Singapore medical journal最新文献_第10页

Comments on: Return to work after surgically treated pelvic ring fractures in Singapore 评论:在新加坡接受骨盆环骨折手术后重返工作岗位

4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-03 DOI: 10.4103/singaporemedj.smj-2023-226

Anne HY Goei, Alvin KW Tan, David Koh

Dear Sir, We read with interest the article ‘Return to work after surgically treated pelvic ring fractures in Singapore’ by Ng et al.[1] The authors have commendably explored perioperative factors affecting return to work (RTW) and underscored the importance of early rehabilitation and work reintegration. However, only one job-related factor — a dichotomous classification of job sedentariness — was analysed. Given the heterogeneity of work, we propose several suggestions to generate meaningful insights on RTW evaluations. First, RTW involves a comprehensive evaluation of patents’ functional capabilities relating to the nature and demands of their current work. This can only be achieved through a detailed occupational history. Often forgotten,[2,3] an occupational history allows the clinician to ascertain what the patient actually does at work (e.g., the need to lift loads, use of machinery, working hours, presence of shift work) to better quantify the risk of reinjury, delayed recovery and to what extent the patient can function at work. Second, the ability to RTW is multifactorial, comprising psychosocial and workplace factors like self-efficacy, workplace support, work satisfaction, RTW coordination programmes and availability of job accommodations.[4] These were not evaluated or adjusted for, and may be potential confounders affecting the ability to detect significant associations. Return to work is a multidisciplinary and multisectoral collaboration, and involvement of the employer is critical. Ideally, patients should not be on medical leave till complete recovery. Instead, early reintegration using stepwise assimilation, with appropriate job restrictions and accommodations provided by the employer are crucial in early RTW and creating a healthier workforce.[5] Editor’s note: The authors, Ng et al., did not respond to the above letter. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

亲爱的先生，我们饶有兴趣地阅读了Ng等人的文章《新加坡骨盆环骨折手术后重返工作岗位》。作者对影响重返工作岗位(RTW)的围手术期因素进行了值得赞扬的探讨，并强调了早期康复和重返工作岗位的重要性。然而，只分析了一个与工作有关的因素-工作久坐的二分分类。鉴于工作的异质性，我们提出了一些建议，以产生对RTW评估有意义的见解。首先，专利审查涉及对专利的功能能力进行综合评估，这些能力与专利当前工作的性质和需求有关。这只能通过详细的职业经历来实现。通常被遗忘的是，[2,3]职业史使临床医生能够确定患者在工作中实际做了什么(例如，举起重物的需要，机械的使用，工作时间，轮班工作的存在)，以更好地量化再次受伤的风险，延迟恢复以及患者在多大程度上可以正常工作。第二，RTW能力是多因素的，包括心理社会和工作场所因素，如自我效能、工作场所支持、工作满意度、RTW协调方案和工作住宿的可用性这些因素没有被评估或调整，可能是潜在的混杂因素，影响检测显著相关性的能力。重返工作是一项多学科和多部门合作，雇主的参与至关重要。理想情况下，病人在完全康复前不应请病假。相反，在雇主提供适当的工作限制和住宿的情况下，通过逐步同化的方式尽早重返社会，对早期重返社会和创造更健康的劳动力至关重要编者注:作者Ng等人没有对上述信件作出回应。财政支持及赞助无。利益冲突没有利益冲突。

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引用次数: 0

Routine preoperative screening computed tomography of the thorax for cardiac surgery 心脏手术术前常规胸部ct筛查

4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-03 DOI: 10.4103/singaporemedj.smj-2021-416

Jai Ajitchandra Sule, Xue Wei Chan, Hari Kumar Sampath, Hai Dong Luo, Mofassel Uddin Ahmed, Giap Swee Kang

Abstract Introduction: This study aimed to evaluate the role of screening computed tomography (CT) of the thorax in cardiac surgery by analysing the presence of CT aortic calcifications in association with changes in operative strategy and postoperative stroke, and the CT features of emphysema with development of pneumonia. Methods: All patients who underwent cardiac surgery from January 2013 to October 2017 by a single surgeon were retrospectively studied. Patients who underwent screening CT thorax before cardiac surgery (CT group) were compared to those who did not (no CT group). Multivariate subgroup analyses were performed to determine significant association with postoperative outcomes. Results: A total of 392 patients were included, of which 156 patients underwent preoperative screening CT thorax. Patients in the CT group were older (63.9 vs. 59.0 years, P = 0.001), had fewer recent myocardial infarctions preoperatively (41% vs. 56.4%, P = 0.003) and had better ejection fraction (>30%; P = 0.02). Operative strategy was changed in 4.3% of patients, and 4.9% of patients suffered stroke postoperatively. The presence of CT aortic calcifications was significantly associated with change in operative strategy ( P = 0.016) but not with postoperative stroke ( P = 0.33). Age was an independent risk factor for change in operative strategy among patients with CT thorax ( P = 0.02). Multivariate age-adjusted analysis showed only palpable plaque to be significantly associated with change in operative strategy ( P < 0.001). None of the patients with CT emphysema features developed pneumonia. Conclusion: The results of this study do not support routine use of preoperative screening CT thorax. Contrasted CT may be advisable in older patients and for other operative planning purposes.

