Risks of SARS-CoV-2 JN.1 infection and COVID-19 associated emergency-department (ED) visits/hospitalizations following updated boosters and prior infection: a population-based cohort study.

INTRODUCTION: Data on protection afforded by updated COVID-19 vaccines (bivalent/XBB 1.5 monovalent) against the emergent JN.1 variant remains limited. METHODS: We conducted a retrospective population-based cohort study amongst all boosted Singaporeans aged ≥18 years during a COVID-19 wave predominantly driven by JN.1, from 26th November 2023 to 13th January 2024. Multivariable Cox regression was utilised to assess risk of SARS-CoV-2 infection and COVID-19 associated emergency-department (ED) visits/hospitalizations, stratified by vaccination status/prior infection; with individuals last boosted ≥1 year utilized as the reference category. Vaccination and infection status were classified using national registries. RESULTS: 3,086,562 boosted adult Singaporeans were included in the study population, accounting for 146,863,476 person-days of observation. During the JN.1 outbreak, 28,160 SARS-CoV-2 infections were recorded, with 2,926 hospitalizations and 3,747 ED-visits. Compared with individuals last boosted ≥1 year prior with ancestral monovalent vaccines, receipt of an updated XBB.1.5 booster 8-120 days prior was associated with lower risk of JN.1 infection (adjusted-hazard-ratio, aHR = 0.59[0.52-0.66]), COVID-19 associated ED-visits (aHR = 0.50[0.34-0.73]) and hospitalizations(aHR = 0.58[0.37-0.91]), while receipt of a bivalent booster 121-365 days prior was associated with lower risk of JN.1 infection (aHR = 0.92[0.88-0.95]) and ED-visits (aHR = 0.80[0.70-0.90]). Lower risk of COVID-19 hospitalization during the JN.1 outbreak (aHR = 0.57[0.33-0.97]) was still observed following receipt of an updated XBB.1.5 booster 8-120 days prior, even when analysis was restricted to previously infected individuals. CONCLUSION: Recent receipt of updated boosters conferred protection against SARS-CoV-2 infection and ED-visits/hospitalization during a JN.1 variant wave, in both previously infected and uninfected individuals. Annual booster doses confer protection during COVID-19 endemicity.

Pre-operative erector spinae plane block should be considered a viable option for laparoscopic colectomies.

BACKGROUND: The Erector Spinae Plane (ESP) block is a recent development in the field of regional anaesthesia and has been increasingly explored for abdominal surgeries to reduce opioid use and improve pain control. Colorectal cancer is the commonest cancer in multi-ethnic Singapore and requires surgery for curative treatment. ESP is a promising alternative in colorectal surgeries, but few studies have evaluated its efficacy in such surgeries. Therefore, this study aims to evaluate the use of ESP blocks in laparoscopic colorectal surgeries to establish its safety and efficacy in this field. METHODS: A prospective two-armed interventional cohort study comparing T8-T10 ESP blocks with conventional multimodal intravenous analgesia for laparoscopic colectomies was conducted in a single institution in Singapore. The decision for doing an ESP block versus conventional multimodal intravenous analgesia was made by a consensus between the attending surgeon and anesthesiologist. Outcomes measured were total intra-operative opioid consumption, post-operative pain control and patient outcome. Post-operative pain control was measured by pain score, analgesia use, and amount of opioids consumed. Patient outcome was determined by presence of ileus. RESULTS: A total of 146 patients were included, of which 30 patients received an ESP block. Overall, the ESP group had a significantly lower median opioid usage both intra-operatively and post-operatively (p = 0.031). Fewer patients required patient-controlled analgesia and rescue analgesia post-operatively for pain control (p < 0.001) amongst the ESP group. Pain scores were similar and post-operative ileus was absent in both groups. Multivariate analysis found that the ESP block had an independent effect on reducing intra-opioid consumption (p = 0.014). Multivariate analysis of post-operative opioid use and pain scores did not yield statistically significant results. CONCLUSIONS: The ESP block was an effective alternative regional anaesthesia for colorectal surgery that reduced intra-operative and post-operative opioid use while attaining satisfactory pain control.

The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis.

