Assessing the effectiveness of texture and color enhancement imaging versus white-light endoscopy in detecting gastrointestinal lesions: A systematic review and meta-analysis

Introduction

Gastrointestinal cancers account for 26% of cancer incidence and 35% of cancer-related deaths globally. Early detection is crucial but often limited by white light endoscopy (WLE), which misses subtle lesions. Texture and color enhancement imaging (TXI), introduced in 2020, enhances texture, brightness, and color, addressing WLE's limitations. This meta-analysis evaluates TXI's effectiveness compared to WLE in gastrointestinal lesion lesion detection.

Methods

A systematic review and meta-analysis were conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Searches of CENTRAL, PubMed, Embase, and Web of Science identified randomized controlled trials and observational studies comparing TXI with WLE. Outcomes included lesion detection rates, color differentiation, and visibility scores. The risk of bias was assessed using the Cochrane ROB 2.0 tool and Newcastle-Ottawa tools, and evidence certainty was evaluated using Grading of Recommendations Assessment, Development, and Evaluation.

Results

Seventeen studies with 16,634 participants were included. TXI significantly improved color differentiation (mean difference: 3.31, 95% confidence interval [CI]: 2.49-4.13), visibility scores (mean difference: 0.50, 95% CI: 0.36-0.64), and lesion detection rates (odds ratio [OR]: 1.84, 95% CI: 1.52-2.22) compared to WLE. Subgroup analyses confirmed TXI's advantages across pharyngeal, esophageal, gastric, and colorectal lesions. TXI also enhanced adenoma detection rates (OR: 1.66, 95% CI: 1.31-2.12) and mean adenoma detection per procedure (mean difference: 0.48, 95% CI: 0.25-0.70).

Conclusion

TXI improves gastriontestinal lesion lesion detection by enhancing visualization and color differentiation, addressing key limitations of WLE. These findings support its integration into routine endoscopy, with further research needed to compare TXI with other modalities and explore its potential in real-time lesion detection.

Endoscopic management of acute cholecystitis in high-risk surgical patients: A comprehensive review article

Acute cholecystitis is frequently encountered in daily clinical practice, and early cholecystectomy is the standard therapy. In high-risk surgical patients, such as those with advanced age, deteriorated performance status, or underlying diseases, conservative treatment is typically preferred to manage acute cholecystitis. However, in patients with a disease that is refractory to conservative treatment, drainage procedures are necessary to control the infection. At present, there are three basic approaches for gallbladder drainage: percutaneous transhepatic gallbladder drainage, endoscopic transpapillary gallbladder drainage, and endoscopic ultrasound gallbladder drainage. Each of these methods has advantages and disadvantages. Therefore, the appropriate treatment method is determined on a case-by-case basis, and no consistent strategy for gallbladder drainage has been established. This review aimed to summarize the characteristics of each drainage method and compare the clinical outcomes of the three procedures for acute cholecystitis in high-risk surgical patients.

Long-term results of palliative placement of very low-axial force self-expandable metallic stents for malignant colorectal obstruction

Objectives

Stent placement is a standard option for palliative decompression in patients with malignant colorectal obstruction. Long-term stent placement is associated with perforation, migration, and stent occlusion. Perforation is associated with life expectancy. Several studies have shown that stents with a high axial force (AF), which is defined as the force required to maintain the stent straight after it has bent, are associated with a higher perforation rate. Therefore, we evaluated the long-term outcomes of using a very low AF stent (Niti-S Enteral Colonic Uncovered stent D-type) for palliative purposes.

Methods

Eighty-one consecutive patients with malignant colorectal obstruction in 33 medical institutions were evaluated. A stent with very low AF was placed using an endoscope system. We evaluated the adverse events (including perforation, migration, and stent occlusion), 1-year survival rate, and cumulative patency rate. Univariate analysis was conducted using Fisher's exact test. The overall survival and cumulative patency rates were assessed using the Kaplan-Meier method.

Results

The 1-year cumulative survival rate was 37.8% after stent placement. The 3-month, 6-month, and 1-year cumulative patency rates after stenting were 93.6%, 84.2%, and 75.8%, respectively. The major adverse events included stent migration (6.2%), stent occlusion (9.9%), and perforation (2.5%). Chemotherapy was administered in 26 cases (32.1%) after stenting, and bevacizumab was administered in five cases. However, no cases of perforation occurred following bevacizumab administration.

Conclusions

Our results suggest that very low AF stents are safe and effective. Therefore, they may be a suitable option for applications, such as palliation. (UMIN 000011304).

Optimal timing of precut sphincterotomy to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in difficult biliary cannulation: A retrospective study

Objectives

Precut sphincterotomy is often performed when bile duct cannulation is difficult; however, the former has a higher risk of complications than conventional methods. Early precut reduces the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP). This study aimed to determine the appropriate timing for precut sphincterotomy to minimize the incidence of PEP.

Methods

This retrospective study analyzed 320 patients who underwent precut sphincterotomy during their first endoscopic retrograde cholangiopancreatography at a single center. The optimal precut timing was identified using receiver operating characteristic analysis. Patients were divided into an optimized precut group (≤12 min, n = 198) and a delayed group (>12 min, n = 122). The incidence and risk factors of PEP were evaluated using multivariate analyses.

Results

Receiver operating characteristic analysis identified 12.5 min as the optimal cutoff for transitioning to precut sphincterotomy (area under the curve, 0.613; sensitivity, 61.5%; specificity, 63.9%). The incidence of PEP was significantly lower in the optimized precut group than in the delayed precut group (5.1% vs. 13.1%, p = 0.02). Multivariate analysis identified delayed precut timing (odds ratio [OR], 3.134; p = 0.04) and the absence of endoscopic pancreatic stenting (OR, 0.284; p = 0.01) as independent risk factors for PEP.

Conclusion

Precut sphincterotomy within 12.5 min of a cannulation attempt reduces the risk of PEP while maintaining procedural safety. Additionally, endoscopic pancreatic stenting can reduce PEP, even in precut scenarios.

Effects of artificial intelligence assistance on endoscopist performance: Comparison of diagnostic performance in superficial esophageal squamous cell carcinoma detection using video-based models

Objectives

Superficial esophageal squamous cell carcinoma (ESCC) detection is crucial. Although narrow-band imaging improves detection, its effectiveness is diminished by inexperienced endoscopists. The effects of artificial intelligence (AI) assistance on ESCC detection by endoscopists remain unclear. Therefore, this study aimed to develop and validate an AI model for ESCC detection using endoscopic video analysis and evaluate diagnostic improvements.

Methods

Endoscopic videos with and without ESCC lesions were collected from May 2020 to January 2022. The AI model trained on annotated videos and 18 endoscopists (eight experts, 10 non-experts) evaluated their diagnostic performance. After 4 weeks, the endoscopists re-evaluated the test data with AI assistance. Sensitivity, specificity, and accuracy were compared between endoscopists with and without AI assistance.

Results

Training data comprised 280 cases (140 with and 140 without lesions), and test data, 115 cases (52 with and 63 without lesions). In the test data, the median lesion size was 14.5 mm (range: 1-100 mm), with pathological depths ranging from high-grade intraepithelial to submucosal neoplasia. The model's sensitivity, specificity, and accuracy were 76.0%, 79.4%, and 77.2%, respectively. With AI assistance, endoscopist sensitivity (57.4% vs. 66.5%) and accuracy (68.6% vs. 75.9%) improved significantly, while specificity increased slightly (87.0% vs. 91.6%). Experts demonstrated substantial improvements in sensitivity (59.1% vs. 70.0%) and accuracy (72.1% vs. 79.3%). Non-expert accuracy increased significantly (65.8% vs. 73.3%), with slight improvements in sensitivity (56.1% vs. 63.7%) and specificity (81.9% vs. 89.2%).

Conclusions

AI assistance enhances ESCC detection and improves endoscopists' diagnostic performance, regardless of experience.

Prognostic factors and long-term outcomes with endoscopic submucosal dissection for colorectal tumors in patients aged 75 years or older

Background

Studies regarding the long-term outcomes of endoscopic submucosal dissection (ESD) performed in older patients with colorectal tumors are limited. Therefore, in this study, we aimed to analyze the long-term outcomes of older patients with colorectal tumors who underwent ESD and identify prognostic factors.

