Comparison of hand-assisted laparoscopic radical gastrectomy and laparoscopic-assisted radical gastrectomy: A systematic review and meta-analysis

BACKGROUND

Gastrectomy is the optimal treatment for gastric cancer. Laparoscopic-assisted gastrectomy (LAG) has been extensively employed, while hand-assisted laparoscopic gastrectomy (HALG), which is similar to LAG, remains controversial. Although HALG is popular in China, some surgeons do not accept it as a minimal-access technique. 

AIM

To assess the safety and practicability of HALG by comparing the short-term outcomes of HALG and LAG.

METHODS

The electronic databases of EMBASE, PubMed, China National Knowledge Infrastructure, and Cochrane Library were thoroughly searched, and randomized controlled trials (RCTs) comparing HALG and LAG were included. The study results, including surgery time, blood loss, retrieved lymphatic nodes, incision length, time to first flatus, hospitalization duration, and all postsurgical complications, were compared between the two groups.

RESULTS

Five RCTs, which included 302 cases with HALG and 298 cases with LAG, were considered eligible for inclusion. Meta-analysis showed that HALG significantly reduced surgery time (P < 0.01), hospital duration (P < 0.01), and overall postsurgical complications (P < 0.01). Additionally, HALG significantly increased the number of retrieved lymphatic nodes (P = 0.01) and incision length (P < 0.01) compared with LAG. The blood loss and time to first flatus were similar between the two groups (P > 0.05).

CONCLUSION

Compared with LAG, HALG is a simpler and safer technique. Additionally, HALG should be used as a minimal-access technique, especially in technologically undeveloped areas.

How far has panic buying been studied?

BACKGROUND

Although panic buying (PB) is a ubiquitous behavior, it became prominent during the coronavirus disease 2019 pandemic. However, studies are inadequate to explore the different aspects of it, even though it covers several perspectives of life and academic domains.

AIM

To assess the research that have been conducted on PB.

METHODS

A search was conducted to identify the articles in PubMed, PubMed Central, Scopus, and Google Scholar using the search term “panic buying” on November 15, 2020. A total of 104 articles was extracted from the initial search. After removing duplicates and initial and full-text screening, 42 articles were included in the study. We only considered peer-reviewed published articles that can be downloaded in a full portable document format. Articles published in other languages and preprints were excluded.

RESULTS

Among the 42 articles, 27 were original contributions, 6 were correspondences, 3 were commentaries, 3 were review articles, and there was one each for editorial, opinion, and discussion type of articles. Several domains have been researched such as psychology, responsible factors, supply chain, management, disaster preparedness, e-commerce, consumer behavior, marketing, prevention strategies, media, social network, economics, personality, and engineering. Authors from several disciplines, such as psychiatry, management, economics, business, sales and marketing, consumer behavior, public health, communication, information management, sociology, engineering, business administration, psychology, nursing, health economics, food policy, epidemiology, and community health, have been studied it. Definition, causative model, econometric model, controlling strategy, and measuring instrument have been reported. A total of 18 papers had cross-country collaboration, and ten were funded projects. Most of the authors were affiliated with the institutions of Australia, Bangladesh, China, India, Singapore, and the United States.

CONCLUSION

PB is a relatively newer concept to get the attention of the research community. Further robust studies with replication of the findings are warranted to explore, predict, and control during crises.

Split-dose vs same-day bowel preparation for afternoon colonoscopies: A meta-analysis of randomized controlled trials

BACKGROUND

Quality of bowel preparation in afternoon colonoscopies has been a struggle. Currently, a choice of same-day preparation (SaD) or split-dose preparation (SpD) exists; however, randomized controlled trials’ results have varied. 

AIM

To examine the outcomes of SaD and SpD for afternoon colonoscopies.

METHODS

An extensive literature search was conducted using multiple databases. Only randomized controlled trials (RCTs) in adults that compared SaD to SpD with Ottawa bowel preparation score (OBPS) were included. Odds ratio (OR) or mean difference was used to analyze outcomes.

RESULTS

Eleven RCTs were included (n = 1846). No difference was observed for satisfactory bowel preparation based on OBPS among participants receiving SaD vs SpD (OR 0.77; 95%CI: -0.57-1.03; P = 0.07; I² = 5%). Subgroup analysis showed no difference in terms of satisfactory bowel preparation based on OBPS between the two groups when receiving same preparation formula (polyethylene glycol) (OR 0.83; 95%CI: 0.51-1.35; P = 0.46; I² = 39%) as well as receiving same formula and volume (4 L polyethylene glycol) (OR 1.14; 95%CI: 0.65-2.01; P = 0.64; I² = 0%).

CONCLUSION

In patients undergoing afternoon colonoscopies, SaD is comparable with SpD in terms of satisfactory bowel preparation. Further studies are needed to validate these results and determine the optimal formula and dosages.

COVID-19-associated stroke risk: Could nutrition and dietary patterns have a contributing role?

The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 has created a life-threatening world pandemic. Unfortunately, this disease can be worse in older patients or individuals with comorbidities, having dangerous consequences, including stroke. COVID-19–associated stroke widely increases the risk of death from COVID-19. In addition to the personal hygiene protocols and preventive policies, it has been proven that immune-compromised, oxidative, and pro-coagulant conditions make a person more susceptible to severe COVID-19 complications, such as stroke; one of the most effective and modifiable risk factors is poor nutritional status. Previous literature has shown that healthy dietary patterns, such as the Mediterranean diet, some food groups, and specific micronutrients, reduce the risk of ischemic and hemorrhagic stroke. In this work, for the first time, we hypothesized that a healthy diet could also be a protective/preventive factor against COVID-19–associated stroke risk. In order to prove this hypothesis, it is required to study nutritional intake and dietary patterns in patients suffering from COVID-19–associated stroke. If this hypothesis is proven, the chronic supportive role of a healthy diet in critical situations will be highlighted once again.

Comparing the incidence of major cardiovascular events and severe microvascular complications in patients with type 2 diabetes mellitus: A systematic review and meta-analysis

BACKGROUND

Type 2 diabetes mellitus (T2DM) causes both macrovascular and microvascular complications. However, currently, selection of glycemic measures and their thresholds to diagnose T2DM, and efficacy outcomes in evaluation of anti-diabetic drugs is predominantly informed by the relation of T2DM to microvascular complications. We can be severely mistaken on T2DM by neglecting macrovascular complications which are generally more severe, if they also occur more commonly than microvascular complications.

AIM

To compare the incidence of major cardiovascular events (MACEs) and severe microvascular complications (SMICs) in T2DM patients.

METHODS

MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials were searched from inception to September 2017. Cohort studies or trials of T2DM patients aged 18 years or older that reported incidence of both MACEs and SMICs were included. MACEs were defined as nonfatal myocardial infarction and stroke, and cardiovascular death, while SMICs included serious retinopathy, nephropathy and diabetic disorder. The relative risk (RR) was estimated as the incidence of MACEs divided by that of SMICs in same patients and combined with meta-analysis in a random-effect model.

RESULTS

Twelve studies with a total of 16 cohorts and 387376 patients were included, and the combined RR was 2.02 (95%CI: 1.46–2.79). The higher incidence of MACEs remained in various subgroup and sensitivity analyses.

CONCLUSION

Patients with T2DM are much more likely to develop MACEs than SMICs. By taking more serious consequences and relatively higher incidence into consideration, macrovascular complications deserve more emphasis in developing the diagnostic criteria of T2DM and in evaluating the efficacy of anti-diabetic drugs.

Gastrointestinal and hepatic manifestations of COVID-19 infection: Lessons for practitioners

Originating from Wuhan in China, coronavirus disease 2019 (COVID-19) spread globally within months and was declared a pandemic by World Health Organization in March 2020, making it one of the biggest healthcare calamities of our time. As more data on COVID-19 infection became available, what was initially thought to be a simple respiratory illness was found to be more complex. Many extra-pulmonary manifestations are now frequently reported for COVID-19 in available literature, most commonly gastrointestinal and hepatopancreato-biliary manifestations. Due to early scarcity of data, extra pulmonary manifestations were initially overlooked and may have contributed to nosocomial spread of the infection. Practitioners, especially gastroenterologists, who frequently encounter patients with these symptoms, need to be aware of them. This can not only help minimize the nosocomial spread, ensure safety of provider but also help conserve already stretched-thin healthcare resources. A tremendous amount of COVID-19 related literature is getting added to the growing pool every day, making it difficult for providers to follow. The aim of our review is to summarize the available evidence for gastrointestinal and hepatopancreatobiliary manifestations of COVID-19. We here briefly discussed the possible pathophysiologic mechanism for these manifestations and summarized the recommendations put forward by multiple gastrointestinal societies regarding safe and effective clinical practice during the ongoing pandemic.

