Pub Date : 2023-11-09DOI: 10.4103/singaporemedj.smj-2022-222
Rugaiyah Fuad Alkhatib, Robert Chun Chen, CAQ Neuroradiology, Benjamin Wei Heng Sing, Sarat Kumar Sanamandra
Dear Sir, While abducens nerve palsy is commonly seen in clinical practice, abducens nerve palsy secondary to an avulsion injury is uncommon. In a retrospective study documenting the causes of abducens nerve palsy, only up to 3.1% were attributed to trauma; the most common cause in adults was related to vascular ischaemia.[1] Unilateral abducens nerve palsy is found in only 1%–2.7% of all head traumas.[2] Here, we present a case of unilateral abducens nerve injury following trauma. A 60-year-old woman with no significant medical history was involved in a road traffic accident. Initial computed tomography (CT) of the brain revealed bilateral acute subarachnoid haemorrhage, as well as an acute subdural haemorrhage along the posterior interhemispheric falx. Multiple facial bone fractures were identified [Figure 1], including fractures of both orbital floors and lateral walls, lamina papyracea, maxilla and left zygomatic process. No fracture was identified along the course of the left abducens nerve. Of note, the left petrous apex in the region of Dorello’s canal, cavernous sinus and lateral rectus muscle appeared unremarkable.Figure 1: Axial CT images in the bone windows. (a) Acute fractures of both lateral orbital walls, lamina papyracea and left zygomatic process (circles). (b) There is also an acute fracture of the left lateral sphenoid wall (circle). Of note, the left petrous apex appears unremarkable, with no acute fracture.The patient subsequently underwent open reduction internal fixation of both zygomaticomaxillary complex fractures with left orbital floor reconstruction 26 days after the accident. Intraoperatively, forced duction test did not reveal any restriction on eye movement. Postoperatively, it was noted that the patient possessed signs of left abducens nerve palsy, with persistent medial deviation and failure of abduction of the left eye. These were likely not detected during the initial few weeks in view of extensive periorbital soft tissue swelling from the facial and orbital fractures, which resolved after surgical fixation. Contrast-enhanced CT of the brain did not demonstrate any new finding to explain the left abducens nerve palsy. Magnetic resonance imaging of the brain and orbits, including a three-dimensional constructive interference in steady-state (3D CISS) sequence of the cranial nerves was performed 35 days after the accident. This showed a discontinuous left abducens nerve in the prepontine cistern, with subtle linear enhancement corresponding to its root exit zone [Figure 2]. Findings pointed towards a traumatic unilateral left abducens nerve avulsion injury resulting from the road traffic accident. An iatrogenic aetiology of the left abducens nerve avulsion was deemed less likely, as the surgery was mainly focused on facial and orbital fracture repairs, with no surgical intervention performed along the course of the left abducens nerve. The patient was subsequently referred to ophthalmology and managed conservativel
{"title":"Unilateral abducens nerve avulsion injury following trauma","authors":"Rugaiyah Fuad Alkhatib, Robert Chun Chen, CAQ Neuroradiology, Benjamin Wei Heng Sing, Sarat Kumar Sanamandra","doi":"10.4103/singaporemedj.smj-2022-222","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-222","url":null,"abstract":"Dear Sir, While abducens nerve palsy is commonly seen in clinical practice, abducens nerve palsy secondary to an avulsion injury is uncommon. In a retrospective study documenting the causes of abducens nerve palsy, only up to 3.1% were attributed to trauma; the most common cause in adults was related to vascular ischaemia.[1] Unilateral abducens nerve palsy is found in only 1%–2.7% of all head traumas.[2] Here, we present a case of unilateral abducens nerve injury following trauma. A 60-year-old woman with no significant medical history was involved in a road traffic accident. Initial computed tomography (CT) of the brain revealed bilateral acute subarachnoid haemorrhage, as well as an acute subdural haemorrhage along the posterior interhemispheric falx. Multiple facial bone fractures were identified [Figure 1], including fractures of both orbital floors and lateral walls, lamina papyracea, maxilla and left zygomatic process. No fracture was identified along the course of the left abducens nerve. Of note, the left petrous apex in the region of Dorello’s canal, cavernous sinus and lateral rectus muscle appeared unremarkable.Figure 1: Axial CT images in the bone windows. (a) Acute fractures of both lateral orbital walls, lamina papyracea and left zygomatic process (circles). (b) There is also an acute fracture of the left lateral sphenoid wall (circle). Of note, the left petrous apex appears unremarkable, with no acute fracture.The patient subsequently underwent open reduction internal fixation of both zygomaticomaxillary complex fractures with left orbital floor reconstruction 26 days after the accident. Intraoperatively, forced duction test did not reveal any restriction on eye movement. Postoperatively, it was noted that the patient possessed signs of left abducens nerve palsy, with persistent medial deviation and failure of abduction