BACKGROUND: For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery. METHODS: Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien-Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity. RESULTS: Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781-0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674-53.673, p = 0.005), but there were no significant differences in the 6MWT at 4 weeks (SMD = 30.342, 95% CI - 2.707-63.391, p = 0.066) and 8 weeks (SMD = 24.563, 95% CI - 6.77-55.900, p = 0.104) postoperatively. CONCLUSIONS: As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.

Systematic review and meta-analysis of postoperative pain and symptoms control following laser haemorrhoidoplasty versus Milligan-Morgan haemorrhoidectomy for symptomatic haemorrhoids: a new standard.

PURPOSE: Haemorrhoidal disease (HD) plagues one in every ten people, with a plethora of surgical treatment modalities, of which laser haemorrhoidoplasty (LHP) is a relatively novel option. This systematic review and meta-analysis objectively evaluated the efficacy, safety, and tolerability of LHP compared against conventional (Milligan-Morgan) open haemorrhoidectomy (CoH). METHOD: A comprehensive search of MEDLINE, EMBASE, CENTRAL, and Google Scholar was conducted. Randomised controlled trials (RCTs) and comparative cohort studies (CCSs) which compared LHP against CoH were included, with postoperative pain as the primary outcome. Secondary outcomes included intraoperative characteristics, short- and moderate-term outcome, and complications. RESULTS: A total of 12 studies (6 RCTs and 6 CCSs), with a total of 1824 patients, were analysed. LHP resulted in reduced postoperative pain for the first day (mean difference of 2.07 visual analogue scale units), week, and month. The mean dosage and duration of postoperative analgesia use was similarly lower, with a mean difference of 4.88 mg (morphine) and 2.25 days, respectively. Crucially, recurrence was equivocal (HR: 0.72, CI: 0.21-2.40) at a mean follow-up duration of 8.58 ± 9.55 months. LHP resulted in lower blood loss and was 12.74 min shorter on average. LHP's postoperative recovery time was 9.03 days less with equivalent or decreased risk of most short- and moderate-term complications except anal thrombosis. CONCLUSION: Our study suggests that LHP is more tolerable than CoH, providing patients with superior postoperative quality of life at equivalent moderate-term efficacy. These findings contribute to improved understanding of LHP and its potential at enhancing the quality of HD care.

Did the COVID-19 lockdown result in a delay of colorectal cancer presentation and outcomes? A single centre review.

PURPOSE: The COVID-19 pandemic and resultant lockdown measures potentially delay management of non-communicable, life-limiting diseases like colorectal cancer (CRC) through avoidance of healthcare facilities by the public and diversion of resources within healthcare systems. This study aims to evaluate the impact of Singapore's "Circuit Breaker (CB)" lockdown measures on CRC disease presentation and short-term surgical outcomes, while comparing Singapore's approach against other countries which employed similar lockdown measures. METHODS: Patients whose initial diagnosis of CRC was made within the 6-month pre-CB (6/10/19-6/4/20) ("pre-CB group") and post-CB (7/4/20-7/10/20) ("post-CB group") period were enrolled retrospectively. The groups were compared based on severity of disease on presentation and short-term operative outcomes. RESULTS: In total, 105 patients diagnosed with CRC were enrolled in this study. When comparing pre-CB and post-CB groups, there was no significant difference in stage of CRC on presentation (p = 0.850). There was also no increase in need for emergent operations (p = 0.367). For patients who had undergone an operation, postoperative morbidity was not significantly higher in the post-CB group (p = 0.201). Both groups of patients had similar length of stay in the hospital (p = 0.438). CONCLUSION: Unlike similar high-income countries, Singapore did not see later stage disease on presentation and poorer operative outcomes after lockdown measures. Possible reasons include lesser healthcare avoidance behaviours amongst Singaporeans, and adequate preparation of resources and contingency plans formed by hospitals after previous pandemics.

Multimodal prerehabilitation for elderly patients with sarcopenia in colorectal surgery.

Sarcopenia, which is characterized by progressive and generalized loss of skeletal muscle mass and strength, has been well described to be associated with numerous poor postoperative outcomes, such as increased perioperative mortality, postoperative sepsis, prolonged length of stay, increased cost of care, decreased functional outcome, and poorer oncological outcomes in cancer surgery. Multimodal prehabilitation, as a concept that involves boosting and optimizing the preoperative condition of a patient prior to the upcoming stressors of a surgical procedure, has the purported benefits of reversing the effects of sarcopenia, shortening hospitalization, improving the rate of return to bowel activity, reducing the costs of hospitalization, and improving quality of life. This review aims to present the current literature surrounding the concept of sarcopenia, its implications pertaining to colorectal cancer and surgery, a summary of studied multimodal prehabilitation interventions, and potential future advances in the management of sarcopenia.