Current trend in the diagnosis and management of malignant pheochromocytoma: Clinical and prognostic factors

Pheochromocytomas are tumors arising from the chromaffin cell of the adrenal gland and paragangliomas as tumors from extra-adrenal sympathetic chromaffin cells. The combined yearly incidence of pheochromocytoma and paraganglioma (PPGL) is approximately 0.8 per 100000 person/year. Malignant pheochro-mocytoma is defined only by the presence of metastasis, as there is no confirmatory histology or biomarkers. The most common metastatic sites of these chromaffin tumors are the lymph node, bone, lungs, and liver. This review focuses on relevant clinical and immunohistological factors that are predictive of malignant PPGL or metastasis and determinants of prognosis. Findings showed that the risk of malignant PPGL, along with disease survival, is closely associated with age, primary tumor size, gender, synchronous metastasis, and absence of surgical excision. Other essential biomarkers or immunohistology investigated were galectin-3, COX-2, nm-23, microRNA-210, ERBB-2 overexpression and succinate dehydrogenase subunit mutation, which were predictive of malignancy as well as disease prognosis. Curative resection is possible but most metastatic diseases are amenable to radiopharmaceuticals and chemotherapy due to late presentation. Other therapeutic options, like molecular-targeted therapy, are still undergoing clinical trials.

Effects of antithrombotic agents on post-operative bleeding after endoscopic resection of gastrointestinal neoplasms and polyps: A systematic review and meta-analysis

BACKGROUND

There are some studies investigating the relationship between antithrombotic medication and postoperative bleeding after endoscopic resection (ER) with controversial results. 

AIM

To perform a meta-analysis evaluating the effects of antithrombotic therapy on postoperative bleeding after ER.

METHODS

A systematic search was conducted on PubMed, Web of Science, Cochrane Library. The Newcastle-Ottawa scale was used to evaluate the quality of studies. Stata 12.0 was used for statistical analysis. The odds ratio (OR) and 95%CI were calculated and heterogeneity was quantified using Cochran’s Q test and I².

RESULTS

Total 66 studies were included in the meta-analysis. Pooled data suggested that antithrombotic therapy was significantly associated with postoperative bleeding (OR = 2.302, 95%CI: 2.057-2.577, P = 0.000) after ER. The risk of postoperative bleeding after endoscopic submucosal dissection, endoscopic mucosal resection and polypectomy in the antithrombotic group was higher than the non-antithrombotic group (OR = 2.439, 95%CI: 1.916-3.105; OR = 2.688, 95%CI: 1.098-6.582; OR = 2.112, 95%CI: 1.434-3.112). 

CONCLUSION

The risk of postoperative bleeding after ER correlated with the types and management of antithrombotic agents by our meta-analysis.

Implications of COVID-19 for inflammatory bowel disease: Opportunities and challenges amidst the pandemic

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic various measures have been taken to mitigate the effects of the global health crisis in this unprecedented time. According to the World Health Organization, more than 5 million people have been infected with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and with more than 300000 deaths attributed to COVID-19 worldwide. There is emerging evidence that SARS-CoV-2 utilizes angiotensin-converting enzyme 2 receptors to enter human cells which are found in abundance in the alveoli and intestines. In addition, the infection is noted to be more severe in patients with co-morbid conditions, those who are malnourished, immunosuppressed and immunocompromised. Inflammatory bowel disease (IBD) which includes ulcerative colitis and Crohn’s disease is chronic remitting and relapsing disorders with intestinal and extraintestinal manifestation. IBD patients are often malnourished and on immunosuppressive medications and there is a hypothetical concern that IBD patients are at substantial risk of COVID-19 infection. The management of IBD patients is often complex and poses unique challenges for gastroenterologists during the pandemic. The purpose of this review article is to summarize the growing level of evidence and understanding of the management of IBD during the COVID-19 pandemic, in the light of international and national gastroenterology society guidelines. We performed a thorough literature search on IBD, SARS-CoV-2 and COVID-19 on PubMed, EMBASE, OVID Medline and Google Scholar and pertaining literature was critically examined and summarized. Per national and international society guidelines and recommendations, IBD is not a risk factor for SARS-CoV-2 infection. IBD patients should continue with their medications and they should follow universal precautions i.e. masks, hand and respiratory hygiene and avoidance of health care facilities and public toilets as general population. Among IBD patients older age, having active disease, and co-morbid conditions are risk factors for a severe SARS-CoV-2 infection. Furthermore, elective endoscopic and surgical procedures can be delayed or deferred until discussing the risks and benefits with patients.

Primary small cell neuroendocrine carcinoma of the right posterior tongue

Small cell neuroendocrine carcinoma (SNEC) is an extremely aggressive tumor and mainly occurs in the lung. Primary extra-pulmonary SNEC is rare. To date, only 11 primary SNECs occurring in the oral cavity have been reported in the English literature. We describe a case of primary SNEC of the right posterior tongue in a 46-year-old man. The patient had stage IVA disease and received adjuvant chemotherapy, followed by radical surgery and radiotherapy. He remained tumor-free for 20 mo before death due to gastrointestinal metastasis. The relevant literature on the 11 previously reported patients was reviewed, and the clinical features, histopathological characteristics, differential diagnosis and therapeutic strategies of this rare tumor were analyzed.

Treatment of Helicobacter pylori infection in children: A systematic review

BACKGROUND

Helicobacter pylori (H. pylori) infection is predominantly acquired in childhood. When indicated, the most accepted treatment for H. pylori eradication in this age group is first-line triple therapy. However, the increasing resistance to clarithromycin and nitroimidazoles has been associated with treatment failure, and thus, alternative treatment regimens have been proposed.

AIM

To perform a systematic review of randomized controlled trials on treatment regimens for H. pylori infection in children.

METHODS

We surveyed relevant articles published in English from 2010 to April 2020 in the PubMed and MEDLINE databases. Keywords included “Helicobacter pylori”/”children or childhood”/”treatment or eradication.” The risk of bias was evaluated according to the Cochrane Handbook of Systematic Reviews for Interventions.

RESULTS

Among the 1144 records identified through the database, 20 articles were selected. Four studies compared the eradication rates of H. pylori infection between standard triple therapies, changing only the main antibiotic used. Seven studies evaluated the effectiveness of standard triple therapy with the addition of probiotics. One study investigated the relationship between the effectiveness in the eradication rates of standard triple therapy and vitamin E levels. Six studies analyzed the eradication rates of sequential therapy.

CONCLUSION

The findings suggest that although standard triple therapy is the most recommended regimen for children by the current guidelines, other therapeutic schemes have shown promising results and may also be recommended for clinical practice in the future.

Integrating contextual variables in meta-analyses

Meta-analysis is an important statistical tool, and it is often used to solve clinical problems. However inevitably when conducting a meta-analysis, the included studies often have heterogeneity. This paper suggests the inclusion of relevant background data or contextual variables into the model. The contextual variables are those variables not explicitly measured in the studies included in a meta-analysis; thus, these must be very well-described and justified as parameters for analyses.

Importance of reporting quality: An assessment of the COVID-19 meta-analysis laboratory hematology literature

BACKGROUND

Meta-analysis, a form of quantitative review, is an attempt to combine data from multiple independent studies to improve statistical power. Because of the complexity of process involved in study selection, data analysis, and evaluation of bias and heterogeneity, checklists have been prepared by the Institutes of Medicine (IOM), Preferred Reporting Items for Systemic Reviews and Meta-analyses (PRISMA), and Meta-analyses of Observational Studies in Epidemiology (MOOSE) to standardize the reporting quality of a meta-analysis.

