Capsular warning syndrome-a case of atrial fibrillation and corona radiata infarct.

BACKGROUND: Capsular warning syndrome (CWS) is a rare clinical syndrome characterised by recurrent and transient episodes of focal neurological deficits with high risk of infarction. The exact physiological mechanism of CWS remains unclear but is most commonly believed to be a result of haemodynamic insufficiency in diseased, small penetrating vessels. There are no defined treatment guidelines or established effective therapy. CASE PRESENTATION: We describe the case of a 65-year-old man who presented to the emergency department with recurrent episodes of dysarthria coupled with right facial droop and right-sided weakness. Symptoms recurred a total of ten times within a span of 3 h. He had new onset atrial fibrillation. An initial cerebral angiogram showed mild intracranial atherosclerotic disease with no proximal large vessel occlusion or acute infarct. Magnetic resonance imaging 1 h later demonstrated an infarct in the left corona radiata. CONCLUSIONS: This case illustrates an uncommon etiology of CWS. We will also discuss the lack of consensus in treatment options for CWS to mitigate a complete stroke.

The use of a formative OSCE to prepare emergency medicine residents for summative OSCEs: a mixed-methods cohort study.

BACKGROUND: The objective structured clinical examination (OSCE) is a part of emergency medicine (EM) examinations such as the Masters of Medicine in Emergency Medicine (MMed) examination and the equivalent Member of the Royal College of Emergency Medicine (MRCEM) examination. The use of formative OSCEs to prepare EM residents for summative OSCEs has not been investigated. This study aimed to evaluate the role of formative OSCEs in preparing EM residents for the MMed and MRCEM OSCE. METHODS: This was an observational, retrospective, mixed-methods cohort study. We analysed data from formative OSCEs conducted by the National Healthcare Group EM residency programme from 2013 to 2019, and from a questionnaire distributed to all residents during the study period. Residents' formative OSCE participation and scores were compared with first-attempt summative OSCE success. Qualitative analysis of residents' opinions on the usefulness of the formative OSCE was performed. RESULTS: Forty-three of the 50 (86.0%) residents attended at least one formative OSCE. Of the 46 who responded to the questionnaire, 40 (87.0%) had attempted and succeeded in the MMed or MRCEM OSCE, of whom 35 (87.5%) had succeeded on the first attempt. Residents who succeeded in the summative OSCE on the first attempt tended to have higher proximate (mean = 70.6, SD = 8.9 vs mean = 64.3, SD = 10.8) and mean (mean = 67.4, SD = 7.1 vs mean = 62.8, SD = 7.3) formative OSCE scores. All 8/40 (20.0%) residents who attended more than three formative OSCEs succeeded in the summative OSCE on their first attempt. Residents' formative OSCE scores tended to improve with successive formative OSCEs, demonstrating a positive training effect. All residents felt that the formative OSCE was useful in preparing them for the summative OSCE. CONCLUSIONS: Participation in multiple formative OSCEs was beneficial in preparing residents for the summative OSCE. The formative OSCE was useful in familiarising residents with the examination, giving them an opportunity to perform in near-examination conditions, and providing feedback to residents and faculty about their progress. Our findings may support the implementation of formative OSCEs in other training programmes to prepare learners for high-stake summative OSCEs.

Infected native aortic aneurysm with spondylodiscitis in an elderly septic man with back pain.

Infected aortic aneurysm is a rare disease and is often overlooked as a source of infection in septic elderly patients. We present a case of a septic elderly man with a ruptured infected aortic aneurysm caused by Salmonella enteritidis This condition was treated non-surgically with percutaneous endovascular aneurysm repair and antibiotics. The postoperative recovery was complicated a month later by spondylodiscitis and psoas abscess. He underwent radiologically guided drainage of the psoas abscess and was placed on lifelong suppressive antibiotics. We discuss the aetiology, treatment options and complications of this condition.

Singapore Advanced Cardiac Life Support Guidelines 2021.

Advanced cardiac life support (ACLS) emphasises the use of advanced airway management and ventilation, circulatory support and the appropriate use of drugs in resuscitation, as well as the identification of reversible causes of cardiac arrest. Extracorporeal cardiopulmonary resuscitation and organ donation, as well as special circumstances including drowning, pulmonary embolism and pregnancy are addressed. Resuscitation does not end with ACLS but must continue in post-resuscitation care. ACLS also covers the recognition and management of unstable pre-arrest tachy- and bradydysrhythmias that may deteriorate further.