Methods

The data of patients aged ≥ 75 years who underwent ESD for colorectal tumors (adenoma and Tis/T1 colorectal cancer) at a single center were retrospectively analyzed. Prognostic factors for overall survival were analyzed using the Kaplan-Meier method and the Cox proportional hazard model.

Results

Of the 156 patients included, 51 patients died during the follow-up period, among whom two deaths were due to colorectal cancer. The univariate analysis revealed that an age ≥83 years, Charlson Comorbidity Index ≥2, prognostic nutritional index <46, and neutrophil-to-lymphocyte ratio (NLR) ≥3 were associated with poor overall survival. The multivariate analysis identified Charlson Comorbidity Index ≥2 (hazard ratio: 2.26; 95% confidence interval (CI): 1.24-4.13; p = 0.0008) and NLR ≥3 (hazard ratio, 1.98; 95% CI: 1.02-3.81; p = 0.042) as independent prognostic factors.

Conclusions

CCI and NLR may be useful parameters for decision-making in older patients undergoing colorectal ESD.

A UK single-center pilot experience using a novel robotic inchworm colonoscopy system

Introduction

Colonoscopy is the gold standard investigation in the lower gastrointestinal tract. However, 75% of patients can experience pain with moderate sedation. The application of robotic technology aims to overcome difficulties faced including better utilization of rooms for advanced procedures and to achieve a complete colonoscopy in patients restricted by pain and technical challenges.

Methods

This pilot study, the first at a UK-National Health Service Hospital between January 2023 to August 2024 with one expert endoscopist performing the robotic colonoscopy (RC). Patients with failed previous standard colonoscopy (SC) along with index diagnostic procedures deemed potentially difficult were recruited. Procedures were performed outside the endoscopy unit similar to an outpatient clinical room.

Results

Ninety-three patients were recruited (41 men:52 women), mean age of 53.8 years over 20 months. The commonest indications for RC were rectal bleeding (26.9%), failed SC (22.6%), and change in bowel habits (17.2%). Twenty-one patients had failed the previous SC with 14 patients achieving completion with subsequent RC (66% improvement). The average cecal intubation time of 41.07 min with an average total procedure time of 76.48 min. A significant improvement in patient discomfort score was reported (4.71 SC vs. 1.71 RC; p < 0.001).

Conclusions

RC provides a significantly more comfortable colonoscopy and has great potential to improve safety in colonoscopy from this early cohort of patients. Direct visualization, biopsy, and polypectomy are still possible with RC. This study has demonstrated a viable alternative to SC. With no sedation it allows procedures to be conducted outside the traditional endoscopy unit such as outpatients. The study highlights a learning curve to reduce cecal intubation time.

A case of hemobilia caused by a pseudoaneurysm resulting in obstructive cholangitis in a patient who underwent plastic stent placement for pancreatic cancer (with video)

Hemobilia, or hemorrhage within the biliary system, is an uncommon cause of stent obstruction associated with bile duct strictures that are rarely observed with plastic stents. Reports of a pseudoaneurysm as a cause of hemobilia after plastic stent placement are also rare. We present a rare case of hemobilia caused by a pseudoaneurysm that resulted in obstructive cholangitis in a patient who underwent plastic stent placement for bile duct invasion caused by pancreatic cancer. A 78-year-old man with a history of stroke who was using antiplatelet therapy presented with obstructive jaundice caused by locally advanced pancreatic cancer and underwent endoscopic plastic stent placement in the bile duct followed by concurrent chemoradiotherapy. Second-line chemotherapy was administered as the disease progressed; however, he experienced obstructive cholangitis and was admitted to our hospital. Hemobilia was identified as the underlying cause; notably, it was not evident during the initial evaluation and was diagnosed during endoscopic stent replacement. Emergency angiography revealed a pseudoaneurysm of the posterior superior pancreaticoduodenal artery, which was successfully treated using coil embolization. Cholangitis and hemobilia resolved, and the patient was discharged without bleeding recurrence.

Clinical backgrounds and outcomes of patients with Barrett's esophageal adenocarcinoma treated via endoscopic submucosal dissection in Kyushu, Japan: A retrospective multicenter cohort study

Objectives

Most esophageal cancers in Japan are squamous cell carcinomas; however, there has been some concern regarding a recent increase in Barrett's esophageal adenocarcinoma (BEA). This study aimed to clarify the clinical characteristics and outcomes of patients treated via endoscopic submucosal dissection (ESD) in Kyushu, including changes over time.

Methods

This multicenter, retrospective, observational study was conducted among 21 institutes situated in Kyushu. Data from patients who underwent ESD for BEA or esophageal squamous cell carcinoma between January 2010 and December 2023 were extracted from the pathology database and reviewed.

Results

The total number of esophageal ESD cases increased from 2299 over the first 7 years to 4009 over the second seven. The incidence of BEA increased from 3.6% (86/2299) over the earlier period to 4.7% (197/4009; p = 0.034) over the latter. We analyzed data from 283 patients (287 lesions). Smaller tumor-sized lesions were detected over the latter period (14.2 ± 11.6 vs. 11.2 ± 9.5 cm2, p = 0.022), significantly reducing treatment times (122.1 ± 81.2 vs. 93.2 ± 53.3 min p < 0.001). The procedure was safe, with low incidence rates, over both the earlier and later periods (respectively), of perforation (0% vs. 1.0%), delayed bleeding (1.2% vs. 2.0%), and pneumonia (4.7% vs. 4.6%).

Conclusion

The proportion of esophageal ESD procedures to treat BEA has increased in Japan's Kyushu region. This procedure has a comparable safety profile to similar ESD procedures used to treat other conditions.

Updated evidence on epidemiology, diagnosis, and treatment for colonic diverticular bleeding

Since 2020, multiple large-scale studies (CODE BLUE-J) in Japan have accelerated the accumulation of evidence on colonic diverticular bleeding (CDB). This review summarizes the latest findings regarding CDB epidemiology and endoscopic hemostasis. Recent data show that CDB has become the most common cause of lower gastrointestinal bleeding in Japan, driven by an aging population and the increased use of antithrombotic medications. Although 70%-90% of patients achieve spontaneous hemostasis, rebleeding occurs in up to 35% of cases within 1 year. Despite an overall mortality rate of < 1%, patients with CDB can present with hypovolemic shock and may require urgent intervention. There are no effective pharmacological treatments for controlling CDB. Therefore, endoscopic therapy plays a crucial role in its management. Based on available evidence, both clipping and endoscopic band ligation are considered effective initial treatments. Recent studies indicate that direct clipping reduces early rebleeding compared with indirect clipping, while endoscopic band ligation achieves lower rebleeding rates (13%-15%) than clipping. The choice between direct clipping and endoscopic band ligation depends on the diverticulum location and the presence of active bleeding. Newer techniques, such as over-the-scope clip and self-assembling peptide application, have shown potential, but require further study. The detection of the bleeding source remains challenging because accurate identification is essential for successful hemostasis. Additional research is needed to refine the endoscopic diagnostic and therapeutic techniques, prevent rebleeding, and improve patient outcomes.

A pilot study on anti-reflux mucoplasty with valve as novel endoscopic therapy for gastroesophageal reflux disease

Background and aims

Endoscopic anti-reflux therapies like anti-reflux mucosectomy (ARMS) and anti-reflux mucosal ablation have shown efficacy for gastroesophageal reflux disease (GERD) in systematic reviews and meta-analyses. Anti-reflux mucoplasty (ARM-P), a refinement of ARMS, incorporates immediate closure of the resection site to reduce complications. Recently, anti-reflux mucosal valvuloplasty (ARMV), which employs endoscopic submucosal dissection to create a mucosal valve, was introduced but retains ARMS's limitations, requiring extensive incisions (three-quarters to four-fifths circumference). To address these challenges, we developed anti-reflux mucoplasty with valve (ARM-P/V), integrating ARMV's valvuloplasty with ARM-P's closure technique to improve safety and reduce complications. This pilot study evaluates the safety, feasibility, and efficacy of ARM-P/V.

Methods

This retrospective study reviewed data from patients undergoing ARM-P/V for proton pump inhibitor (PPI)-refractory or PPI-dependent GERD at Showa University Koto Toyosu Hospital, Tokyo, from April to August 2024. Symptom severity and quality of life were assessed using validated questionnaires (GERD-Health Related Quality of Life Questionnaire [GERD-HRQL], GERD Questionnaire [GerdQ], and Frequency Scale for the Symptoms of GERD [FSSG]), comparing pre- and post-treatment scores. PPI discontinuation rates were also analyzed.