AIM

To use these checklists to assess the reporting quality of the coronavirus disease-2019 (COVID-19) meta-analysis literature relevant to laboratory hematology.

METHODS

After a search of the literature 19 studies were selected for analysis, including 10 studies appearing in the preprint literature (studies that can be identified by database search but have not yet completed peer review).

RESULTS

The average IOM (76% of required elements completed), PRISMA (75% of required elements completed), and MOOSE (60% of required elements completed) scores enumerated demonstrated a reporting quality inferior to that of earlier reports of pathology and medicine meta-analyses. There was no statistically significant difference in performance between accepted/ published and preprint studies. Comparison of the results of PRISMA and MOOSE studies demonstrated a weak positive correlation (Pearson’s correlation coefficient = 0.39).

CONCLUSION

The most common deficits in the studies included sensitivity analysis, assessment for bias, and details of the search strategy. Although the COVID-19 laboratory hematology meta-analysis literature can be a helpful source of information, readers should be aware of these reporting quality deficits.

Prevalence, awareness and control of hypertension in Malaysia from 1980-2018: A systematic review and meta-analysis

BACKGROUND

Hypertension is a common public health problem worldwide and is a well-known risk factor for increased risk of cardiovascular diseases, contributing to high morbidity and mortality. However, there has been no systematic review and meta-analysis of a multiethnic population such as that of Malaysia.

AIM

To determine the trend in prevalence, awareness and control rate of hypertension in Malaysia.

METHODS

Systematic searches were conducted in six databases (PubMed, Scopus, Ovid, CINAHL, Malaysian Medical Repository and Malaysia Citation Index) for articles published between 1980 and 2018. Two authors reviewed the studies and performed quality assessment and data extraction independently. Pooled estimates of hypertension prevalence, awareness and control rate were calculated using the DerSimonian-Laird random-effects model. Subgroup and sensitivity analyses were performed.

RESULTS

We included 56 studies involving a total of 241796 participants. The overall pooled prevalence of hypertension aged ≥ 18 years was 29.7%. The prevalence of hypertension was the lowest in the 1980s (16.2%, 95% confidence interval (CI): 13.4, 19.0), increasing up to 36.8% (95%CI: 6.1, 67.5) in the 1990s, then decreasing to 28.7% (95%CI: 21.7, 35.8) in the 2000s and 26.8% (95%CI: 21.3, 32.3) in the 2010s. The prevalence of awareness was 51.4% (95%CI: 46.6, 56.3), while 33.3% (95%CI: 28.4, 38.2) of those on treatment had achieved control of their blood pressure.

CONCLUSION

In Malaysia, three in ten adults aged ≥ 18 years have hypertension, while four in ten adults aged ≥ 30 years have hypertension. Five out of ten people are aware of their hypertension status and only one-third of those under treatment achieved control of their hypertension. Concerted efforts by policymakers and healthcare professionals to improve awareness and control of hypertension should be of high priority.

Hydatidosis and the duodenum: A systematic review of the literature

BACKGROUND

Injury to the duodenum (fistula formation, compression, or other complications) by a hydatid cyst (HC) is an exceptional complication.

AIM

To perform a systematic review of the literature on the fistulization of HC in the duodenum.

METHODS

Following PRISMA guidelines, a search for HC with duodenal involvement was carried out in the databases of PubMed, SCielo and EMBASE without time limits.

RESULTS

Fourteen patients were identified, seven men and seven women, with a mean age of 53.14 years (SD = 17.65, range: 28-78). Three out of the 14 (21%) had HC relapse. The most frequent clinical manifestations were abdominal pain and nausea and/or vomiting. Various imaging studies were performed in almost all cases, the most commonly used being abdominal computed tomography (10/14, 71%). A range of surgical techniques were reported, most frequently HC drainage (41%) and enucleations (16%). Ten of the 14 patients had no complications and one patient died. The follow-up period and recurrences could not be determined.

CONCLUSION

The most frequent symptoms were abdominal pain, nausea and vomiting. Computed tomography was the most used diagnostic imaging technique, and HC drainage and fistula closure via laparotomy was the most frequent treatment. However, all diagnostic and therapeutic options for HC fistulizing the duodenum had a low level of evidence.

Thrombopoietin-receptor agonists in perioperative treatment of patients with chronic liver disease

Thrombocytopenia is a multifactorial disorder that is common in patients with chronic liver disease (CLD), leading to challenging perioperative planning. As thrombocytopenia in CLD is associated with thrombopoietin (TPO) deficiency, the use of TPO-receptor agonists (TPO-RAs) to increase platelet counts is a promising approach. This has led to the development of various TPO-RAs, including romiplostim, eltrombopag, avatrombopag, and lusutrombopag. Of these, only avatrombopag and lusutrombopag are approved by the United States Food and Drug Administration for the perioperative treatment of thrombocytopenia in patients with CLD. Platelet transfusion is commonly used for the clinical management of thrombocytopenia in patients with CLD undergoing invasive procedures. However, the limitations and possible risks of transfusion, including short duration of efficacy, development of antiplatelet antibodies, risk of infections and such complications as transfusion-related acute lung injury or circulatory overload, and possibility of refractoriness, limit its use. Moreover, there is no consensus among guidelines as to the platelet count at which transfusions are indicated. Results from studies using TPO-RAs perioperatively in patients with thrombocytopenia and CLD are promising and provide an alternative to platelet transfusions in the pre- and post-operative setting. These TPO-RAs are the subject of this review, with focus on their use in the perioperative setting in patients with thrombocytopenia, associated supporting clinical trials, efficacy and safety data, and their use with respect to platelet transfusions.

Immunotherapy in hepatocellular carcinoma: Combination strategies

Liver cancer is one of the most common causes of cancer death globally, and its incidence in the United States is increasing. Patients with advanced hepatocellular carcinoma (HCC) who are not candidates for surgical resection, liver transplant, or locoregional therapies can be treated with systemic therapies. Multiple agents, including sorafenib, lenvatinib, and regorafenib are approved for use as either first- or second-line therapy in this patient population, but all have relatively modest survival benefits. HCC is potentially susceptible to therapy with checkpoint inhibitors, including agents such as nivolumab and pembrolizumab, which are both approved by the Food and Drug Administration for patients previously treated with sorafenib but have not demonstrated superior overall survival in phase III trials. It is clear that more effective approaches are needed to potentiate the effects of checkpoint inhibitors in patients with HCC. This review will outline and appraise the current literature on the use of checkpoint inhibitors in HCC as part of a combination treatment involving an additional mode of therapy. The list of agents that can be paired with checkpoint inhibitors includes an additional checkpoint inhibitor, vascular endothelial growth factor or vascular endothelial growth factor receptor inhibitors, tyrosine kinase inhibitors, OX-40 agonists, and PT-112 inhibitors. The main non-pharmacologic therapies currently being studied for inclusion in a combination strategy include radiation therapy, trans-arterial chemoembolization, and ablation.

Learning and competence development via clinical cases – what elements should be investigated to best train good medical doctors?

In European higher education, application of information technology, concentration on the learning-processes, consistent implementation, transfer learning, case-based learning, autonomous learning has been extensively studied in the last decade. Educational sciences based on neuroscientific findings use brain-based learning and teaching, including integrated thematic instructions and emotion-theory. Elements essential to this strategy, such as theory and methods for learning, competencies, attitudes, social reality, and a metadiscourse are described herein. Research on learning tends to focus on declarative knowledge, associative learning with conditional stimuli, and procedural knowledge with polythematic/crosslinking thinking. Research on competencies: In research on competencies (e.g., for clinical reasoning, decision-making), intuitive and analytical components are studied. As repeated presentation and exercising of clinical cases is crucial for an efficient learning process, the implementation of interactive scenarios including affectively involving didactics is considered. For competence-development observational methods, questionnaires/item sets or factors have to be targeted and empirically validated. Attitudes and social reality: Clinical decision-making, identification processes and attitudes (“Hidden curriculum”), as well as secondary socialization processes (integration of social norms, values, preparation of role-acquisition, occupational role) are studied via process research, conceptual research, and observational methods. With respect to social reality research, conscious and unconscious bargaining processes have to be taken into account. Methodology: Neuroscience – memory, neuronal, molecular biology, and computer science (Neurocircuits) are integrated into observational process research (e.g., affective-cognitive interface, identification processes) and conceptual research is added and studied on the meta-level, including discussion of research paradigms. This discussion provides ongoing feedback to projects in a hermeneutic circle.