of the left eye. These were likely not detected during the initial few weeks in view of extensive periorbital soft tissue swelling from the facial and orbital fractures, which resolved after surgical fixation. Contrast-enhanced CT of the brain did not demonstrate any new finding to explain the left abducens nerve palsy. Magnetic resonance imaging of the brain and orbits, including a three-dimensional constructive interference in steady-state (3D CISS) sequence of the cranial nerves was performed 35 days after the accident. This showed a discontinuous left abducens nerve in the prepontine cistern, with subtle linear enhancement corresponding to its root exit zone [Figure 2]. Findings pointed towards a traumatic unilateral left abducens nerve avulsion injury resulting from the road traffic accident. An iatrogenic aetiology of the left abducens nerve avulsion was deemed less likely, as the surgery was mainly focused on facial and orbital fracture repairs, with no surgical intervention performed along the course of the left abducens nerve. The patient was subsequently referred to ophthalmology and managed conservativel","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" 13","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135291099","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}
Pub Date : 2023-11-09DOI: 10.4103/singaporemedj.smj-2022-132
Jinghao Nicholas Ngiam, Tze Sian Liong, Thanawin Pramotedham, Ching-Hui Sia, Eric Jou, William Kok-Fai Kong, Kian-Keong Poh
Abstract Vortex formation during left ventricular diastolic filling may provide clinically useful insights into cardiac health. In recent years, there has been growing interest in the measurement of vortex formation time (VFT), especially because it is derived noninvasively. There are important applications of VFT in valvular heart disease, athletic physiology, heart failure and hypertrophic cardiomyopathy. The formation of the vortex as fluid propagates into the left ventricle from the left atrium is important for efficient fluid transport. Quantifying VFT may thus help in evaluating and understanding disease and pathophysiological processes.
{"title":"Left ventricular vortex formation time: emerging clinical applications and limitations","authors":"Jinghao Nicholas Ngiam, Tze Sian Liong, Thanawin Pramotedham, Ching-Hui Sia, Eric Jou, William Kok-Fai Kong, Kian-Keong Poh","doi":"10.4103/singaporemedj.smj-2022-132","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-132","url":null,"abstract":"Abstract Vortex formation during left ventricular diastolic filling may provide clinically useful insights into cardiac health. In recent years, there has been growing interest in the measurement of vortex formation time (VFT), especially because it is derived noninvasively. There are important applications of VFT in valvular heart disease, athletic physiology, heart failure and hypertrophic cardiomyopathy. The formation of the vortex as fluid propagates into the left ventricle from the left atrium is important for efficient fluid transport. Quantifying VFT may thus help in evaluating and understanding disease and pathophysiological processes.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" 43","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135290961","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}
Pub Date : 2023-11-03DOI: 10.4103/singaporemedj.smj-2022-072
Zainura Che Isa, Jo Anne Lim, Amelia Mohamed Ain, Fatin Aliaa Othman, Yee Cheng Kueh, Mei Mei Tew, Maz Jamilah Masnan, Aznita Ibrahim
Abstract Introduction: Dengue is endemic in tropical countries. Severe dengue has a high risk of morbidity and mortality. We aimed to identify factors associated with dengue survival among our intensive care unit (ICU) patients. Methods: A retrospective study was conducted among dengue cases admitted to the ICU of Hospital Sultan Abdul Halim, Kedah, Malaysia from 2016 to 2019. Results: Out of 1,852 dengue cases admitted to the hospital, 7.2% of patients required ICU admission. Survival rate was 88.6% among severe dengue cases. The majority of severe dengue patients were obese, while other notable comorbidities included hypertension and diabetes mellitus. Also, 73% of patients presented in the critical phase, at a median of Day 4 of illness. All patients admitted to the ICU had a history of fever. The predominant warning signs were lethargy, fluid accumulation and haemoconcentration with rapid platelet reduction. Among nonsurvivors, 69.2% had fulminant hepatitis, 53.8% had massive bleeding or disseminated intravascular coagulation, 38.5% had haemophagocytic lymphohistiocytosis and 30.8% had myocarditis. The predominant serotypes were DENV-3 and DENV-1. The least number of cases was seen in 2017, when all serotypes were equally presented. Multiple logistic regression showed that Sequential Organ Failure Assessment (SOFA) score, peak international normalised ratio, peak partial thromboplastin time and aspartate aminotransferase on admission were independent risk factors for survival. This model had an area under the curve of 0.98, giving an overall 98.2% accuracy. Conclusions: Specific warning signs and blood investigations in dengue patients may aid in early decision for ICU admission. Monitoring of SOFA scores plus coagulation and liver enzyme profiles could improve dengue survival rates.
