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.

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.

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.

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.

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.