Singapore medical journal最新文献

{"title":"Unilateral abducens nerve avulsion injury following trauma","authors":"Rugaiyah Fuad Alkhatib, Robert Chun Chen, CAQ Neuroradiology, Benjamin Wei Heng Sing, Sarat Kumar Sanamandra","doi":"10.4103/singaporemedj.smj-2022-222","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-222","url":null,"abstract":"Dear Sir, While abducens nerve palsy is commonly seen in clinical practice, abducens nerve palsy secondary to an avulsion injury is uncommon. In a retrospective study documenting the causes of abducens nerve palsy, only up to 3.1% were attributed to trauma; the most common cause in adults was related to vascular ischaemia.[1] Unilateral abducens nerve palsy is found in only 1%–2.7% of all head traumas.[2] Here, we present a case of unilateral abducens nerve injury following trauma. A 60-year-old woman with no significant medical history was involved in a road traffic accident. Initial computed tomography (CT) of the brain revealed bilateral acute subarachnoid haemorrhage, as well as an acute subdural haemorrhage along the posterior interhemispheric falx. Multiple facial bone fractures were identified [Figure 1], including fractures of both orbital floors and lateral walls, lamina papyracea, maxilla and left zygomatic process. No fracture was identified along the course of the left abducens nerve. Of note, the left petrous apex in the region of Dorello’s canal, cavernous sinus and lateral rectus muscle appeared unremarkable.Figure 1: Axial CT images in the bone windows. (a) Acute fractures of both lateral orbital walls, lamina papyracea and left zygomatic process (circles). (b) There is also an acute fracture of the left lateral sphenoid wall (circle). Of note, the left petrous apex appears unremarkable, with no acute fracture.The patient subsequently underwent open reduction internal fixation of both zygomaticomaxillary complex fractures with left orbital floor reconstruction 26 days after the accident. Intraoperatively, forced duction test did not reveal any restriction on eye movement. Postoperatively, it was noted that the patient possessed signs of left abducens nerve palsy, with persistent medial deviation and failure of abduction of the left eye. These were likely not detected during the initial few weeks in view of extensive periorbital soft tissue swelling from the facial and orbital fractures, which resolved after surgical fixation. Contrast-enhanced CT of the brain did not demonstrate any new finding to explain the left abducens nerve palsy. Magnetic resonance imaging of the brain and orbits, including a three-dimensional constructive interference in steady-state (3D CISS) sequence of the cranial nerves was performed 35 days after the accident. This showed a discontinuous left abducens nerve in the prepontine cistern, with subtle linear enhancement corresponding to its root exit zone [Figure 2]. Findings pointed towards a traumatic unilateral left abducens nerve avulsion injury resulting from the road traffic accident. An iatrogenic aetiology of the left abducens nerve avulsion was deemed less likely, as the surgery was mainly focused on facial and orbital fracture repairs, with no surgical intervention performed along the course of the left abducens nerve. The patient was subsequently referred to ophthalmology and managed conservativel","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" 13","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135291099","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Left ventricular vortex formation time: emerging clinical applications and limitations","authors":"Jinghao Nicholas Ngiam, Tze Sian Liong, Thanawin Pramotedham, Ching-Hui Sia, Eric Jou, William Kok-Fai Kong, Kian-Keong Poh","doi":"10.4103/singaporemedj.smj-2022-132","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-132","url":null,"abstract":"Abstract Vortex formation during left ventricular diastolic filling may provide clinically useful insights into cardiac health. In recent years, there has been growing interest in the measurement of vortex formation time (VFT), especially because it is derived noninvasively. There are important applications of VFT in valvular heart disease, athletic physiology, heart failure and hypertrophic cardiomyopathy. The formation of the vortex as fluid propagates into the left ventricle from the left atrium is important for efficient fluid transport. Quantifying VFT may thus help in evaluating and understanding disease and pathophysiological processes.