Prevalence of anxiety among gestational diabetes mellitus patients: A systematic review and meta-analysis

BACKGROUND

A diagnosis of gestational diabetes mellitus (GDM) negatively influences maternal mental health. There is a lack of systematic review and meta-analysis on prevalence of anxiety among GDM women.

AIM

To pool data from existing literature to determine the pooled estimates for the prevalence of anxiety among women diagnosed with GDM.

METHODS

We searched multiple databases including MEDLINE, Cinahl, PubMed and Scopus to identify studies published up to 31 October 2019 with data on the prevalence of anxiety among women diagnosed with GDM. Data were extracted from published reports. Estimates were pooled using random-effects meta-analyses.

RESULTS

We reviewed 19 abstracts, retrieved 10 articles and included three studies incorporating 12744 GDM women from three countries. The pooled prevalence of anxiety was 29.5% (95%CI: 6.9, 52.0) among GDM women.

CONCLUSION

Prevalence of anxiety among GDM women was high. We suggest that epidemiological studies on anxiety should be conducted urgently as it merits clinical attention. In addition, it is important to identify factors associated with anxiety among women diagnosed with GDM.

COVID-19: Off-label therapies based on mechanism of action while waiting for evidence-based medicine recommendations

The world pandemic due to coronavirus disease 2019, known as COVID-19, embodies a high rate of disease transmission that causes a critical hospitalization overload. As of May 15, 2020, the disease has been the cause of more than 4 million infections and more than 280000 deaths all over the world. At the beginning, we underestimated the disease; now, we have sufficient information and it is clear that it is not just a respiratory disease. In fact, if a prompt treatment is not initiated, the disease may evolve towards an abnormal immune response and cytokine storm with an important thrombophilic pattern. Therefore, we think that while waiting for certainties to be established by evidence-based medicine, it is not ethical to not try off-label therapies for some of the well-known drugs, as they could have some efficacy based on their mechanisms of action.

Role of non-coding RNAs in pathogenesis of gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are considered the model solid malignancies of targeted therapy after the discovery of imatinib effectiveness against their tyrosine kinase inhibitors. Non-coding RNAs are molecules with no protein coding capacity that play crucial role to several biological steps of normal cell proliferation and differentiation. When the expression of these molecules found to be altered it seems that they affect the process of carcinogenesis in multiple ways, such as proliferation, apoptosis, differentiation, metastasis, and drug resistance. This review aims to provide an overview of the latest research papers and summarize the current evidence about the role of non-coding RNAs in pathogenesis of GISTs, including their potential clinical applications.

Combined endoscopy/laparoscopy/percutaneous transhepatic biliary drainage, hybrid techniques in gastrointestinal and biliary diseases

In recent years, a wide range of gastrointestinal endoscopy techniques have been developed, such as endoscopic submucosal dissection (ESD) and endoscopic retrograde cholangiopancreatography (ERCP). Although ESD and ERCP have an important role in gastrointestinal and biliary diseases, each technique has its limitations. Hybrid techniques that combine endoscopic and surgical procedures have emerged that have the advantages of different procedures and negate their limitations at the same time. Laparoscopic endoscopic cooperative surgery and modified laparoscopic endoscopic cooperative surgery combine ESD and laparoscopic techniques to resect submucosal tumors with minimum resection area. Air leak test by intraoperative endoscopy can effectively identify a mechanically insufficient anastomosis and decrease the complication rate. The rendezvous technique that combines percutaneous transhepatic biliary drainage and endoscopy can be performed as a rescue approach for the treatment of biliary obstruction, stenosis and bile duct injuries. For patients with simultaneous presence of stones in the gallbladder and the common bile duct, the laparo-endoscopic rendezvous technique can perform ERCP and laparoscopic cholecystectomy at the same time and reduces the risk of pancreatic injury caused by ERCP. Biliobiliary and bilioenteric anastomosis using magnetic compression anastomosis is another choice for biliary obstruction. The most common used approach to deliver the magnets is by percutaneous-peroral tract. Laparoscopic-assisted ERCP is a safe and highly effective therapy for patients who develop biliary diseases after Roux-en-Y gastric bypass surgery.

Exclusive cigar smoking in the United States and smoking-related diseases: A systematic review

BACKGROUND

Little information has been published on the risks of cigar smoking. Since 1990 cigar smoking has become more prevalent in the United States.

AIM

To summarise the evidence from the United States relating exclusive cigar smoking to risk of the major smoking-related diseases.

METHODS

Literature searches detected studies carried out in the United States which estimated the risk of lung cancer, chronic obstructive pulmonary disease (COPD), heart disease, stroke or overall circulatory disease in exclusive cigar smokers as compared to those who had never smoked any tobacco product. Papers were identified from reviews and detailed searches on MEDLINE. For each study, data were extracted onto a study database and a linked relative risk database. Relative risks and 95%CIs were extracted, or estimated, relating to current, former or ever exclusive cigar smokers, and meta-analysed using standard methods. Sensitivity analyses were conducted including or excluding results from studies that did not quite fit the full selection criteria (for example, a paper presenting combined results from five studies, where 86% of the population were in the United States).

RESULTS

The literature searches identified 17 relevant publications for lung cancer, four for COPD and 12 for heart disease, stroke and circulatory disease. These related to 11 studies for lung cancer, to four studies for COPD and to eight studies for heart disease, stroke or overall circulatory disease. As some studies provided results for more than one disease, the total number of studies considered was 13, with results from four of these used in sensitivity analyses. There was evidence of significant heterogeneity in some of the meta-analyses so the random-effects estimates are summarized below. As the results from the sensitivity analyses were generally very similar to those from the main analyses, and involved more data, only the sensitivity results are summarized below. For lung cancer, relative risks (95%CI) for current, former and ever smokers were respectively, 2.98 (2.08 to 4.26), 1.61 (1.23 to 2.09), and 2.22 (1.79 to 2.74) based on 6, 4 and 10 individual study estimates. For COPD, the corresponding estimates were 1.44 (1.16 to 1.77), 0.47 (0.02 to 9.88), and 0.86 (0.48 to 1.54) based on 4, 2 and 2 estimates. For ischaemic heart disease (IHD) the estimates were 1.11 (1.04 to 1.19), 1.26 (1.03 to 1.53) and 1.15 (1.08 to 1.23) based on 6, 3 and 4 estimates, while for stroke they were 1.02 (0.92 to 1.13), 1.08 (0.85 to 1.38), and 1.11 (0.95 to 1.31) based on 5, 3 and 4 estimates. For overall circulatory disease they were 1.10 (1.05 to 1.16), 1.11 (0.84 to 1.46), and 1.15 (1.06 to 1.26) based on 3, 3 and 4 estimates.

CONCLUSION

Exclusive cigar smoking is associated with an increased risk of lung cancer, and less so with COPD and IHD. The increases are lower than for cigarettes.

Helicobacter pylori and gastric cardia cancer: What do we know about their relationship?

The incidence of gastric cardia cancer is increasing around the world. Since the discovery of Helicobacter pylori (H. pylori), numerous studies have proved that it is a causative factor for many kinds of digestive system tumors. Although the literature on gastric cardia cancer and H. pylori is not scarce, there are still many controversies on the relationship between gastric cardia cancer and H. pylori. Many Western research results showed that there was a negative or no correlation between H. pylori infection and gastric cardia cancer, but in several studies in Asian countries, such as China, H. pylori was demonstrated to be a risk factor for gastric cardia cancer. Therefore, we intended to analyze the related studies to find out the relationship between H. pylori and gastric cardia cancer and find out the causes of the above controversies. We also conducted a meta-analysis of the relationship between cagA positive expression of H. pylori and gastric cardia cancer, to find out whether there is an effect between those two. The primary purpose of this paper was to explore the relationship between gastric cardia cancer and H. pylori. Through analysis, the study showed the reasons for the controversies mentioned above: (1) Geographical factors could affect the relationship between H. pylori and gastric cardia cancer; (2) The definition of gastric cardia cancer in various studies is inconsistent. The result of a meta-analysis about the relationship between H. pylori virulence factor cagA and gastric cardia cancer showed that there was no relationship between these two.

