This case highlights the importance of arboviral screening of donor blood, especially for populations in endemic areas during outbreaks.

Routine mammography screening is currently the standard tool for finding cancers at an early stage, when treatment is most successful. Current breast screening programmes are one-size-fits-all which all women above a certain age threshold are encouraged to participate. However, breast cancer risk varies by individual. The BREAst screening Tailored for HEr (BREATHE) study aims to assess acceptability of a comprehensive risk-based personalised breast screening in Singapore. Advancing beyond the current age-based screening paradigm, BREATHE integrates both genetic and non-genetic breast cancer risk prediction tools to personalise screening recommendations. BREATHE is a cohort study targeting to recruit ~3,500 women. The first recruitment visit will include questionnaires and a buccal cheek swab. After receiving a tailored breast cancer risk report, participants will attend an in-person risk review, followed by a final session assessing the acceptability of our risk stratification programme. Risk prediction is based on: a) Gail model (non-genetic), b) mammographic density and recall, c) BOADICEA predictions (breast cancer predisposition genes), and d) breast cancer polygenic risk score. For national implementation of personalised risk-based breast screening, exploration of the acceptability within the target populace is critical, in addition to validated predication tools. To our knowledge, this is the first study to implement a comprehensive risk-based mammography screening programme in Asia. The BREATHE study will provide essential data for policy implementation which will transform the health system to deliver a better health and healthcare outcomes.

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Background High-intensity focused ultrasound (HIFU) is a recent noninvasive technique of treating thyroid nodules. Our study aims to investigate the efficacy and safety of HIFU in treating benign thyroid nodules. Methods This is a retrospective analysis of consecutive patients who underwent HIFU of benign thyroid nodules at our institution from July 2017-2018. All procedures were performed by a single surgeon. Patients were evaluated immediately post-procedure, and at subsequent intervals of 1 week, 1 month, 3 months, and 6 months. The primary endpoint was thyroid nodule volume reduction at 6 months posttreatment. Secondary endpoints were post-procedure local complications. Results Ten patients with 13 thyroid nodules were included. The median follow-up period was 426 days (range 238-573). Mean maximum diameter reduced from 2.6 cm (±0.8) pretreatment to 1.4 cm (±0.7, P \ 0.05) 6 months posttreatment. Mean nodule volume reduced from 5.2 cm 3 (±4.2) pretreatment to 1.5 cm 3 (±1.3,P= 0.01) 6 months posttreatment. Mean volume reduction ratio (VRR) at 6 months posttreatment was 63.2% (±22.5, P \ 0.05), with volume reduction of C50% in 10 of 13 (76.9%) nodules. Two nodules (15.4%) showed size increases from 4 months posttreatment. No patients experienced local skin burns or hematomas. Mean pain scores were 1.5 (±1.2) immediate post-procedure, 0.8 (±1.5) at 1 week, and 0.6 (±1.2) at 1 month post-procedure, respectively, with no reports of pain beyond 1 month. Only two (20.0%) patients had early, temporary posttreatment voice hoarseness. Conclusion Our study shows HIFU ablation to be efficacious and safe-with significant thyroid nodule volume reductions, and no significant or prolonged local complications.

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

Background Practice variations exist amongst parathyroid surgeons depending on their expertise and resources. Our study aims to elucidate the choice of surgical techniques and adjuncts used in parathyroid surgery by surgeons in the Asia-Pacific region. Methods A 25-question online survey was sent to members of five endocrine surgery associations. Questions covered training background, practice environment and preferred techniques in parathyroid surgery. Respondents were divided into three regions: Australia/New Zealand, South/South East Asia and East Asia, and responses were analysed according to region, specialty, case volume and years in practice. Results One hundred ninety-six surgeons returned the questionnaire. Most surgeons (98%) routinely perform preoperative imaging, with 75% preferring dual imaging with 99m Tcsestamibi and ultrasound. Ten per cent of surgeons use parathyroid 4DCT as first-line imaging, more commonly in East Asia (p = 0.038). Minimally invasive parathyroidectomy is the favoured technique of choice (97%). Most surgeons reporting robotic or endoscopic approaches are from East Asia. Rapid intraoperative parathyroid hormone is accessible to just under half of the surgeons but less available in Australian/New Zealand (p \ 0.001). The use of intraoperative neuromonitoring is not commonly used, even less so amongst Asian surgeons (p = 0.048) and surgeons with low case load (p = 0.013). Conclusion Dual localisation techniques are the preferred choice of investigations in preparation for parathyroid surgery, with minimally invasive surgery without neuromonitoring the preferred approach. Use of adjuncts is sporadic and limited to certain centres.

HighlightsSplenic abscess is rare conditions seen in children.Salmonellosis is a common cause of infection in splenic abscess.Splenic abscess can be managed with partial splenectomy.

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