventions to enable the community to cope with stress and anxiety

Precautions When Providing Dental Care During Coronavirus Disease 2019 (COVID-19) Pandemic.

Abstract: Transmission of coronavirus disease 2019 (COVID-19)-caused by novel severe acute respiratory syndrome coronavirus 2-through aerosolised saliva and respiratory droplets is possible when aerosol-generating dental procedures are performed Consequently, dental practitioners are at increased risk of being infected when treating COVID-19 patients A comprehensive review of the current literature on precautions when providing dental care during the COVID-19 pandemic is discussed and recommendations for dental practitioners are made Dental practitioners should actively keep themselves abreast of the guidelines published by both national and international authorities and adhere strictly to them

Contact Dermatitis from Hand Hygiene Practices in the COVID-19 Pandemic

Abstract: Coronavirus disease 2019 (COVID-19) pandemic continues to spread globally at a staggering speed. At present, there is no effective treatment or vaccine for COVID-19. Hand disinfection is a cost-effective way to prevent its transmission. According to the Centres for Disease Control and Prevention (CDC) guidelines, we should wash our hands with soap and water for at least 20 seconds. If soap and water are not readily available, alcohol-based hand rubs (ABHRs) with at least 60% alcohol are the alternative. With diligent hand disinfection reinforced during COVID-19, there is an increased prevalence of contact dermatitis. This commentary highlights the fact that contact dermatitis is a readily treatable condition and should not cause any deviation of proper hand hygiene. In irritant contact dermatitis (ICD), the management strategies are selection of less irritating hand hygiene products, frequent use of moisturisers to rebuild the skin barrier, and education on proper hand hygiene practices. In allergic contact dermatitis (ACD), the identification and avoidance of the contact allergen is the key to treatment. However, ACD is less common and only accounts for 20% of the cases. The identified allergens in hand cleansers are predominantly preservative excipients and ACD attributable to ABHR are very uncommon. Alcohol-free hand rubs are widely available on the market but it is not a recommended alternative to ABHRs by the CDC.

Current Status of Laparoscopic and Robotic Pancreatic Surgery and Its Adoption in Singapore.

Abstract: Despite the potential clinical advantages offered by laparoscopic pancreatic surgery (LPS), the main obstacle to its widespread adoption is the technically demanding nature of the procedure and its steep learning curve. LPS and robotic pancreatic surgery (RPS) have been proven to result in superior short-term perioperative outcomes and equivalent long-term oncological outcomes compared to the conventional open approach, with the caveat that they are performed by expert surgeons who have been trained to perform such procedures. The primary challenge faced by most pancreatic surgeons is the steep learning curve associated with these complex procedures and the need to undergo surgical training, especially with regards to laparoscopic and robotic pancreaticoduodenectomy. Current evidence suggests that RPS may help to shorten the lengthy learning curve required for LPS. More robust evidence-in the form of large randomised controlled trials-is needed to determine whether LPS and RPS can be safely adopted universally.

The Role of Social Media During the COVID-19 Pandemic

Abstract: Dear Editor, With the widespread implementation of socialdistancing measures, the coronavirus disease (COVID-19) pandemic has resulted in an exponential increase in screen time for everyone. Personal and professional lives have merged through platforms such as Facebook, Twitter and Instagram, unified in isolation. By listing the ways in which social media has been used during the pandemic locally and globally, we hope to inspire readers to leverage on social media in employing novel methods in medical education, research, patient care and staff support. We also present potential pitfalls based on current literature.

Clinical Challenges and Considerations in Management of Chronic Pain Patients During a COVID-19 Pandemic

Abstract: Since the coronavirus disease 2019 (COVID-19) was deemed a pandemic on 11 March 2020, we have seen exponential increases in the number of cases and deaths worldwide. The rapidly evolving COVID-19 situation requires revisions to clinical practice to defer non-essential clinical services to allocate scarce medical resources to the care of the COVID-19 patient and reduce risk to healthcare workers. Chronic pain patients require long-term multidisciplinary management even during a pandemic. Fear of abandonment, anxiety and depression may increase during this period of social isolation and aggravate pain conditions. Whilst physical consults for chronic pain patients were reduced, considerations including continuity of support and analgesia, telemedicine, allied health support and prioritising necessary pain services and interventions, were also taken to ensure biopsychosocial care for them. Chronic pain patients are mostly elderly with multiple comorbidities, and are more susceptible to morbidity and mortality from COVID-19. It is imperative to review pain management practices during the COVID-19 era with respect to infection control measures, re-allocation of healthcare resources, community collaborations, and analgesic use and pain interventions. The chronic pain patient faces a potential risk of functional and emotional decline during a pandemic, increasing healthcare burden in the long term. Clinical decisions on pain management strategies should be based on balancing the risks and benefits to the individual patient. In this commentary, we aim to discuss the basis behind some of the decisions and safeguards that were made at our tertiary pain centre over the last 6 months during the COVID-19 outbreak.

Practical Considerations for Converting Operating Rooms and Post-anaesthesia Care Units into Intensive Care Units in the COVID-19 Pandemic - Experience from a Large Singapore Tertiary Hospital.

