Optimizing Best Practice Advisory alerts in electronic medical records with a multi-pronged strategy at a tertiary care hospital in Singapore.

Objective: Clinical decision support (CDS) alerts can aid in improving patient care. One CDS functionality is the Best Practice Advisory (BPA) alert notification system, wherein BPA alerts are automated alerts embedded in the hospital's electronic medical records (EMR). However, excessive alerts can change clinician behavior; redundant and repetitive alerts can contribute to alert fatigue. Alerts can be optimized through a multipronged strategy. Our study aims to describe these strategies adopted and evaluate the resultant BPA alert optimization outcomes. Materials and Methods: This retrospective single-center study was done at Jurong Health Campus. Aggregated, anonymized data on patient demographics and alert statistics were collected from January 1, 2018 to December 31, 2021. "Preintervention" period was January 1-December 31, 2018, and "postintervention" period was January 1-December 31, 2021. The intervention period was the intervening period. Categorical variables were reported as frequencies and proportions and compared using the chi-square test. Continuous data were reported as median (interquartile range, IQR) and compared using the Wilcoxon rank-sum test. Statistical significance was defined at P < .05. Results: There was a significant reduction of 59.6% in the total number of interruptive BPA alerts, despite an increase in the number of unique BPAs from 54 to 360 from pre- to postintervention. There was a 74% reduction in the number of alerts from the 7 BPAs that were optimized from the pre- to postintervention period. There was a significant increase in percentage of overall interruptive BPA alerts with action taken (8 [IQR 7.7-8.4] to 54.7 [IQR 52.5-58.9], P-value < .05) and optimized BPAs with action taken (32.6 [IQR 32.3-32.9] to 72.6 [IQR 64.3-73.4], P-value < .05). We estimate that the reduction in alerts saved 3600 h of providers' time per year. Conclusions: A significant reduction in interruptive alert volume, and a significant increase in action taken rates despite manifold increase in the number of unique BPAs could be achieved through concentrated efforts focusing on governance, data review, and visualization using a system-embedded tool, combined with the CDS Five Rights framework, to optimize alerts. Improved alert compliance was likely multifactorial-due to decreased repeated alert firing for the same patient; better awareness due to stakeholders' involvement; and less fatigue since unnecessary alerts were removed. Future studies should prospectively focus on patients' clinical chart reviews to assess downstream effects of various actions taken, identify any possibility of harm, and collect end-user feedback regarding the utility of alerts.

Limb salvage versus primary amputation in Gustilo-Anderson IIIB and IIIC tibial fractures: a systematic review and meta-analysis.

INTRODUCTION: The last systematic review on this topic was published in 2008. With advances in surgical techniques, patients with mangled extremities may now be potentially salvageable with comparable outcomes. This review aims to evaluate the outcomes of limb salvage compared to primary amputation in patients with severe open tibial fractures. MATERIALS AND METHODS: A comprehensive search on PubMed, MEDLINE, Embase, Web of Science, Scopus, CENTRAL and CINAHL was performed from inception to 19 January 2022. The primary outcome was to evaluate clinical and functional outcomes. Secondary outcomes were to evaluate pain, patient preference, quality of life, and patient preferences. Methodological quality was evaluated using the MINORS criteria. Pooled estimates of relative risk (RR) and mean difference (MD) with 95% confidence interval (CI) were used as a summary statistic for dichotomous variables and continuous variables, respectively. RESULTS: Sixteen studies with 645 patients met inclusion criteria. The methodological quality was moderate based on the MINORS score. The majority were male. Mean age was 36.3 years. There was no significant differences in the length of hospitalization (n = 8), return to work rates (n = 9), return to sport rates (n = 4) and quality of life scores (n = 4). Patients with primary amputation had a significantly lower risk of total complications (RR 0.21, 95% CI 0.08-0.53, p = 0.001) (n = 10), infections (RR 0.46, 95% CI 0.25-0.85, p = 0.01) (n = 9), and number of surgeries (MD - 4.17, 95% CI - 6.49 to - 1.85, p = 0.0004) (n = 6). Patients with primary amputation were able to ambulate significantly earlier (MD - 4.06, 95% CI - 7.65 to - 0.46, p = 0.03) (n = 3). Three studies found a significantly higher cost of hospitalization in limb salvage patients. Functional outcomes were similar in both groups. CONCLUSION: While patients with primary amputation had better clinical outcomes in the short-term, functional outcomes were not significantly different in both groups. Despite the heterogenicity of the results in this review, surgeons need to contextualize the decision making for their patients and incorporate these findings. LEVEL OF EVIDENCE: III. TRIAL REGISTRATION: PROSPERO CRD42022303357.

