Which approach of total hip arthroplasty is the best efficacy and least complication?

BACKGROUND Total hip arthroplasty is as an effective intervention to relieve pain and improve hip function.Approaches of the hip have been exhaustively explored about pros and cons.The efficacy and the complications of hip approaches remains inconclusive.This study conducted an umbrella review to systematically appraise previous meta-analysis(MAs)including conventional posterior approach(PA),and minimally invasive surgeries as the lateral approach(LA),direct anterior approach(DAA),2-incisions method,mini-lateral approach and the newest technique direct superior approach(DSA)or supercapsular percutaneouslyassisted total hip(SuperPath).AIM To compare the efficacy and complications of hip approaches that have been published in all MAs and randomized controlled trials(RCTs).METHODS MAs were identified from MEDLINE and Scopus from inception until 2023.RCTs were then updated from the latest MA to September 2023.This study included studies which compared hip approaches and reported at least one outcome such as Harris Hip Score(HHS),dislocation,intra-operative fracture,wound compliData were independently selected,extracted and assessed by two reviewers.Network MA and cluster rank and surface under the cumulative ranking curve(SUCRA)were estimated for treatment efficacy and safety.RESULTS Finally,twenty-eight MAs(40 RCTs),and 13 RCTs were retrieved.In total 47 RCTs were included for reanalysis.The results of corrected covered area showed high degree(13.80%).Among 47 RCTs,most of the studies were low risk of bias in part of random process and outcome reporting,while other domains were medium to high risk of bias.DAA significantly provided higher HHS at three months than PA[pooled unstandardized mean difference(USMD):3.49,95%confidence interval(CI):0.98,6.00 with SUCRA:85.9],followed by DSA/SuperPath(USMD:1.57,95%CI:-1.55,4.69 with SUCRA:57.6).All approaches had indifferent dislocation and intraoperative fracture rates.SUCRA comparing early functional outcome and composite complications(dislocation,intra-operative fracture,wound complication,and nerve injury)found DAA was the best approach followed by DSA/SuperPath.CONCLUSION DSA/SuperPath had better earlier functional outcome than PA,but still could not overcome the result of DAA.This technique might be the other preferred option with acceptable complications.

Ventricular Arrhythmia in the Fontan Circulation:Prevalence,Risk Factors and Clinical Implications

Objective:Sudden cardiac death(SCD)and malignant ventricular arrhythmia(VA)are increasingly recognized as important issues for people living with a Fontan circulation,but data are lacking.We sought to characterize the cohort who had sudden cardiac death,most likely related to VA and/or documented VA in the Australia and New Zealand Fontan Registry including risk factors and clinical outcomes.Methods:A retrospective cohort study was performed.Inclusion criteria were documented non-sustained ventricular tachycardia,sustained ventricular tachycardia,ventricular fibrillation,resuscitated cardiac arrest or SCD>30 days post-Fontan completion.Results:Of 1611 patients,20(1.2%)had VA;14(1.0%)had VA without SCD and 6(<1%)had SCD(6%of all deaths recorded in Registry;5 of those had documented VA at the time of arrest and 1 was presumed to be VA-associated).The median age at first VA was 20.5(14–32)years,10(50%)were females,and the median age at Fontan operation was 8(4–17)years.On univariable analysis,hypoplastic left heart syndrome(p=0.03)and older age Fontan operation(p<0.001)were associated with VA.Earlier Fontan era(p<0.003),atriopulmonary Fontan(p<0.001),pre-Fontan atrioventricular valve repair(p=0.013)pre-or post-Fontan atrial arrhythmia(p=0.010)were associated with SCD.Patients with VA had a 3 times higher risk of death or heart transplant(HR 3.27(1.19,8.98),p=0.02).Conclusions:A proportion of people living with a Fontan circulation have malignant VA.Routine VA screening in this cohort is essential.More data are needed to aid risk stratification.

