Buprenorphine ; therapeutic use ; Humans ; Methadone ; therapeutic use ; Naltrexone ; therapeutic use ; Narcotic Antagonists ; therapeutic use ; Narcotics ; therapeutic use ; Opioid-Related Disorders ; rehabilitation

In patients presenting with gunshot wounds, a high clinical suspicion of injury to vasculature and viscera remote from the projectile track is paramount. We present a case of a 17 year old male who sustained a gunshot wound to his abdomen and subsequently developed a right external iliac artery contusion requiring surgery as an indirect effect of the pressure wave from the bullet.
Adolescent ; Humans ; Iliac Artery ; injuries ; Male ; Pressure ; Wounds, Gunshot ; complications ; surgery

BACKGROUND: Hypoalbuminemia (serum albumin < 3.5 g/dL) is associated with increased morbidity and mortality in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, costs associated with hypoalbuminemia remain unknown. This study investigated the effect of serum albumin on direct treatment costs, length of stay (LOS), and readmissions for primary and revision THA and TKA patients. METHODS: All adult patients at a single institution undergoing primary or revision THA or TKA between January 2014 and December 2016 were retrospectively reviewed. Patients were stratified by preoperative serum albumin level. The primary outcome was total direct costs at index hospitalization. Secondary outcomes included LOS and readmission within 30 days. Multivariable regressions were utilized to adjust for demographics and comorbidities. RESULTS: Of 3,785 patients, 114 (3.0%) had hypoalbuminemia. After adjustment, hypoalbuminemia was associated with a 16.2% increase in costs (β = 0.162; 95% confidence interval [CI], 0.112 to 0.213; p < 0.001), representing an average cost increase of $3,383 (95% CI, $2,281 to $4,485) relative to costs for serum albumin > 4.5 g/dL. The increased total costs were significantly higher in revision ($4,322, p = 0.034) than in primary ($3,446, p < 0.001) procedures. In adjusted regression, each 1.0 g/dL increase in serum albumin yielded a 6.6% reduction in costs (β = −0.066; 95% CI, −0.090 to −0.042]; p < 0.001), for average savings of $1,282 (95% CI, $759 to $1,806) per unit albumin. Adjusted regressions demonstrated that a 1-point increase in serum albumin reduced readmissions by 53% (odds ratio, 0.47; 95% CI, 0.31–0.73; p = 0.001) and LOS by 0.6 days (β = −0.60; 95% CI, −0.76 to −0.44; p < 0.001). CONCLUSIONS: Hypoalbuminemia is associated with increased total direct costs, LOS, and readmissions following primary and revision THA and TKA. Future efforts to predict and address total costs should take into consideration the patient's preoperative serum albumin levels.
Adult ; Arthroplasty, Replacement, Hip ; Arthroplasty, Replacement, Knee* ; Comorbidity ; Demography ; Health Care Costs* ; Hip* ; Hospitalization ; Humans ; Hypoalbuminemia ; Income ; Knee* ; Length of Stay ; Mortality ; Retrospective Studies ; Serum Albumin*

Cardiovascular disease is a major cause of death in Australia. The Tick Program by the National Heart Foundation was designed to assist consumers in making healthier food choices. The aim of our study was to evaluate the awareness of university students regarding the Tick Program as a sustainable approach in preventing the onset of cardiovascular disease (CVD) in youth. Following Ethics Committee approval, a cross-sectional study was undertaken in 2006 to measure university students’ level of awareness of the Tick Program using a self-administered survey form. Inclusion criteria were full-time university students who have lived in Australia for a minimum duration of twelve months and do their own shopping. Students of less than 18 years of age were excluded from the study. Of 110 university students surveyed, 97 questionnaires were successfully completed (response rate: 88%). Overall there was a high level of awareness (72.2%) of the Tick program, which was also considered trustworthy by a majority of participants, with a mean rating of 3.87 (on a scale of 1 to 5). Tick-approved products were also considered a healthier choice by participants (mean 4.06 out of 5). Participants were also asked to identify potential barriers limiting the use of the Tick in making purchase decisions. The most important barrier identified to the Tick program was the limited range of Tick-approved products. A significant proportion of respondents also believed there was limited publicity of the program. The Tick Program is considered to be trustworthy and the approved products were regarded as healthy, with the results showing that participants have confidence in the Tick Program. This research also highlighted the potential areas for improvement of the Tick Program.
Cardiovascular Diseases ; Food Preferences ; Students ; Universities ; Australia