摘要简介:本研究旨在通过分析CT主动脉钙化与手术策略改变和术后卒中的相关性，以及肺气肿与肺炎发展的CT特征，来评估胸部CT筛查在心脏手术中的作用。方法:回顾性分析2013年1月至2017年10月由同一位外科医生进行心脏手术的所有患者。将心脏手术前进行胸部CT筛查的患者(CT组)与未进行胸部CT筛查的患者(未进行CT组)进行比较。进行多变量亚组分析以确定与术后预后的显著相关性。结果:共纳入392例患者，其中156例术前行胸部CT筛查。CT组患者年龄较大(63.9 vs. 59.0岁，P = 0.001)，术前近期心肌梗死较少(41% vs. 56.4%， P = 0.003)，射血分数较好(>30%;P = 0.02)。4.3%的患者改变了手术策略，4.9%的患者术后发生卒中。CT主动脉钙化的存在与手术策略的改变显著相关(P = 0.016)，但与术后卒中无关(P = 0.33)。年龄是CT胸患者手术策略改变的独立危险因素(P = 0.02)。多因素年龄调整分析显示，只有可触及斑块与手术策略的改变显著相关(P <0.001)。CT表现为肺气肿的患者均未出现肺炎。结论:本研究结果不支持术前常规使用CT胸腔筛查。在老年患者和其他手术计划中，对比CT可能是明智的。

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引用次数: 0

Safety attitudes, burnout and well-being among healthcare workers during the COVID-19 pandemic: an Indo-Pacific regional cross-sectional study. COVID-19大流行期间医护人员的安全态度、职业倦怠和幸福感:一项印度-太平洋地区横断面研究

IF 2.7 4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-01 DOI: 10.11622/smedj.2022014

Abhiram Kanneganti, Benjamin Yong Qiang Tan, Nik Hisamuddin Nik Ab Rahman, Aloysius Sheng-Ting Leow, Max Denning, Ee Teng Goh, Lucas Jun Hao Lim, Ching-Hui Sia, Ying Xian Chua, James Kinross, Melanie Tan, Li Feng Tan, Yi Min Wan, Arvind Sharma, Rivan Danuaji, R N Komal Kumar, Chew Keng Sheng, Cheah Phee Kheng, Sarah Shaikh Abdul Karim, Mohd Najib Abdul Ghani, Suhaimi Mahmud, Yiong Huak Chan, Vijay Kumar Sharma, Kang Sim, Shirley Beng Suat Ooi

Introduction: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact in Asia and has placed significant burden on already stretched healthcare systems. We examined the impact of COVID-19 on the safety attitudes among healthcare workers (HCWs), as well as their associated demographic and occupational factors, and measures of burnout, depression and anxiety.

Methods: A cross-sectional survey study utilising snowball sampling was performed involving doctors, nurses and allied health professions from 23 hospitals in Singapore, Malaysia, India and Indonesia between 29 May 2020 and 13 July 2020. This survey collated demographic data and workplace conditions and included three validated questionnaires: the Safety Attitudes Questionnaire (SAQ), Oldenburg Burnout Inventory and Hospital Anxiety and Depression Scale. We performed multivariate mixed-model regression to assess independent associations with the SAQ total percentage agree rate (PAR).

Results: We obtained 3,163 responses. The SAQ total PARs were found to be 35.7%, 15.0%, 51.0% and 3.3% among the respondents from Singapore, Malaysia, India and Indonesia, respectively. Burnout scores were highest among respondents from Indonesia and lowest among respondents from India (70.9%-85.4% vs. 56.3%-63.6%, respectively). Multivariate analyses revealed that meeting burnout and depression thresholds and shifts lasting ≥12 h were significantly associated with lower SAQ total PAR.

Conclusion: Addressing the factors contributing to high burnout and depression and placing strict limits on work hours per shift may contribute significantly towards improving safety culture among HCWs and should remain priorities during the pandemic.

2019年冠状病毒病(COVID-19)大流行在亚洲产生了前所未有的影响，并给本已不堪重负的医疗保健系统带来了沉重负担。我们研究了COVID-19对医护人员(HCWs)安全态度的影响，以及相关的人口统计学和职业因素，以及倦怠、抑郁和焦虑的测量。方法:在2020年5月29日至2020年7月13日期间，利用滚雪球抽样对来自新加坡、马来西亚、印度和印度尼西亚的23家医院的医生、护士和专职卫生专业人员进行了横断面调查研究。本调查整理了人口统计数据和工作场所条件，包括三份有效问卷:安全态度问卷(SAQ)、奥尔登堡倦怠量表和医院焦虑抑郁量表。我们采用多变量混合模型回归来评估与SAQ总同意率(PAR)的独立关联。结果:我们获得了3163份回复。新加坡、马来西亚、印度和印度尼西亚受访者的SAQ总par分别为35.7%、15.0%、51.0%和3.3%。印度尼西亚受访者的倦怠得分最高，印度受访者的倦怠得分最低(分别为70.9%-85.4%和56.3%-63.6%)。多变量分析显示，达到倦怠和抑郁阈值以及轮班时间≥12小时与较低的SAQ总par显著相关。结论:解决导致高倦怠和抑郁的因素，严格限制每班工作时间，可能有助于显著改善卫生保健工作者的安全文化，在大流行期间应优先考虑。

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引用次数: 2

Wide complex tachycardias detected by smartwatch: what is the diagnosis? 智能手表检测广泛复杂的心动过速:诊断是什么?