Online training module for micro suturing incorporating motor imagery and mental practice: a design and development research study.

INTRODUCTION: There have been reduced opportunities for surgical skill acquisition due to the COVID-19 pandemic and the regulated training hours. Despite these challenges, self-regulated learning allows trainees to learn continuously, and one form of this is through mental practice and motor imagery. The study aimed to design and develop an online basic micro suturing training module for skill acquisition for self-regulated learning using a low-fidelity rubber glove model. METHODS: This study utilized a design and developmental research framework and Mayer's multimedia theory guidelines. The primary author created an online instructional module on micro suturing based on the ADDIE instructional design model. This module was then evaluated in a pilot study comparing the new training model to traditional methods of learning using an experimental design. RESULTS: This study describes the use of Design and Development Research to create a new model for surgical skill training and a tool for producing instructional materials and learning products for online learning. The product was evaluated using an experimental design and showed a significant effect on the quality of motor skill outcome and the richness of motor imagery using the resource developed in the research. CONCLUSION: This study describes the methodological approach of a design and developmental framework to create an online training module for micro suturing which has significant utility in hand surgery.

Patient and Surgeon Reported Experiences of Locoregional Anesthesia in Hand Surgery.

Introduction Locoregional anesthesia techniques have been increasingly adopted for use in hand surgery in recent years. However, locoregional anesthesia techniques may place patients under significant psychological stress, and there has been limited evaluation of acceptance and satisfaction rates of these techniques. Materials and Methods An observational study was conducted in a single tertiary institution. Data were collected from patients undergoing upper limb surgery procedures with locoregional anesthesia. After completion of surgery, a questionnaire adapted from Evaluation du Vecu de l'Anesthesie LocoRegionale (EVAN-LR), with scores from 1 to 5 on the Likert scale, was conducted on the same day to evaluate patient satisfaction. Responses were also obtained from the operating surgeon to assess satisfaction. Results A total of 101 patients were evaluated as part of the study. All EVAN-LR domains received a mean score >4.5. Responses from surgeons also showed good acceptance of locoregional anesthesia techniques with almost all giving scores ≥4 on the Likert scale. Conclusion The results of this study showed good satisfaction and acceptance of locoregional anesthesia among patients for upper limb procedures. This provides reassurance regarding the quality of care with locoregional anesthesia techniques. It remains important to be aware of potential sources of discomfort such as tourniquet pain to minimize discomfort and maximize patient satisfaction.

Incidence of Radiolucent Lines after Cemented Total Knee Arthroplasty.

Background: Cemented Total Knee Arthroplasty (TKA) provides excellent long-term survival rates and functional results, however, radiolucent lines (RLLs) often appear during early post-operative follow-up and their incidence and clinical significance are unknown. The primary aim was to establish the incidence, location, frequency, and time taken for RLLs to appear within the first year after a primary cemented TKA with an anatomic tibial baseplate (Smith and Nephew, LEGION Total Knee System). Methods: This was a retrospective analysis of 135 primary cemented TKA in 131 patients over three years. We compared demographics, serial radiographs, and early clinical and functional outcomes. Results: There were 65 TKAs (48%) in 62 patients who had RLLs within the first year post-operatively. Most were females (58.8%). Mean age was 68.3 ± 7.9 years. There were 88 RLLs, with the most and second commonest location at the medial tibial baseplate (38%) and anterior femoral flange (23%). 89% were in the bone-cement interface. The largest average length of RLLs were at the anterior flange of the femoral component (1.98 ± 1.33 mm). The average time to development was 6.5 ± 4.1 months. None of these patients had infections nor required revision. Patients with RLLs did not do worse in functional and clinical scoring at 1-year. Conclusion: There was a 48% incidence of physiological RLLs after cemented TKA, with the highest occurrence at the medial tibial baseplate at 38%. These radiolucent lines did not affect early post-operative clinical and functional outcomes of patients.

Diagnosing surgical site infections using telemedicine: A Systematic Review.