A national trauma database analysis of alcohol- associated injuries.

INTRODUCTION: Knowledge of the pattern of alcohol-associated injury (AAI) is lacking in Singapore. We aimed to determine the local demographic pattern, injury mechanism, injury severity and outcomes of AAI. METHODS: Data on trauma cases presenting to emergency departments in 2012-2013 was extracted from the National Trauma Registry. Cases with missing data fields and those aged 1-15 years were excluded. Patients were classified as alcohol positive (A+) or negative (A-) based on clinical assessment. The two groups' demographics, injury mechanism, injury severity, mortality and disposition were compared. Logistic regression analysis was used to determine independent associations with mortality. RESULTS: 105,468 trauma cases met the inclusion criteria. 3.9% were A+ and their peak age range was 25-44 years. The A+ group had more Indian males (p < 0.001), and significantly more assaults, self-harm and falls (p < 0.001). Injuries in the A+ group were more common in public areas and less common in homes, recreational facilities and workplaces. Outcomes in the A+ group showed higher mean Injury Severity Score and mortality (p < 0.001). Significantly more A+ patients were admitted to hospital but had shorter mean length of stay (p < 0.001). Multivariate logistic regression revealed age > 44 years and male gender as independent predictors of mortality. CONCLUSION: AAI in Singapore is associated with more severe injuries and resource utilisation. Using data from the registry, 'at risk' demographic groups are identified for targeted injury prevention. However, alcohol use is not an independent predictor of mortality in trauma cases.

Unusual case of acute urinary retention in a young female.

We report an unusual case of a 17-year-old young female presenting to the emergency department with varicella infection, acute urinary retention (AUR) and no other neurological deficits. An MRI of the spine confirmed the diagnosis of acute transverse myelitis. Positive serum IgG antibodies against varicella zoster virus (VZV) suggested a parainfectious aetiology. The patient eventually developed weakness and a sensory level from the third thoracic dermatome on day 2 of hospitalisation. Awareness that AUR can precede other neurological deficits in VZV transverse myelitis will prevent misdiagnosis and allow for the prompt treatment of this debilitating illness.

Advanced Cardiac Life Support: 2016 Singapore Guidelines.

The main areas of emphasis in the Advanced Cardiac Life Support (ACLS) guidelines are: early recognition of cardiac arrest and call for help; good-quality chest compressions; early defibrillation when applicable; early administration of drugs; appropriate airway management ensuring normoventilation; and delivery of appropriate post-resuscitation care to enhance survival. Of note, it is important to monitor the quality of the various care procedures. The resuscitation team needs to reduce unnecessary interruptions to chest compressions in order to maintain adequate coronary perfusion pressure during the ACLS drill. In addition, the team needs to continually look out for reversible causes of the cardiac arrest.

Seventeen years of life support courses for nurses: where are we now?

The Life Support Course for Nurses (LSCN) equips nurses with the resuscitation skills to be first responders in in-hospital cardiac arrests. Seventeen years after the initiation of the LSCN, a confidential cross-sectional Qualtrics™ survey was conducted in May 2016 on LSCN graduands to assess the following: confidence in nurse-initiated resuscitation post-LSCN; defibrillation experience and outcomes; and perceived barriers and usefulness of the LSCN. The majority of respondents reported that the course was useful and enhanced their confidence in resuscitation. Skills retention can be enhanced by organising frequent team-based resuscitation training. Resuscitation successes should be publicised to help overcome perceived barriers.

"Floating shoulder" injuries.

"Floating shoulder" is a rare injury complex resulting from high-energy blunt force trauma to the shoulder, resulting in scapulothoracic dissociation. It is commonly associated with catastrophic neurovascular injury. Two cases of motorcyclists with floating shoulder injuries are described.

Teaching and evaluating multitasking ability in emergency medicine residents - what is the best practice?