Patterns of kidney diseases diagnosed by kidney biopsy and the impact of the COVID-19 pandemic in Yogyakarta,Indonesia:A single-center study

BACKGROUND Glomerular diseases rank third among the causes of chronic kidney disease worldwide and in Indonesia,and its burden continues to increase,especially regarding the sociodemographic index.Kidney biopsy remains the gold standard for the diagnosis and classification of glomerular diseases.It is crucial for developing treatment plans,determining the degree of histologic changes,and identifying disease relapse.AIM To describe the patterns of biopsy-proven kidney diseases in adult patients.METHODS We retrospectively reviewed the demographic,histopathologic,clinical,and laboratory data of 75 adult patients with biopsy-proven kidney diseases at our institution recorded from 2017 to 2022.RESULTS Among the patients,43(57.3%)were females,and the mean age was 31.52 years±11.70 years.The most common histopathologies were lupus nephritis(LN)(33.3%),minimal change disease(MCD)(26.7%),and focal segmental glomerulosclerosis(10.7%).LN(41.7%)was frequently diagnosed in women and MCD(28.1%)in men.The most common cause of nephritic syndrome was LN(36.7%)and of nephrotic syndrome was MCD(40%).CONCLUSION Different kidney disease patterns were observed in different sexes,age categories,clinical syndromes,and biopsy dates relative to the coronavirus disease 2019 pandemic.

Ischemic colitis after enema administration: Incidence, timing, and clinical features

BACKGROUND Enema administration is a common procedure in the emergency department(ED). However, several published case reports on enema-related ischemic colitis(IC) have raised the concerns regarding the safety of enema agents. Nevertheless, information on its true incidence and characteristics are still lacking.AIM To investigate the incidence, timing, and risk factors of IC in patients receiving enema.METHODS We consecutively collected the data of all adult patients receiving various enema administrations in the ED from January 2010 to December 2018 and identified patients confirmed with IC following enema. Of 8320 patients receiving glycerin enema, 19 diagnosed of IC were compared with an age-matched control group without IC.RESULTS The incidence of IC was 0.23% among 8320 patients receiving glycerin enema;however, there was no occurrence of IC among those who used other enema agents. The mean age ± standard deviation(SD) of patients with glycerin enemarelated IC was 70.2 ± 11.7. The mean time interval ± SD from glycerin enema administration to IC occurrence was 5.5 h ± 3.9 h(range 1-15 h). Of the 19 glycerin enema-related IC cases, 15(79.0%) were diagnosed within 8 h. The independent risk factors for glycerin-related IC were the constipation score [Odds ratio(OR), 2.0;95% confidence interval(CI): 1.1-3.5, P = 0.017] and leukocytosis(OR, 4.5;95%CI: 1.4-14.7, P = 0.012).CONCLUSION The incidence of glycerin enema-related IC was 0.23% and occurred mostly in the elderly in the early period following enema administration. Glycerin enemarelated IC was associated with the constipation score and leukocytosis.

External use of mirabilite to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis in children:A multicenter randomized controlled trial