Results

Eighteen patients (mean age 55.4 years) underwent ARM-P/V. Within 3 months, 72.2% (13/18) reduced or discontinued PPI use. GERD-HRQL scores improved from 20.3 to 10.9 (p = 0.004), GerdQ from 10.4 to 6.9 (p < 0.001), and FSSG from 24.0 to 13.2 (p < 0.001). No severe complications (Clavien-Dindo Grade ≥3), delayed bleeding or dysphagia requiring balloon dilation were reported.

Conclusions

ARM-P/V demonstrates safety, technical feasibility, and short-term efficacy in GERD treatment. As a refinement of ARMV, it offers a promising alternative to current techniques.

Stress granules: Guardians of cellular health and triggers of disease

Stress granules are membraneless organelles that serve as a protective cellular response to external stressors by sequestering non-translating messenger RNAs (mRNAs) and regulating protein synthesis. Stress granules formation mechanism is conserved across species, from yeast to mammals, and they play a critical role in minimizing cellular damage during stress. Composed of heterogeneous ribonucleoprotein complexes, stress granules are enriched not only in mRNAs but also in noncoding RNAs and various proteins, including translation initiation factors and RNA-binding proteins. Genetic mutations affecting stress granule assembly and disassembly can lead to abnormal stress granule accumulation, contributing to the progression of several diseases. Recent research indicates that stress granule dynamics are pivotal in determining their physiological and pathological functions, with acute stress granule formation offering protection and chronic stress granule accumulation being detrimental. This review focuses on the multifaceted roles of stress granules under diverse physiological conditions, such as regulation of mRNA transport, mRNA translation, apoptosis, germ cell development, phase separation processes that govern stress granule formation, and their emerging implications in pathophysiological scenarios, such as viral infections, cancer, neurodevelopmental disorders, neurodegeneration, and neuronal trauma.

Neuromodulation technologies improve functional recovery after brain injury: From bench to bedside

Spontaneous recovery frequently proves maladaptive or insufficient because the plasticity of the injured adult mammalian central nervous system is limited. This limited plasticity serves as a primary barrier to functional recovery after brain injury. Neuromodulation technologies represent one of the fastest-growing fields in medicine. These techniques utilize electricity, magnetism, sound, and light to restore or optimize brain functions by promoting reorganization or long-term changes that support functional recovery in patients with brain injury. Therefore, this review aims to provide a comprehensive overview of the effects and underlying mechanisms of neuromodulation technologies in supporting motor function recovery after brain injury. Many of these technologies are widely used in clinical practice and show significant improvements in motor function across various types of brain injury. However, studies report negative findings, potentially due to variations in stimulation protocols, differences in observation periods, and the severity of functional impairments among participants across different clinical trials. Additionally, we observed that different neuromodulation techniques share remarkably similar mechanisms, including promoting neuroplasticity, enhancing neurotrophic factor release, improving cerebral blood flow, suppressing neuroinflammation, and providing neuroprotection. Finally, considering the advantages and disadvantages of various neuromodulation techniques, we propose that future development should focus on closed-loop neural circuit stimulation, personalized treatment, interdisciplinary collaboration, and precision stimulation.

Blood-brain barrier disruption and neuroinflammation in the hippocampus of a cardiac arrest porcine model: Single-cell RNA sequencing analysis

JOURNAL/nrgr/04.03/01300535-202602000-00043/figure1/v/2025-05-05T160104Z/r/image-tiff Global brain ischemia and neurological deficit are consequences of cardiac arrest that lead to high mortality. Despite advancements in resuscitation science, our limited understanding of the cellular and molecular mechanisms underlying post-cardiac arrest brain injury have hindered the development of effective neuroprotective strategies. Previous studies primarily focused on neuronal death, potentially overlooking the contributions of non-neuronal cells and intercellular communication to the pathophysiology of cardiac arrest-induced brain injury. To address these gaps, we hypothesized that single-cell transcriptomic analysis could uncover previously unidentified cellular subpopulations, altered cell communication networks, and novel molecular mechanisms involved in post-cardiac arrest brain injury. In this study, we performed a single-cell transcriptomic analysis of the hippocampus from pigs with ventricular fibrillation-induced cardiac arrest at 6 and 24 hours following the return of spontaneous circulation, and from sham control pigs. Sequencing results revealed changes in the proportions of different cell types, suggesting post-arrest disruption in the blood-brain barrier and infiltration of neutrophils. These results were validated through western blotting, quantitative reverse transcription-polymerase chain reaction, and immunofluorescence staining. We also identified and validated a unique subcluster of activated microglia with high expression of S100A8, which increased over time following cardiac arrest. This subcluster simultaneously exhibited significant M1/M2 polarization and expressed key functional genes related to chemokines and interleukins. Additionally, we revealed the post-cardiac arrest dysfunction of oligodendrocytes and the differentiation of oligodendrocyte precursor cells into oligodendrocytes. Cell communication analysis identified enhanced post-cardiac arrest communication between neutrophils and microglia that was mediated by neutrophil-derived resistin, driving pro-inflammatory microglial polarization. Our findings provide a comprehensive single-cell map of the post-cardiac arrest hippocampus, offering potential novel targets for neuroprotection and repair following cardiac arrest.

Not too much, not too little. Titrating flow rate to minimise inspiratory effort during helmet CPAP: A bench study

BACKGROUND

Non-invasive helmet respiratory support is suitable for several clinical conditions. Continuous-flow helmet CPAP systems equipped with HEPA filters have become popular during the recent Coronavirus pandemic. However, HEPA filters generate an overpressure above the set PEEP.

METHODS

A lung simulator was used to mimic patient respiratory mechanics and effort. Compared to room air spontaneous breathing, the additional inspiratory effort attributable to helmet CPAP (ΔPmusHelmet) was recorded at different continuous-flow rates (30-150 L/min), PEEP levels (5, 10, 12.5 cmH2O) and respiratory rates (15, 20, 25, 30 breaths/minute), both with and without a HEPA filter at the outlet port.

RESULTS

Helmet pressure swings during inspiration largely explained ΔPmusHelmet variations (p<0.001, Spearman's Rho=0.964). The lowest ΔPmusHelmet levels (0.2 [0; 0.4] cmH2O) were frequently recorded (>70%) at a 90 L/min flow rate. Higher ΔPmusHelmet levels were recorded when the continuous-flow was lower than the peak inspiratory flow (3.7 [3.1; 5.6] cmH2O, p<0.001) or when a HEPA filter was used (2.7 [2.2; 3.5], p<0.001). Increasing the flow rate resulted in higher overpressure levels, particularly with a HEPA filter (p<0.001). Overpressure levels correlated with ΔPmusHelmet (p<0.001, Spearman's Rho=0.598).

CONCLUSIONS

Helmet pressure swings below PEEP lead to additional inspiratory efforts. The HEPA filter acts as a flow resistor, generating an overpressure leading to increased respiratory effort. The continuous-flow rate should be titrated high enough to slightly exceed the peak inspiratory flow; however, further flow increase is not recommended as it leads to an increase in overpressure and helmet pressure swings below PEEP.

Public Policy and Health System Responses to Diabetes Mellitus in Nigeria: A Call for Reform

Diabetes mellitus, once a rare diagnosis in precolonial and early post-colonial Nigeria, now has the highest prevalence and fatality rates in sub-Saharan Africa. This increased prevalence is attributed to rising population affluence characterized by sedentary lifestyles and higher consumption of processed and ultra-processed foods. The burden is further exacerbated by a poorly responsive healthcare system. Currently, less than 50% of affected individuals are aware of their condition. Factors such as misconceptions about the disease, a preference for unproven traditional herbal treatments, and the high cost of treatment hinder effective secondary responses. Health system challenges in diabetes management in Nigeria include inadequate implementation of existing policies and guidelines, high out-of-pocket payments, poor quality of healthcare, and limited public education about the disease. To address these issues, we recommend a policy focus on:  1) Implementing actionable policies and guidelines for diabetes prevention and care; 2) Improving the pre-paid care system to reduce out-of-pocket payments; 3) Enhancing the quality of services at all healthcare levels, with the establishment of centers of excellence for specialized diabetes management; 4) Continuing the training, retraining, motivation, and expansion of the workforce responsible for diabetes care; and 5) Health promotion and health awareness aimed at the public to address inaccurate beliefs and practices about diabetes. Addressing these multifaceted factors will help to reduce the rising incidence of diabetes in Nigeria.