Colovaginal Fistula: An Uncommon Complication After Vaginal Hysterectomy and Pelvic Floor Repair With Mesh Surgery.

A colovaginal fistula (CVF) is an abnormal epithelialized connection between the colon and the vagina. It is a rare complication following gynaecology surgery and can significantly affect patients' quality of life. CVFs are commonly associated with diverticular disease and are usually seen in patients with a previous hysterectomy. We report an uncommon case of postsurgical CVF following vaginal hysterectomy with mesh-augmented pelvic floor repair, which was unrelated to diverticulitis. The patient was successfully managed by a multidisciplinary team with staged surgery.

Changing trends of cesarean section births by the Robson Ten Group Classification in a tertiary teaching hospital.

OBJECTIVE: To analyse changing trends of cesarean section (CS) birth rates over an 11 year period (2000-2010) using the Robson Ten Group Classification System (RTGCS) to identify the main contributors to the rising CS birth rates at a tertiary teaching hospital in Singapore. DESIGN: Retrospective study. SETTING: National University Hospital, Singapore. POPULATION: All women who delivered between 1 January 2000 and 31 December 2010 (hospital maternity database). METHODS: The RTGCS was used to classify these women according to parity, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labor/delivery. MAIN OUTCOME MEASURES: The RTGCS results. RESULTS: From 2000 to 2010 the CS rate increased from 19.9 to 29.6 per 100 births. Multiparous women with a previous cesarean birth (Group 5) were the greatest contributor to the CS rate, followed by nulliparous women with singleton cephalic full-term pregnancy in spontaneous labor (Group 1). These two groups contributed to 75% of the rise in the CS rate from 2000 to 2010. CONCLUSIONS: The increase in CS rate is attributed largely to the rising CS rate in Group 5, followed by Group 1. We propose that future efforts to reduce overall CS rate should be focused on increasing vaginal birth after cesarean and reduce CS rates in nulliparous women with singleton cephalic full-term pregnancy (Groups 1 and 2), which in turn will reduce the number of pregnant women with a previous CS.

Simultaneous cardiocerebral infarctions: a five-year retrospective case series reviewing natural history.

Introduction: Concurrent cardiocerebral infarction (CCI), a rare condition defined as simultaneous occlusions in the cerebrovascular and coronary vessels, has high mortality but very limited literature on optimum treatment methods. A better understanding of the natural history and effect of treatment would improve patient outcomes. Methods: Using our prospective stroke database from 2014 to 2018, ten consecutive patients with CCI were identified (incidence = 0.29%). We recorded patient demographics, cardiovascular risk factors, cardiac and cerebral occlusions, circumstances of admission and management of each patient. Patient notes and imaging findings were reviewed to determine the underlying cause of CCI. Results: Median National Institute of Health Stroke Scale score was 15 (range 4-27). Mean patient age was 59 years and 90% were men. Two patients were treated with intravenous tissue plasminogen activator (IV tPA) only and three underwent endovascular treatment in both the cerebral and coronary vessels sequentially. One patient underwent percutaneous coronary intervention (PCI) only and two underwent PCI after IV tPA therapy. Two patients were conservatively treated due to poor premorbid status. At the three-month follow-up, five patients had excellent functional outcomes (modified Rankin Scale 0-1) while three died. Conclusion: CCI is a rare but devastating clinical scenario, with high incidence of morbidity and mortality. Treatment strategy can impact patient outcome, and further research is warranted on the ideal acute and post-reperfusion treatments for CCI. In this series, IV tPA at stroke doses appeared to be the preferred initial step for its treatment, with subsequent coronary or cerebral endovascular therapy, if necessary.

Clinical outcomes of severe tricuspid valve infective endocarditis related to intravenous drug abuse - a case series.