BACKGROUND Acute pancreatitis is the most common complication of endoscopic retrograde cholangiopancreatography(ERCP).Currently,there is no suitable treatment for post-ERCP pancreatitis(PEP)prophylaxis.Few studies have prospectively evaluated interventions to prevent PEP in children.AIM To assess the efficacy and safety of the external use of mirabilite to prevent PEP in children.METHODS This multicenter,randomized controlled clinical trial enrolled patients with chronic pancreatitis scheduled for ERCP according to eligibility criteria.Patients were randomly divided into the external use of mirabilite group(external use of mirabilite in a bag on the projected abdominal area within 30 min before ERCP)and blank group.The primary outcome was the incidence of PEP.The secondary outcomes included the severity of PEP,abdominal pain scores,levels of serum inflammatory markers[tumor necrosis factor-alpha(TNF-α)and serum interleukin-10(IL-10)],and intestinal barrier function markers[diamine oxidase(DAO),D-lactic acid,and endotoxin].Additionally,the side effects of topical mirabilite were investigated.RESULTSA total of 234 patients were enrolled,including 117 in the external use of mirabilite group and theother 117 in the blank group.The pre-procedure and procedure-related factors were notsignificantly different between the two groups.The incidence of PEP in the external use ofmirabilite group was significantly lower than that in the blank group(7.7%vs 26.5%,P<0.001).The severity of PEP decreased in the mirabilite group(P=0.023).At 24 h after the procedure,thevisual analog scale score in the external use of mirabilite group was lower than that in the blankgroup(P=0.001).Compared with those in the blank group,the TNF-αexpressions weresignificantly lower and the IL-10 expressions were significantly higher at 24 h after the procedurein the external use of mirabilite group(P=0.032 and P=0.011,respectively).There were nosignificant differences in serum DAO,D-lactic acid,and endotoxin levels before and after ERCPbetween the two groups.No adverse effects of mirabilite were observed.CONCLUSIONExternal use of mirabilite reduced the PEP occurrence.It significantly alleviated post-proceduralpain and reduced inflammatory response.Our results favor the external use of mirabilite toprevent PEP in children.

Exclusive breastfeeding greater than 50%, success of education in a university hospital in Bogotá: Case-control study

BACKGROUND Maintenance rates of exclusive breastfeeding(EBF)worldwide are low,thus,one of the objectives of the summary of policies on breastfeeding(BF)in world nutrition goals for 2025 are that at least 50%of infants under six months of age receive EBF that year.The Objective of this study is to document the rates of EBF in children born in San Ignacio University Hospital(HUSI)and identify factors associated with maintenance.AIM To document the percentages of EBF in those that were born at HUSI and identify factors associated to their maintenance.METHODS This is a study of cases and controls in an analytic,retrospective cohort that took children born alive between January 2016 and January 2019 at HUSI located in the city of Bogotá,Colombia.RESULTS Receiving information about BF at HUSI was able to maintain EBF up until 4 mo(OR=1.65;95%CI:1.02-2.66).The presence of gynecologic and obstetric comorbidities(OR=0.32;95%CI:0.12-0.83),having mastitis(OR=0.56;95%CI:0.33-0.94),and receiving information from mass media(OR=0.52;95%CI:0.31-0.84)are factors associated with not maintaining EBF.CONCLUSION Receiving education at a Women-and Child-Friendly Institution was the only significant factor to achieve EBF until 4 mo,with a frequency greater than the one reported in the country,which matches multiple studies where counseling and individualized support on BF achieve this purpose.Knowledge about BF and early detection of obstetric/gynecologic complications must be strengthened among the healthcare staff in charge of mothers during post-partum.Additionally,strategies must be promoted to continue BF such as creating milk banks with the objective of increasing BF rates even when mothers return to work.

Changes on Stroke Burden Attributable to Ambient Fine Particulate Matter in China

Objective In recent decades,China has implemented a series of policies to address air pollution.We aimed to assess the health effects of these policies on stroke burden attributable to ambient fine particulate matter(PM_(2.5)).Methods Joinpoint regression was applied to explore the temporal tendency of stroke burden based on data from the Global Burden of Disease 2019 study.Results The age-standardized rates of disability-adjusted life year(DALY)for stroke attributable to ambient PM2.5 in China,increased dramatically during 1990-2012,subsequently decreased at an annual percentage change(APC)of-1.98[95% confidence interval(CI):-2.26,-1.71]during 2012-2019.For ischemic stroke(IS),the age-standardized DALY rates doubled from 1990 to 2014,and decreased at an APC of-0.83(95%CI:-1.33,-0.33)during 2014-2019.Intracerebral hemorrhage(ICH)showed a substantial increase in age-standardized DALY rates from 1990 to 2003,followed by declining trends,with APCs of-1.46(95%CI:-2.74,-0.16)during 2003-2007 and-3.33(95%CI:-3.61,-3.06)during 2011-2019,respectively.Conversely,the age-standardized DALY rates for subarachnoid hemorrhage(SAH)generally declined during 1990-2019.Conclusion Our results clarified the dynamic changes of the ambient PM_(2.5)-attributable stroke burden in China during 1990-2019,highlighting the health effects of air quality improvement policies.