4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-01 DOI: 10.4103/singaporemedj.smj-2021-302

Weien Chow, Colin Yeo, Vern Hsen Tan

CASE 1 Clinical presentation A 64-year old woman with no significant past medical history presented to our cardiology clinic for recurrent intermittent palpitations at rest for the past 7 years. She also had an episode of left-sided chest pain. Her symptoms occurred about once a month, lasted 2–3 h with sudden onset and offset and were irregular in nature. The symptoms were associated with giddiness, and she complained of lethargy after the palpitations stopped. She did not have any near-syncopal or syncopal episodes. The patient is a non-smoker and non-drinker, and does brisk walking twice a week (30–45 min each session). Her electrocardiogram (ECG) at the clinic showed normal sinus rhythm with normal PR, QRS and QTc interval [Figure 1]. Serial event monitors (including 24-h monitoring, 14 days of transtelephonic ECG monitoring) showed intermittent rate-related left bundle branch block (LBBB), no significant pause and infrequent premature atrial (<1%) and ventricular (<1%) ectopics. No symptom was recorded while she was on the event monitors.Figure 1: Case 1. 12-lead ECG shows normal sinus rhythm with normal PR, QRS and QTc interval.Other investigations included computed tomography (CT) coronary angiogram, which showed minor coronary artery disease. The patient’s myocardial perfusion imaging was negative for ischaemia, and 2D echocardiography showed a normal left ventricular ejection fraction (LVEF) of 57%, normal left atrium (LA) size (LA volume 29.9 mL/m2) and mild to moderate mitral regurgitation. The patient continued to have intermittent symptoms despite being started on beta-blocker empirically. Due to her recurrent symptoms, her son decided to use his Apple Watch to record the ECG tracing for her whenever she was symptomatic. ECG interpretation The smartwatch ECG tracing (correlates to lead I) showed an irregularly irregular wide complex tachycardia [Figure 2]. The differential diagnosis included the following the: (a) atrial fibrillation (AF) with rate-related bundle branch block; (b) pre-excited AF; and (c) polymorphic ventricular tachycardia (VT) (torsades de pointes).Figure 2: Case 1. Smartwatch ECG tracing (represents lead I) shows an irregularly irregular wide complex tachycardia.Clinical course The patient was counselled on AF due to her symptoms and tracing from her smartwatch. In the later part of the day, she was admitted to the hospital for sudden onset of palpitations associated with shortness of breath when climbing the stairs. On examination, her pulse was irregularly irregular. The rest of the physical examination was unremarkable. The patient’s ECG showed an irregularly irregular wide complex (left bundle branch block pattern) tachycardia [Figure 3], similar to that shown by the smartwatch ECG tracing. The patient was diagnosed with AF with aberrancy and rapid ventricular rate of 160 bpm. Her troponin T level was normal at 5 ng/L and electrolytes were normal.Figure 3: Case 1. 12-lead ECG shows an irregularly irregular wide