BACKGROUND: Surgical site infections (SSI) are preventable post-operative complications. With the increase in use of telehealth modalities, there is a need to assess if telehealth modalities are safe for assessment of SSI. AIM: This review aims to assess the accuracy of using telemedicine in the diagnosis of SSI in post-surgical adult patients as compared to in-person assessments. METHODS: A comprehensive search on 6 databases (PubMed, MEDLINE, Embase, Web of Science, Scopus and CENTRAL) was performed from inception to 1 December 2020. Data was extracted to determine accuracy, feasibility, acceptability, and usability of using telemedicine to detect SSIs. The primary outcome of this review was to review the diagnostic accuracy of telemedicine to diagnose SSIs as compared to direct, in-person assessment. Methodological quality was evaluated using the MINORS criteria. RESULTS: Six studies met inclusion criteria. Results were summarized qualitatively. The overall methodological quality of the studies was moderate based on the MINORS score. Four studies utilized telephone surveillance, whilst two utilized mobile applications. Telemedicine modalities were able to accurately diagnose 66 SSIs, where an additional 15 were found on direct clinical review. The diagnostic accuracy across the studies ranged from 69.5 to 100%. Between 82.5 and 100% of patients were able to be contacted through these telemedicine modalities. CONCLUSIONS: Telemedicine modalities are a feasible option for post-operative follow-up, especially in the identification of SSIs. As technology becomes more affordable and widely available, future applications of telemedicine are limitless. However, further research is still required to ensure that telemedicine is a safe and effective tool.

Intravascular Papillary Endothelial Hyperplasia: Case Report of a Recurrent Masson's Tumor of the Finger and Review of Literature.

Intravascular papillary endothelial hyperplasia (IPEH), often referred to as Masson's Tumor, is an uncommon yet benign vascular disease of the skin and subcutaneous tissues. It usually arises within a blood vessel, but is considered to be a non-neoplastic reactive endothelial proliferation commonly associated with vascular injury. Although it is rare, knowledge of this disease is important as it may mimic other benign and malignant tumors, especially angiosarcoma, which may lead to unnecessary aggressive management. Typically, IPEHs are asymptomatic and are slow growing soft-tissue masses with extremely low-recurrence rates. In this article, we describe a 19-year-old male with a recurrence of Masson's Tumor over the right little finger within 2 months of a routine excision of the lesion. We also present accompanying multimodality clinical, radiological, and pathological imaging. This case illustrates the innocuous nature of the initial lesion easily mistaken for a hemangioma. Awareness of the possibility of a recurrence of a Masson's Tumor is important for clinicians to rule out the presence of malignant vascular lesions.

Can Open Hand Injuries Wait for Their Surgery in a Tertiary Hospital?

Objective Open hand injuries are routinely admitted and planned for surgery acutely, competing with other surgical emergencies. This retrospective study aims to evaluate if a delay in timing to surgery for open hand injuries led to an increased rate of infection. Materials and Methods All patients who sustained open hand injuries and underwent semi-emergent day surgery from January 1, 2015 to December 31, 2016 were included. Outcome of postoperative infection was analyzed against demographic data, injury details, and delay from trauma to therapy. Results There were 232 cases (91% males) included, with 92.0% performed under local anesthesia. Deep seated postoperative infection was seen in 1.3%, which was not significantly associated with delay to surgery. Conclusion We had comparable infection rates as compared with published literature. Delayed timing of surgical treatment in open hand injuries was not associated with increased rates of deep-seated infection. Managing open hand injuries as semi-emergent surgeries may be acceptable given the low infection rates.

Return to work after medial unicompartmental knee arthroplasty: A systematic review.

INTRODUCTION: This study aims to evaluate the current literature with regard to the average time to and overall rate of return to work (RTW) following medial unicompartmental knee arthroplasty (UKA). METHODS: A systematic search was conducted on MEDLINE (Ovid), Embase, Pubmed, CINAHL, Web of Science, Scopus, and the Cochrane Library to identify studies reporting RTW after UKA. Primary outcomes were the rate and time to RTW after UKA. Secondary outcomes were postoperative changes in work intensity, functional scores, and factors affecting RTW. Methodological quality was evaluated using the the Methodological Index for Non-Randomized Studies (MINORS) criteria. RESULTS: Seven studies met inclusion criteria. Results were summarized qualitatively. The overall methodological quality of the studies was moderate based on the MINORS score. These studies included 636 patients with 46.5% male. Mean age was 63.1 years. The average rate of RTW was 81.7%. The average time to RTW was 5.4 ±â€¯3.9 weeks (range 1-32 weeks). 81.8% of patients in one study returned to an equally or more physically demanding job, while 83.5% were able to work the same or longer hours postoperatively in another study. Functional scores improved after surgery (n = 6 studies). Factors affecting RTW were postoperative rehabilitation, retirement, and the effects of surgery. CONCLUSION: Limited evidence from the included studies with moderate quality suggests that UKA allows patients to RTW faster, with a high rate of RTW and improved functional outcomes. However, consensus definitions and methods of work status analysis are needed for future studies.

Return to work after surgically treated acetabular fractures in an Asian population.

