A Comparison of the P-POSSUM and NELA Risk Score for Patients Undergoing Emergency Laparotomy in Singapore.

BACKGROUND (AIMS, HYPOTHESES, OR OBJECTIVES): Emergency laparotomy (EL) is a high-risk surgical procedure associated with considerable morbidity and mortality around the world. A reliable risk-assessment tool that is specific to patients undergoing EL allows the early identification of high-risk patients and enables appropriate healthcare resource allocation. The objective of this study was to compare the commonly used Portsmouth-physiologic and operative severity score for the enumeration of mortality and morbidity (P-POSSUM) with the recently developed National Emergency Laparotomy Audit (NELA) score in terms of their accuracy for identifying patients at increased risk of 30-day mortality in a predominantly Asian population. METHODS: Physiological and operative data from a prospectively collected audit of adult patients undergoing EL in 2018 and 2019 across two tertiary hospitals in Singapore were used to retrospectively calculate both the P-POSSUM and NELA scores for each patient encounter. This was then compared to actual mortality rates to determine each model's accuracy and precision. RESULTS: 830 patients were included in the study with a 30-day mortality of 5.66%. The area under the receiver operating characteristics curve (AUROC) was similar for both the NELA (0.86, p < 0.001, 95% CI 0.81-0.91) and the P-POSSUM models (0.84, p < 0.001, 95% CI 0.78-0.89). While the models over-predicted mortality, overall O:E ratios showed that the NELA model performance was superior to that of P-POSSUM (0.58 [95% CI 0.43-0.77] compared to 0.34 [95% CI 0.26-0.46]). CONCLUSION: The NELA risk-prediction model accurately predicts 30-day mortality in this large cohort of patients undergoing EL and outperforms the current P-POSSUM model. We recommend that the NELA score should replace the P-POSSUM score as a model to distinguish between high- and low-risk patients undergoing EL.

Seroma prevention strategies in laparoscopic ventral hernia repair: a systematic review.

BACKGROUND: Laparoscopic ventral hernia repair (LVHR) has been increasing in popularity over the years. Seroma formation is a common complication of LVHR. The aim of this study is to review the current evidence on seroma prevention strategies following LVHR. METHODS: A systematic search of PubMed, Embase (1946-13 February 2019) and Medline (1946-13 February 2019) databases was conducted using terms which include "seroma", "hernia, ventral" and "laparoscopy". All studies are comparative retrospective or prospective human adult studies in peer-reviewed journals describing at least one intra-operative intervention designed to decrease the rate of seroma formation in laparoscopic ventral hernia repair. RESULTS: The database searches identified 3762 citations, and 21 studies were included for final analysis. Five studies compared the different methods of mesh fixation, nine studies compared primary defect closure (PFC) and bridged repair, two studies compared the effect of different types of meshes, two studies looked into the use of electrical cauterization, one study compared single- site laparoscopy with conventional laparoscopy, one study looked into the use of fibrin sealant and one study compared transabdominal preperitoneal placement of mesh with conventional repair. PFC appears to be the most promising with large studies showing a low rate of seroma formation with additional benefits of decreasing wound infection and recurrence rate. Cauterisation of hernia sac and injection of fibrin sealant also show promising results but are mainly derived from small studies. Other strategies did not demonstrate benefit. CONCLUSION: Currently, primary fascial closure appears to be the most promising strategy available to decrease seroma formation after LVHR based on the results of large studies. Other promising strategies that decrease dead space such as cauterisation of the sac and fibrin sealant injection will require further multicentre trials to confirm benefit before an increase in operative time and cost can be justified for their routine use.

Knowledge, attitudes and behaviour towards needlestick injuries among junior doctors.

BACKGROUND: Needlestick injuries (NSIs) are common healthcare-related injuries and possible consequences include blood-borne infections. Despite that, a large proportion of NSIs are not reported. AIMS: To estimate the prevalence of under-reporting of NSIs and to evaluate the knowledge, attitude and behaviour towards NSIs among junior doctors in a tertiary hospital in Singapore. METHODS: An explanatory sequential mixed-methods design was employed. Quantitative data were collected through questionnaires completed by 99 junior doctors. Descriptive statistics and bivariate analysis were performed to evaluate socio-demographic characteristics, NSI history and NSI reporting practices. Qualitative data were collected through 12 in-depth interviews. Participants were purposively recruited, and semi-structured topic guides were developed. Data were analysed using a thematic approach. RESULTS: Fifty-two per cent of respondents had history of NSI. Of those with history of NSI, 31% did not report injury. NSI reporters were 1.52 times as likely to be aware of how to report injury (P < 0.05), and 1.63 times as likely to feel that reporting benefits their health (P < 0.01) compared with non-reporters. NSI reporters were 83% more likely to report a clean NSI (P = 0.05). For non-reporters, the main reasons for not reporting were perceived low risk of transmission (41%) and lack of time to report (35%). Themes identified in the qualitative data include perceived benefits, perceived barriers, perceived threats, cues to action and organizational culture. CONCLUSION: Under-reporting of NSIs may have significant implications for patients and healthcare workers. Addressing identified factors and instituting targeted interventions will help to improve reporting rates.

Fractional laser resurfacing for acne scars: a review.

This review investigates the effectiveness of ablative and nonablative fractional photothermolysis (FP) lasers for treating facial acne scars. Twenty-six studies (13 ablative FP, 13 nonablative FP) published between 2003 and January 2011 were reviewed. Quantitative and qualitative data from each article were examined and analysed. Four studies were split-face randomized controlled studies. While the data analysed were all clinically relevant and significant, there were some methodological differences between the studies. Outcomes included subjective and objective assessment of scar appearance, pre- and postoperative treatment, side-effects and pain scores. A small number of studies used three-dimensional optical imaging profiling and histology for objective assessment. Even allowing for methodological variability, ablative FP had an improvement range of 26-83% whereas nonablative FP had an improvement range of 26-50%. Patients who underwent treatment with an ablative FP laser experienced erythema for 3-14 days which resolved by 12 weeks, whereas patients who opted for the nonablative FP laser experienced erythema for between 1 and 3 days and this resolved within a week. A higher proportion of patients (up to 92·3%) who underwent ablative FP experienced postinflammatory hyperpigmentation (PIH) than those who had nonablative FP (up to 13%). The maximum duration of PIH in ablative FP was up to 6 months whereas in nonablative FP it lasted for up to 1 week. The procedure with ablative FP was relatively uncomfortable compared with nonablative FP. The pain score with ablative FP ranged from 5·90 to 8·10 (scale 1-10) and with nonablative FP from 3·90 to 5·66 (scale 1-10).