病例1临床表现一名64岁女性，既往无明显病史，因休息时复发性间歇性心悸7年来到我们心内科诊所。她还出现过左侧胸痛。她的症状大约一个月出现一次，持续2-3 h，突然发作和抵消，性质不规则。症状与头晕有关，心悸停止后她主诉昏睡。她没有任何近晕厥或晕厥发作。患者不吸烟不喝酒，每周快走两次(每次30-45分钟)。临床心电图显示窦性心律正常，PR、QRS、QTc间期正常[图1]。连续事件监测(包括24小时监测，14天的经电话心电监测)显示间歇性心率相关的左束支传导阻滞(LBBB)，无明显暂停和罕见的早房(<1%)和室性(<1%)异位。当她在事件监视器上时，没有记录任何症状。图1:案例1。12导联心电图显示窦性心律正常，PR、QRS、QTc间期正常。其他调查包括计算机断层扫描(CT)冠状动脉造影，显示轻微的冠状动脉疾病。患者心肌灌注显像为缺血阴性，二维超声心动图示左室射血分数(LVEF) 57%正常，左心房(LA)大小正常(LA容积29.9 mL/m2)，二尖瓣轻度至中度返流。尽管开始使用β受体阻滞剂，患者仍有间歇性症状。由于她的症状反复出现，她的儿子决定在她出现症状时用他的苹果手表记录她的心电图。智能手表心电图示踪(与导联I相关)显示不规则不规则宽性复杂心动过速[图2]。鉴别诊断包括:(a)心房颤动(AF)伴心率相关束支阻滞;(b)预激AF;(c)多态性室性心动过速(VT)(点扭转)。图2:案例1。智能手表心电示踪(表示导联I)显示不规则不规则宽性复杂心动过速。根据患者的症状和智能手表的追踪，建议患者进行房颤治疗。当天晚些时候，她因爬楼梯时突然出现心悸并呼吸急促而入院。经检查，她的脉搏不规则。身体检查的其余部分都很普通。患者心电图显示不规则宽复型(左束支阻滞型)心动过速[图3]，与智能手表示图相似。患者被诊断为房颤异常，室率160 bpm。她的肌钙蛋白T水平正常，为5 ng/L，电解质正常。图3:案例1。12导联心电图显示不规则宽复合(左束支阻滞型)心动过速。患者静脉给予胺碘酮150 mg，心律转变为窦性心律[图4]。患者开始使用氟氯胺100mg / d，并将比索洛尔剂量增加至1.25 mg / d，以更好地控制剂量。她无症状，出院当天仍保持正常窦性心律。图4:案例1。12导联心电图显示静脉注射胺碘酮后窦性心律恢复正常。病例2临床表现一名19岁女性，表现为突发性和反复发作的阵发性心悸。她的症状与体力消耗无关，每次发作持续30分钟至1小时。她的心脏科医生要求进行心脏事件记录1个月，但未发现心律失常。静息12导联心电图显示窦性心律正常，PR、QRS、QTc间期正常，无预兴奋[图5]。超声心动图显示心脏结构正常。六个月后，她再次出现心悸，这被她的智能手表捕捉到了。图5:案例2。12导联心电图显示窦性心律正常，PR、QRS、QTc间期正常，无预兴奋。智能手表上的心电图示踪显示有规律的宽幅复杂心动过速[图6]。鉴别诊断包括:(a)室上性心动过速伴异常(SVT);(b) VT;(c) 1:1传导的心房扑动。图6:案例2。智能手表心电图显示有规律的宽性复杂心动过速。患者随后接受了电生理检查，证实了SVT异常的诊断。电生理检查显示患者为正侧房室再入性心动过速，逆行肢体沿隐蔽性左游离壁副通道上行，射频消融术成功。在智能手表上解读单导联心电图可能具有挑战性。病例1的区别之一是预兴奋性房颤。这是不太可能的，因为没有缓慢的QRS上搏，这可能表明心室预兴奋。此外，先前的心电图[图1]未显示心室预兴奋的证据。另一种差异是多态VT(点扭转)，其特征是连续变化幅度的波动，交替出现在基线上方和下方，通常与较长的QTc有关。然而，在病例1中，QRS复合物在振幅和形态上相似。“点的扭曲”很可能是由于患者在智能手表上记录心电图时手腕运动导致的心电图基线徘徊。智能手表心电图显示广泛的复杂心动过速，不规则，提示房颤。患者也有心率相关的LBBB病史，先前的动态心电图记录的QRS形态相似。考虑到临床表现，在没有晕厥发作或心脏骤停的情况下，房颤伴心率相关束支阻滞是最有可能的诊断。病例2的区别之一是特发性室性心动过速。患者以前没有潜在的缺血性心脏病或结构性心脏病病史，这使得由潜在底物引起的室性心动过速的可能性较小。伴有异常的室上性心动过速和1:1传导的心房扑动是其他可能的区别。不幸的是，如果不进行电生理学研究，将很难区分这些鉴别诊断。越来越多的文献报道使用智能手表心电图作为检测临床显著心律失常的辅助手段。这包括AF、[1,2]心房扑动、[3]SVT[4,5]和VT的诊断。2018年9月11日发布的美国食品和药物管理局(FDA)设备分类决定指出，非处方使用的ECG软件设备可创建、分析和显示ECG数据，并可提供识别心律失常的信息。该设备不是用来提供诊断的。该声明补充说，心电图波形旨在补充心律分类，以区分房颤和正常窦性心律，而不是为了取代传统的诊断或治疗方法FDA表示，该设备应被归类为II类设备，通用名称为“非处方使用的心电图软件”。这两个病例强调了咨询医学专业人员进行临床决策的重要性，如果患者有症状，应建议患者就医，以便12导联心电图可以检测所有类型的心律失常，而不仅仅是房颤。鉴于不规则宽性复杂心动过速和规则宽性复杂心动过速的区别，这对本文中提出的两例病例尤其重要。2020年欧洲心脏病学会AF诊断和管理指南还指出，当通过筛查工具(包括移动或可穿戴设备)检测到AF时，单导联心电图示踪≥30秒或12导联心电图显示AF，由具有ECG节律解释专业知识的医生分析，这对于确定AF的明确诊断是必要的。当AF检测不是基于ECG记录，或在设备提供的ECG示踪解释不确定的情况下，必须使用额外的ECG记录(例如12导联ECG、动态心电图监测、事件环路记录器、可植入环路记录器)获得确认的ECG诊断。电生理学研究等)值得注意的是，案例1中使用的智能手表并不属于患者。这凸显了患者使用智能手表的便利性，即使他们没有智能手表。医生可能会看到更多的患者带着智能手表上的心电图记录来到诊所。这款智能手表可能会被用作诊断心律失常的辅助设备;然而，它不应该取代基于既定指南的临床实践。病人如有症状，亦应提醒他们求医。财政支持及赞助无。利益冲突没有利益冲突。SMC 3B类CME课程在线测试:https://www.sma.org.sg/cme-programme截止提交时间:2023年12月7日下午6点