BACKGROUND: Acetabular fractures are rare but are severe injuries that occur in younger patients with a significant economic impact. There is limited evidence describing the return to work rates in this group of patients. The aim of our study was to examine the rate and time to return to work (RTW) after surgical fixation of acetabular fractures. METHODS: We performed a retrospective study on all patients with surgically treated acetabular fractures at a single institution between 1 July 2010 and 31 December 2018. Medical records were reviewed to analyze demographics such as age, gender, occupation and RTW characteristics. RESULTS: There were 30 patients, with a mean age of 43.3 ± 12.7 years. There were 26 patients who were employed prior to injury. The most common mechanism of injury was from a road traffic accident (73.3%). The average ISS was 8.9 ± 5.2. The mean follow-up duration was 21.5 months ± 15.7. The rate of RTW was 80.8%. Eighteen patients (85.7%) returned to the same job and duties, while two (9.5%) returned with same job but lighter duties and one (4.8%) had to change job. Three patients (11.5%) retired. The average time to return to work was 8.3 months (range 2-57.5). RTW rates were 15.4%, 61.5%, 69.2% at 3, 6 and 12 months, respectively. CONCLUSION: Acetabular fractures can lead to loss of economic productivity, with 80.8% of patients returning to work. Work reintegration programs after acetabular fractures are important.

The Influence of Obesity on Unicompartmental Knee Arthroplasty Outcomes: A Systematic Review And Meta-Analysis.

Obesity is associated with a greater prevalence of symptomatic knee osteoarthritis. Obese patients are thought to have worse outcomes following unicompartmental knee arthroplasty (UKA).The aim is to compare clinical and functional outcomes of UKA in obese to non-obese patients. A systematic review on six databases (PubMed, MEDLINE, Embase, Web of Science, Scopus, and CENTRAL) from inception through July 2020 was performed. We extracted data to determine revision risk (all-cause, septic, and aseptic), complication risk, and infection risk, functional outcome scores (Knee Society Score [KSS], Oxford Knee Score [OKS], and range of movement [ROM]) in patients with obesity (BMI >30kg/m2) to non-obese patients (BMI <30kg/m2). Meta-analysis was performed using a random effects model. The MINORS criteria was used for quality assessment. Twelve of 715 studies were eligible. Compared with non-obese patients, obese patients had a higher risk ratio for all-cause revision (RR 1.49; 95% CI 1.04 to 2.13; p = 0.03); aseptic revision (RR 1.36; 95% CI 1.01 to 1.81; p=0.04) and complications (RR 2.12; 95% CI 1.17 to 3.85; p=0.01). No significant differences were found in risk of septic revision and overall infection. Obese patients also had lower KSS scores (MD -3.21; 95% CI -5.52 to -0.89; p<0.01), OKS scores (MD -2.21; 95% CI -3.94 to -0.48; p=0.01), and ROM (MD -7.17; 95% CI -12.31 to -2.03; p<0.01). The average MINORS score was 14.2, indicating a moderate quality of evidence. In conclusion, the risk of revision, aseptic revision, and complications are higher in obese patients. The clinical significance of a lower functional score in obese may not be appreciable. Despite the greater risks, there is no conclusive evidence that obesity should be a contraindication to UKA. Further studies are required to corroborate the current conclusions with higher-quality study designs.

Experience with the Use of Splint Caps for the Management of Fingertip Amputation Injuries.

Background: Fingertip amputation injuries are common hand injuries amongst all ages. If occurring as a result of workplace accidents, these injuries has the potential to lead to significant socioeconomic costs. Non-surgical techniques can treat these injuries with the potential to alleviate the burden of these socioeconomic costs. The aim of our study is to describe an alternative, cost-effective device to manage fingertip amputation injuries, and to present our short-term outcomes with this treatment modality. Methods: A retrospective study of patients with isolated fingertip amputation injuries who received treatment with semi-occlusive dressing and splint cap from 1 February 2018-21 December 2018 was conducted. The semi-occlusive dressing used was UrgoTul. The splint cap is a 3-dimensional thermoplastic splint to cover the semi-occlusive dressing of the injured finger. Results: There were 28 patients and 31 digits. The average age was 39.9 ± 12.7 years. 89.3% were male, 75% were foreign workers, 96.4% were blue-collared workers, 40% had dominant hand injuries and 25.8% had nailbed involvement. The average duration of follow-up was 66 ± 37.4 days and the average duration of hospital leave was 6.5 ± 4 weeks. The splint cap was applied for an average of 18.1 ± 6.2 days. The total time for tissue regrowth was 27.5 ± 8.8 days. 14.8% had residual nail deformities and return of sensation took 31.5 ± 11 days. Grip strength was 82.5% of unaffected hand. The mean range of motion at the distal interphalangeal, proximal interphalangeal and metacarpophalangeal joint was 58.8 ± 21.3°, 86.9 ± 15.5°, 81.4 ± 6.0° respectively, and 63.9 ± 23.6° and 66.3 ± 17.3° at the interphalangeal and metacarpophalangeal joint of the thumb respectively. Cost analysis will be further elaborated in the paper. Conclusions: Fingertip amputation injuries have a potential for regeneration through healing by secondary intention under semi-occlusive dressing conditions. The splint cap provides an easy to fashion, cost-efficient and comfortable addition to semi-occlusive dressings for fingertip injuries.