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" 43","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135290961","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical profiles and predictors of survival in severe dengue cases","authors":"Zainura Che Isa, Jo Anne Lim, Amelia Mohamed Ain, Fatin Aliaa Othman, Yee Cheng Kueh, Mei Mei Tew, Maz Jamilah Masnan, Aznita Ibrahim","doi":"10.4103/singaporemedj.smj-2022-072","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-072","url":null,"abstract":"Abstract Introduction: Dengue is endemic in tropical countries. Severe dengue has a high risk of morbidity and mortality. We aimed to identify factors associated with dengue survival among our intensive care unit (ICU) patients. Methods: A retrospective study was conducted among dengue cases admitted to the ICU of Hospital Sultan Abdul Halim, Kedah, Malaysia from 2016 to 2019. Results: Out of 1,852 dengue cases admitted to the hospital, 7.2% of patients required ICU admission. Survival rate was 88.6% among severe dengue cases. The majority of severe dengue patients were obese, while other notable comorbidities included hypertension and diabetes mellitus. Also, 73% of patients presented in the critical phase, at a median of Day 4 of illness. All patients admitted to the ICU had a history of fever. The predominant warning signs were lethargy, fluid accumulation and haemoconcentration with rapid platelet reduction. Among nonsurvivors, 69.2% had fulminant hepatitis, 53.8% had massive bleeding or disseminated intravascular coagulation, 38.5% had haemophagocytic lymphohistiocytosis and 30.8% had myocarditis. The predominant serotypes were DENV-3 and DENV-1. The least number of cases was seen in 2017, when all serotypes were equally presented. Multiple logistic regression showed that Sequential Organ Failure Assessment (SOFA) score, peak international normalised ratio, peak partial thromboplastin time and aspartate aminotransferase on admission were independent risk factors for survival. This model had an area under the curve of 0.98, giving an overall 98.2% accuracy. Conclusions: Specific warning signs and blood investigations in dengue patients may aid in early decision for ICU admission. Monitoring of SOFA scores plus coagulation and liver enzyme profiles could improve dengue survival rates.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"29 4","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135873724","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Comments on: Return to work after surgically treated pelvic ring fractures in Singapore","authors":"Anne HY Goei, Alvin KW Tan, David Koh","doi":"10.4103/singaporemedj.smj-2023-226","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2023-226","url":null,"abstract":"Dear Sir, We read with interest the article ‘Return to work after surgically treated pelvic ring fractures in Singapore’ by Ng et al.[1] The authors have commendably explored perioperative factors affecting return to work (RTW) and underscored the importance of early rehabilitation and work reintegration. However, only one job-related factor — a dichotomous classification of job sedentariness — was analysed. Given the heterogeneity of work, we propose several suggestions to generate meaningful insights on RTW evaluations. First, RTW involves a comprehensive evaluation of patents’ functional capabilities relating to the nature and demands of their current work. This can only be achieved through a detailed occupational history. Often forgotten,[2,3] an occupational history allows the clinician to ascertain what the patient actually does at work (e.g., the need to lift loads, use of machinery, working hours, presence of shift work) to better quantify the risk of reinjury, delayed recovery and to what extent the patient can function at work. Second, the ability to RTW is multifactorial, comprising psychosocial and workplace factors like self-efficacy, workplace support, work satisfaction, RTW coordination programmes and availability of job accommodations.[4] These were not evaluated or adjusted for, and may be potential confounders affecting the ability to detect significant associations. Return to work is a multidisciplinary and multisectoral collaboration, and involvement of the employer is critical. Ideally, patients should not be on medical leave till complete recovery. Instead, early reintegration using stepwise assimilation, with appropriate job restrictions and accommodations provided by the employer are crucial in early RTW and creating a healthier workforce.[5] Editor’s note: The authors, Ng et al., did not respond to the above letter. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"29 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135873726","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Routine preoperative screening computed tomography of the thorax for cardiac surgery","authors":"Jai Ajitchandra Sule, Xue Wei Chan, Hari Kumar Sampath, Hai Dong Luo, Mofassel Uddin Ahmed, Giap Swee Kang","doi":"10.4103/singaporemedj.smj-2021-416","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2021-416","url":null,"abstract":"Abstract Introduction: This study aimed to evaluate the role of screening computed tomography (CT) of the thorax in cardiac surgery by analysing the presence of CT aortic calcifications in association with changes in operative strategy and postoperative stroke, and the CT features of emphysema with development of pneumonia. Methods: All patients who underwent cardiac surgery from January 2013 to October 2017 by a single surgeon were retrospectively studied. Patients who underwent screening CT thorax before cardiac surgery (CT group) were compared to those who did not (no CT group). Multivariate subgroup analyses were performed to determine significant association with postoperative outcomes. Results: A total of 392 patients were included, of which 156 patients underwent preoperative screening CT thorax. Patients in the CT group were older (63.9 vs. 59.0 years, P = 0.001), had fewer recent myocardial infarctions preoperatively (41% vs. 56.4%, P = 0.003) and had better ejection fraction (>30%; P = 0.02). Operative strategy was changed in 4.3% of patients, and 4.9% of patients suffered stroke postoperatively. The presence of CT aortic calcifications was significantly associated with change in operative strategy ( P = 0.016) but not with postoperative stroke ( P = 0.33). Age was an independent risk factor for change in operative strategy among patients with CT thorax ( P = 0.02). Multivariate age-adjusted analysis showed only palpable plaque to be significantly associated with change in operative strategy ( P < 0.001). None of the patients with CT emphysema features developed pneumonia. Conclusion: The results of this study do not support routine use of preoperative screening CT thorax. Contrasted CT may be advisable in older patients and for other operative planning purposes.","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"32 3","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135873122","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Wide complex tachycardias detected by smartwatch: what is the diagnosis?","authors":"Weien Chow, Colin Yeo, Vern Hsen Tan","doi":"10.4103/singaporemedj.smj-2021-302","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2021-302","url":null,"abstract":"CASE 1 Clinical presentation A 64-year old woman with no significant past medical history presented to our cardiology clinic for recurrent intermittent palpitations at rest for the past 7 years. She also had an episode of left-sided chest pain. Her symptoms occurred about once a month, lasted 2–3 h with sudden onset and offset and were irregular in nature. The symptoms were associated with giddiness, and she complained of lethargy after the palpitations stopped. She did not have any near-syncopal or syncopal episodes. The patient is a non-smoker and non-drinker, and does brisk walking twice a week (30–45 min each session). Her electrocardiogram (ECG) at the clinic showed normal sinus rhythm with normal PR, QRS and QTc interval [Figure 1]. Serial event monitors (including 24-h monitoring, 14 days of transtelephonic ECG monitoring) showed intermittent rate-related left bundle branch block (LBBB), no significant pause and infrequent premature atrial (&lt;1%) and ventricular (&lt;1%) ectopics. No symptom was recorded while she was on the event monitors.Figure 1: Case 1. 12-lead ECG shows normal sinus rhythm with normal PR, QRS and QTc interval.Other investigations included computed tomography (CT) coronary angiogram, which showed minor coronary artery disease. The patient’s myocardial perfusion imaging was negative for ischaemia, and 2D echocardiography showed a normal left ventricular ejection fraction (LVEF) of 57%, normal left atrium (LA) size (LA volume 29.9 mL/m2) and mild to moderate mitral regurgitation. The patient continued to have intermittent symptoms despite being started on beta-blocker empirically. Due to her recurrent symptoms, her son decided to use his Apple Watch to record the ECG tracing for her whenever she was symptomatic. ECG interpretation The smartwatch ECG tracing (correlates to lead I) showed an irregularly irregular wide complex tachycardia [Figure 2]. The differential diagnosis included the following the: (a) atrial fibrillation (AF) with rate-related bundle branch block; (b) pre-excited AF; and (c) polymorphic ventricular tachycardia (VT) (torsades de pointes).Figure 2: Case 1. Smartwatch ECG tracing (represents lead I) shows an irregularly irregular wide complex tachycardia.Clinical course The patient was counselled on AF due to her symptoms and tracing from her smartwatch. In the later part of the day, she was admitted to the hospital for sudden onset of palpitations associated with shortness of breath when climbing the stairs. On examination, her pulse was irregularly irregular. The rest of the physical examination was unremarkable. The patient’s ECG showed an irregularly irregular wide complex (left bundle branch block pattern) tachycardia [Figure 3], similar to that shown by the smartwatch ECG tracing. The patient was diagnosed with AF with aberrancy and rapid ventricular rate of 160 bpm. Her troponin T level was normal at 5 ng/L and electrolytes were normal.Figure 3: Case 1. 