{"title":"Clinical profiles and predictors of survival in severe dengue cases","authors":"Zainura Che Isa, Jo Anne Lim, Amelia Mohamed Ain, Fatin Aliaa Othman, Yee Cheng Kueh, Mei Mei Tew, Maz Jamilah Masnan, Aznita Ibrahim","doi":"10.4103/singaporemedj.smj-2022-072","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-072","url":null,"abstract":"Abstract Introduction: Dengue is endemic in tropical countries. Severe dengue has a high risk of morbidity and mortality. We aimed to identify factors associated with dengue survival among our intensive care unit (ICU) patients. Methods: A retrospective study was conducted among dengue cases admitted to the ICU of Hospital Sultan Abdul Halim, Kedah, Malaysia from 2016 to 2019. Results: Out of 1,852 dengue cases admitted to the hospital, 7.2% of patients required ICU admission. Survival rate was 88.6% among severe dengue cases. The majority of severe dengue patients were obese, while other notable comorbidities included hypertension and diabetes mellitus. Also, 73% of patients presented in the critical phase, at a median of Day 4 of illness. All patients admitted to the ICU had a history of fever. The predominant warning signs were lethargy, fluid accumulation and haemoconcentration with rapid platelet reduction. Among nonsurvivors, 69.2% had fulminant hepatitis, 53.8% had massive bleeding or disseminated intravascular coagulation, 38.5% had haemophagocytic lymphohistiocytosis and 30.8% had myocarditis. The predominant serotypes were DENV-3 and DENV-1. The least number of cases was seen in 2017, when all serotypes were equally presented. Multiple logistic regression showed that Sequential Organ Failure Assessment (SOFA) score, peak international normalised ratio, peak partial thromboplastin time and aspartate aminotransferase on admission were independent risk factors for survival. This model had an area under the curve of 0.98, giving an overall 98.2% accuracy. Conclusions: Specific warning signs and blood investigations in dengue patients may aid in early decision for ICU admission. Monitoring of SOFA scores plus coagulation and liver enzyme profiles could improve dengue survival rates.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"29 4","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135873724","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}
Pub Date : 2023-11-03DOI: 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.
{"title":"Comments on: Return to work after surgically treated pelvic ring fractures in Singapore","authors":"Anne HY Goei, Alvin KW Tan, David Koh","doi":"10.4103/singaporemedj.smj-2023-226","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2023-226","url":null,"abstract":"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.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"29 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135873726","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}
Pub Date : 2023-11-03DOI: 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。
{"title":"Routine preoperative screening computed tomography of the thorax for cardiac surgery","authors":"Jai Ajitchandra Sule, Xue Wei Chan, Hari Kumar Sampath, Hai Dong Luo, Mofassel Uddin Ahmed, Giap Swee Kang","doi":"10.4103/singaporemedj.smj-2021-416","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2021-416","url":null,"abstract":"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.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"32 3","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135873122","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}
Pub Date : 2023-11-01DOI: 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
{"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":"88 12","pages":"0"},"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}
Clare Anne Yoke Kum Fong, Benjamin Wei Liang Tung, Weiqin Lin, Kay Choong See
{"title":"Malignant arrhythmia in a COVID-19 patient with a structurally normal heart.","authors":"Clare Anne Yoke Kum Fong, Benjamin Wei Liang Tung, Weiqin Lin, Kay Choong See","doi":"10.11622/smedj.2021191","DOIUrl":"10.11622/smedj.2021191","url":null,"abstract":"","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" ","pages":"683-686"},"PeriodicalIF":2.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10754366/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39854520","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}
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。
{"title":"Second-generation laryngeal mask airway as an alternative to endotracheal tube in prolonged laparoscopic abdominal surgery: a comparative analysis of intraoperative gas exchanges.","authors":"Sukhee Park, Ja Eun Lee, Gyu Sung Choi, Jong Man Kim, Justin Sangwook Ko, Duck Hwan Choi, Gaab Soo Kim","doi":"10.11622/smedj.2021143","DOIUrl":"10.11622/smedj.2021143","url":null,"abstract":"<p><strong>Introduction: </strong>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.</p><p><strong>Methods: </strong>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 (ETCO<sub>2</sub>), tidal volume (TV), respiratory rate (RR), peak inspiratory pressure (PIP), arterial partial pressure of carbon dioxide (PaCO<sub>2</sub>), 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.</p><p><strong>Results: </strong>The values of ETCO<sub>2</sub>, TV, RR and PIP during pneumoperitoneum were comparable between the two groups. Although PaCO<sub>2</sub> 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.</p><p><strong>Conclusion: </strong>During prolonged laparoscopic abdominal surgery, second-generation LMA facilitates adequate intraoperative gas exchange and may serve as an alternative to ETT.</p>","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" ","pages":"651-656"},"PeriodicalIF":2.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10754369/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39494805","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}
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.
{"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":"<p><strong>Introduction: </strong>Singapore instituted lockdown measures from 7 February 2020 to 1 June 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic.</p><p><strong>Methods: </strong>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.</p><p><strong>Results: </strong>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.</p><p><strong>Conclusion: </strong>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.</p>","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" ","pages":"677-682"},"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}
Pub Date : 2023-11-01DOI: 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
{"title":"Vaccine administration during COVID-19 pandemic: an overview of safe injection technique and local complications","authors":"Wen Loong Paul Yuen, Yuen Khong Keith Chong, Choon How How, Sir Young James Loh","doi":"10.4103/singaporemedj.smj-2022-059","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-059","url":null,"abstract":"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","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"22 8","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135510333","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}
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