Background and aim COVID-19 pandemic has resulted in an unprecedented increased usage of Personal protective equipment (PPE) by healthcare-workers. PPE usage causes headache in majority of users. We evaluated changes in cerebral hemodynamics among healthcare-workers using PPE. Methods Frontline healthcare-workers donning PPE at our tertiary center were included. Demographics, co-morbidities and blood-pressure were recorded. Transcranial Doppler (TCD) monitoring of middle cerebral artery was performed with 2-MHz probe. Mean flow velocity (MFV) and pulsatility index (PI) were recorded at baseline, after donning N95 respirator-mask, and after donning powered air-purifying respirator (PAPR), when indicated. End-tidal carbon-dioxide (ET-CO2) pressure was recorded for participants donning PAPR in addition to the N95 respirator-mask. Results A total of 154 healthcare-workers (mean age 29 ± 12 years, 67% women) were included. Migraine was the commonest co-morbidity in 38 (25%) individuals while 123 (80%) developed de-novo headache due to N95 mask. Donning of N95 respirator-mask resulted in significant increase in MFV (4.4 ± 10.4 cm/s, p < 0.001) and decrease in PI (0.13 ± 0.12; p < 0.001) while ET-CO2 increased by 3.1 ± 1.2 mmHg (p < 0.001). TCD monitoring in 24 (16%) participants donning PAPR and N95 respirator mask together showed normalization of PI, accompanied by normalization of ET-CO2 values within 5-min. Combined use of N95 respirator-mask and PAPR was more comfortable as compared to N95 respirator-mask alone. Conclusion Use of N95 respirator-mask results in significant alterations in cerebral hemodynamics. However, these effects are mitigated by the use of additional PAPR. We recommend the use of PAPR together with the N95 mask for healthcare-workers doing longer duties in the hospital wards.

EditordThe 2019 novel coronavirus disease (COVID-19) pandemic has overwhelmed healthcare systems worldwide, profoundly impacting the lives of anaesthesiologists, intensivists, and nurses caring for the critically ill. Such high-acuity patient care imposes a significant physical and cognitive burden, which is further compounded by increased workloads, staffing deficiencies, and equipment shortages. Participation in aerosol-generating procedures and frequent direct patient contact may increase risk of infection. Government-imposed containment measures may lead to social isolation and restrict access to usual coping mechanisms. Exposure to contagion may also engender concerns from staff living with older people and young children. The previous severe acute respiratory syndrome outbreak of 2003 saw emotional exhaustion, anxiety, depression, and burnout afflicting healthcare workers. 1,2 Similarly, studies on healthcare workers from China and Italy have described stress-related anxiety and depression during the COVID-19 pandemic. 3,4 These studies did not specifically examine intensive care providers, who may constitute a highrisk subgroup. We sought to determine the prevalence and severity of psychological distress amongst anaesthesiologists and nurses working in ICUs during this pandemic, and identify potential risk factors. We also studied their main concerns, perceptions of pandemic preparedness, training adequacy, and staff protection. This observational, cross-sectional study was conducted at a 1240-bed tertiary academic medical centre in Singapore. During this pandemic, anaesthesiologists were rostered into ICUs in our hospital. Ethics approval was obtained from the institutional domain-specific review board (2020/00648) before commencement of the study. All anaesthesiologists (including trainees) and nurses working in ICUs were invited to participate with a one-time self-administered online questionnaire. The sampling period was June 11e15, 2020, during which Singapore saw 400 to 500 new cases daily, with a cumulative total exceeding 40 000 cases for a population of~5.8 million. Two survey completion reminders were issued. All participants completed a 46question, closed-ended, self-reporting questionnaire (Supplementary Appendix 1). No identifying information was collected. The anonymised questionnaire collected participant characteristics, medical history, and workplace characteristics, such as redeployment outside normal professional boundaries, direct COVID-19 patient care, workload during the pandemic,

As a contribution to worldwide efforts towards a tobacco-free society, this paper considers the possibility of a long-term phasing-in of a total ban, by proposing that individuals born in or after the year 2000 have their supply of tobacco restricted. In conjunction, a survey that we have conducted in Singapore indicates strong public support (even among current smokers) for the proposal.

VAC therapy is an effective treatment option for orocutaneous fistulas.

The Coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving and affecting healthcare systems across the world. Singapore has escalated its alert level to Disease Outbreak Response System Condition (DORSCON) Orange, signifying severe disease with community spread. We aimed to study the overall volume of AIS cases and the delivery of hyperacute stroke services during DORSCON Orange. This was a single-centre, observational cohort study performed at a comprehensive stroke centre responsible for AIS cases in the western region of Singapore, as well as providing care for COVID-19 patients. All AIS patients reviewed as an acute stroke activation in the Emergency Department (ED) from November 2019 to April 2020 were included. System processes timings, treatment and clinical outcome variables were collected. We studied 350 AIS activation patients admitted through the ED, 206 (58.9%) pre-and 144 during DORSCON Orange. Across the study period, number of stroke activations showed significant decline (p = 0.004, 95% CI 6.513 to − 2.287), as the number of COVID-19 cases increased exponentially, whilst proportion of activations receiving acute recanalization therapy remained stable (p = 0.519, 95% CI − 1.605 to 2.702). Amongst AIS patients that received acute recanalization therapy, early neurological outcomes in terms of change in median NIHSS at 24 h (-4 versus-4, p = 0.685) were largely similar between the pre-and during DORSCON orange periods. The number of stroke activations decreased while the proportion receiving acute recanalization therapy remained stable in the current COVID-19 pandemic in Singapore.