European Specialty Examination in Gastroenterology and Hepatology examination — improving education in gastroenterology and hepatology

The Federation of Royal Colleges, the British Society of Gastroenterology (BSG) and the European Section and Board of Gastroenterology and Hepatology developed the European Specialty Examination in Gastroenterology and Hepatology (ESEGH) from the United Kingdom Specialty Certificate Examination, which was the original examination. Since 2018 the Specialty Certificate Examination and the ESEGH were combined into a single exam, identical across Europe and the rest of the world. The ESEGH is mandated in 4 countries (United Kingdom, Switzerland, The Netherlands and Malta) and the number of entries increased from 50 in 2014 to 490 in 2019. Candidates from countries were the ESEGH is not mandated are sitting the Exam, showing us they realize the enormous interest of holding a certificate for knowledge in their Curriculum. We also have an increasing number of candidates from countries outside Europe.

Pathological characterization of occult hepatitis B virus infection in hepatitis C virus-associated or non-alcoholic steatohepatitis-related hepatocellular carcinoma

Occult hepatitis B virus (HBV) infection, by definition, is a state in which infection with this virus does not manifest with the conventional diagnostic laboratory criteria reserved for the obvious form of HBV infection. As a result, occult HBV infection is commonly a surprise finding discovered accidently during the evaluation of other apparent liver diseases, such as hepatitis C virus (HCV) infection or non-alcoholic fatty liver disease and, more importantly, their evolution into life-threatening hepatocellular carcinoma. As infection with HCV and occult HBV is rarely considered when assessing these more obvious conditions, and in an attempt to offer a better understanding of this phenomenon, this study attempted to shed some light onto the uniqueness of occult HBV infection by addressing the natural history of HBV and HCV infections, as well as non-alcoholic fatty liver disease. This was carried out by taking into account the exclusive integration process undertaken by the HBV genome into infected host hepatocytes, with consideration given to conditions which afford reactivation of the occult infection and stress on the molecular mechanisms that underlie occult HBV infection. Finally, the clinical outcome of occult HBV infection and its relation to hepatocellular carcinoma is analyzed.

Treatment strategies and preventive methods for drug-resistant Helicobacter pylori infection

The infection and drug resistance rates of Helicobacter pylori (H. pylori) are high and must be prevented and treated by better strategies. Based on recent research advances in this field as well as the results from our team and those on traditional Chinese medicine, we review the causes of drug resistance, and prevention and treatment strategies for drug-resistant H. pylori infection, with an aim to make suggestions for the development of new drugs, such as establishment of new target identification and screening systems, modification of existing drug structures, use of new technologies, application of natural products, and using a commercial compound library. This article may provide reference for eradication of drug-resistant H. pylori.

Probiotics in inflammatory bowel disease: Does it work?

The number of patients with inflammatory bowel disease (IBD), a group of diseases mainly represented by Crohn’s disease (CD) and ulcerative colitis (UC), has increased in recent decades. As a consequence, the number of people undergoing any drug treatment against these diseases has expanded. However, IBD conventional therapies present several limitations, which lead researchers to look for better alternatives to improve the quality of life of patients. Moreover, microbiome imbalance seems to play a crucial role in the pathogenesis of IBD, since important alterations in bacterial, viral, protist and fungal populations are observed in the gut microbiota of affected individuals. Given the importance of such life forms in that context, the use of probiotics becomes a plausible alternative for treating affected patients. Trials have been developed aiming the evaluation of probiotics potential to induce and to maintain remission in CD and UC. Regarding the tested microorganisms, various non-pathogenic bacteria and fungi have been assessed. However, consistent results have been obtained only with some of them, including Escherichia coli Nissle 1917, VSL#3, Saccharomyces boulardii, Lactobacillus, and Bifidobacterium. Therefore, this minireview aims to explore the role of microbiota in the genesis of such a disorder and to compile the most concrete data on probiotic-related efficiency in IBD treatment.

Systematic review with meta-analysis of the epidemiological evidence relating smoking to type 2 diabetes

BACKGROUND

Evidence relating tobacco smoking to type 2 diabetes has accumulated rapidly in the last few years, rendering earlier reviews considerably incomplete.

AIM

To review and meta-analyse evidence from prospective studies of the relationship between smoking and the onset of type 2 diabetes.

METHODS

Prospective studies were selected if the population was free of type 2 diabetes at baseline and evidence was available relating smoking to onset of the disease. Papers were identified from previous reviews, searches on Medline and Embase and reference lists. Data were extracted on a range of study characteristics and relative risks (RRs) were extracted comparing current, ever or former smokers with never smokers, and current smokers with non-current smokers, as well as by amount currently smoked and duration of quitting. Fixed- and random-effects estimates summarized RRs for each index of smoking overall and by various subdivisions of the data: Sex; continent; publication year; method of diagnosis; nature of the baseline population (inclusion/exclusion of pre-diabetes); number of adjustment factors; cohort size; number of type 2 diabetes cases; age; length of follow-up; definition of smoking; and whether or not various factors were adjusted for. Tests of heterogeneity and publication bias were also conducted.

RESULTS

The literature searches identified 157 relevant publications providing results from 145 studies. Fifty-three studies were conducted in Asia and 53 in Europe, with 32 in North America, and seven elsewhere. Twenty-four were in males, 10 in females and the rest in both sexes. Fifteen diagnosed type 2 diabetes from self-report by the individuals, 79 on medical records, and 51 on both. Studies varied widely in size of the cohort, number of cases, length of follow-up, and age. Overall, random-effects estimates of the RR were 1.33 [95% confidence interval (CI): 1.28-1.38] for current vs never smoking, 1.28 (95%CI: 1.24-1.32) for current vs non-smoking, 1.13 (95%CI: 1.11-1.16) for former vs never smoking, and 1.25 (95%CI: 1.21-1.28) for ever vs never smoking based on, respectively, 99, 156, 100 and 100 individual risk estimates. Risk estimates were generally elevated in each subdivision of the data by the various factors considered (exceptions being where numbers of estimates in the subsets were very low), though there was significant (P < 0.05) evidence of variation by level for some factors. Dose-response analysis showed a clear trend of increasing risk with increasing amount smoked by current smokers and of decreasing risk with increasing time quit. There was limited evidence of publication bias.

CONCLUSION

The analyses confirmed earlier reports of a modest dose-related association of current smoking and a weaker dose-related association of former smoking with type 2 diabetes risk.

Chinese research into ulcerative colitis from 1978 to 2017: A bibliometric analysis

BACKGROUND

Over the last 40 years, with accumulating evidence demonstrating a significant increase in the incidence of ulcerative colitis (UC) in China, the number of studies on UC has been rapidly increasing. But it still lacks a comprehensive meta-analysis of publications regarding UC for the last four decades in China. Thus, a bibliometric analysis of UC is warranted to investigate the trend and distribution of the publications on UC in China in recent years. And it is supposed that the number of the papers related to UC increased by year.

AIM

To investigate the current status of research output from Chinese studies related to UC during the period of 1978 to 2017, with special attention paid to the distribution of publication dates, journals, regions, and research organizations.

METHODS

Publications on UC were searched in the Chinese periodical database SinoMed from January 1978 to December 2017. The search term used for retrieval was “ulcerative colitis”. The language of the publications was restricted to English or Chinese. The studies have to be performed in China. Then, a bibliometric analysis was performed on the distribution of publication dates, journals, regions, and research organizations with EndNote, Excel, MySQL, and GraphPad Prism.

RESULTS

A total of 16257 papers matched the search criteria, which included 7561 papers published in core journals, 4641 evidence-based articles, and 4177 publications of randomized controlled trials. These papers were mainly published in Chinese Journal of Coloproctology, World Chinese Journal of Digestology, Chinese Journal of Digestion, Chinese Journal of Integrated Traditional and Western Medicine on Digestion, and Modern Journal of Integrated Traditional Chinese and Western Medicine. In particular, the majority of these organizations were located in Jiangsu, Henan, Shandong, and Guangdong Provinces which are rich areas or have the largest population per province. Most of these studies were conducted by academic institutions.