{"title":"Wide complex tachycardias detected by smartwatch: what is the diagnosis?","authors":"Weien Chow, Colin Yeo, Vern Hsen Tan","doi":"10.4103/singaporemedj.smj-2021-302","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2021-302","url":null,"abstract":"CASE 1 Clinical presentation A 64-year old woman with no significant past medical history presented to our cardiology clinic for recurrent intermittent palpitations at rest for the past 7 years. She also had an episode of left-sided chest pain. Her symptoms occurred about once a month, lasted 2–3 h with sudden onset and offset and were irregular in nature. The symptoms were associated with giddiness, and she complained of lethargy after the palpitations stopped. She did not have any near-syncopal or syncopal episodes. The patient is a non-smoker and non-drinker, and does brisk walking twice a week (30–45 min each session). Her electrocardiogram (ECG) at the clinic showed normal sinus rhythm with normal PR, QRS and QTc interval [Figure 1]. Serial event monitors (including 24-h monitoring, 14 days of transtelephonic ECG monitoring) showed intermittent rate-related left bundle branch block (LBBB), no significant pause and infrequent premature atrial (<1%) and ventricular (<1%) ectopics. No symptom was recorded while she was on the event monitors.Figure 1: Case 1. 12-lead ECG shows normal sinus rhythm with normal PR, QRS and QTc interval.Other investigations included computed tomography (CT) coronary angiogram, which showed minor coronary artery disease. The patient’s myocardial perfusion imaging was negative for ischaemia, and 2D echocardiography showed a normal left ventricular ejection fraction (LVEF) of 57%, normal left atrium (LA) size (LA volume 29.9 mL/m2) and mild to moderate mitral regurgitation. The patient continued to have intermittent symptoms despite being started on beta-blocker empirically. Due to her recurrent symptoms, her son decided to use his Apple Watch to record the ECG tracing for her whenever she was symptomatic. ECG interpretation The smartwatch ECG tracing (correlates to lead I) showed an irregularly irregular wide complex tachycardia [Figure 2]. The differential diagnosis included the following the: (a) atrial fibrillation (AF) with rate-related bundle branch block; (b) pre-excited AF; and (c) polymorphic ventricular tachycardia (VT) (torsades de pointes).Figure 2: Case 1. Smartwatch ECG tracing (represents lead I) shows an irregularly irregular wide complex tachycardia.Clinical course The patient was counselled on AF due to her symptoms and tracing from her smartwatch. In the later part of the day, she was admitted to the hospital for sudden onset of palpitations associated with shortness of breath when climbing the stairs. On examination, her pulse was irregularly irregular. The rest of the physical examination was unremarkable. The patient’s ECG showed an irregularly irregular wide complex (left bundle branch block pattern) tachycardia [Figure 3], similar to that shown by the smartwatch ECG tracing. The patient was diagnosed with AF with aberrancy and rapid ventricular rate of 160 bpm. Her troponin T level was normal at 5 ng/L and electrolytes were normal.Figure 3: Case 1. 12-lead ECG shows an irregularly irregular wide","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135515129","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Malignant arrhythmia in a COVID-19 patient with a structurally normal heart. 心脏结构正常的COVID-19患者恶性心律失常1例。

IF 2.7 4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-01 DOI: 10.11622/smedj.2021191

Clare Anne Yoke Kum Fong, Benjamin Wei Liang Tung, Weiqin Lin, Kay Choong See

引用次数: 0

Second-generation laryngeal mask airway as an alternative to endotracheal tube in prolonged laparoscopic abdominal surgery: a comparative analysis of intraoperative gas exchanges. 第二代喉罩气道替代气管内插管在长时间腹腔镜腹部手术中的应用:术中气体交换的比较分析。

IF 2.7 4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-01 DOI: 10.11622/smedj.2021143

Sukhee Park, Ja Eun Lee, Gyu Sung Choi, Jong Man Kim, Justin Sangwook Ko, Duck Hwan Choi, Gaab Soo Kim

Introduction: Laryngeal mask airway (LMA), which is used in difficult airway maintenance conditions during emergencies, is rarely used in prolonged surgery despite its advantages over endotracheal tube (ETT). In this study, we conducted a comparative analysis of intraoperative gas exchanges between second-generation LMA and ETT during prolonged laparoscopic abdominal surgery.

Methods: Prolonged surgery was defined as a surgery lasting more than 2 h. In total, 394 patients who underwent laparoscopic liver resection via either second-generation LMA or ETT were retrospectively analysed. The following parameters were compared between the two groups of patients: end-tidal pressure of carbon dioxide (ETCO₂), tidal volume (TV), respiratory rate (RR), peak inspiratory pressure (PIP), arterial partial pressure of carbon dioxide (PaCO₂), pH and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) during surgery. In addition, the incidence of postoperative pulmonary complications (PPCs), including pulmonary aspiration, was compared.

Results: The values of ETCO₂, TV, RR and PIP during pneumoperitoneum were comparable between the two groups. Although PaCO₂ at 2 h after induction was higher in patients in the LMA group (40.5 vs. 38.5 mmHg, P < 0.001), the pH and PFR values of the two groups were comparable. The incidence of PPC was similar.

Conclusion: During prolonged laparoscopic abdominal surgery, second-generation LMA facilitates adequate intraoperative gas exchange and may serve as an alternative to ETT.