BACKGROUND: Right-sided infective endocarditis (IE) related to intravenous drug use (IVDU) can follow an acute fulminant course. However, there is limited information on its longer-term clinical outcomes. AIM AND METHODS: We assessed a cohort of consecutive patients who presented with IVDU complicated by severe tricuspid valve regurgitation to determine their presentation, treatment, and long-term outcomes. In this study, severe tricuspid regurgitation (TR) was defined by the European Association of Cardiovascular Imaging criteria at initial presentation to the hospital. RESULTS: Thirty-three patients with a mean age of 35 ± 18 years (72% males) presented with IVDU associated with severe TR. At the initial presentation, 15 patients were in septic shock and required inotropes. 26 patients had septic pulmonary emboli; 10 patients had associated metastatic systemic sites of infection of which 5 patients had central nervous system (CNS) involvement. Three patients were in disseminated intravascular coagulation (DIC) and 1 patient had multi-organ failure (MOF), but not requiring dialysis or mechanical ventilation. Most patients had large tricuspid valve vegetations of >20mm. Eleven patients underwent surgery with 18% perioperative mortality. The Median follow-up was 6.4 years (0.5-11.4). Recurrent IE occurred in one-third of patients, the overall incidence of heart failure and Atrial fibrillation (AF) on follow-up was low in all 3 groups. Five-year survival was 94%. CONCLUSION: Acute severe TR following associated endocarditis IVDU results in a fulminant initial presentation, but a longer-term prognosis is good with surgical and medical treatment.

Case to highlight a rare differential diagnosis of necrotising fasciitis in the presence of a stoma: peristomal pyoderma gangrenosum.

Peristomal pyoderma gangrenosum (PPG) is a rare clinical entity, which can masquerade as the more common and lethal necrotising fasciitis. The authors present a case of PPG in a 65-year-old woman who underwent robotic abdominoperineal resection for low rectal carcinoma and returned 8 days postoperation for peristomal skin ulcerations and pain, accompanied by leucocytosis; thus, she was treated as per necrotising fasciitis and underwent surgical debridement. Thereafter, her wound continued to worsen despite conventional wound care with vacuum-assisted closure and demonstrated signs of pathergy. The case was referred to dermatology where a diagnosis of PPG was made. This case report presents a cautionary tale for fellow clinicians, highlights the diagnostic challenge, and presents an updated literature review on diagnosis and management of this unique condition.

Penile gangrene from calciphylaxis is salvageable with intravenous sodium thiosulfate and early total parathyroidectomy.

Penile gangrene is a rare but fatal complication of calciphylaxis in end-stage renal disease (ESRD). To date, there are no guidelines on its management, and outcomes are generally poor with high mortality rate. We present a case of a diabetic patient with ESRD presenting with dry gangrene of the glans penis due to calciphylaxis and successfully treated with intravenous sodium thiosulfate (STS) and early total parathyroidectomy. We further analysed existing literatures on cases that utilized STS in the treatment of penile calciphylaxis.

Chronic thromboembolic pulmonary hypertension: a review.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a unique form of pulmonary hypertension resulting from obstruction of the pulmonary artery by fibrotic thromboembolic material, usually initiated by recurrent or incomplete resolution of pulmonary embolism. This distinct form of pulmonary hypertension is classified under Group 4 of the World Health Organization classification. Further investigations are usually initiated, with transthoracic echocardiography followed by right heart catheterisation and pulmonary angiography as the gold standard. Definitive treatment is usually in the form of surgical pulmonary endarterectomy. Inoperable CTEPH is medically treated with pharmacological agents such as phosphodiesterase Type 5 inhibitors, endothelin receptor antagonists, soluble guanylate cyclase stimulators and prostacyclin. Recent developments have made balloon pulmonary angioplasty a viable option as well.

Red Palm Oil: A Review on Processing, Health Benefits and Its Application in Food.

This review is aimed to provide a comprehensive overview of the physicochemical properties and extraction processes of red palm oil, its nutritional properties and applications in food. Crude palm oil is firstly extracted from the fruit mesocarp and processed into red palm oil using pre-treatment of crude palm oil, with deacidification steps, and deodorization via short-path distillation. These processes help to retain ß-carotene and vitamin E in red palm oil. Palmitic, stearic and myristic acids are the saturated fatty acids in red palm oil, while the unsaturated fatty acids are oleic, linoleic and linolenic acids. It is reported to overcome vitamin A deficiency, promote heart health and have anti-cancer properties.