CONCLUSION

Over the past four decades, the output of research into UC in China has increased significantly, with academic institutions playing a central role in the academic field, but the number and quality of these researches vary substantially among different regions.

Single-balloon and spiral enteroscopy may have similar diagnostic and therapeutic yields to double-balloon enteroscopy: Results from a meta-analysis of randomized controlled trials and prospective studies

BACKGROUND

Double-balloon, single-balloon, and spiral enteroscopy (DBE, SBE, and SE) have revolutionized the management of intestinal diseases. However, evidence about efficacies of these methods is lacking. We aimed to conduct a meta-analysis comparing the clinical outcomes among DBE, SBE, and SE.

METHODS

We searched randomized controlled trials and prospective studies in MEDLINE, PubMed, EMBASE, Cochrane Library, and Chinese CQVIP database. Studies referencing the comparison of at least two of these three methods were included. Primary outcome was diagnostic yield. Other outcomes were therapeutic yield, total enteroscopy, examination time, time to maximum insertion, and depth of maximal insertion (DMI).

RESULTS

Eleven studies including 727 patients were identified: DBE vs SE (n = 6), DBE vs SBE (n = 4), and SBE vs SE (n = 1). The diagnostic and therapeutic yields did not differ significantly when comparing DBE with SE [odds ratio (OR) = 1.19, 95% confidence interval (CI): 0.68-2.08; OR = 1.17, 95%CI: 0.61-2.23] and DBE with SBE (OR = 0.85, 95%CI: 0.55-1.33; OR = 1.71, 95%CI: 0.64 - 4.60). Total enteroscopy, examination time, time to maximum insertion, and DMI were similar between SBE and DBE. DBE was superior to SE with regard to DMI [mean difference (MD) = 36.76, 95%CI: 5.09-68.43], with longer time to maximum insertion (MD = 15.14, 95%CI: 12-18.27) and examination time (MD = 12.98, 95%CI: 9.57-16.38).

CONCLUSION

DBE and SBE have similar clinical outcomes. Compared with DBE, SE seems to have similar diagnostic and therapeutic yields, but shorter procedural time in cost of less depth of insertion. SE needs further evaluation vs SBE. DBE is recommended for complete enteroscopy.

Effectiveness and safety of sedation in gastrointestinal endoscopy: An opinion review

Although endoscopy is a less invasive procedure than surgery, patients can experience pain without sedation. Patients expect reduced pain during endoscopies from effective and safe sedatives. Midazolam and propofol are used for endoscopic sedation in many countries and regions. Midazolam is a widely available benzodiazepine, and many clinical trials have shown it to be an effective sedative. However, patients who are sedated with midazolam require rest in the recovery room due to its relatively long half-life, and an antagonist such as flumazenil may need to be administered in cases of deep or prolonged sedation. Propofol is a short-acting sedative with a short half-life and a quick recovery time. Therefore, the use of propofol has been increasing. However, propofol has a narrow margin of safety and often induces adverse effects such as respiratory depression. Also, propofol has no specific antagonist, and should be administered by an anesthesiologist or an endoscopist familiar with anesthesia. Remimazolam, which is a novel ultra-short-acting benzodiazepine, has recently gained attention. Remimazolam has a short half-life and an antagonist. Both effective and safe sedation is desired in accordance with the increasing need for sedative endoscopies. Therefore, in this review each sedative is summarized.

Utility of gastrointestinal ultrasound in functional gastrointestinal disorders: A narrative review

Gastrointestinal (GI) ultrasound (GIUS) is valuable in the evaluation of GI diseases such as inflammatory bowel disease, but its use in functional GI disorders (FGIDs) is largely unknown although promising. In order to review the current knowledge on current and potential uses of GIUS in FGIDs, information was obtained via a structured literature search through PubMed, EMBASE and Google Scholar databases with a combination of MESH and keyword search terms: “ultrasound”, “functional GI disorders”, “irritable bowel syndrome”, “functional dyspepsia”, “intestinal ultrasound”, “point of care ultrasonography”, “transabdominal sonography”, “motility”, “faecal loading”, “constipation”. GIUS is currently used for various settings involving upper and lower GI tracts, including excluding organic diseases, evaluating physiology, guiding treatment options and building rapport with patients. GIUS can be potentially used to correlate mechanisms with symptoms, evaluate mechanisms behind treatment efficacy, and investigate further the origin of symptoms in real-time. In conclusion, GIUS is unique in its real-time, interactive and non-invasive nature, with the ability of evaluating several physiological mechanisms with one test, thus making it attractive in the evaluation and management of FGIDs. However, there are still limitations and concerns of operator dependence and lack of validation data for widespread implementation of GIUS in FGIDs.

Hypoxia and oxidative stress: The role of the anaerobic gut, the hepatic arterial buffer response and other defence mechanisms of the liver

The liver is considered a vital organ and is the hub for multiple chemical functions, such as intermediary metabolism and the detoxification of ingested toxins, which are essential for the preservation of life, hence, the origin or the word “liver”. The liver has enormous, highly diversified catalytic potential. This enormous catalytic potential generates massive oxidative stress, which is important for the functions of the liver but is detrimental to the viability of the liver. The liver receives approximately 80% of its blood supply from the portal vein, which brings less saturated blood from the gastrointestinal tract. Hepatocytes operate in a relatively hypoxic microenvironment due to this portal inflow. The development of this hypoxic microenvironment of the liver is an important evolutionary adaptation for its detoxification function that is not recognized in the literature as a defence mechanism against the oxidative stress generated during the detoxification process. This review describes liver function in relation to its oxidative catalytic potential and the oxidative stress generated by it as well as the evolutionary defence mechanisms present in the liver against this oxidative stress to provide new insights into liver function.

L-carnitine supplementation in non-alcoholic fatty liver disease: A systematic review and meta-analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) dominates the landscape of modern hepatology. Affecting 25% of the general population, there is critical unmet need to identify broadly available, safe and cost-effective treatments. Cumulative evidence in animal and human models suggests that intrahepatic and skeletal muscle fatty acid oxidation is impaired in NAFLD, such that lipid accretion is not matched by efficient utilisation. L-carnitine is a crucial mediator of fatty acid metabolism in vivo, promoting mitochondrial lipid β-oxidation and enhancing tissue metabolic flexibility. These physiological properties have generated research interest in L-carnitine as a potentially effective adjunctive therapy in NAFLD.

AIM

To systematically review randomised trials reporting effects of dietary L-carnitine supplementation on liver biochemistry, liver fat and insulin sensitivity in NAFLD.

METHODS

Search strategies, eligibility criteria and analytic methods were specified a priori (PROSPERO reference: CRD42018107063). Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Science and the Cochrane Library were searched from their inception until April 2019. Outcome measures included serum concentrations of alanine and aspartate aminotransferase (ALT and AST), liver fat and insulin sensitivity assessed by the homeostasis model of insulin resistance (HOMA-IR). A random effects meta-analysis was performed for, ALT, AST and HOMA-IR measures separately. Between-study heterogeneity was measured using I² statistics.

RESULTS

Five eligible randomised trials were included in the qualitative and quantitative synthesis (n = 338). All of the 5 included trials assessed the effect of L-carnitine on serum ALT, identified from Italy, South Korea and Iran. Weighted mean difference (WMD) for ALT between L-carnitine and control groups after intervention was -25.34 IU/L [95%CI: -41.74-(-8.94); P = 0.002]. WMD for AST between L-carnitine and control groups was -13.68 IU/L (95%CI: -28.26-0.89; P = 0.066). In three studies (n = 204), HOMA-IR was evaluated. WMD for HOMA-IR between L-carnitine and control groups was -0.74 units [95%CI: -1.02-(-0.46); P < 0.001]. Two studies using validated outcome measures reported a significant reduction in liver fat in L-carnitine vs control groups post-intervention (P < 0.001).

