RESUMEN
BACKGROUND: Medical students in Singapore engage in short term medical missions, locally known as Overseas Community Involvement Projects (OCIPs). Little is known about the learning outcomes of an OCIP and how this complements their medical education back home. Understanding this can help the medical educators structure the OCIP to optimise its learning value. OBJECTIVES: This study aims to gain an in-depth understanding of the experiences and learning outcomes of the medical students who participated in the OCIP. METHODS: This was a qualitative study involving Singaporean students from one medical school travelling to Nepal. Data was collected from reflective journals, overall group reflections and two focus group discussions. The data was thematically analysed using the Accreditation Council for Graduate Medical (ACGME) core competencies for medical professionals. RESULTS: The data could be classified under various themes within the six domains of the ACGME framework. The study revealed themes of: humanism, socioeconomic and cultural determinants of health under the domain of patient care, application of medical knowledge, investigating and evaluating the needs of a population and feedback to drive improvement under the domain of practice-based learning and improvement, use of non-verbal cues and communicating across language barriers under the domain of interpersonal and communication skills, healthcare systems and delivery, resourcefulness and adaptability, health equity and accessibility under the domain of systems-based practice, ethics, role-modelling, teamwork and leadership skills, interprofessional skills and resilience under the domain of professionalism. Understanding the students' motivations, utilising reflections, and following the patients' journey facilitated attainment of these outcomes. CONCLUSIONS: This OCIP experience translated to learning outcomes aligned with the ACGME framework. There is great potential for the experiential learning from a well-structured OCIP to help with personal and professional development and global health education.
Asunto(s)
Grupos Focales , Misiones Médicas , Investigación Cualitativa , Estudiantes de Medicina , Humanos , Estudiantes de Medicina/psicología , Singapur , Nepal , Femenino , Masculino , Educación de Pregrado en MedicinaRESUMEN
Background: The Schatzker classification system for tibial plateau fractures is one of the most commonly used systems. However, there has been controversy if a Schatzker III type fracture truly exists by their original definition. We aimed to correlate the radiographic and CT images of type III fractures, describe the additional propagating fracture patterns and determine if these fractures do exist by their original description. Methods: This multicenter retrospective cohort observational study included patients with tibial plateau fractures across five trauma centers over 9 years were identified. All X-rays and CT scans were assessed. Two independent fellowship trained, Orthopaedic trauma surgeons reviewed all knee X-rays and classified them according to the Schatzker system. The CTs were subsequently reviewed and the fractures were reclassified based on CT findings. Results: 569 Tibial plateau fractures in 566 patients were analyzed. All X-ray classified Schatzker III fractures were reclassified to a Schatzker II type after review of CT scans by both assessors independently as there were always at least two or more fracture lines propagating from the depressed fragment to the lateral cortex in all cases. The interobserver variability as assessed by the kappa correlation coefficient (κ) for X-rays and CT-based classifications were κ = 0.274 and κ = 0.906, respectively. The majority of cases had two lateral cortical breaks (83.8%). In addition, the depression occurred mostly in the anterolateral and posterolateral positions (60.3%) of the lateral tibial plateau. Conclusion: This study did not support the existence of true Schatzker Type III fractures.
RESUMEN
Carbohydrate antigen 19-9 (CA 19-9) is a tumor marker widely accepted as the most useful blood test in diagnosing and monitoring pancreatic cancer. However, CA 19-9 may also be raised in other conditions such as colorectal, hepatic, lung, and ovarian carcinoma as well as benign conditions such as hepatobiliary and pulmonary diseases. CA 19-9 is rarely elevated above 200 U/ml in benign conditions with values exceeding 1000 U/ml being highly suggestive of malignancy. The mechanism of secretion in both malignant and benign conditions remains unclear. Desmoplastic fibroblastoma (DF) is a benign soft tissue tumor. CA 19-9 has not been reported in association with DF previously. We present a case of raised serum CA 19-9 in a 71-year-old male attributed solely to DF in his left cubital fossa. The patient's CA 19-9 level rose from 56 U/ml at the time of presentation to 3763.8 U/ml over a period of 9 months. Post-DF excision, the CA 19-9 level decreased to 1464 U/ml at 1 month, 162.3 U/ml at 2.5 months, and 24U/ml, within normal range, at 7 months post-surgery. CA 19-9 levels continued to remain at 24 U/ml 1.5 years post-tumor excision. The CA 19-9 level in this patient was highly elevated which is unusual in association with a benign tumor. The rate of decrease in CA 19-9 level post-excision was in keeping with that reported after pancreatic cancer resections. This is the first case of DF in association with raised CA 19-9.
RESUMEN
OBJECTIVE: Hip fractures are common orthopaedic injuries in the elderly. Opioids can provide peri-operative pain relief in hip fracture patients, but may have side effects. Peripheral nerve blocks such as the fascia iliaca compartment block (FICB) have become an established part of the multimodal analgesic regime administered peri-operatively to hip fracture patients. We compare the efficacy of the continuous infusion FICB (CFICB) on peri-operative pain relief, opioid usage, its associated complications and the short as well as long term rehabilitation status in geriatric hip fractures patients. MATERIALS AND METHODS: In this retrospective matched case control study, 40 geriatric patients with hip fractures who had received the CFICB from Nov 2014 to April 2016 were matched in a 1:3 ratio with similar patients whom had not received the CFICB from our institution's hip fracture database of 913 patients. RESULTS: A total of 157 patients in both the CFICB group (N = 40) and the control group (N = 117) were studied. The post-operative pain scores and the total opioid consumption during the first 3 days in the CFICB group were significantly less than the control group (p < 0.0001, respectively). The systemic complications in the CFICB group were comparable with the control group. The CFICB group had slower rehabilitation at up to 2 weeks but there was no significant difference at 1 year post surgery in terms of function and mobility between the two groups. In both groups, better pre-fracture function was associated with faster short term rehab outcomes in post-operative patients. CONCLUSION: The CFICB provides safe and effective post-operative pain relief in geriatric hip fracture patients. Post-operative opioid usage is decreased in older hip fracture patients treated with CFICB. Rehabilitation milestones are slower in the short term, but have no significant difference at 1-year post surgery.