简介:喉罩气道(LMA)用于紧急情况下气道维持困难的情况，尽管其优于气管内插管(ETT)，但很少用于长时间的手术。在本研究中，我们对长时间腹腔镜腹部手术中第二代LMA和ETT的术中气体交换进行了比较分析。方法:延长手术时间定义为手术时间超过2小时。回顾性分析了394例经第二代LMA或ETT行腹腔镜肝切除术的患者。比较两组患者术中二氧化碳末潮压(ETCO2)、潮气量(TV)、呼吸频率(RR)、吸气峰压(PIP)、动脉二氧化碳分压(PaCO2)、pH、动脉氧分压与吸气分氧之比(PFR)。此外，还比较了术后肺部并发症(PPCs)的发生率，包括肺误吸。结果:两组患者气腹期间ETCO2、TV、RR、PIP值具有可比性。虽然LMA组患者诱导后2 h PaCO2较高(40.5 vs 38.5 mmHg, P < 0.001)，但两组的pH和PFR值具有可比性。PPC的发生率相似。结论:在长时间腹腔镜腹部手术中，第二代LMA可促进术中气体交换，可作为ETT的替代方案。

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引用次数: 2

Pelvic inflammatory disease with obstructive complications: two cases and a literature review. 盆腔炎伴阻塞性并发症:2例并文献复习。

IF 2.7 4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-01 DOI: 10.11622/smedj.2022021

Grace Ming Fen Chan, Lionel Hon Wai Lum, Pearl Shuang Ye Tong

引用次数: 0

Impact of nationwide COVID-19 lockdown on workload and injury patterns of major trauma cases in a regional trauma centre in Singapore. 全国COVID-19封锁对新加坡区域创伤中心重大创伤病例工作量和损伤模式的影响。

IF 2.7 4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-01 DOI: 10.11622/smedj.2021131

Min Li Kang, Woan Wui Lim, Daniel Jin Keat Lee, Jerry Tiong Thye Goo

Introduction: Singapore instituted lockdown measures from 7 February 2020 to 1 June 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic.

Methods: A retrospective analysis of cases from the national trauma registry was carried out comparing the lockdown period (from 7 February 2020 to 1 June 2020) to the pre-lockdown period (from 7 February 2019 to 1 June 2019). Data extracted included the volume of Tier 1 (injury severity score [ISS] >15) and Tier 2 (ISS 9-15) cases and epidemiology. Subgroup analysis was performed for Tier 1 patient outcomes.

Results: Trauma volume decreased by 19.5%, with a 32% drop in Tier 1 cases. Road traffic and workplace accidents decreased by 50% (P < 0.01), while interpersonal violence showed an increase of 37.5% (P = 0.34). There was an 18.1% decrease in usage of trauma workflows (P = 0.01), with an increase in time to intervention for Tier 1 patients from 88 to 124 min (P = 0.22). Discharge to community facilities decreased from 31.4% to 17.1% (P < 0.05). There was no increase in inpatient mortality, length of stay in critical care or length of stay overall.

Conclusion: There was an overall decrease in major trauma cases during the lockdown period, particularly road traffic accidents and worksite injuries, and a relative increase in interpersonal violence. Redeployment of manpower and hospital resources may have contributed to decreased usage of trauma workflows and community facilities. In the event of further lockdowns, it is necessary to plan for trauma coverage and maintain the use of workflows to facilitate early intervention.

导言:为应对2019年冠状病毒病(COVID-19)大流行，新加坡于2020年2月7日至2020年6月1日实施了封锁措施。方法:对国家创伤登记处的病例进行回顾性分析，将封锁期间(2020年2月7日至2020年6月1日)与封锁前(2019年2月7日至2019年6月1日)进行比较。提取的数据包括1级(损伤严重程度评分[ISS] >15)和2级(ISS 9-15)病例的数量和流行病学。对1级患者的预后进行亚组分析。结果:创伤体积减少19.5%，其中一级病例减少32%。道路交通事故和工伤事故下降了50% (P < 0.01)，人际暴力增加了37.5% (P = 0.34)。创伤工作流程的使用减少了18.1% (P = 0.01)，一级患者的干预时间从88分钟增加到124分钟(P = 0.22)。社区设施排污量由31.4%降至17.1% (P < 0.05)。住院死亡率、重症监护住院时间或总体住院时间均未增加。结论:在封锁期间，以道路交通事故和工地伤害为主的重大创伤案件总体减少，人际暴力事件相对增加。人力和医院资源的重新部署可能有助于减少对创伤工作流程和社区设施的使用。在进一步封锁的情况下，有必要制定创伤覆盖计划，并保持使用工作流程，以促进早期干预。

{"title":"Impact of nationwide COVID-19 lockdown on workload and injury patterns of major trauma cases in a regional trauma centre in Singapore.","authors":"Min Li Kang, Woan Wui Lim, Daniel Jin Keat Lee, Jerry Tiong Thye Goo","doi":"10.11622/smedj.2021131","DOIUrl":"10.11622/smedj.2021131","url":null,"abstract":"Introduction: Singapore instituted lockdown measures from 7 February 2020 to 1 June 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic.Methods: A retrospective analysis of cases from the national trauma registry was carried out comparing the lockdown period (from 7 February 2020 to 1 June 2020) to the pre-lockdown period (from 7 February 2019 to 1 June 2019). Data extracted included the volume of Tier 1 (injury severity score [ISS] >15) and Tier 2 (ISS 9-15) cases and epidemiology. Subgroup analysis was performed for Tier 1 patient outcomes.Results: Trauma volume decreased by 19.5%, with a 32% drop in Tier 1 cases. Road traffic and workplace accidents decreased by 50% (P < 0.01), while interpersonal violence showed an increase of 37.5% (P = 0.34). There was an 18.1% decrease in usage of trauma workflows (P = 0.01), with an increase in time to intervention for Tier 1 patients from 88 to 124 min (P = 0.22). Discharge to community facilities decreased from 31.4% to 17.1% (P < 0.05). There was no increase in inpatient mortality, length of stay in critical care or length of stay overall.Conclusion: There was an overall decrease in major trauma cases during the lockdown period, particularly road traffic accidents and worksite injuries, and a relative increase in interpersonal violence. Redeployment of manpower and hospital resources may have contributed to decreased usage of trauma workflows and community facilities. In the event of further lockdowns, it is necessary to plan for trauma coverage and maintain the use of workflows to facilitate early intervention.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":null,"pages":null},"PeriodicalIF":2.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10754364/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39494807","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Vaccine administration during COVID-19 pandemic: an overview of safe injection technique and local complications COVID-19大流行期间的疫苗接种:安全注射技术和局部并发症概述