Abstract: COVID-19 has spread globally, infecting and killing millions of people worldwide. The use of operating rooms (ORs) and the post-anaesthesia care unit (PACU) for intensive care is part of surge response planning. We aim to describe and discuss some of the practical considerations involved in a large tertiary hospital in Singapore. Firstly, considerations for setting up a level III intensive care unit (ICU) include that of space, staff, supplies and standards. Secondly, oxygen supply of the entire hospital is a major determinant of the number of ventilators it can support, including those on non-invasive forms of oxygen therapy. Thirdly, air flows due to positive pressure systems within the OR complex need to be addressed. In addition, due to the worldwide shortage of ICU ventilators, the US Food and Drug Administration has granted temporary approval for the use of anaesthesia gas machines for patients requiring mechanical ventilation. Lastly, planning of logistics and staff deployment needs to be carefully considered during a crisis. Although OR and PACU are not designed for long-term care of critically ill patients, they may be adapted for ICU use with careful planning in the current pandemic.

Knowledge and Confidence Level Among Emergency Healthcare Workers in Airway Management and Resuscitation of Suspected COVID-19 Patients: A Cross Sectional Study in Malaysia

Abstract: Introduction: This study aims to evaluate the knowledge and confidence of emergency healthcare workers (EHCW) in facing the COVID-19 pandemic Materials and Methods: A cross-sectional online study using a validated questionnaire was distributed to doctors (MD), assistant medical officers (AMO), and staff nurses (SN) at an urban tertiary Emergency Department It comprised of 40 knowledge and 10 confidence-level questions related to resuscitation and airway management steps Results: A total of 135 from 167 eligible EHCW were enrolled 68 9% (n = 93) had high knowledge while 53 3% (n = 72) possessed high confidence level Overall knowledge mean score was 32 96/40 (SD = 3 63) between MD (33 88 +/- 3 09), AMO (32 28 +/- 4 03), and SN (32 00 +/- 13 60), P = 0 025 EHCWs with a length of service (LOS) between 4-10 years had the highest knowledge compared to those with LOS <4-year (33 71 +/- 3 39 versus 31 21 +/- 3 19 P = 0 002) Airway-related knowledge was significantly different between the designations and LOS (P = 0 002 and P = 0 003, respectively) Overall, EHCW confidence level against LOS showed significant difference [F (2, 132) = 5 46, P = 0 0051 with longer LOS showing better confidence MD showed the highest confidence compared to AMO and SN (3 67 +/- 0 69, 3 53 +/- 10 68, 3 26 +/- 0 64) P = 0 049 The majority EHCW were confident in performing high-quality chest-compression, and handling of Personal Protective Equipment but less than half were confident in resuscitating, leading the resuscitation, managing the airway or being successful in first intubation attempt Conclusions: EHCW possessed good knowledge in airway and resuscitation of COVID-19 patients, but differed between designations and LOS A longer LOS was associated with better confidence, but there were some aspects in airway management and resuscitation that needed improvement

COVID-19-A Review of the Impact it has made on Supportive and Palliative Care Services Within a Tertiary Hospital and Cancer Centre in Singapore

Abstract: 1Division of Supportive and Palliative Care, National Cancer Centre Singapore, Singapore 2Division of Cancer Education, National Cancer Centre Singapore, Singapore 3Academic Clinical Programme, SingHealth Duke-NUS Academic Medical Centre, Singapore 4Lien Center for Palliative Care, Duke-NUS Graduate Medical School, Singapore 5Department of Internal Medicine, Singapore General Hospital, Singapore 6Palliative Care Institute Liverpool, Academic Palliative and End of Life Care Centre, University of Liverpool, United Kingdom; Cancer Research Centre, University of Liverpool, United Kingdom 7Centre for Biomedical Ethics, National University of Singapore, Singapore 8PalC, The Palliative Care Centre for Excellence in Research and Education, Singapore Address for Correspondence: Dr Lalit Kumar Radha Krishna, Palliative Care Institute Liverpool, Academic Palliative and End of Life Care Centre, University of Liverpool, United Kingdom; Cancer Research Centre, University of Liverpool, 200 London Rd, Liverpool L3 9TA, United Kingdom Email: lalit.radha-krishna@liverpool.ac.uk COVID-19 — A Review of the Impact it has made on Supportive and Palliative Care Services Within a Tertiary Hospital and Cancer Centre in Singapore Shirlynn Ho, 1MBBS, MRCP (UK), MMed (IM), Yung Ying Tan , 1MN, RN, Shirlyn Hui Shan Neo, 1MBBS, MRCP (UK), MMed (IM), Qingyuan Zhuang, 1MBBS, MMED (FM), Min Chiam, 2MSc (Med Hum), Jamie Xuelian Zhou, 1,3,4MBBS, MRCP (UK), MMed (IM), Natalie Liling Woong, 5MBBS, Guozhang Lee, 5MBBS, MRCP (UK), MMed (IM), Lalit Kumar Radha Krishna, 1,2,6–8MBChB, FRCP, FAMS Commentary