Multitasking is an essential skill to develop during Emergency Medicine (EM) residency. Residents who struggle to cope in a multitasking environment risk fatigue, stress, and burnout. Improper management of interruption has been causally linked with medical errors. Formal teaching and evaluation of multitasking is often lacking in EM residency programs. This article reviewed the literature on multitasking in EM to identify best practices for teaching and evaluating multitasking amongst EM residents. With the advancement in understanding of what multitasking is, deliberate attempts should be made to teach residents pitfalls and coping strategies. This can be taught through a formal curriculum, role modeling by faculty, and simulation training. The best way to evaluate multitasking ability in residents is by direct observation. The EM Milestone Project provides a framework by which multitasking can be evaluated. EM residents should be deployed in work environments commiserate with their multitasking ability and their progress should be graduated after identified deficiencies are remediated.

Newspaper media reporting of motor vehicle crashes in Singapore: an opportunity lost for injury prevention education?

Newspaper media advocacy can help steer public attention away from motor vehicle crash (MVC) injuries as a personal problem to that of a social and public health issue. If used properly, newspaper media is potentially a powerful mass educator on MVC prevention. However, there is often a conflict of interest in which newspapers, in an attempt to boost readership and revenue, may over-emphasize and sensationalize the human-interest aspect of an MVC story. The aim of this study is to examine newspaper articles of MVCs in Singapore to assess how our newspaper media coverage portray MVCs and identify factors that mitigate injury and educate the public on injury prevention measures. Details of the MVC were extracted from 12 months of newspaper coverage in Singapore. Two independent coders were used to establish inter-rater reliability. From 1 January to 31 December 2007, 201 articles about MVCs were published. About 74.1% of articles assigned blame to a particular road user, negligence on either road user was implied in 56.7% of articles, and road safety messages were mentioned in 8% of the articles. The mainstream communication tone used was positive for law enforcement (71.1%) and neutral towards injury prevention or road safety messages (89.1%). Newspaper media reporting of MVCs in Singapore generally does not include injury prevention messages or highlight injury-mitigating measures. This is a lost opportunity for public education. Collaboration between public health practitioners and newspaper media is required to address this issue.

Injuries to cargo area passengers of heavy goods vehicles.

Transporting manual labourers in the cargo area of heavy goods vehicles is a common practice in Singapore. Earlier studies have reported higher fatalities and more serious injuries in such unrestrained cargo area passengers compared with those sitting in the cabin of the vehicle. We conducted a case series of injured cargo area passengers presenting to the Emergency Department from 1 January 2006 to 31 December 2007. A total of 34 male casualties (mean age 29.7 years) were treated. They were injured in four separate heavy goods vehicle crashes during the study period. Patients who were nonresident manual labourers comprised 94.1%; 44.1% (15 patients) were ejected from the vehicle but despite this, the mean Injury Severity Score was 2.2 (SD 3.5). Three of the patients were admitted to hospital, with one patient (Injury Severity Score 22) requiring surgery and intensive care stay. The remaining patients were discharged from the Emergency Department, and there were no deaths. Six patients reattended the Emergency Department for unresolved pain from their injuries. A total of 173 absent-days were incurred. This report highlights the fact that cargo area passengers are at high risk of ejection, and they incur significant morbidity from their injuries with subsequent loss of productivity. In addition, heavy goods vehicle crashes are usually mass casualty events, severely taxing the receiving Emergency Department. Safer alternatives for mass transport of manual labourers are required.

Adapted motivational interviewing for women with binge eating disorder: a randomized controlled trial.

In this randomized controlled trial, 108 women with binge-eating disorder (BED) recruited from the community were assigned to either an adapted motivational interviewing (AMI) group (1 individual AMI session + self-help handbook) or control group (handbook only). They were phoned 4, 8, and 16 weeks following the initial session to assess binge eating and associated symptoms (depression, self-esteem, quality of life). Postintervention, the AMI group participants were more confident than those in the control group in their ability to change binge eating. Although both groups reported improved binge eating, mood, self-esteem, and general quality of life 16 weeks following the intervention, the AMI group improved to a greater extent. A greater proportion of women in the AMI group abstained from binge eating (27.8% vs. 11.1%) and no longer met the binge frequency criterion of the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) for BED (87.0% vs. 57.4%). AMI may constitute a brief, effective intervention for BED and associated symptoms.