Use of a clinical pathway in laparoscopic gastrectomy for gastric cancer

AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.METHODS: A standardized clinical pathway for gastric cancer(GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1%(n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 8 3. 8 8 %(n = 1 7 4 0) a n d 8 4. 3 6 %(n = 2 0 7 1), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications(n = 463, 9.7%) and the need for patient observation(n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54(1.1%). In a multivariate analysis, the intraoperative events(OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male(OR = 1.459), advanced age(OR = 1.727), total gastrectomy(OR = 2.444), combined operation(OR = 1.731), and ASA score(OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.

Totally laparoscopic total gastrectomy using the modified overlap method and conventional open total gastrectomy:A comparative study

BACKGROUND Although several methods of totally laparoscopic total gastrectomy(TLTG)have been reported.The best anastomosis technique for LTG has not been established.AIM To investigate the effectiveness and surgical outcomes of TLTG using the modified overlap method compared with open total gastrectomy(OTG)using the circular stapled method.METHODS We performed 151 and 131 surgeries using TLTG with the modified overlap method and OTG for gastric cancer between March 2012 and December 2018.Surgical and oncological outcomes were compared between groups using propensity score matching.In addition,we analyzed the risk factors associated with postoperative complications.RESULTS Patients who underwent TLTG were discharged earlier than those who underwent OTG[TLTG(9.62±5.32)vs OTG(13.51±10.67),P<0.05].Time to first flatus and soft diet were significantly shorter in TLTG group.The pain scores at all postoperative periods and administration of opioids were significantly lower in the TLTG group than in the OTG group.No significant difference in early,late and esophagojejunostomy(EJ)-related complications or 5-year recurrence free and overall survival between groups.Multivariate analysis demonstrated that body mass index[odds ratio(OR),1.824;95%confidence interval(CI):1.029-3.234,P=0.040]and American Society of Anaesthesiologists(ASA)score(OR,3.154;95%CI:1.084-9.174,P=0.035)were independent risk factors of early complications.Additionally,age was associated with≥3 Clavien-Dindo classification and EJrelated complications.CONCLUSION Although TLTG with the modified overlap method showed similar complication rate and oncological outcome with OTG,it yields lower pain score,earlier bowel recovery,and discharge.Surgeons should perform total gastrectomy cautiously and delicately in patients with obesity,high ASA scores,and older ages.

Distribution and changes in hepatitis C virus genotype in China from 2010 to 2020

BACKGROUND Hepatitis C virus(HCV)causes a large number of infections worldwide.New infections seem to be increasing according to a report of the World Health Organization in 2015.Although direct-acting antivirals are quite effective for most genotypes of the HCV,some genotypes fail to respond.Therefore,the trend of genotype distribution is vital to better control the development of this infection.AIM To analyze the distribution and trends of the HCV genotype before and after the emergence of direct-acting antivirals in China.METHODS We searched all literature published in five electronic databases-China National Knowledge Infrastructure,Wan Fang Data,VIP Chinese Journal Database,Chinese Biomedical Literature Service System,and PubMed-from January 1,2010 to December 31,2020.The search strategy combined medical subject headings and free-text terms,including“hepatitis C virus”or“HCV”and“genotype”or“subtype”and“China”or“Chinese”.Additional relevant articles were searched by manual selection.Data were extracted to build a database.All of the data were totaled according to regions,periods,routes of transmission,and sexes.The percentages in various stratifications were calculated.RESULTS There were 76110 samples from 30 provinces included in the study.Genotype 1(G1)accounted for 58.2%of cases nationwide,followed by G2,G6,G3b,G3a,unclassified and mixed infections(17.5%,7.8%,6.4%,4.9%,1.8%,and 1.2%,respectively).The constitution of genotype varied among different regions,with G6 and G3b being more common in the south and southwest,respectively(28.1%,15.4%).The past ten years have witnessed a decrease in G1 and G2 and an increase in G3 and G6 in almost all regions.The drug-use population had the most abundant genotypes,with G6 ranking first(33.3%),followed by G1 and G3b(23.4%,18.5%).CONCLUSION G3 and G6 pose a new challenge for HCV infection.This study revealed the distribution of HCV genotypes in China over the past 10 years,providing information for HCV management strategies.