Efficient and Effective Diabetes Care in the Era of Digitalization and Hypercompetitive Research Culture: A Focused Review in the Western Pacific Region with Malaysia as a Case Study

There are approximately 220 million (about 12% regional prevalence) adults living with diabetes mellitus (DM) with its related complications, and morbidity knowingly or unconsciously in the Western Pacific Region (WP). The estimated healthcare cost in the WP and Malaysia was 240 billion USD and 1.0 billion USD in 2021 and 2017, respectively, with unmeasurable suffering and loss of health quality and economic productivity. This urgently calls for nothing less than concerted and preventive efforts from all stakeholders to invest in transforming healthcare professionals and reforming the healthcare system that prioritizes primary medical care setting, empowering allied health professionals, improvising health organization for the healthcare providers, improving health facilities and non-medical support for the people with DM. This article alludes to challenges in optimal diabetes care and proposes evidence-based initiatives over a 5-year period in a detailed roadmap to bring about dynamic and efficient healthcare services that are effective in managing people with DM using Malaysia as a case study for reference of other countries with similar backgrounds and issues. This includes a scanning on the landscape of clinical research in DM, dimensions and spectrum of research misconducts, possible common biases along the whole research process, key preventive strategies, implementation and limitations toward high-quality research. Lastly, digital medicine and how artificial intelligence could contribute to diabetes care and open science practices in research are also discussed.

How Health Systems World-wide Fail Type 2 Diabetics

For over 50 years, health systems the world over have failed people with type 2 diabetes mellitus (T2DM). The WHO documents a quadrupling of people with diabetes in a 34-year period to 422 million in 2014, the overwhelming majority of whom were T2DM. This happened despite extensive scientific literature on the causes of, as well as proven treatments for, this disease. Using a health systems prism to review the extensive medical and nutritional T2DM published research, we identified three main shortcomings of health systems in T2DM: (i) failure in early detection; (ii) failure in understanding the actionable lifestyle drivers; and (iii) subsidizing the causes of the disease. Although small-scale success stories in T2DM control exist, the lack of documented evidence of any country-wide health system's successful attempt to address this epidemic is alarming. The immense and ever-growing health and economic burdens of T2DM should provide all the motivation needed for national and global efforts to counteract the political-economy constraints standing in the way of successful whole-of-system approaches to T2DM.

Chronic pancreatitis

Chronic pancreatitis is a progressive fibroinflammatory disease primarily caused by a complex interplay of environmental and genetic risk factors. It might result in pancreatic exocrine and endocrine insufficiency, chronic pain, reduced quality of life, and increased mortality. The diagnosis is based on the presence of typical symptoms and multiple morphological manifestations of the pancreas, including pancreatic duct stones and strictures, parenchymal calcifications, and pseudocysts. Management of chronic pancreatitis consists of prevention and treatment of complications, requiring a multidisciplinary approach focusing on lifestyle modifications, exocrine insufficiency, nutritional status, bone health, endocrine insufficiency, pain management, and psychological care. To optimise clinical outcomes, screening for complications and evaluation of treatment efficacy are indicated in all patients with chronic pancreatitis.

The Current Landscape of Endoscopic Submucosal Training in the United States

PURPOSE OF REVIEW

Endoscopic submucosal dissection (ESD) has been found to increase en bloc and R0 resection as well as decrease risk of recurrence. However, despite literature supporting the benefits of endoscopic submucosal dissection, adoption of ESD in the United States has been challenging, driven by factors including requirement for specialized training as well as limitations in training availability.

RECENT FINDINGS

Many devices have been developed to improve ease and therefore adoption for the procedure, with advancements in stability, resection as well as closure of the mucosal defect following resection. While the Japanese model of training in ESD centers around the Master-Apprentice model, this is scarce in the United States. Most US endoscopists therefore must follow other paths to learn and become proficient at ESD. There has been a rapid expansion in literature on ESD, fellowship programs, opportunities for case observation, and significant evolution in ex vivo training models that can assist an endoscopist in receiving training in ESD. Currently, there are three main ways of learning to perform ESD in the United States: 1. Third space endoscopy fellowship; 2. Master-apprentice model; 3. Utilization of live courses and proctored procedures. ESD is the optimal method to ensure en bloc resection of large mucosal neoplasms of the gastrointestinal tract. While several barriers hinder adoption of ESD in the United States, there has been significant development both in procedural and training aspects. Further research and discussions are needed to determine criteria for credentialing and proficiency in ESD.

Microbiota transplant therapy in inflammatory bowel disease: advances and mechanistic insights

Microbiota transplant therapy is an emerging therapy for inflammatory bowel disease, but factors influencing its efficacy and mechanism remain poorly understood. In this narrative review, we outline key elements affecting therapeutic outcomes, including donor factors (such as age and patient relationship), recipient factors, control selection, and elements impacting engraftment and its correlation with clinical response. We also examine potential mechanisms through inflammatory bowel disease trials, focusing on the interplay between the microbiota, host, and immune system. Finally, we briefly explore potential future directions for microbiota transplant therapy and promising emerging treatments.

The coping experiences in patients with hepatocellular carcinoma and their spouses following postoperative recurrence: A dyadic qualitative study

Objective

Dyadic coping practices can vary depending on cultural contexts, socioeconomic factors, and the stages of the cancer journey. This study aimed to explore the dyadic coping experiences of hepatocellular carcinoma (HCC) patients and their spouses following postoperative recurrence in the Chinese cultural context, where cancer recurrence is frequently seen as a death sentence, and family-centered care is prioritized.

Methods

A descriptive qualitative research design was used, involving face-to-face, in-depth semi-structured interviews with 13 pairs of hepatocellular carcinoma patients and their spouses at a tertiary cancer hospital from July to October 2023. The interview guide was designed based on the Actor-Partner Interdependence Model (APIM) framework. Data were analyzed using thematic analysis, and the study adhered to the COnsolidated criteria for REporting Qualitative research (COREQ) checklist.

Results

Three themes were identified: (1) active coping strategies, (2) negative coping tendencies, and (3) the need for systematic coping support. The majority of couples perceived hepatocellular carcinoma recurrence as a death sentence, which prompted them-especially the spouses-to adopt proactive strategies, such as striving to seek advanced treatments and concealing unfavorable information. In contrast, patients, particularly those with a hereditary hepatocellular carcinoma background, often exhibited passivity, withdrawal, and contemplation of treatment abandonment. Spouses frequently felt overwhelmed and unable to alleviate their partners' anxiety about recurrence and death, particularly in the absence of support from health care professionals. They expressed a strong need for professional guidance and targeted interventions to address end-of-life concerns, emphasizing the need for increased financial support, empowerment through knowledge, and access to peer support networks.

Conclusions

This research emphasizes the importance of recognizing the interdependent coping experiences of recurrent HCC patients and their spouses. Health care professionals are encouraged to implement culturally sensitive, dyadic interventions that foster collaborative coping, address death-related anxiety, and empower couples in managing recurrence together, thereby enhancing their coping strategies and confidence.

Fecal microbiota transplantation modulates myeloid-derived suppressor cells and attenuates renal fibrosis in a murine model

BACKGROUND

Renal fibrosis is a hallmark of progressive chronic kidney disease (CKD), with emerging evidence linking gut microbiota dysbiosis to disease progression. Myeloid-derived suppressor cells (MDSCs) have demonstrated renoprotective effects, yet the impact of fecal microbiota transplantation (FMT) on MDSC-mediated modulation of renal fibrosis remains unclear.

METHODS

C57BL/6J mice underwent unilateral ureteral obstruction (UUO) to induce renal fibrosis, followed by FMT administration via gavage. Flow cytometry was used to quantify granulocytic (G-MDSCs) and monocytic (M-MDSCs) MDSC populations in peripheral blood, kidney, and spleen. To elucidate the role of MDSCs in FMT-mediated effects, MDSCs were depleted or adoptively transferred in vivo. Renal fibrosis severity and inflammatory cytokine expression were subsequently analyzed.