Sleep disturbance in children with migraine.

The objectives of this study were to determine if (1) children with migraine experience greater sleep disturbances than their siblings, (2) those with more severe migraine have greater levels of sleep disruption, and (3) these sleep disturbances lead to greater behavioral problems and more missed school. Children aged 6 to 18 years with a diagnosis of migraine for > 6 months, who had at least one sibling without migraine in the same age range, were identified through our neurology clinic database or at the time of the clinic visit. Parents completed the (1) demographic, general health, and migraine information questionnaire; (2) Child Sleep Habits Questionnaire; and (3) Behavior Assessment System for Children: Second Edition (BASC-2) Parent Rating Scales for each child. Cases with migraine had higher total sleep (P < .02), sleep delay (P < .03), and daytime sleepiness scores (P < .001) than controls. Cases with more severe migraines had higher total sleep (P < .01) and sleep duration scores (P < .03) than those with milder headaches. In cases, higher total sleep scores predicted greater behavior problems on all four composite scales on the Behavior Assessment System for Children: Second Edition (Externalizing Problems, P < .05; Internalizing Problems, P < .005; Behavior Systems Index, P < .003; and Adaptability Skills, P < .006). We conclude that children with migraine are prone to greater sleep and behavioral disturbances than children without headache. Sleep disorders should be routinely queried and appropriate advice on sleep hygiene provided.

Moderate alcohol intake and motor vehicle crashes: the conflict between health advantage and at-risk use.

AIMS: To review the evidence on moderate alcohol intake and motor vehicle crash (MVC) risk, and discuss the possible public health tension in balancing risk reduction and increment with respect to moderate alcohol intake. METHOD: A Medline review was conducted on moderate alcohol intake, MVC, and cardiovascular disease (CVD) risks. RESULT: Moderate alcohol intake (24 g ethanol, two US standard drinks, or less a day) is associated with 20% reduction in risk of CVD. Public awareness of this may contribute to why rates of driving with blood alcohol content (BAC) <0.08 g/dl in the United States are static. Studies show 3- to 17-fold increased risk of a fatal MVC with BAC < 0.08 g/dl compared to sober drivers. The United States has 0.08 g/dl BAC laws, higher than that reached by a driver drinking two drinks per day or less. CONCLUSION: The public should be educated that although moderate alcohol drinking may not violate BAC laws, it still carries significant risk of MVC. Current BAC laws in some countries needs re-evaluation.

Complications of intercostal catheter insertion using EMST techniques for chest trauma.

BACKGROUND: The purpose of the present study was to determine the complication rates associated with intercostal catheter insertion (ICI) performed using Early Management of Severe Trauma (EMST) guidelines on trauma patients admitted through The Alfred Trauma Centre. METHODS: The Alfred Trauma Registry identified demographic and clinical data for patients who underwent ICI in the Alfred hospital following admission for trauma. The medical histories were subsequently reviewed for complications resulting from ICI. RESULTS: There were 211 ICI performed on 173 trauma patients at The Alfred Trauma Centre between July 2001 and June 2002. The mean injury severity score was 34. Mean age was 38 (range 15-82 years), with 77% of the patients being men. Chest injury was the result of blunt trauma in 90.2% and penetrating trauma in 9.8%. ICI occurred in the Trauma Centre (84%), operating theatre (6%), intensive care unit (9%) and in the general ward (1%). Eighty per cent of patients had a unilateral ICI. The indications for ICI were pneumothorax (45.7%), haemothorax (15.0%), haemopneumothorax (28.3%) and tension pneumothorax (7.5%). There were no insertional and 11 (5.2%) positional complications. The infection rate was 2.4% comprising two superficial and three deep (empyema thoraces) infections. No statistically significant association was found between infective complications and age, injury severity score (ISS), haemothorax, penetrating trauma, prehospital needle thoracostomy and time to ICI. There was no mortality arising from ICI complications. CONCLUSION: Intercostal catheter insertion for chest trauma performed in accordance with EMST guidelines has a low complication rate. Prehospital prophylactic chest decompression for ventilated patients with chest trauma, using a lateral rather than an anterior approach, may decrease the incidence of untreated tension pneumothorax.