Scope of Hand Surgery Using Surgeon Administered Local/Regional Anaesthesia.

INTRODUCTION: Hand and wrist surgeries are often carried out under local/regional anesthesia. We describe our experience using Surgeon Administered Local/Regional Anaesthesia (SALoRA) without sedation to deliver acute and elective hand surgery anesthesia in a tertiary public hospital in Singapore. This is in comparison to wide awake local anesthesia no tourniquet, which has been increasing in popularity. METHODS: Retrospective analysis was conducted on all surgeries performed under SALoRA between January 1, 2013, to December 31, 2016, at our institution. Surgeries on areas other than the hand, wrist, forearm, and elbow were excluded. The records were reviewed to analyze the demographics of the patients, profile of cases performed, and their outcomes. RESULTS: Of a total of 3016 cases performed, 1994 patients (1275 men; age, 45.78 ± 16 years) fulfilled the inclusion criteria and were available for analysis for the study period. The case distribution was similar to most other published data on day hand surgery cases. Tourniquet was used in 1357 (68%) of cases with an average operation time of 26 ± 19 minutes. Mean tourniquet use was 24 ± 15 minutes. Detailed analysis will be presented. CONCLUSION: This study shows the versatility of SALoRA in delivering hand surgery in a cost-effective manner. A wide spectrum of surgeries in the hand, wrist, forearm, and elbow can be performed using SALoRA safely. This has increased productivity, efficiency, and use of resources. SALoRA has the advantage of a guaranteed and reliable bloodless field, quick turnaround time without the need of extra personnel and resources needed for patient monitoring to abide by Joint Commission International requirements and the potential risk of systemic adrenaline effects.

Accessory Palmaris Longus: A Concise Anatomic Review With a Relevant Case Study.

Current medical literature has described many variations of the palmaris longus. One variation that is rarely seen is that of the accessory palmaris longus, which is better known in literature as the "palmaris profundus." This brief review will describe the anatomy and the developmental origins of the palmaris longus, as well as the clinical relevance of an accessory palmaris longus. We will also present a case on the accessory palmaris longus and discuss whether the accessory palmaris longus, if encountered during a routine carpal tunnel surgery, should be resected intraoperatively.

Early weight loss after laparoscopic sleeve gastrectomy predicts midterm weight loss in morbidly obese Asians.

BACKGROUND: Laparoscopic sleeve gastrectomy (SG) is a popular bariatric procedure in morbidly obese Asians. OBJECTIVES: To investigate the effect of initial weight loss on midterm weight maintenance and remission of co-morbidities after laparoscopic SG in morbidly obese Asians. SETTING: University Hospital, Singapore. METHODS: Data of patients who underwent laparoscopic SG were analyzed. Change in body mass index (BMI), percentage of total weight loss (%WL), and of excess weight loss (%EWL) was calculated and remission of obesity-related co-morbidities was examined. Linear regression analysis was performed to determine the effect of initial weight loss on successful weight maintenance. Receiver operative characteristic curve analysis was used to define optimal cutoff values. RESULTS: Two hundred and seventy-two patients were included in this study. Mean preoperative weight and BMI were 115.4±25.5 kg and 42.5±8.0 kg/m2, respectively. Mean follow-up duration was 27.6±16.4 months. Successful weight loss of>50% EWL was achieved by 65.7%, 65.5%, and 50.8% of patients at 1, 2, and 3 years, postoperatively. There was a significant correlation of %EWL at 3 months with %EWL up to 3 years (P≤.005). Receiver operative characteristic analysis showed initial EWL of 35% at 3 months best predicted successful weight loss at 1 year (sensitivity 73.1%, specificity 81.4%). Patients achieving>35% EWL were significantly more likely to achieve remission of co-morbidities (P≤.005) at 1 year after surgery. CONCLUSION: Early weight loss at 3 months predicts weight maintenance up to 3 years and remission of co-morbidities at 1 year after laparoscopic SG in Asians.