Letter to the Editor Dear Editor, The COVID-19 pandemic has brought about profound challenges in Singapore 1 with surgery drawing scrutiny due to the need to conserve personal protection equipment (PPE), ventilators, intensive care unit (ICU) beds as well as concerns of concurrent COVID-19 infection in surgical patients with reported mortality rate of up to 20%. 2 Given the scarcity of resources and risks associated with concurrent COVID-19 infection in the surgical patient, international guidelines have recommended medical treatment for acute issues related to cholelithiasis that are normally treated surgically. 3 This stance has implications on the management of acute cholecystitis (AC) with meta-analyses demonstrating conclusive benefits of index admission early laparoscopic cholecystectomy (ELC) over interval delayed laparoscopic cholecystectomy (DLC) that include decreased total length of stay, decreased readmission for persistent pain and gallstone-related morbidity, earlier return to work, improved quality of life and increased cost-effectiveness. 4,5 The need to balance the surgical risk and resource considerations of acute cholecystitis with the obligations of delivering optimal outcomes and avoiding morbidity thus poses an ethical dilemma during this pandemic. With the rapidly evolving pandemic coupled with different subspecialty surgeons managing AC in Singapore, opinions and practices may inevitably vary among institutions and surgeons. Resource and manpower constraints would also translate to changing practices on the ground. Thus, the aim of this study is to evaluate the impact of COVID-19 on the management of AC in Singapore. An anonymous online survey was developed and disseminated across all seven public restructured hospitals in Singapore in April 2020 via electronic mail. Inclusion criteria was consultant specialist surgeons who perform laparoscopic cholecystectomy in Singapore. The survey was administered through an online platform, Google Forms (Google LLC, Menlo Park, California, USA). The survey includes questions on demographics of survey respondents, impact of the

Introduction Breast cancer is the leading cause of death in Singaporean women, with advanced stage rendering a poorer prognosis. This study aims to explore the barriers to early presentation, information needs and sources in patients with locally advanced breast cancer (LABC). Materials & methods A convenience sample of patients who presented with locally advanced breast cancer to the Department of General Surgery in a teaching tertiary hospital were recruited for the study. We conducted semi-structured interviews face to face with the recruited patients. We recorded the interviews, transcribed them verbatim and analysed using thematic content analysis. Results Twenty-three participants were recruited of which 12 were Chinese and 11 were Malay women. Mean age was 60 years (± 13 SD). The most common knowledge barrier resulting in delay was the misconception that a breast lump must be painful to be malignant. Other knowledge barriers include the lack of knowledge and misinformation from the internet or other social media platforms. Some perceived barriers include fear of diagnosis, fear of treatment and fear of imposing financial burden on family members. A significant proportion of participants were also not aware of a national breast screening programme. Conclusions Our study has found that barriers to early presentation of women with locally advanced breast cancer remain similar and have persisted over the years despite targeted efforts. There is a need for a rethink of existing strategies and to develop new innovative ways to reach out to this group of patients.

Background Breast cancer is the most common cancer in women worldwide. Major breast cancer surgery especially with axillary lymph node dissection (ALND), is associated with upper limb functional decline. Majority of studies are conducted in Western population and may not be applicable to Asians. This pilot study aims to evaluate whether major breast surgery results in upper limb functional impairment in a cohort of Asian women with breast cancer. Methods This is a prospective cohort study of 41 patients who underwent 44 major breast surgeries from April 2018 to August 2019. Main inclusion criteria were patients over 21 years of age undergoing major breast surgery for breast cancer. Major breast surgery was defined as wide local excision (WLE) or mastectomy. Main exclusion criteria were patients with pre-existing neurological or rheumatological co-morbidities affecting upper limb function or previous trauma with resulting deformities to the upper limbs. Patients underwent early rehabilitation from post-operative day 1. Shoulder flexion and abduction active range of motion (AROM) and QuickDASH disability score were assessed 1 week before surgery, post-operative week 2 and week 6. Baseline demographics and peri-operative data were also collected. Results Median age was 62.5 years. There were 16 (36.4%) wide local excisions and 28 (63.6%) simple mastectomies. Two (4.5%) cases had neoadjuvant chemotherapy. Fifteen (34.1%) cases had ALND. At post-operative week 6, shoulder flexion was comparable to baseline (p = 0.775), while abduction improved from baseline (p = 0.016). However, QuickDASH disability score was significantly worse at post-operative week 6 compared to baseline (median score 2.5 vs 0, p = 0.027). Subgroup analysis of patients with ALND demonstrated significantly worse QuickDASH disability score at post-operative week 6 (p = 0.010) but not for patients with only sentinel lymph node biopsy (p = 0.396). Conclusion This pilot study in an Asian cohort found that patients were able to regain AROM of shoulder after major breast surgery at post-operative week 6 but had a worse QuickDASH disability score, especially in the subgroup with ALND. Aggressive and early rehabilitation should be encouraged. However, a longer follow-up is required to evaluate long term functional outcomes.

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