12-lead ECG shows an irregularly irregular wide","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"88 12","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135515129","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Malignant arrhythmia in a COVID-19 patient with a structurally normal heart.","authors":"Clare Anne Yoke Kum Fong, Benjamin Wei Liang Tung, Weiqin Lin, Kay Choong See","doi":"10.11622/smedj.2021191","DOIUrl":"10.11622/smedj.2021191","url":null,"abstract":"","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" ","pages":"683-686"},"PeriodicalIF":2.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10754366/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39854520","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Second-generation laryngeal mask airway as an alternative to endotracheal tube in prolonged laparoscopic abdominal surgery: a comparative analysis of intraoperative gas exchanges.","authors":"Sukhee Park, Ja Eun Lee, Gyu Sung Choi, Jong Man Kim, Justin Sangwook Ko, Duck Hwan Choi, Gaab Soo Kim","doi":"10.11622/smedj.2021143","DOIUrl":"10.11622/smedj.2021143","url":null,"abstract":"<p><strong>Introduction: </strong>Laryngeal mask airway (LMA), which is used in difficult airway maintenance conditions during emergencies, is rarely used in prolonged surgery despite its advantages over endotracheal tube (ETT). In this study, we conducted a comparative analysis of intraoperative gas exchanges between second-generation LMA and ETT during prolonged laparoscopic abdominal surgery.</p><p><strong>Methods: </strong>Prolonged surgery was defined as a surgery lasting more than 2 h. In total, 394 patients who underwent laparoscopic liver resection via either second-generation LMA or ETT were retrospectively analysed. The following parameters were compared between the two groups of patients: end-tidal pressure of carbon dioxide (ETCO₂), tidal volume (TV), respiratory rate (RR), peak inspiratory pressure (PIP), arterial partial pressure of carbon dioxide (PaCO₂), pH and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) during surgery. In addition, the incidence of postoperative pulmonary complications (PPCs), including pulmonary aspiration, was compared.</p><p><strong>Results: </strong>The values of ETCO₂, TV, RR and PIP during pneumoperitoneum were comparable between the two groups. Although PaCO₂ at 2 h after induction was higher in patients in the LMA group (40.5 vs. 38.5 mmHg, P < 0.001), the pH and PFR values of the two groups were comparable. The incidence of PPC was similar.</p><p><strong>Conclusion: </strong>During prolonged laparoscopic abdominal surgery, second-generation LMA facilitates adequate intraoperative gas exchange and may serve as an alternative to ETT.</p>","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" ","pages":"651-656"},"PeriodicalIF":2.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10754369/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39494805","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Impact of nationwide COVID-19 lockdown on workload and injury patterns of major trauma cases in a regional trauma centre in Singapore.","authors":"Min Li Kang, Woan Wui Lim, Daniel Jin Keat Lee, Jerry Tiong Thye Goo","doi":"10.11622/smedj.2021131","DOIUrl":"10.11622/smedj.2021131","url":null,"abstract":"<p><strong>Introduction: </strong>Singapore instituted lockdown measures from 7 February 2020 to 1 June 2020 in response to the coronavirus disease 2019 (COVID-19) pandemic.</p><p><strong>Methods: </strong>A retrospective analysis of cases from the national trauma registry was carried out comparing the lockdown period (from 7 February 2020 to 1 June 2020) to the pre-lockdown period (from 7 February 2019 to 1 June 2019). Data extracted included the volume of Tier 1 (injury severity score [ISS] >15) and Tier 2 (ISS 9-15) cases and epidemiology. Subgroup analysis was performed for Tier 1 patient outcomes.