Operative vs non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials

AIM: To perform a systematic review and meta-analysis comparing operative vs non-operative treatment of displaced proximal humerus fractures in elderly patients.METHODS: A systematic literature search was performed using EMBASE and MEDLINE through the OVID interface,CINAHL,the Cochrane Central Register of Controlled Trials(CENTRAL),Proquest,Web of Science,SAE digital library,and Transportation Research Board's TRID database.Searches of conference proceedings were also conducted.All available randomized controlled trials comparing operative vs non-operative management of displaced three- and four-part proximal humerus fractures in elderly patients were included.The primary outcomes measures included physical function,pain,health related quality of life,mortality,and the re-operation rate.RESULTS: Six randomized controlled trials(n = 287) were included.There was no statistically significant difference in function(MD = 1.72,95%CI:-2.90-6.34,P = 0.47),as measured by the Constant score,between the operative and the non-operative treatment groups.There was no statistically significance difference insecondary outcomes of health related quality of life(standardized MD = 0.27,95%CI:-0.05-0.59,P = 0.09),and mortality(relative risk 1.29,95%CI: 0.50-3.35,P = 0.60).Operative treatment had a statistically significant higher re-operation rate(relative risk 4.09,95%CI: 1.50-11.15,P = 0.006),and statistically significant decreased pain(MD = 1.26,95%CI: 0.02-2.49,P = 0.05).CONCLUSION: There is moderate quality evidence to suggest that there is no difference in functional outcomes between the two treatments.Further high quality randomized controlled trials are required to determine if certain subgroup populations benefit from surgical management.

Association of visceral obesity and early colorectal neoplasia

AIM:To examine whether visceral adipose tissue(VAT)serves as a risk factor for colorectal adenoma-early colorectal cancer(CRC)sequence.METHODS:A retrospective case-control study was conducted with 153 patients with stageⅠCRC,age/sex-matched 554 patients with colorectal adenoma and557 normal controls.All subjects underwent various laboratory tests,abdominal fat computed tomography(CT),and colonoscopy.VAT was defined as an intraabdominal adipose tissue area measured by CT scan.Adipose tissue area was measured at the level of the umbilicus from CT scan.We used the lowest quartile of VAT and subcutaneous adipose tissue area as a reference group.RESULTS:The body mass index(BMI),total cholesterol,fasting glucose and VAT areas were significantly different among normal,adenoma and CRC groups.The VAT area was 120.6±49.0 cm2in normal controls,130.6±58.4 cm2in adenoma group and 117.6±51.6cm2in CRC group(P=0.002).In univariate analysis,increased BMI was a risk factor for CRC compared to control(P=0.025).However,VAT area was not a risk factor for CRC compared to control.In multivariate analysis that adjusted for smoking,alcohol consumption and subcutaneous adipose tissue area,VAT area was inversely related to CRC,compared to the adenoma(OR=0.53,95%CI:0.31-0.92,highest quartile vs lowest quartile).CONCLUSION:Our study shows that visceral obesity is not a risk factor for early CRC.Visceral obesity might influence the normal-adenoma sequence but not the adenoma-early carcinoma sequence.