We present a rare case of a patient with aortoiliac occlusive disease on the background of type A crossed renal ectopia, for whom open surgical intervention was required. Aortic exposure in patients with concomitant crossed renal ectopia can present technical challenges to the vascular surgeon. The knowledge of variations in the ectopic renal blood supply is of paramount importance when performing surgery to treat this condition and affects the choice of surgical exposure. We present and discuss the operative details of our patient and outline an approach to this subset of patients.
Atherosclerosis ; Blood Vessel Prosthesis Implantation ; Humans ; Vascular Diseases

Purpose: Alcohol use disorder is a leading mental health disorder in the United States. Few studies evaluating the association of alcohol use disorder following primary total hip arthroplasty (THA) have been reported.Therefore, the purpose of this study was to determine whether patients with alcohol use disorder undergoing primary THA have higher rates of: 1) in-hospital lengths of stay (LOS); 2) complications (medical/implant-related);and 3) costs. Materials and Methods: Using a nationwide claims database from January 1st, 2005 to March 31st, 2014, patients with alcohol use disorder undergoing primary THA were identified and matched to a comparison group according to age, sex, and various comorbidities, resulting in 230,467 patients who were included in the study (n=38,416) and a matched-cohort (n=192,051). Outcomes of interest included comparison of LOS, 90-day medical and 2-year implant-related complications, and costs. A P-value less than 0.002 was considered statistically significant. Results: Patients with alcohol use disorder had longer in-hospital LOS (4 days vs 3 days; P<0.0001) as well as higher frequency and odds ratio (OR) of 90-day medical (45.94% vs 12.25%; OR, 2.89; P<0.0001) and 2-year implant-related complications (17.71% vs 8.46%; OR, 1.97; P<0.0001). Patients in the study group incurred higher 90-day costs of care ($17,492.63 vs $14,921.88; P<0.0001). Conclusion With the growing prevalence of alcohol use disorder in the United States, the current investigation can be utilized to evaluate the need for interventions prior to THA which can potentially minimize the rates of morbidity and mortality within this population.

INTRODUCTION: To improve the nutritional care and resource allocation of critically ill patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), we described their characteristics, treatment modalities and clinical outcomes, and compared their nutrition interventions against the American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations. METHODS: This was a retrospective observational study conducted in 5 tertiary hospitals in Singapore. Characteristics, treatment modalities, clinical outcomes and nutrition interventions of critically ill patients with SARS-CoV-2 who received enteral and parenteral nutrition were collected between January and May 2020. RESULTS: Among the 83 critically ill patients with SARS-CoV-2, 22 (28%) were obese, 45 (54%) had hypertension, and 21 (25%) had diabetes. Neuromuscular blockade, prone therapy and dialysis were applied in 70% (58), 47% (39) and 35% (29) of the patients, respectively. Refeeding hypophosphataemia and hospital mortality occurred respectively in 6% (5) and 18% (15) of the critically ill patients with SARS-CoV-2. Late enteral nutrition and cardiovascular comorbidities were associated with higher hospital mortality (adjusted relative risk 9.00, 95% confidence interval [CI] 2.25-35.99; 6.30, 95% CI 1.15-34.40, respectively). Prone therapy was not associated with a higher incidence of high gastric residual volume (≥250mL). The minimum caloric (15kcal/kg) and protein (1.2g/kg) recommendations of ASPEN were achieved in 54% (39) and 0% of the patients, respectively. CONCLUSION The high obesity prevalence and frequent usage of neuromuscular blockade, prone therapy, and dialysis had considerable implications for the nutritional care of critically ill patients with SARS-CoV-2. They also did not receive adequate calories and protein. More audits should be conducted to refine nutritional interventions and guidelines for this ever-evolving disease.
COVID-19/therapy* ; Critical Illness/therapy* ; Humans ; Nutritional Support ; SARS-CoV-2 ; Singapore/epidemiology* ; United States

INTRODUCTIONArterial base excess is an established marker of shock and predictor of survival in trauma patients. However, venous blood is more quickly and easily obtained. This study aimed to determine if venous base excess could replace arterial base excess as a marker in trauma patients at presentation and if venous base excess is predictive of survival at 24 hours and one week.