</p><p><strong>Results: </strong>Trauma volume decreased by 19.5%, with a 32% drop in Tier 1 cases. Road traffic and workplace accidents decreased by 50% (P < 0.01), while interpersonal violence showed an increase of 37.5% (P = 0.34). There was an 18.1% decrease in usage of trauma workflows (P = 0.01), with an increase in time to intervention for Tier 1 patients from 88 to 124 min (P = 0.22). Discharge to community facilities decreased from 31.4% to 17.1% (P < 0.05). There was no increase in inpatient mortality, length of stay in critical care or length of stay overall.</p><p><strong>Conclusion: </strong>There was an overall decrease in major trauma cases during the lockdown period, particularly road traffic accidents and worksite injuries, and a relative increase in interpersonal violence. Redeployment of manpower and hospital resources may have contributed to decreased usage of trauma workflows and community facilities. In the event of further lockdowns, it is necessary to plan for trauma coverage and maintain the use of workflows to facilitate early intervention.</p>","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":" ","pages":"677-682"},"PeriodicalIF":2.7,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10754364/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39494807","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Vaccine administration during COVID-19 pandemic: an overview of safe injection technique and local complications","authors":"Wen Loong Paul Yuen, Yuen Khong Keith Chong, Choon How How, Sir Young James Loh","doi":"10.4103/singaporemedj.smj-2022-059","DOIUrl":"https://doi.org/10.4103/singaporemedj.smj-2022-059","url":null,"abstract":"Opening Vignette Madam Tan, a 65-year-old housewife, visited your clinic for left shoulder pain. The pain started 1 day after she was vaccinated in her left shoulder at a vaccination drive. Your initial assessment was that of postinjection site pain. You prescribed her with a course of nonsteroidal anti-inflammatory drugs (NSAIDs) and advised rest. She returned a week later with worsening and severe pain over her left shoulder, which affected her daily activities. Clinical examination showed generalised tenderness and effusion over her left shoulder joint with limited range of motion. Madam Tan recollected that she felt the injection had been given ‘too high and too deep’. Due to the temporal nature of the symptoms, you suspected that her shoulder pain could be related to vaccine administration. Due to the progressing severity of the symptoms, you referred her to a tertiary hospital for orthopaedic evaluation.HOW RELEVANT IS THIS TO MY PRACTICE? Vaccination is a procedure routinely performed by doctors and nurses in the primary healthcare setting. In the adult population, the most common site for vaccination is the deltoid muscle. The deltoid muscle is preferred due to its size and ease of exposure and administration on a seated patient in the clinic setting. The vaccine needs to be administered with the proper technique to maximise its efficacy and minimise the risk of an adverse event at the injection site. During the coronavirus disease 2019 (COVID-19) pandemic, large-scale vaccination programmes were held, and a potential rise in complications from vaccinations is expected. Therefore, it is important to have in place safe and competent vaccination practices. WHAT TO EXPECT AT THE INJECTION SITE? Common symptoms postinjection include induration, erythema and pain at the injection side. These symptoms are usually self-limiting and resolve spontaneously over a week. More serious complications, such as shoulder injury related to vaccine administration (SIRVA), are rare. There is a spectrum of shoulder pathologies contributed by poor injection techniques. It includes traumatic injury or inappropriate administration of vaccine material into the subdeltoid bursa or shoulder joint, leading to an inflammatory cascade and damage to the surrounding structures. The first local case of SIRVA complication following COVID-19 vaccination was reported in 2021.[1] WHAT CAN I DO IN MY PRACTICE? It is important that the family physician or nursing practitioner perform safe vaccination for each patient. To achieve this, good working knowledge of the following is necessary: (a) shoulder anatomy and surface landmarking; (b) appropriate needle selection; (c) safe injection technique; (d) alternate injection site; and (e) approach to postvaccination injection site and shoulder pain. It is recommended to counsel the patient about common local site reactions, such as induration, pain and erythema, and red flags suggestive of more serious complications. Shoulder anatomy","PeriodicalId":21752,"journal":{"name":"Singapore medical journal","volume":"22 8","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"135510333","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}