RESULTS

FMT altered MDSC distribution, increasing M-MDSC accumulation in the blood and kidney. This was associated with downregulation of proinflammatory cytokines and attenuation of renal fibrosis. Adoptive MDSC transfer similarly produced anti-inflammatory and antifibrotic effects, reinforcing their therapeutic role in FMT-mediated renal protection.

CONCLUSIONS

FMT enhances M-MDSC-mediated immunomodulation, reducing inflammation and renal fibrosis in UUO-induced CKD. These findings suggest a potential therapeutic strategy targeting the gut-kidney axis in CKD management.

Role of endoscopic ultrasound as a predictor of histological healing in ulcerative colitis

BACKGROUND

Ulcerative colitis (UC) is a chronic inflammatory bowel disease with rising global prevalence.Histological healing (HH) is a key treatment target associated with better long-term outcomes. Although endoscopic ultrasound (EUS) is known to be related to both clinical and endoscopic activity in UC, its role in defining HH remains unclear. Therefore, this study was aimed at investigating the association between EUS and histological activity (HA), as well as the predictive potential of EUS for HH.

METHOD

In this cross-sectional analysis, 68 UC adults underwent EUS and colonoscopy with biopsies. We used the Mayo Endoscopic Score (MES) for endoscopic activity, the Nancy Index (NI) for biopsy grading, and the Endoscopic Ultrasound-Ulcerative Colitis (EUS-UC) score for EUS analysis, defining endoscopic remission as MES ≤ 1 and HH as NI ≤ 1.A receiver operating characteristic (ROC) curve was employed to evaluate the ability of the indices to predict HH.

RESULTS

Totally 23 patients (33.80%) achieved HH, while 45 (66.20%) showed HA. The EUS-UC scores were significantly lower in the HH group (p < 0.001) and correlated strongly with NI (ρ = 0.73). EUS-UC score was an independent risk factor for HH (adjusted OR = 1.918, 95% CI: 1.195-3.080, p = 0.007). The EUS-UC score demonstrated a strong predictive value for HH, with an AUC of 0.840, a sensitivity of 75.56%, and a specificity of 78.26%.

CONCLUSION

The EUS-UC score has a significant correlation with histological outcomes and shows strong potential as a reliable, invasive predictor of HH in UC, with implications for improved disease monitoring.

The role and function of lncRNA in ageing-associated liver diseases

Liver diseases are a significant global health issue, characterized by elevated levels of disorder and death. The substantial impact of ageing on liver diseases and their prognosis is evident. Multiple processes are involved in the ageing process, which ultimately leads to functional deterioration of this organ. The process of liver ageing not only renders the liver more susceptible to diseases but also compromises the integrity of other organs due to the liver's critical function in metabolism regulation. A growing body of research suggests that long non-coding RNAs (lncRNAs) play a significant role in the majority of pathophysiological pathways. They regulate gene expression through a variety of interactions with microRNAs (miRNAs), messenger RNAs (mRNAs), DNA, or proteins. LncRNAs exert a major influence on the progression of age-related liver diseases through the regulation of cell proliferation, necrosis, apoptosis, senescence, and metabolic reprogramming. A concise overview of the current understanding of lncRNAs and their potential impact on the development of age-related liver diseases will be provided in this mini-review.

Expert consensus and recommendations on the live attenuated hepatitis A vaccine and immunization practices in India

While Hepatitis A Virus (HAV) vaccination in global immunization programs has shown a virtual elimination of the disease within few years of the vaccination program, changing epidemiological landscape in India underscores the need for evidence-based, updated guidance on immunization practices. In May 2024, a panel of 15 distinguished opinion leaders and an organizing committee convened for an intensive, face-to-face advisory board meeting on high burden of HAV infection among adults, increased mortality rate in adolescents, symptomatic presentation in children, and evolving landscape globally and within India. Extensive comparable deliberations on long-term follow-up data from India and data from country of origin advocated immunogenicity, tolerability, and long-term protective effects of single-dose live attenuated HAV vaccine in children. Finally, a consensus was achieved on recognition of increased global attention toward HAV prevention through vaccination coverage. The need for a single dose of live attenuated HAV vaccine was an important outcome of this meeting.

TGF-β: elusive target in diabetic kidney disease

Transforming growth factor-beta (TGF-β), a cytokine with near omnipresence, is an integral part of many vital cellular processes across the human body. The family includes three isoforms: Transforming growth factor-beta 1, 2, and 3. These cytokines play a significant role in the fibrosis cascade. Diabetic kidney disease (DKD), a major complication of diabetes, is increasing in prevalence daily, and the classical diagnosis of diabetes is based on the presence of albuminuria. The occurrence of nonalbuminuric DKD has provided new insight into the pathogenesis of this disease. The emphasis on multifactorial pathways involved in developing DKD has highlighted some markers associated with tissue fibrosis. In diabetic nephropathy, TGF-β is significantly involved in its pathology. Its presence in serum and urine means that it could be a diagnostic tool while its regulation provides potential therapeutic targets. Completely blocking TGF-β signaling could reach untargeted regions and cause unanticipated effects. This paper reviews the basic details of TGF-β as a cytokine, its role in DKD, and updates on research carried out to validate its candidacy.

The gut microbiota predicts and time-restricted feeding delays experimental colitis

The etiology of inflammatory bowel disease (IBD) remains unclear, treatment options unsatisfactory and disease development difficult to predict for individual patients. Dysbiosis of the gastrointestinal microbiota and disruption of the biological clock have been implicated and studied as diagnostic and therapeutic targets. Here, we examine the relationship of IBD to biological clock and gut microbiota by using the IL-10 deficient (IL-10-/-) mouse model for microbiota-dependent spontaneous colitis in combination with altered (4 h/4 h) light/dark cycles to disrupt and time-restricted feeding (TRF) to restore circadian rhythmicity. We show that while altered light/dark cycles disrupted the intestinal clock in wild type (WT) mice, IL-10-/- mice were characterized by altered microbiota composition, impaired intestinal clock, and microbiota rhythmicity irrespective of external clock disruption, which had no consistent colitis-promoting effect on IL-10-/- mice. TRF delayed colitis onset reduced the expression of inflammatory markers and increased the expression of clock genes in the intestine, and increased gut microbiota rhythmicity in IL-10-/- mice. Compositional changes and reduced rhythmicity of the fecal microbiota preceded colitis and could predict colitis symptoms for individual IL-10-/- mice across different experiments. Our findings provide perspectives for new diagnostic and TRF-based, therapeutic applications in IBD that should be further explored.

Association of Log Odds of Positive Lymph Nodes with Overall Survival in Patients with Primary Malignant Anorectal Melanoma: A Population-Based Study

BACKGROUND

Malignant anorectal melanoma (AM) is a rare tumor characterized by its aggressive behavior. To date, there has been no comprehensive investigation into the association between the log odds of positive lymph nodes (LODDS) and the prognosis of patients with malignant AM who have undergone surgical intervention.

METHODS

Data were extracted from the Surveillance, Epidemiology and End Results (SEER) database for patients diagnosed with primary malignant AM who have undergone surgical intervention between 2000 and 2021. The Kaplan-Meier (KM) method with the log-rank test was used to compare survival curves between different LODDS groups. Multivariate Cox models were employed to evaluate the independent association between LODDS and overall survival (OS). An analysis to explore the potential influence of unmeasured confounders on the relationship between LODDS and OS was conducted using the E value.

RESULTS

The study included a total of 126 eligible patients. KM analysis revealed that patients with low LODDS exhibited significantly improved OS compared to those with high LODDS (p < 0.001). The multivariate Cox analysis demonstrated that LODDS was independently associated with OS. The calculated E value suggested that the potential impact of unmeasured confounders on the association between LODDS and OS was likely minimal.

CONCLUSION

The findings indicate that LODDS is independently associated with the prognosis of patients with AM undergoing surgical intervention. These results may enhance clinicians' understanding of the prognosis of this rare malignancy and provide a basis for guiding therapeutic decisions.