Long-term bone and lung consequences associated with hospital-acquired severe acute respiratory syndrome:a 15-year follow-up from a prospective cohort study

The most severe sequelae after rehabilitation from SARS are femoral head necrosis and pulmonary fibrosis. We performed a 15-year follow-up on the lung and bone conditions of SARS patients. We evaluated the recovery from lung damage and femoral head necrosis in an observational cohort study of SARS patients using pulmonary CT scans, hip joint MRI examinations, pulmonary function tests and hip joint function questionnaires. Eighty medical staff contracted SARS in 2003. Two patients died of SARS, and78 were enrolled in this study from August 2003 to March 2018. Seventy-one patients completed the 15-year follow-up. The percentage of pulmonary lesions on CT scans diminished from 2003(9.40 ± 7.83)% to 2004(3.20 ± 4.78)%(P < 0.001) and remained stable thereafter until 2018(4.60 ± 6.37)%. Between 2006 and 2018, the proportion of patients with interstitial changes who had improved pulmonary function was lower than that of patients without lesions, as demonstrated by the one-second ratio(FEV1/FVC%, t = 2.21, P = 0.04) and mid-flow of maximum expiration(FEF25%–75%, t = 2.76, P = 0.01). The volume of femoral head necrosis decreased significantly from 2003(38.83 ± 21.01)% to 2005(30.38 ± 20.23)%(P = 0.000 2), then declined slowly from 2005 to 2013(28.99 ± 20.59)% and plateaued until 2018(25.52 ± 15.51)%. Pulmonary interstitial damage and functional decline caused by SARS mostly recovered, with a greater extent of recovery within 2 years after rehabilitation. Femoral head necrosis induced by large doses of steroid pulse therapy in SARS patients was not progressive and was partially reversible.

Cost effectiveness analysis of population-based serology screening and ^(13)C-Urea breath test for Helicobacter pylori to prevent gastric cancer:A markov model

AIM:To compare the costs and effectiveness of no screening and no eradication therapy, the population- based Helicobacter pylori (H pylori) serology screening with eradication therapy and 13C-Urea breath test (UBT) with eradication therapy. METHODS:A Markov model simulation was carried out in all 237 900 Chinese males with age between 35 and 44 from the perspective of the public healthcare provider in Singapore. The main outcome measures were the costs, number of gastric cancer cases prevented, life years saved, and quality-adjusted life years (QALYs) gained from screening age to death. The uncertainty surrounding the cost-effectiveness ratio was addressed by one-way sensitivity analyses. RESULTS:Compared to no screening, the incremental cost-effectiveness ratio (ICER) was $16 166 per life year saved or $13 571 per QALY gained for the serology screening, and $38 792 per life year saved and $32 525 per QALY gained for the UBT. The ICER was $477 079 per life year saved or $390 337 per QALY gained for the UBT compared to the serology screening. The cost- effectiveness of serology screening over the UBT was robust to most parameters in the model. CONCLUSION:The population-based serologyscreening for H pylori was more cost-effective than the UBT in prevention of gastric cancer in Singapore Chinese males.

Early results of circularity and centration of capsulotomy prepared by three different methods

AIM:To compare the difference of capsulotomy produced by precision pulse capsulotomy(PPC),manual(M-CCC),and femtosecond laser assisted capsulotomy(FLAC)in relation to intraocular lens(IOL)centration,circularity and its effect on visual outcomes.METHODS:Prospective,non-randomized comparative study conducted at LV Prasad Eye Institute,Hyderabad,India.Sixty eyes of 52 patients were grouped into 3(FLAC,PPC and M-CCC)based on capsulotomy techniques used.Twenty consecutive eyes with uneventful phacoemulsification and with no comorbidities affecting the capsulotomy or visual outcome were included in each group.The main outcome measure was IOL centration in relation to capsulotomy and pupil.Secondary outcome measures were post-operative visual acuity,manifest refraction and aberration profile between groups.RESULTS:At 5 wk the visual,refractive outcomes and endothelial cell density were comparable between the 3 groups.The median circularity index of FLAC was statistically significantly different to M-CCC or PPC(1-10)groups(P<0.01)but PPC(11-20)was comparable to FLAC.Decentration of IOL center in relation to capsulotomy was seen only between the PPC(1-10)group and FLAC group(P=0.02).The IOL was well centered in relation to the pupil in all the groups(P=0.46).The quality of vision parameters like the higher order aberrations,spherical aberration,coma,trefoil,modular transfer function,and Strehl ratio were comparable between the groups.CONCLUSION:Our study shows that despite differences in the morphology of capsulotomy produced by PPC,M-CCC,FLAC a well-centered IOL can be achieved.The measured capsular morphology parameters do not affect visual outcomes.