4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-01 DOI: 10.4103/singaporemedj.smj-2022-059

Wen Loong Paul Yuen, Yuen Khong Keith Chong, Choon How How, Sir Young James Loh

Opening Vignette Madam Tan, a 65-year-old housewife, visited your clinic for left shoulder pain. The pain started 1 day after she was vaccinated in her left shoulder at a vaccination drive. Your initial assessment was that of postinjection site pain. You prescribed her with a course of nonsteroidal anti-inflammatory drugs (NSAIDs) and advised rest. She returned a week later with worsening and severe pain over her left shoulder, which affected her daily activities. Clinical examination showed generalised tenderness and effusion over her left shoulder joint with limited range of motion. Madam Tan recollected that she felt the injection had been given ‘too high and too deep’. Due to the temporal nature of the symptoms, you suspected that her shoulder pain could be related to vaccine administration. Due to the progressing severity of the symptoms, you referred her to a tertiary hospital for orthopaedic evaluation.HOW RELEVANT IS THIS TO MY PRACTICE? Vaccination is a procedure routinely performed by doctors and nurses in the primary healthcare setting. In the adult population, the most common site for vaccination is the deltoid muscle. The deltoid muscle is preferred due to its size and ease of exposure and administration on a seated patient in the clinic setting. The vaccine needs to be administered with the proper technique to maximise its efficacy and minimise the risk of an adverse event at the injection site. During the coronavirus disease 2019 (COVID-19) pandemic, large-scale vaccination programmes were held, and a potential rise in complications from vaccinations is expected. Therefore, it is important to have in place safe and competent vaccination practices. WHAT TO EXPECT AT THE INJECTION SITE? Common symptoms postinjection include induration, erythema and pain at the injection side. These symptoms are usually self-limiting and resolve spontaneously over a week. More serious complications, such as shoulder injury related to vaccine administration (SIRVA), are rare. There is a spectrum of shoulder pathologies contributed by poor injection techniques. It includes traumatic injury or inappropriate administration of vaccine material into the subdeltoid bursa or shoulder joint, leading to an inflammatory cascade and damage to the surrounding structures. The first local case of SIRVA complication following COVID-19 vaccination was reported in 2021.[1] WHAT CAN I DO IN MY PRACTICE? It is important that the family physician or nursing practitioner perform safe vaccination for each patient. To achieve this, good working knowledge of the following is necessary: (a) shoulder anatomy and surface landmarking; (b) appropriate needle selection; (c) safe injection technique; (d) alternate injection site; and (e) approach to postvaccination injection site and shoulder pain. It is recommended to counsel the patient about common local site reactions, such as induration, pain and erythema, and red flags suggestive of more serious complications. Shoulder anatomy