METHODSThis was a prospective study of 394 trauma patients presenting to the emergency department of a tertiary hospital over a 17-month period. Data on base excess at presentation, vital signs, shock index (SI), injury severity score (ISS), and mortality at 24 hours and one week was collected and analysed.

RESULTSArterial and venous blood gas tests were performed on 260 and 134 patients, respectively. Patients were stratified into groups based on their SI and ISS for analysis. There was no statistical difference between mean venous blood gas and arterial blood gas levels at presentation when SI > 0.7, regardless of ISS (p > 0.05). The mortality rate was 4.57%. Both venous and arterial base excess was lower in nonsurvivors compared to survivors (p < 0.05). However, at 24 hours and one week, the difference in base excess values at presentation between survivors and nonsurvivors was greater when using venous base excess compared to arterial base excess (11.53 vs. 4.28 and 11.41 vs. 2.66, respectively).

CONCLUSIONIn conclusion, venous base excess can replace arterial base excess in trauma patients as a means of identifying and prognosticating early shock.

Acid-Base Imbalance ; blood ; etiology ; mortality ; Adolescent ; Adult ; Aged ; Aged, 80 and over ; Arteries ; Biomarkers ; blood ; Blood Chemical Analysis ; Child ; Female ; Follow-Up Studies ; Humans ; Injury Severity Score ; Male ; Middle Aged ; Predictive Value of Tests ; Prospective Studies ; Shock, Traumatic ; blood ; complications ; epidemiology ; Singapore ; epidemiology ; Survival Rate ; trends ; Time Factors ; Trauma Centers ; Veins ; Wounds and Injuries ; blood ; complications ; diagnosis ; Young Adult

The guidelines represent an agreed consensus view of the ILROG steering committee on the use of RT in NHL in the modern era. The roles of reduced volume and reduced doses are addressed,integrating modern imaging with 3-dimensional planning and advanced techniques of RT delivery. In the modern era,combined-modality treatment with systemic therapy is appropriate. A new concept,involved-site RT,defines the clinical target volume. For indolent NHL,often treated with RT alone,larger fields should be considered. Newer treatment techniques,including intensity modulated RT,breath holding,image guided RT,and 4-dimensional imaging,should be implemented,and their use is expected to decrease significantly the risk for normal tissue damage while still achieving the primary goal of local tumor control.

BACKGROUND: Timely reperfusion in ST-segment elevation myocardial infarction (STEMI) improves outcomes. System delay is that between first medical contact and reperfusion therapy, comprising prehospital and hospital components. This study aimed to characterize prehospital system delay in Singapore. METHODS: A retrospective chart review was performed for 462 consecutive STEMI patients presenting to a tertiary hospital from December 2006 to April 2008. Patients with cardiac arrest secondarily presented were excluded. For those who received emergency medical services (EMS), ambulance records were reviewed. Time intervals in the hospital were collected prospectively. The patients were divided into two equal groups of high/low prehospital system delay using visual binning technique. RESULTS: Of 462 patients, 76 received EMS and 52 of the 76 patients were analyzed. The median system delay was 125.5 minutes and the median prehospital system delay was 33.5 minutes (interquartile range [IQR]=27.0, 42.0). Delay between call-received-by-ambulance and ambulance-dispatched was 2.48 minutes (IQR=1.47, 16.55); between ambulance-dispatch and arrival-at-patient-location was 8.07 minutes (IQR=1.30, 22.13); between arrival-at- and departure-from-patient-location was 13.12 minutes (IQR=3.12, 32.2); and between leaving-patient-location to ED-registration was 9.90 minutes (IQR=1.62, 32.92). Comparing patients with prehospital system delay of less than 35.5 minutes versus more showed that the median delay between ambulance-dispatch and arrival-at-patient-location was shorter (5.75 vs. 9.37 minutes, P<0.01). The median delay between arrival-at-patient-location and leaving-patient-location was also shorter (10.78 vs. 14.37 minutes, P<0.01). CONCLUSION: Prehospital system delay in our patients was suboptimal. This is the first attempt at characterizing prehospital system delay in Singapore and forms the basis for improving efficiency of STEMI care.