Association between the levels of prostaglandin E2 in tears and severity of dry eye

AIM: To investigate the relationship between the levels of prostaglandin E2(PGE2) in tears and dry eye disease severity based on both clinical symptoms and signs.METHODS: Tear samples were collected from 36 non-Sj?gren syndrome dry eye patients(10 males and 26 females, mean age 50.11±11.17 y). All participants completed the Ocular Surface Disease Index(OSDI) questionnaire and underwent a detailed ophthalmic examination including, tear film breakup time(TBUT), ocular surface fluorescein staining, Schirmer I test, and meibomian gland assessment. The level of PGE2 in tears was measured using enzyme-linked immunosorbent assay(ELISA). The independent associations between tear PGE2 levels and other variables including demographics, OSDI scores, TBUT, Schirmer scores, ocular surface staining scores, and stage of meibomian gland dysfunction(MGD) were evaluated using linear regression analysis. RESULTS: The mean PGE2 level in tears of dry eye patients was 537.85±234.02 pg/mL. The tear PGE2 levels significantly positively correlated with OSDI scores(R=0.608, P<0.001), however, they did not significantly associate with TBUT(R=0.153, P=0.373), Schirmer scores(R=-0.098, P=0.570), ocular surface staining scores(R=0.282, P=0.095), and stage of MGD(R=-0.107, P=0.535).Male sex was significantly negatively correlated with tear PGE2 levels.CONCLUSION: The levels of PGE2 in tears are positively correlated with dry eye symptoms. However, no significant association was found between tear PGE2 levels and the results of other common dry eye diagnostic tests.

Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn’s disease

BACKGROUND Acute severe lower gastrointestinal bleeding(LGIB)is an uncommon but challenging complication of Crohn’s disease(CD).AIM To identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.METHODS A retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center,a tertiary university hospital in Korea.Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB.A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD.RESULTS Multivariable Cox regression analysis revealed that early use of thiopurines[hazard ratio(HR):0.23,95%confidence interval(CI):0.12-0.48;P<0.001]and female sex(HR:0.51,95%CI:0.27-0.94;P=0.031)were significantly associated with a lower risk of acute severe LGIB.The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups(P=0.139 and P=0.769,respectively).The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group(22.1/100 vs 13.2/100 patient-years;P=0.012).However,if hospitalizations due to bleeding episodes were excluded from the analysis,the hospitalization rate was not significantly different between the bleeding group and the matched nonbleeding group(14.5/100 vs 13.2/100 patient-years;P=0.631).CONCLUSION Early use of thiopurines may reduce the risk of acute severe LGIB.History of acute severe LGIB may not have a significant prognostic value in patients with CD.

Temporal trends in the misdiagnosis rates between Crohn's disease and intestinal tuberculosis