开场小品谭女士，一位65岁的家庭主妇，因左肩疼痛来您的诊所就诊。在接种疫苗后1天，她左肩开始疼痛。你最初的评估是注射后部位疼痛。你给她开了一个疗程的非甾体抗炎药(NSAIDs)并建议她休息。一周后，她回到医院，左肩疼痛加剧，影响了她的日常活动。临床检查显示左肩关节普遍压痛和积液，活动范围有限。谭女士回忆说，她觉得注射得“太高太深”。鉴于症状的暂时性，你怀疑她的肩痛可能与注射疫苗有关。由于她的症状越来越严重，你建议她去三级医院做骨科评估。这和我的执业有什么关系?疫苗接种是初级卫生保健机构中医生和护士的例行程序。在成人人群中，最常见的接种部位是三角肌。三角肌是首选，因为它的大小和易于暴露和给药，在临床设置的坐着的病人。需要采用适当的技术接种疫苗，以最大限度地发挥其效力，并尽量减少注射部位发生不良事件的风险。在2019年冠状病毒病(COVID-19)大流行期间，开展了大规模疫苗接种规划，预计疫苗接种并发症可能会增加。因此，重要的是要有安全和合格的疫苗接种做法。注射部位会发生什么?注射后常见症状包括注射侧硬化、红斑和疼痛。这些症状通常是自限性的，并在一周内自行消退。更严重的并发症，如与疫苗接种相关的肩伤(SIRVA)，是罕见的。不良的注射技术导致了一系列的肩部病变。它包括外伤性损伤或不适当地将疫苗材料注射到三角肌下滑囊或肩关节，导致炎症级联反应和周围结构损伤。2021年报告了首例COVID-19疫苗接种后SIRVA并发症的本地病例。[1]在我的实践中我能做些什么?重要的是，家庭医生或护理从业人员进行安全接种每个病人。要做到这一点，以下方面的良好工作知识是必要的:(a)肩部解剖和表面地标;(b)合适的针头选择;(c)安全注射技术;(d)备选注射部位;(e)疫苗接种后注射部位及肩部疼痛的处理方法。建议咨询患者常见的局部反应，如硬化、疼痛和红斑，以及提示更严重并发症的危险信号。三角肌是覆盖在盂肱关节上的一块巨大的三角形肌肉。肌肉起源于锁骨，肩峰和肩胛骨的外侧三分之一，并插入肱骨的三角粗隆。在三角肌注射中有几个潜在的结构可能受损[图1]。注射针的目的是在不损伤周围组织的情况下将疫苗注射到三角肌的肌肉中。三角肌位于皮肤和皮下脂肪层之下。当患者皮下层非常厚时，短针可能导致疫苗沉积仅限于这一层，并引起不必要的皮肤反应，如皮下结节、无菌脓肿、脂肪萎缩和皮下肺气肿。[2]肩峰下滑囊延伸至肩峰外侧边缘远端3 - 6厘米，而三角下滑囊位于三角肌块下方。[3]当针头指向“太高”或“太深”时，不适当地注射到这些交通滑囊会导致滑囊炎。有损伤危险的两种神经包括桡神经和腋窝神经前支。有报道称，当注射位置过后时，桡神经损伤，当神经斜绕肱骨近端进入螺旋沟时受损。[2]当注射太近和太深时，它会导致腋窝神经的前支受伤，因为它缠绕在肱骨的手术颈部。针头接触肱骨近端处的深度注射可导致骨挫伤和骨坏死。图1:肩关节解剖图显示了三角肌注射时可能损伤的结构。必须注意确定正确的进入点，并选择合适大小的针头，以达到最佳的组织穿透(最低针头)。与三角肌注射类似，注射区域(大腿和腿部)应充分暴露。注射部位位于大腿外侧的大转子和股骨外侧髁之间一条线的中间三分之一处。注射时也应与皮肤呈90°角。[6]注射部位疼痛和压痛是接种疫苗后常见的主诉，但通常是轻度和自限性的。[1,7]通常报道的疫苗接种局部症状包括肌肉疼痛、皮肤红斑或硬化，它们通常不影响肩部的活动范围或功能[8]。更为严重的并发症是SIRVA，通常表现为严重的肩部疼痛、虚弱和肩关节活动范围减小等症状，这些症状在接种疫苗后可能持续数月。[7-9] SIRVA的体格检查结果与其他常规肩部损伤相似，其标志性特征是症状和体征通常在接种疫苗后48小时内出现，并且不能通过常规止痛药改善[4]。常规x线片对SIRVA的诊断作用有限，但对排除其他病理是有用的。[10]磁共振成像(MRI)可用于评估疑似SIRVA病例。SIRVA患者的典型MRI表现包括肩峰下滑囊炎、关节滑膜炎、粘连性囊炎和肩袖损伤。[1,11]对于SIRVA的最佳治疗方法尚无共识。目前主要的治疗方法包括非甾体类抗炎药、物理治疗和关节内皮质类固醇注射。[3]保守治疗难治性的病例可能需要手术。[12]据报道，无论是保守治疗还是手术治疗，SIRVA患者的病情都只有适度的改善。[13]只有四分之一到三分之一的患者完全康复，相当一部分患者有残留症状。[7,10]我什么时候应该看专科医生?初级保健提供者在我们当地的疫苗接种规划中发挥着关键作用，当患者因并发症返回时，往往是第一个作出反应的人。危险信号症状包括严重的肩部疼痛，接种疫苗后出现的活动范围有限和虚弱，通常在休息和止痛后仍持续存在。这样的表现需要专家的进一步检查和管理。肌内三角肌疫苗接种是初级保健机构的常见程序，我们需要采取必要措施确保疫苗接种安全有效。安全肌内注射三角肌疫苗的步骤包括适当的患者体位、暴露注射部位、适当的针头选择、识别表面标志和安全注射技术。重要的是教育患者接种疫苗后的局部反应和危险信号症状。疑似SIRVA的患者应转诊给专科医生作进一步评估。一位骨科医生检查了谭女士，她的左肩MRI显示广泛的肩峰下滑囊炎和肩袖肌腱炎伴关节积液。鉴于其症状的时间性质(肌内三角肌注射48小时后开始)和MRI表现，诊断为SIRVA。保守治疗:镇痛(包括非甾体抗炎药)和物理治疗。经过一年的康复，她能够进行日常活动了。财政支持及赞助无。利益冲突CH是SMJ编辑委员会的成员。SMC 3B类CME课程在线测试:https://www.sma.org.sg/cme-programme截止提交日期:2023年12月7日

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引用次数: 0

Atypical presentation of COVID-19 with abdominal pain and no respiratory symptoms: a case series. COVID-19的非典型表现，腹痛，无呼吸道症状:病例系列

IF 2.7 4区医学 Q2 Medicine

Singapore medical journal

Pub Date : 2023-11-01 DOI: 10.11622/smedj.2021196

Pei Hua Lee, Stephanie Sutjipto, Hock Foong Lui, Kalisvar Marimuthu, Mona Manghani, Serene Si Ning Goh, Huimin Liu, Shawn Vasoo

引用次数: 0