The influence of childhood trauma on social media-induced secondary traumatic stress among college students: the chain mediating effect of self-compassion and resilience

Background: Studies have shown that media exposure to critical public events can lead to secondary traumatic stress (STS). Personal trauma history, self-compassion and resilience are important factors influencing STS in healthy professionals. However, whether these variables are associated with social media-induced STS in college students and the underlying mechanisms remain unclear. The purpose of this study was to explore the complex relationship linking childhood trauma to social media-induced STS in a large sample of college students.Methods: A total of 1151 Chinese college students from Chengdu, Sichuan Province of China completed a web-based cross-sectional survey, which included standard assessments of childhood trauma, self-compassion, resilience and social media-induced STS, as well as sociodemographic questionnaires. The chain mediation model was tested using the PROCESS macro programme in SPSS software.Results: There was a moderate correlation between childhood trauma and social media-induced STS (r = 0.34, p < .001). This association was significantly mediated by self-compassion (indirect effect [95% CI] = 0.14[0.11, 0.17]) and resilience (indirect effect = 0.03[0.01, 0.04]), respectively. Further, a chained mediating effect was observed with self-compassion and resilience consecutively mediated the relationship between childhood trauma and social media-induced STS (indirect effect = 0.02[0.01, 0.03]). These results persisted after sociodemographic characteristics were included as controlling variables.Conclusions: Early life trauma impacts STS induced by exposure to traumatic materials on social media through self-compassion and resilience among Chinese college students. Psychological interventions targeting self-compassion and resilience can be implemented to reduce the risk of STS, especially in vulnerable individuals.

Fusobacterium nucleatum upregulates the immune inhibitory receptor PD-L1 in colorectal cancer cells via the activation of ALPK1

Fusobacterium nucleatum is a Gram-negative oncobacterium that is associated with colorectal cancer. The molecular mechanisms utilized by F. nucleatum to promote colorectal tumor development have largely focused on adhesin-mediated binding to the tumor tissue and on the pro-inflammatory capacity of F. nucleatum. However, the exact manner in which F. nucleatum promotes inflammation in the tumor microenvironment and subsequent tumor promotion remains underexplored. Here, we show that both living F. nucleatum and sterile F. nucleatum-conditioned medium promote CXCL8 release from the intestinal adenocarcinoma HT-29 cell line. We determined that the observed pro-inflammatory effect was ALPK1-dependent in both HEK293 and HT-29 cells and that the released F. nucleatum molecule had characteristics that match those of the pro-inflammatory ALPK1 ligand ADP-heptose or related heptose phosphates. In addition, we determined that not only F. nucleatum promoted an ALPK1-dependent pro-inflammatory environment but also other Fusobacterium species such as F. varium, F. necrophorum and F. gonidiaformans generated similar effects, indicating that ADP-heptose or related heptose phosphate secretion is a conserved feature of the Fusobacterium genus. By performing transcriptional analysis of ADP-heptose stimulated HT-29 cells, we found several inflammatory and cancer-related pathways to be differentially regulated, including DNA mismatch repair genes and the immune inhibitory receptor PD-L1. Finally, we show that stimulation of HT-29 cells with F. nucleatum resulted in an ALPK1-dependent upregulation of PD-L1. These results aid in our understanding of the mechanisms by which F. nucleatum can affect tumor development and therapy and pave the way for future therapeutic approaches.

Digital health competences and AI beliefs as conditions for the practice of evidence-based medicine: a study of prospective physicians in Canada

BACKGROUND

The practice of evidence-based medicine (EBM) has become pivotal in enhancing medical care and patient outcomes. With the diffusion of innovation in healthcare organizations, EBM can be expected to depend on medical professionals' competences with digital health (dHealth) and artificial intelligence (AI) technologies.

OBJECTIVE

We aim to investigate the effect of dHealth competences and perceptions of AI on the adoption of EBM among prospective physicians. By focusing on dHealth and AI technologies, the study seeks to inform the redesign of medical curricula to better prepare students for the demands of evidence-based medical practice.

METHODS

A cross-sectional survey was administered online to students at the University of Montreal's medical school, which has approximately 1,400 enrolled students. The survey included questions on students' dHealth competences, perceptions of AI, and their practice of EBM. Using structural equation modeling (SEM), we analyzed data from 177 respondents to test our research model.

RESULTS

Our analysis indicates that medical students possess foundational knowledge competences of dHealth technologies and perceive AI to play an important role in the future of medicine. Yet, their experiential competences with dHealth technologies are limited. Our findings reveal that experiential dHealth competences are significantly related to the practice of EBM (β = 0.42, p < 0.001), as well as students' perceptions of the role of AI in the future of medicine (β = 0.39, p < 0.001), which, in turn, also affect EBM (β = 0.19, p < 0.05).

CONCLUSIONS

The study underscores the necessity of enhancing students' competences related to dHealth and considering their perceptions of the role of AI in the medical profession. In particular, the low levels of experiential dHealth competences highlight a promising starting point for training future physicians while simultaneously strengthening their practice of EBM. Accordingly, we suggest revising medical curricula to focus on providing students with practical experiences with dHealth and AI technologies.

Identification of a postoperative survival scoring index for adult liver transplantation

BACKGROUND

In addition to surgical technology, successful liver transplantation (LT) depends on perioperative management, which needs an effective prognostic index. Therefore, a simplified and sensitive postoperative index for adult LT should be developed.

METHODS

In total, 906 patients who underwent LT were included in this cross-sectional study. Univariate analysis was used to identify the independent risk factors for recipient survival. Multivariate logistic and stepwise regression analyses were used to construct and simplify the model design. Area under the curve (AUC) and Kaplan-Meier's (K-M) analysis demonstrated superiority of the new index. The postoperative survival score (POSS) index was further simplified via restricted cubic spline (RCS) analysis. Finally, the interpretation of the long-term mortality and subgroup analyses extended the application of the POSS index.

RESULTS

Finally, a total of five factors (donor sex, recipient body mass index (BMI), total bilirubin (Tbil), international normalized ratio (INR) and total operative time) were identified as independent risk parameters and included in our POSS index. The AUCs of the original and simplified POSS indices were 0.764 and 0.723, respectively. Patients with high scores had poor short-term survival. Our index also functioned well in predicting long-term mortality, and it was more effective for patients with hepatitis B cirrhosis or hepatocellular carcinoma (HCC).

CONCLUSIONS

We constructed a simplified and effective postoperative survival scoring index to predict short-term complications and survival in adult LT patients.

Prophylactic effects of nutrition, dietary strategies, exercise, lifestyle and environment on nonalcoholic fatty liver disease

BACKGROUND

Nonalcoholic fatty liver disease (NAFLD) is a chronic liver disease and its prevalence has risen sharply. However, whether nutrition, dietary strategies, exercise, lifestyle and environment have preventive value for NAFLD remains unclear.

METHODS

Through searching 4 databases (PubMed, Web of Science, Embase and the Cochrane Library) from inception to January 2025, we selected studies about nutrition, dietary strategies, exercise, lifestyle and environment in the prevention of NAFLD and conducted a narrative review on this topic.

RESULTS

Reasonable nutrient intake encompassing macronutrients and micronutrients have an independent protective relationship with NAFLD. Besides, proper dietary strategies including mediterranean diet, intermittent fasting diet, ketogenic diet, and dietary approaches to stop hypertension diet have their inhibitory effects on the developmental process of NAFLD. Moreover, right exercises including walking, jogging, bicycling, and swimming are recommended for the prevention of NAFLD because they could effectively reduce weight, which is an important risk factor for NAFLD, and improve liver function. In addition, embracing a healthy lifestyle including reducing sedentary behavior, not smoking, sleeping well and brushing teeth regularly is integral since it not only could reduce the risk of NAFLD but also significantly contribute to overall prevention and control. Finally, the environment, including the social and natural environments, plays a potential role in NAFLD prevention.

CONCLUSION

Nutrition, dietary strategies, exercise, lifestyle and environment play an important role in the prevention of NAFLD. Moreover, this review offers comprehensive prevention recommendations for people at high risk of NAFLD.

Sex hormone-binding globulin as a biomarker for metabolic risk in European women with polycystic ovary syndrome

OBJECTIVE

Sex hormone-binding globulin (SHBG) is suggested to be a biomarker for metabolic disturbances in women with polycystic ovary syndrome (PCOS). Insulin resistance and hyperinsulinemia is common in PCOS patients. Low SHBG increases free testosterone levels, which further induces hyperinsulinemia. There is no established cutoff level for SHBG in PCOS patients. The goal of this study is to examine SHBG as a biomarker for metabolic dysregulation in European women with PCOS in relation to hyperandrogenemia.