Comparative outcomes of needlescopic, single-incision laparoscopic, standard laparoscopic, mini-laparotomy, and open cholecystectomy: A systematic review and network meta-analysis of 96 randomized controlled trials with 11,083 patients.

BACKGROUND: Most randomized trials on minimally invasive cholecystectomy have been conducted with standard (3/4-port) laparoscopic or open cholecystectomy serving as the control group. However, there exists a dearth of head-to-head trials that directly compare different minimally invasive techniques for cholecystectomy (eg, single-incision laparoscopic cholecystectomy versus needlescopic cholecystectomy). Hence, it remains largely unknown how the different minimally invasive cholecystectomy techniques fare up against one another. METHODS: To minimize selection and confounding biases, only randomized controlled trials were considered for inclusion. Perioperative outcomes were compared using frequentist network meta-analyses. The interpretation of the results was driven by treatment effects and surface under the cumulative ranking curve values. A sensitivity analysis was also undertaken focusing on a subgroup of randomized controlled trials, which recruited patients with only uncomplicated cholecystitis. RESULTS: Ninety-six eligible randomized controlled trials comprising 11,083 patients were identified. Risk of intra-abdominal infection or abscess, bile duct injury, bile leak, and open conversion did not differ significantly between minimally invasive techniques. Needlescopic cholecystectomy was associated with the lowest rates of wound infection (surface under the cumulative ranking curve value = 0.977) with an odds ratio of 0.095 (95% confidence interval: 0.023-0.39), 0.32 (95% confidence interval: 0.11-0.98), 0.33 (95% confidence interval: 0.11-0.99), 0.36 (95% confidence interval: 0.14-0.98) compared to open cholecystectomy, single-incision laparoscopic cholecystectomy, mini-laparotomy, and standard laparoscopic cholecystectomy, respectively. Mini-laparotomy was associated with the shortest operative time (surface under the cumulative ranking curve value = 0.981) by a mean difference of 22.20 (95% confidence interval: 13.79-30.62), 12.17 (95% confidence interval: 1.80-22.54), 9.07 (95% confidence interval: 1.59-16.54), and 8.36 (95% confidence interval: -1.79 to 18.52) minutes when compared to single-incision laparoscopic cholecystectomy, needlescopic cholecystectomy, standard laparoscopic cholecystectomy, and open cholecystectomy, respectively. Needlescopic cholecystectomy appeared to be associated with the shortest hospitalization (surface under the cumulative ranking curve value = 0.717) and lowest postoperative pain (surface under the cumulative ranking curve value = 0.928). CONCLUSION: Perioperative outcomes differed across minimally invasive techniques and, in some instances, afforded superior outcomes compared to standard laparoscopic cholecystectomy. These findings suggest that there may be equipoise for exploring further the utility of novel minimally invasive techniques and potentially incorporating them into the general surgery training curriculum.

Initial experience of laparoscopic right hemicolectomy with complete mesocolic excision in Singapore: a case series.

INTRODUCTION: Laparoscopic colorectal surgery is increasingly performed worldwide due to its multiple advantages over traditional open surgery. In the surgical treatment of right-sided colonic tumours, the latest technique is laparoscopic right hemicolectomy with complete mesocolic excision (lapCME), which aims to lower the rate of local recurrence and maximise survival as compared to standard laparoscopic right hemicolectomy (lapS). METHODS: We conducted a retrospective analysis of our initial experience with lapCME in Singapore General Hospital between 2012 and 2015. All procedures were performed by a single surgeon. RESULTS: Nine patients underwent lapCME and 16 patients underwent lapS. Indication for lapCME was cancer in the right colon. None of the patients required conversion to open surgery, and all were discharged well. The number of lymph nodes resected in the lapCME group was significantly greater than in the lapS group (29 ± 15 vs. 19 ± 6; p = 0.02) during the study period, and the mean operation time was significantly longer for lapCME (237 ± 50 minutes vs. 156 ± 46 minutes; p = 0.0005). There were no statistically significant differences in terms of demographics, tumour stage, time taken for bowel to open postoperatively, time taken for patient to resume a solid diet postoperatively and length of hospital stay. Two patients who underwent lapS were re-admitted for intra-abdominal collections - one patient required radiology-guided drainage, while the other patient was managed conservatively. CONCLUSION: Our initial experience with lapCME confirms the feasibility and safety of the procedure.