Asunto(s)
Fracturas de Cadera/cirugía , Bloqueo Nervioso/métodos , Anciano , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Estudios de Casos y Controles , Humanos , Bloqueo Nervioso/efectos adversos , Dolor Postoperatorio/tratamiento farmacológico , Estudios Retrospectivos , Resultado del TratamientoAsunto(s)
Infecciones por Coronavirus , Infección Hospitalaria/prevención & control , Asignación de Recursos para la Atención de Salud , Control de Infecciones/normas , Ortopedia/normas , Pandemias , Neumonía Viral , Procedimientos Quirúrgicos Operativos/normas , Betacoronavirus , COVID-19 , Infecciones por Coronavirus/diagnóstico , Infecciones por Coronavirus/epidemiología , Infección Hospitalaria/etiología , Procedimientos Quirúrgicos Electivos/normas , Asignación de Recursos para la Atención de Salud/normas , Unidades Hospitalarias/normas , Humanos , Control de Infecciones/instrumentación , Tamizaje Masivo , Equipo de Protección Personal/normas , Admisión y Programación de Personal , Neumonía Viral/diagnóstico , Neumonía Viral/epidemiología , SARS-CoV-2 , Singapur/epidemiología , Telemedicina , TriajeRESUMEN
IMPORTANCE: Although Singapore was one of the first countries outside of China to be affected by COVID-19, for the first 2.5 months since its first reported case on January 23, 2020, it remained one of the few nations with successful containment of spread of the pandemic with little mortality and zero intra-hospital transmissions, without instituting a major lockdown of the country. In times of an infectious epidemic where medical subspecialties lead the frontline, a surgeon's role becomes rather vague. However, the only obstacle that stands in between the surgeon and fighting in the frontline of an infectious disease outbreak, is the traditional perception of what a surgeon can do. By presenting the strategies employed by our institution and its surgical unit, which remains the epicenter of the COVID-19 fight in Singapore, together with our medical counterparts, we hope to be able to improve our practices to respond and prevent the pandemic from escalating further as a collective community of surgeons across the globe. OBSERVATIONS: Contingencies should be in place for prioritization of existing patients, triaging and treatment of suspected patients, infection control, manpower management and novel strategies for inter-disciplinary communications and education in a hospital's surgical unit during a pandemic. Working in a high risk environment with manpower and resource limitations for prolonged periods of time has effect on morale and affects surgeon burn-out. Transparent communication, avenues to address psychological needs of surgeons and leadership by example are key strategies in ensuring a sustainable fight against the pandemic. CONCLUSIONS AND RELEVANCE: With the varies strategies implemented, every surgical discipline and every surgeon should be unified and place their desire to operate aside. There should not be any differentiation between surgeon and physician, but instead, everyone has to work together as one united health care front battling the common enemy - COVID-19.
Asunto(s)
Infecciones por Coronavirus/epidemiología , Control de Infecciones , Pandemias/prevención & control , Rol del Médico , Neumonía Viral/epidemiología , Cirujanos , Servicio de Cirugía en Hospital/organización & administración , Betacoronavirus , COVID-19 , Estudios de Cohortes , Comunicación , Infecciones por Coronavirus/prevención & control , Humanos , Relaciones Interprofesionales , Cuerpo Médico de Hospitales/educación , Cuerpo Médico de Hospitales/organización & administración , Neumonía Viral/prevención & control , SARS-CoV-2 , Singapur/epidemiología , TriajeRESUMEN
BACKGROUND: When primary repair of transected peripheral nerves is not possible due to large gaps, nerve grafts or repair using conduits are other options to bridge the gap such that the nerve is repaired without tension. When nerve gaps are repaired primarily, there is a worry about tension, failure, and poor healing. In this biomechanical study comparing nerves repaired primarily versus those repaired with conduits, we hypothesized that conduit repair provided greater mechanical breaking strength. METHODS: We dissected fresh cadaveric sheep hooves and transacted their peripheral nerves. Subsequently, we divided these transacted nerves into 2 groups: primary repair versus repair using a nerve conduit. After repair using a standardized technique, we tensioned each of these repairs via a load tester and recorded the force required till repair failure occurred. RESULTS: Six nerves using primary nerve repair and 6 nerves repaired with a nerve conduit (10 mm length × 2.5 mm diameter) were studied. The average breaking strength of the nerves repaired with the nerve conduit was 0.92 N and that using the primary nerve repair technique was 0.46 N (P = 0.001). All the nerves repaired using nerve conduit repair had an additional 5 mm added to their total length as compared with the nerves in the other group. CONCLUSIONS: Nerve repair using a nerve conduit ensures a higher breaking strength and potentially a greater tension-free repair as compared with primary nerve repairs in a sheep model. This study supports the use of conduits in the bridging of nerve gaps.