METHODS

Retrospective data was collected from the outpatient clinic for menstrual cycle disorders at Maastricht University Medical Center+. 208 women were included, aged between 18 and 40 years old. During a one-time visit to the clinic, physical examination and vaginal ultrasound evaluation were performed as well as endocrine evaluation performed after overnight fast. The women were diagnosed with PCOS according to the European Society of Human Reproduction and Embryology (ESHRE) 2018 guideline.

RESULTS

BMI was inversely associated with SHBG (β -0.598, 95% CI [-0.710 to -0.485]) and waist circumference (β -0.604, [-0.715 to -0.492]), even after correction for HOMA-IR and testosterone. A cutoff level <40 nmol/L was significantly, and unfavorably, associated with all metabolic outcomes. Its AUROC was optimal for waist circumference (sensitivity 0.75, specificity 0.82).

CONCLUSIONS

SHBG levels <40 nmol/L are indicative for metabolic dysregulation in European women with PCOS. Waist circumference is an important predictor for SHBG, comparable to BMI. Visceral adiposity might play an important role in the expression of SHBG and etiology of PCOS.

A Porcine Model of Laparoscopic Intersphincteric Resection for Ultra-Low Rectal Cancer

OBJECTIVE

To develop a porcine model for laparoscopic intersphincteric resection (ISR) targeting ultra-low rectal cancer.

METHODS

Six Bama mini-pigs underwent a standard laparoscopic ISR procedure: (1) Ligation and transection of the inferior mesenteric vessels; (2) Exposure and sparing of the pelvic autonomic nerves; (3) Dissection of the rectum; (4) Dissection and transection of hiatal ligament and rectourethralis muscle; (5) Transanal dissection of the anal canal; (6) Dissection of the intersphincteric space (ISS); (7) End-to-end handsewn coloanal anastomosis (CAA). Pathological evaluations were conducted to ascertain the precision of the ISR. Furthermore, postoperative fecal incontinence scores were systematically assessed on a weekly basis throughout a 12-week post-surgery follow-up period.

RESULTS

All six pigs survived surgery without conversion to an open approach. There were no occurrences of incisional infection or any surgical complications, including anastomotic leakage, anastomotic bleeding, or ileus. Postoperatively, one pig manifested constipation and three exhibited anal redness, both conditions ameliorating within a week. No erosive ulcers were detected. Notably, all animals exhibited fecal staining on their tails within the first two weeks post-surgery, transitioning to formed feces by the third week. Improvement in defecation frequency was observed after 6 weeks, with a noticeable reduction in defecation areas after one month. Incontinence scores, evaluated three months post ISR surgery, revealed no significant abnormalities in anal function compared to preoperative assessments.

CONCLUSIONS

This study established a replicable porcine model for laparoscopic ISR, demonstrating its potential utility in clinical and fundamental research related to ultra-low rectal cancer treatment.

Effect of adipose-related parameters on mortality in patients with liver cirrhosis: a meta-analysis

BACKGROUND

Some adipose-related parameters exhibit distinct prognostic value in patients with cirrhosis. However, the magnitude and direction of the association between individual adipose parameter and mortality in patients with cirrhosis are unclear.

AIM

This study aimed to evaluate the association between individual adipose parameter and mortality in patients with cirrhosis using the meta-analysis method.

METHODS

The PubMed, Embase, Web of Science, China Biological Medicine, WanFang, and China National Knowledge Infrastructure databases were searched from inception through December 15, 2023, to identify eligible studies. The impact of each adipose parameter on mortality was assessed by the pooled unadjusted or adjusted hazard ratio (HR) with 95% confidence intervals (CIs) using the random effects model.

RESULTS

A total of 33 studies involving 9626 patients were included in our analysis, with 11 adipose parameters evaluated. The pooled prevalence of sarcopenic obesity (SO) and myosteatosis in patients with cirrhosis was 15.5% and 34.4%, respectively. In adjusted analysis, each unit increase in subcutaneous adipose tissue index (SATI) (HR: 0.99, 95% CI: 0.98-1.00) or muscle attenuation (MA) (HR: 0.94, 95% CI: 0.90-0.98) and each unit decrease in visceral-to-subcutaneous adipose tissue ratio (VSR) (HR: 1.92, 95% CI: 1.45-2.54) showed an independent association with a decreased risk of mortality. However, concurrent myosteatosis (HR: 1.88, 95% CI: 1.48-2.40) or SO (HR: 2.77, 95% CI: 1.95-3.93) significantly increased the risk of mortality in patients with cirrhosis.

CONCLUSION

Decreased SATI or MA, increased VSR, and concurrent myosteatosis or SO were independently associated with a higher risk of mortality in patients with cirrhosis.

A real-world study on the influence of unplanned reoperations on hospitalized patients using the diagnosis-related group

OBJECTIVE

The issue of unplanned reoperations poses significant challenges within healthcare systems, with assessing their impact being particularly difficult. The current study aimed to assess the influence of unplanned reoperations on hospitalized patients by employing the diagnosis-related group (DRG) to comprehensively consider the intensity and complexity of different medical services.

METHODS

A retrospective cohort study of surgical patients was conducted at a large tertiary hospital with two hospital districts employing data sourced from a DRG database. Hospital length of stay (LOS) and hospitalization costs were measured as the primary outcomes. Discharge to home was measured as the secondary outcome. Frequency matching based on DRG, regression modeling, subgroup comparison and sensitivity analysis were applied to evaluate the influence of unplanned reoperations.

RESULTS

We identified 20820 surgical patients distributed across 79 DRGs, including 188 individuals who underwent unplanned reoperations and 20632 normal surgical patients in the same DRGs. After DRG-based frequency matching, 564 patients (188 with unplanned reoperations, 376 normal surgical patients) were included. Unplanned reoperations led to prolonged LOS (before matching: adjusted difference, 12.05 days, 95% confidence interval [CI] 10.36-13.90 days; after matching: adjusted difference, 14.22 days, 95% CI 11.36-17.39 days), and excess hospitalization costs (before matching: adjusted difference, $4354.29, 95% CI: $3,817.70-$4928.67; after matching: adjusted difference, $5810.07, 95% CI $4481.10-$7333.09). Furthermore, patients who underwent unplanned reoperations had a reduced likelihood of being discharged to home (before matching: hazard ratio [HR] 0.27, 95% CI 0.23-0.32; after matching: HR 0.31, 95% CI 0.25-0.39). Subgroup analyses indicated that the outcomes across the various subgroups were mostly uniform. In high-level surgery subgroups (levels 3-4) and in relation to complex diseases (relative weight ≥ 2), the increase in hospitalization costs and LOS was more pronounce after unplanned reoperations. Similar results were observed with sensitivity analysis by propensity score matching and excluding short LOS.

CONCLUSIONS

Incorporating the DRG allows for a more effective assessment of the influence of unplanned reoperations. In managing such reoperations, mitigating their influence, especially in the context of high-level surgeries and complex diseases, remains a significant challenge that requires special consideration.

Mid-term failure rates, timing, and mechanisms for osteochondral allograft transplantation in the knee: Characterizing risk factors and identifying modifiable variables

Background

Knee osteochondral allograft transplantation (OCAT) is consistently successful, however, higher failure rates for multisurface and bipolar OCATs persist. Failure mechanisms have involved OCA erosion, delamination, degeneration, fracture, and/or fragmentation, and progression of joint disease, associated with older patient age, higher BMI, male sex, nicotine use, comorbidities, low chondrocyte viability, larger OCA volume, and bipolar OCAT.

Methods

Patient outcomes were prospectively followed after primary knee OCAT and analyzed for failure mechanisms categorized as OCA Cartilage, OCA Bone, Meniscus Allograft, Joint Disease Progression, or Unknown. Cases were included when OCAT was performed >5 years prior; all failure cases were included regardless of final follow-up (FFU) time. Failure and non-failure cohorts, and failure mechanism subcohorts, were compared based on patient sex, age, BMI, nicotine use, concurrent procedures, OCAT surgery type, and adherence.

Results

There were 186 cases in 184 patients (n = 112 males; mean age = 37.1 years; mean BMI = 28.5 kg/m2; mean FFU = 79 months). Initial failure rate was 23.1% (n = 43) with mechanisms attributed to OCA Bone (n = 15; 34.9%), Meniscus (n = 13; 30.2%), Joint Disease Progress (n = 11; 25.6%), OCA Cartilage (n = 2; 4.7%), or Unknown (n = 2; 4.7%). Risk factors included concurrent ligament reconstruction, ipsilateral osteotomy, and tibiofemoral bipolar + OCAT. However, older age and higher BMI, as well as potential barriers for post-operative adherence should be considered during patient selection.