CONCLUSION

Pooled results indicate that L-carnitine supplementation attenuates ALT, liver fat and insulin resistance in NAFLD cohorts, confirming a beneficial effect of L-carnitine for a highly prevalent condition with a growing economic burden.

Long-term efficacy of capecitabine plus oxaliplatin chemotherapy on stage III colon cancer: A meta-analysis

BACKGROUND

Many clinical studies for the long-term survival or efficacy of capecitabine plus oxaliplatin (XELOX) in colon cancer have already been studied, but its clinical benefit is controversial.

AIM

To evaluate the long-term efficacy of XELOX regimen in comparison with other adjuvant chemotherapy protocols in colon cancer.

METHODS

By searching the PubMed, EMBASE and Cochrane databases, a total of 12 randomized controlled trials involving 6698 stage III colon cancer cases (XELOX protocol: n = 3298 cases; other adjuvant chemotherapy protocol: n = 3268 cases) were included. The parameter outcomes included the overall survival and the disease-free survival. The quality control of selected literature was based on the Jadad scale and the GRADE system.

RESULTS

In comparison to other adjuvant chemotherapy regimen, XELOX regimen showed a better overall survival (odds ratio = 1.29, 95% confidence interval: 1.15-1.44, P < 0.0001) and a better disease-free survival (odds ratio = 1.32, 95% confidence interval: 1.18-1.46, P < 0.0001) for colon cancer patients, suggesting the XELOX regimen can be a good option for postoperative treatment of stage III colon cancer.

CONCLUSION

The XELOX regimen can be a preferred option for adjuvant treatment of stage III colon cancer after surgery.

Is there still a role for sucralfate in the treatment of gastritis?

The endoscopic diagnosis of gastritis is usually made when a patient develops symptoms and undergoes an upper gastrointestinal endoscopy. There are often obvious aetiological causes such as smoking, alcohol Helicobacter pylori infection or drug treatment. Lifestyle changes can sometimes improve symptoms but often patients will be treated with a proton pump inhibitor. The stomach mucosa produces a protective mucous to prevent damage cause by gastric acid and exogenous agents can disrupt this layer. Repair of this protective layer can be enhanced by reduction in gastric acid secretion using H2 receptor antagonist or proton pump inhibitors or by cytoprotective drugs such as misoprostol, sucralfate, aluminium ions or bismuth subsalts. Sucralfate is a complex polymer which at a low pH changes its chemical configuration and binds to serum protein to form a protective layer protecting the mucosa against further injury. Cytoprotective drugs were the first line treatment for peptic disease including gastritis for many years but since the launch of cimetidine in 1976 and the subsequent launch of omeprazole in 1988, their use has slowly declined. First line treatment for patients with symptomatic gastritis after removal of potential causative factors is likely to be a proton pump inhibitor in 2019. This is despite the fact that there is some evidence that sucralfate is superior than a H2 receptor antagonist in the endoscopic healing rates in patients with gastritis. The logical treatment choice in patients with resistance symptoms is a combination of a proton pump inhibitor and sucralfate but evidence is lacking. Until such evidence is available In the meantime, we would suggest that there is a role for sucralfate in the treatment of intransigent gastritis and that mucosal protection should be considered even ahead of acid suppression given its favourable safety and toxicity profile.

Gender prevalence of cardiovascular diseases in the geriatric population of India: A meta-analysis using R

BACKGROUND

Population ageing is an important challenge for developed as well as developing countries due to the downward trends in mortality rates. The elderly population is increasing worldwide. Cardiovascular diseases (CVDs) are one of the most common diseases in the geriatric population. These diseases involve the heart or blood vessels and include hypertension, rheumatic heart disease, heart failure, and heart attack. An estimated 17.7 million people in India will die from CVDs representing 31% of all global deaths.

AIM

To perform a systematic review and meta-analysis of the gender prevalence of CVDs in the geriatric population of India.

METHODS

In the present study, we searched databases such as Google Scholar, PubMed and MEDLINE from the year 2003 to 2019 to identify the prevalence of CVDs in the Indian geriatric population. A meta-analysis was conducted using the statistical software R version 3.4.3 and the random effect model was used to determine the pooled estimate of the prevalence of CVDs in the geriatric population of India along with the 95% confidence interval rather than using the fixed effect model. The random effect model takes into consideration the heterogeneity across the various studies.

RESULTS

The prevalence of CVDs in the Indian geriatric population was determined in 6586 male subjects from 32 studies and 8164 female subjects from 32 studies, respectively. The overall prevalence of CVDs in the Indian geriatric population was 36.6% (95%CI: 31.9%-41.3%). In addition, calculation of the various heterogeneity statistics (Cochran’s Q = 3836.85, I² = 98.6%, P < 0.0001) indicated heterogeneity in the prevalence of CVDs in the elderly Indian population in these studies. The prevalence of CVDs in elderly males was 38.0% (95%CI: 33.0%-43.0%) and the prevalence of CVDs in elderly females was 40.9% (95%CI: 35.5%-46.2%).

CONCLUSION

The results indicate that the prevalence of CVDs in the female geriatric population was relatively higher than that in the male geriatric population. Policy makers must take immediate steps to prevent CVDs and improve geriatric health care services in India.

Use of music during colonoscopy: An updated meta-analysis of randomized controlled trials

BACKGROUND

Music seems to be beneficial in multiple clinical areas. Colonoscopy is a stressful event for patients, especially with conscious sedation. Music during colonoscopy has been evaluated in multiple randomized controlled trials (RCTs) with varied results. Even meta-analyses on the subject over the years have yielded inconsistent conclusions. Therefore, we conducted an up-to-date meta-analysis regarding music during colonoscopy.

AIM

To assess the effects of music played during colonoscopy on patients’ perspectives and sedation requirements.

METHODS

Multiple large databases were aggressively searched (November 2018). RCTs comparing music to without music during colonoscopy on adult patients were included. Pooled estimates were calculated for sedative medication doses, total procedure time, and patients’ experience, willingness to repeat procedure, and pain scores using odds ratio (OR) and mean difference (MD) with random effects model.

RESULTS

Eleven studies (n = 988) were included. Music during colonoscopy showed a statistically significant reduction in procedure times (MD: -2.3 min; 95%CI: -4.13 to -0.47; P = 0.01) and patients’ pain (MD: -1.26; 95%CI: -2.28 to -0.24; P = 0.02) while improving patients’ experience (MD: -1.11; 95%CI: -1.7 to -0.53; P < 0.01) as compared to no music. No statistically significant differences were observed between music and no music during colonoscopy for midazolam (MD: -0.4 mg; 95%CI: -0.9 to 0.09; P = 0.11), meperidine (MD: -3.06 mg; 95%CI: -10.79 to 4.67; P = 0.44), or patients’ willingness to repeat the colonoscopy (OR: 3.89; 95%CI: 0.76 to 19.97; P = 0.1).

CONCLUSION

Music appears to improve overall patient experience while reducing procedure times and patient pain. Therefore, music, being a non-invasive intervention, should be strongly considered during colonoscopy.

Mechanisms of action of aqueous extract from the Hunteria umbellata seed and metformin in diabetes

The plant kingdom is an important potential source of effective treatment for various diseases. Most herbs have long been used for medicinal purposes, and plant metabolites with their derivatives had been used in ethnomedicine. However, concerns exist about the quality and safety of herbal medicine products, particularly relating to safety, dosage, and mechanism of action. This mini review reveals some insights about the Hunteria umbellate seed, which is similar to that of insulin secretagogue metformin. Studies have validated its beneficial role in hyperglycemic, insulin resistance and obesity conditions, which are components of metabolic syndrome. However, none of these studies evaluated the mechanisms by which this plant extract performs its anti-hyperglycemic, insulin resistance and anti-obesity actions in metabolic syndrome. This understanding would provide considerable progress toward drug design using this plant material. Hence the need for this awareness to sensitize the researchers in this field who are passionate about drug design to consider the pathways discussed below for Hunteria umbellata seeds. Hunteria umbellata seed extract may represent a new therapeutic strategy for type-2 diabetes in place of metformin if it is well-studied.

