Increasing the completion rate of the advance directives in primary care setting - a randomized controlled trial.

BACKGROUND: The completion rate of Advance Directives (ADs) has been low. This study aims to examine the effectiveness of two interventions 1) active counseling sessions coupled with passive patient education pamphlets, and 2) patient education pamphlets alone, compared with 3) control group (usual care), in increasing the completion rates of ADs in the primary care setting. METHODS: Multicenter randomised controlled trial in four public primary care clinics in Singapore under Singapore Health Services. Randomization was performed via block randomization with Sequential Numbered Opaque Sealed Envelopes. Participants were randomized into 1) active intervention group (both counseling by primary care physicians and patient education pamphlets) or 2) passive intervention group (only patient education pamphlets), and 3) control group (usual care) with follow-up at 6 weeks. The main outcome measure is the proportion of participants who completed / planned to complete) ADs six weeks post-intervention. RESULTS: Four hundred five participants were eligible to participate in the study. One hundred eighty-eight participants were recruited into the study (response rate = 46.4%), of which 158 completed the study. There was no significant difference between the control group, passive intervention group, and active intervention group, in terms of completion rates of ADs (29.4, 36.4, and 30.8% respectively). CONCLUSIONS: This randomized controlled trial did not support the use of patient education pamphlets with or without active counseling sessions in increasing the completion of ADs in a primary care setting in Singapore. The optimal intervention strategy depends on each health system's context and resources, taking into consideration patients' profiles, which deserves further studies. TRIAL REGISTRATION: Registered on April 17, 2018 clinicaltrials.gov ( NCT03499847 ).

Transient Neonatal Zinc Deficiency Caused by a Novel Mutation in the SLC30A2 Gene.

This is a case report of a 4-month-old full-term, fully breastfed boy who presented with a persistent periorificial and groin rash associated with poor weight gain and irritability. His serum zinc level was low. The mother's breast milk zinc level was found to be low despite her serum zinc levels being normal, confirming the diagnosis of transient neonatal zinc deficiency. Mutational analysis revealed a novel mutation in the mother's SLC30A2 gene, which encodes a zinc transporter expressed in mammary gland epithelial cells.

Relative Energy Deficiency in Sport (REDs) and knee injuries: current concepts for female athletes.

In athletes, a mismatch between caloric intake and energy expended in exercise can eventually lead to Relative Energy Deficiency in Sport (REDs), where the athlete suffers from physiological derangements and decreased sport performance. The prevalence of REDs is higher in females than males. Females are already at a higher risk of knee injuries, which has been attributed to a multitude of factors such as hormonal influences, differences in musculoskeletal anatomy and neuromuscular control compared to males. The literature demonstrates an even higher risk of knee injuries in female athletes with symptoms of REDs. We propose the various factors that influence this risk. A reduction in anabolic hormones can affect muscle development and tendon repair. A relationship between poor neuromuscular control and knee injury has been established, and this can be further worsened in patients with menstrual dysfunction. Chronic deficiency in nutrients such as collagen and vitamin D can result in poorer recovery from microtrauma in tendons and ligaments. All these factors may contribute to increasing the risk of knee injuries, which may include anterior cruciate ligament tears, patella tendinopathy and patellofemoral pain syndrome. This review aims to educate sports clinicians to have a high index of suspicion when treating knee injuries in females; to screen and then manage for REDs if present, for holistic patient care.

Risk Stratification of Paediatric Sports Injuries Seen at a Tertiary Hospital.

INTRODUCTION: In this study, we described paediatric sports injuries seen in the paediatric emergency department of a large, tertiary paediatric hospital in Singapore and evaluated risk factors for severe sports injuries. METHODS: This is a retrospective review of a paediatric trauma surveillance registry from February 2012 to October 2017, including patient demographics, type of sports, circumstances, type of injuries, and clinical management in the hospital. Patients 5 to 17 years old with a sports-related injury were included. We performed logistic regression to identify predictors of severe sports injuries (defined by Injury Severity Score of ≥9), injuries requiring hospitalisation, trauma team activation, resuscitation, or those that resulted in death. RESULTS: Among 10,951 patients analysed, the most common injuries sustained were fractures (4,819, 44.0%), sprains and contusions (3,334, 30.4%). For patients with severe injuries, the median length of hospital stay was 2 days (IQR 1-3 days), and time away from sports was 162 days (IQR 104-182 days). Predictors for severe injuries include transportation by emergency medical service (aOR 6.346, 95% CI 5.147-7.823), involvement in rugby (aOR 2.067, 95% CI 1.446-2.957), neurological injuries (aOR 4.585, 95% CI 2.393-4.365), dislocations (aOR 2.779, 95% CI 1.744-4.427), fractures (aOR 1.438, 95% CI 1.039-1.990), injuries to the head and neck (aOR 2.274, 95% CI 1.184-4.365), and injuries to the abdomen and pelvis (aOR 5.273, 95% CI 3.225-8.623). CONCLUSION: Predictors for severe sports injuries identified may aid in risk stratification and resource allocation.

A comparative study of anterior cruciate ligament reconstruction with double, single, or selective bundle techniques.

PURPOSE: Reconstruction of the anterior cruciate ligament (ACL) is the most frequently performed reconstructive surgery in the knee. Biomechanical studies have shown that double bundle (DB) reconstruction is better than single bundle (SB) reconstruction with regard to rotational stability. It is postulated that resection of ACL fibres that remain in continuity may be counterproductive for the knee as these fibres have the capacity to produce collagen. In this study, we aimed to evaluate the efficacy among selective bundle, DB and SB ACL reconstructions over a 2-year post-operative follow-up period. METHODS: A retrospective comparative study was conducted for comparison between selective bundle, DB and SB reconstructions. Between 2012 and 2014, 291 ACL reconstructions were performed. Of these, 68 patients had selective ACL reconstructions (group SLB), 147 had DB ACL reconstructions (group DB) and 76 had SB ACL reconstructions (group SB). Institutional Review Board approval was obtained, and all patients provided informed consent. Clinical results were assessed with the International Knee Documentation Committee (IKDC), Lysholm and Tegner scores. Stability was measured using Lachman, pivot shift and anterior drawer stress tests using the KT1000 at 30° of knee flexion. RESULTS: There was no significant difference in ligament grade, function grade, IKDC grade, as well as Tegner and Lysholm means among all three groups after a 2-year follow-up period. CONCLUSION: Selective bundle reconstruction provides comparable results to DB and SB reconstruction techniques. It is a viable alternative for patients with partial tears.

Progressive scarring facial lesions in a boy.

Hydroa vacciniforme is a photosensitivity disorder characterized by the childhood onset of necrotic vesiculopapules on exposed areas. We present a case of a 10-year-old boy with a 1-year history of papular lesions over his face. In this report, we discuss the in-depth histology of hydroa vacciniforme, and the management options.