Conclusions

Recent advances have mitigated key risk factors, such that reductions in knee OCAT failure rates with improvements in function, mental health, and quality of life have been more consistently realized.

Level of evidence

2, prospective cohort study.

Structural or functional abnormality of sphincter of Oddi: an important factor for the recurrence of choledocholithiasis after endoscopic treatment

A high recurrence rate is undesirable after treatment of common bile duct (CBD) stones. A major risk factor identified for recurrence is that invasive techniques, including surgical or endoscopic treatments, will impair the biliary tract system either by direct incision of the CBD or by cutting or dilating the ampulla of Vater. During endoscopic treatment, two main assisted methods for lithotomy, sphincterotomy and papillary balloon dilation, can result in different degrees of damage to the structure and function of the sphincter of Oddi (SO), contributing to slowing of biliary excretion, cholestasis, biliary bacterial infection, and promotion of bile duct stone recurrence. In this review, the relationship between endoscopic lithotomy and structural impairment or functional abnormality of the SO will be summarized, and their relationship with the recurrence of CBD stones will also be analyzed. Further improvement of these endoscopic methods or exploration of some novel methods, such as endoscopic endoclip papilloplasty, temporary insertion of a self-expandable metal stent, and combined application of peroral cholangioscopy, may aid in providing more appropriate treatment for patients with choledocholithiasis, repair or protect the function and structure of SO, reduce or prevent the recurrence of bile duct stones, and improve patient outcomes.

Undenatured type II collagen for knee osteoarthritis

INTRODUCTION

Knee Osteoarthritis (OA) leads to significant pain and reduced function and affects patients' overall quality of life (QoL). Conservative modalities are the first line of management, resorting to surgery only if they fail. However, these modalities have limitations, and do not address the underlying cause of knee OA. The use of nutraceuticals, including native/undenatured type II collagen (UC-2), has evolved and shown promise in the conservative management of knee OA. This article highlights the mechanism of action, and qualitatively presents the pre-clinical, clinical and on-going scientific literature exploring the safety and efficacy of UC-2 for the management of knee OA.

METHODS

A search was performed using multiple databases (PubMed, Web of Science, Embase and Scopus) employing terms for UC-2 and Knee OA for articles published in English language, while adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. All pre-clinical and clinical studies utilizing UC-2 for knee OA were included. Studies not using UC-2 alone or not focusing on the management of knee OA were excluded.

RESULTS

Twelve studies (3 pre-clinical studies, 8 clinical studies and 1 study with both pre-clinical and clinical component) met our pre-defined search and inclusion criteria, and were included in this review.

DISCUSSION

UC-2 acts via a specific immune mediated mechanism, known as oral tolerance, which can lead to reduced inflammation and enhanced cartilage repair in the knee joint. In addition, administration of UC-2 (40 mg daily) is safe and efficacious in the short- and mid-term, reducing inflammation and pain, and improving function, range of motion (ROM) and overall QoL. Nonetheless, more adequately powered, prospective, multi-center, non-randomized and randomized controlled trials with longer follow-up are warranted to establish the long-term efficacy of UC-2 in knee OA patients and justify its routine clinical use.

L3-SMI as a predictor of overall survival in oesophageal cancer patients receiving PD-1 inhibitors combined with chemotherapy

BACKGROUND

Programmed death ligand-1 (PD-1), as an immunotherapy target, has been increasingly used in tumour therapies. But as reactions and outcomes to PD-1 inhibitors combined with chemotherapy vary individually, it is primarily important to identify an ideal indicator for predicting the therapeutic effectiveness in individual patients. Oesophageal cancer (EC) patients often have difficulty eating due to tumour blockage of the oesophagus, leading to malnutrition and muscle loss. Sarcopenia is one of the influencing factors for poor prognosis in tumour patients, but its role in PD-1 inhibitors combined with chemotherapy of EC patients is not fully clarified. In this study, we aimed to explore the prognostic significance of Sarcopenia measured by CT in EC patients treated with PD-1 antibody combined with chemotherapy.

METHODS

The third lumbar skeletal muscle mass index (L3-SMI) was obtained from 83 EC patients before and 3 months after administration of PD-1 inhibitors combined with chemotherapy using conventional CT scans.

RESULTS

Baseline L3-SMI and 3-month L3-SMI values were found not suitable for predicting the overall survival (OS) of EC patients (p = 0.32 & p = 0.055). Longitudinal change in L3-SMI (ΔL3-SMI) during PD-1 inhibitors combined with chemotherapy was identified as a relevant marker of OS in univariable analysis (HR: 0.98, 95% CI: 0.96-1.00, p = 0.042) and multivariable analysis (HR: 0.96, 95% CI: 0.93-0.99, p = 0.02). L3-SMI-positive patients generally had better OS (p = 0.041).

CONCLUSION

Excessive muscle loss rather than muscle loss before and after administration of PD-1 inhibitors combined with chemotherapy is an important prognostic factor for therapeutic outcomes and OS in EC patients.

Analyzing factors influencing hospitalization costs for five common cancers in China using neural network models

BACKGROUND

Malignant tumors are a major global health crisis, causing 25% of deaths in China, with lung, liver, thyroid, breast, and colon cancers being the most common. Understanding the factors influencing hospitalization costs for these cancers is crucial for public health and economics. This study aimed to identify key cost factors and develop a neural network model for predicting hospitalization costs, thereby providing tools to ease the financial burden on patients and healthcare systems.

METHODS

Data on hospitalization costs for 30,893 cancer patients from secondary or higher-level hospitals in Zhuhai, Guangdong Province, between 2017 and 2022, were analyzed. Neural network classification and feature importance analysis were used to determine the main factors influencing costs and to develop predictive models. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC), with a 95% confidence interval (CI) calculated for the AUROC value.

RESULTS

The key factors influencing hospitalization costs for lung cancer are metastasis and malignant solid tumor (MST), with correlation coefficients of 0.126 and 0.086, respectively, both showing statistical significance (p < 0.05). For colon cancer, the key factors influencing hospitalization costs are mortality and coronary disease (CD), with correlation coefficients of 0.092 and 0.090, respectively, both demonstrating statistical significance (p < 0.05). The AUROC value for the lung cancer model is 0.9078 (95% CI = 0.8975-0.9186), and the AUROC value for the colon cancer model is 0.9017 (95% CI = 0.8848-0.9196).

CONCLUSION

This study confirmed the strong clinical applicability of the neural network predictive model in analyzing hospitalization costs for lung and colon cancer and revealed the factors that influence hospitalization costs for these cancers.

Electroacupuncture versus sham for insomnia in patients undergoing maintenance hemodialysis: study protocol for a pilot randomized controlled trial

BACKGROUND

Insomnia causes severe health problems and poor quality of life in patients with end-stage renal disease (ESRD) undergoing maintenance hemodialysis (MHD). Conventional therapies are limited due to the poor availability and opaque evidence, and electroacupuncture (EA) is considered an alternative for improving insomnia in patients with ESRD undergoing MHD.

METHODS

This is a study protocol for a pilot randomized, sham-controlled, single-center, clinical trial. A total of 60 patients with insomnia in ESRD undergoing MHD will be randomly assigned to treatment group (EA, 3 sessions per week for 4 weeks), or sham group (sham EA, 3 sessions per week for 4 weeks) in a 1:1 ratio. Participants will complete the trial by visiting the research center at Week 8 for a follow-up assessment. The primary outcome is the response rate: the proportion of patients achieving a minimal clinically important difference, which is defined as ≥7 points on insomnia severity index (ISI) at Week 4 compared with baseline. Secondary outcomes include sleep diary, ISI, pittsburgh sleep quality index (PSQI), short form health survey-12 (SF-12), fatigue severity scale (FSS), 24-Hour ambulatory blood pressure, and plasma levels of C-reactive protein (CRP) and D-Dimer.

DISCUSSION

This is the first standardized protocol investigating the efficacy and safety of EA for patients with ESRD undergoing MHD. This trial may provide evidence for clinical application of EA for patients with ESRD undergoing MHD.

TRIAL REGISTRATION

Chinese Clinical Trial Registry (registered number: ChiCTR2300071814).