Fecal microbiota transplantation: Historical review and current perspective

There is a growing interest in the use of fecal transplantation for chronic intestinal conditions. We aim to review the methodology and safety of fecal microbiota transplantation and the evidence to support its use in treating a variety of diseases. We reviewed the history of fecal transplantation in China and found that there were varieties of fecal material used in ancient China. The first written record on fecal treatment was found in an ancient tomb in Middle China. This paper explores the historical and current perspectives of fecal microbiota transplantation. The ancient fecal transplantations did not have any background support from life science. In those ancient days, short of knowledge about bacteria, clinicians were aiming at a change of intestinal environment. Today, we aim at a change of the intestinal microbiome.

Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice

Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.

Preventive strategies for anastomotic leakage after colorectal resections: A review

Anastomosis is a crucial step in radical cancer surgery. Despite being a daily practice in gastrointestinal surgery, anastomotic leakage (AL) stands as a frequent postoperative complication. Because of increased morbidity, mortality, combined with longer hospital stay, the rate of re-intervention, and poor oncological outcomes, AL is considered the most feared and life-threatening complication after colorectal resections. Furthermore, poor functional outcomes with a higher rate of a permeant stoma in 56% of patients this could negatively affect the patient’s quality of life. This a narrative review which will cover intraoperative anastomotic integrity assessment and preventive measures in order to reduce AL. Although the most important prerequisites for the creation of anastomosis is well-perfused and tension-free anastomosis, surgeons have proposed several preventive measures, which were assumed to reduce the incidence of AL, including antibiotic prophylaxis, intraoperative air leak test, omental pedicle flap, defunctioning stoma, pelvic drain insertion, stapled anastomosis, and general surgical technique. However, lack of clear evidence of which preventive measures is superior over the other combined with the fact that the decision remains based on the surgeon’s choice. Despite the advances in surgical techniques, AL remains a serious health problem associated with increased morbidity, mortality with additional cost. Many preventative measures were employed with no clear evidence supporting the superiority of stapled anastomosis over hand-Sewn anastomosis, coating of the anastomosis, or pelvic drain. Defunctioning stoma, when justified it could decrease the leakage-related complications and the incidence of reoperation. MBP combined with oral antibiotics still recommended.

Antidiabetic agents in patients with hepatic impairment

Chronic liver disease (CLD) often coexists with type 2 diabetes mellitus, making diabetes management a challenge to the clinician. It is well known that liver is the major site of drug metabolism, and, therefore, its impairment affects hepatic metabolism of many antidiabetic agents. Furthermore, patients with CLD have serious comorbidities such as impaired renal function, hypoalbuminemia, lactic acidosis, hypoglycemia and malnutrition, making their treatment even more difficult. On the other hand, most of the antidiabetic agents, with the exception of insulin, need dosage titration due to alterations to their pharmacokinetics in patients with CLD. For well-established antidiabetic treatments, like metformin and sulfonylureas there are studies regarding their dosage chance in these patients. However, despite the growing problem of management of diabetes in patients with CLD the existing literature data, especially on newer antidiabetic agents, are limited and, furthermore, no direct guidelines exist. Therefore, in the present review article we try to summarize the existing literature data regarding management of diabetes in patients with CLD.

Tofacitinib for the treatment of ulcerative colitis: A review of the literature

Ulcerative colitis (UC) is a chronic immune-mediated inflammatory condition affecting the colon. Recently, tofacitinib, an oral small molecule that is an inhibitor of the Janus kinase signal transduction pathway, was proven efficacious for inducing and maintaining remission in adult patients with moderate to severe UC in three global Phase III studies. The purpose of this review is to summarize existing data on the efficacy, safety, and quality of life issues related to use tofacitinib as well as highlight recent real-world experience with this drug among patients with UC.

Blood glucose control in the intensive care unit: Where is the data?

Blood glucose control, including hyperglycemia correction, maintaining glucose at optimal level and avoiding hypoglycemia, is a challenge clinicians face every day in intensive care units (ICUs). If managed inadequately, its related mortality can increase. Prior to 2001, no relevant data from randomized, controlled studies assessing glucose control in the ICU were available. In the past 18 years, however, many clinical trials have defined criteria for managing abnormal blood glucose levels, as well as provided suggestions for glycemic monitoring. Point-of-care blood glucose monitors have become the preferred bedside technology to aid in glycemic management. In addition, in some institutions, continuous glucose monitoring is now available. Cost-effectiveness of adequate glycemic control in the ICU must be taken into consideration when addressing this complex issue. Newer types of glycemic monitoring may reduce nursing staff fatigue and shorten times for the treatment of hyperglycemia or hypoglycemia. There are a variety of glycemic care protocols available. However, not all ICU clinicians are aware of them. The following minireview describes some of these concepts.

Effect of dl-3-n-butylphthalide on infarction volume in animal models of ischemic stroke: A meta-analysis

BACKGROUND

Ischemic stroke is a frequently-occurring disease in the elderly and characterized by high morbidity and mortality. Dl-3-n-butylphthalide (NBP), a synthetic compound based on natural celery seeds, has potential therapeutic effects on cerebral ischemia, brain trauma, memory impairment, and epilepsy.

AIM

To evaluated the effect of NBP on infarct volume in experimental ischemic stroke.

METHODS

Twenty one relevant literatures were included from the PubMed, EMBASE, Web of Science, Chinese National Knowledge Infrastructure, VIP information database, and Wanfang database, and data on the effect of dl-3-n-butylphthalide on infarction volume in the middle cerebral artery occlusion model were extracted. Statistical analysis was performed using standard mean difference with random effects model of Revman 5.3.

RESULTS

The data of meta-analysis of the 21 studies had suggested that NBP reduced the cerebral infarction volume of middle cerebral artery occlusion model animals compared to the control group significantly [SMD: -3.97, 95%CI: -4.71 to -3.23, P < 0.01; heterogeneity: χ² = 59.09, df = 20 (P < 0.01); I² = 66 %].

CONCLUSION

NBP was effective in experimental ischemic stroke.

Pediatric recurrent Clostridium difficile infections in immunocompetent children: Lessons learned from case reports of the first twelve consecutive patients

BACKGROUND

Recurrent Clostridium difficile infection (CDI) in children can be difficult to manage and may represent an unidentified underlying pathology. Recurrence can be frequently encountered in immunodeficiency disorders and inflammatory bowel disease (IBD).

AIM

To report cases of a select population of children with recurrent CDI who are immunocompetent and do not have an identified IBD and examine the potential for any underlying risk factors, disease course and disease outcome.

METHODS

Review of charts for children aged 1-21 years with recurrent CDI referred to see pediatric gastroenterology service was performed. All subjects with known immunosuppression or IBD were excluded. Subjects were followed for at least 24 mo.

RESULTS

Twelve children seen consecutively were identified. All patients were treated with antibiotic courses for CDI prior to their referral. Five out of 12 patients had an underlying pathology that was not previously identified, including eosinophilic colitis and IBD. CDI symptoms resolved after treatment of underlying colitis without the need to target therapy for CDI. There were 9 patients that failed antibiotic treatment of CDI and required fecal microbiome transplant, which was safe and highly effective in preventing recurrence (100% efficacy). The gut microbial changes after fecal transplant were characterized by a remarkable and durable increase in diversity and in abundance of Bacteroides.

CONCLUSION

Pediatric patients with frequent recurrence of CDI may have an unidentified underlying gastrointestinal pathology that may warrant further investigation by a specialist who can identify these diseases and help optimize management. Many of these children may benefit from fecal microbial transplant which appears to be a safe, highly effective therapy that results in long term changes in the gut microbiome.

Phantom of the inflammasome in the gut: Cytomegalovirus

Cytomegalovirus (CMV) is frequently detected in inflammatory bowel tissue, especially in corticosteroid-refractory patients, and it has been blamed for adverse outcomes. However, the first acquisition of CMV does not involve the colon. In particular in the colonic mucosa, which evolved due to the gut microbial relationship, CMV promotes inflammation via recruited monocytes and not through replication in resident macrophages. Whether CMV is the last straw in the process of mucosal inflammation, a doomed agent, or an innocent bystander is a difficult question that remains elusive. With this work, we will try to review the relationship between intestinal mucosa and CMV in the framework of basic virological principles.