AIM To investigate the temporal trends in the misdiagnosis rate between Crohn's disease(CD) and intestinal tuberculosis(ITB) in South Korea. METHODS We retrospectively reviewed the medical records of patients managed for CD or ITB at Asan Medical Center, a tertiary referral hospital, Seoul, Korea between 1996 and 2014. The temporal trends in the misdiagnosis rates between the two diseases were analyzed. The demographic and clinical characteristics were compared between CD patients who were initially misdiagnosed as ITB(final CD group) and vice versa(final ITB group). Final diagnostic criteria for ITB and medication for CD before definite diagnosis of TB were also analyzed in final ITB group.RESULTS In total, 2760 patients were managed for CD and 772 patients for ITB between 1996 and 2014. As well, 494 of the 2760 CD patients(17.9%) were initially misdiagnosed as ITB and 83 of the 772 ITB patients(10.8%) as CD. The temporal trend in misdiagnosing CD as ITB showed a decrease(OR = 0.89, 95%CI: 0.87-0.91, P < 0.001), whereas the temporal trend in misdiagnosing ITB as CD showed an increase(OR = 1.06, 95%CI: 1.01-1.11, P = 0.013). Age at diagnosis, presenting symptoms, and proportion of patients with active/past perianal fistula and active/inactive pulmonary tuberculosis(TB) were significantly different between final CD group and final ITB group. Forty patients(48.2%) in final ITB group were diagnosed by favorable response to empirical anti-TB treatment. Seventeen patients(20.5%) in final ITB group had inappropriately received corticosteroids and/or thiopurines due to misdiagnosis as CD. However, there were no mortalities in both groups. CONCLUSION Cases of CD misdiagnosed as ITB have been decreasing, whereas cases of ITB misdiagnosed as CD have been increasing over the past two decades.

Short-term and long-term outcomes of laparoscopic vs open ileocolic resection in patients with Crohn's disease: Propensityscore matching analysis

BACKGROUND Laparoscopic ileocolic resection(LICR)is the preferred surgical approach for primary ileocolic Crohn’s disease(CD)because it has greater recovery benefits than open ICR(OICR).AIM To compare short-and long-term outcomes in patients who underwent LICR and OICR.METHODS Patients who underwent ICR for primary CD from 2006 to 2017 at a single tertiary center specializing in CD were included.Patients who underwent LICR and OICR were subjected to propensity-score matching analysis.Patients were propensityscore matched 1:1 by factors potentially associated with 30-d perioperative morbidity.These included demographic characteristics and disease-and treatment-related variables.Factors were compared using univariate and multivariate analyses.Long-term surgical recurrence-free survival(SRFS)in the two groups was determined by the Kaplan-Meier method and compared by the log-rank test.RESULTS During the study period,348 patients underwent ICR,211 by the open approach and 137 laparoscopically.Propensity-score matching yielded 102 pairs of patients.The rate of postoperative complication was significantly lower(14%versus 32%,P=0.003),postoperative hospital stay significantly shorter(8 d versus 13 d,P=0.003),and postoperative pain on day 7 significantly lower(1.4 versus 2.3,P<0.001)in propensity-score matched patients who underwent LICR than in those who underwent OICR.Multivariate analysis showed that postoperative complications were significantly associated with preoperative treatment with biologics[odds ratio(OR):3.14,P=0.01]and an open approach to surgery(OR:2.86,P=0.005).The 5-and 10-year SRFS rates in the matched pairs were 92.9%and 83.3%,respectively,with SRFS rates not differing significantly between the OICR and LICR groups.The performance of additional procedures was an independent risk factor for surgical recurrence[hazard ratio(HR):3.28,P=0.02].CONCLUSION LICR yielded better short-term outcomes and postoperative recovery than OICR,with no differences in long-term outcomes.LICR may provide greater benefits in selected patients with primary CD.

Association between Caregiver Quality of Life and the Care Provided to Persons with Alzheimer’s Disease: Systematic Review

We reviewed the literature to examine whether an association exists between the quality of life (QoL) of primary informal Alzheimer's disease (AD) caregivers and the level and quality of care that these caregivers provide to their loved ones with AD. We obtained studies focusing on the care that these caregivers provide for their family members with AD. Our outcome of interest was level or quality of care and the independent variable was caregiver QoL. We extracted data in tabular form and used a narrative synthesis approach to describe our findings. Only one relevant study was included in the review. Overall, the evidence was equivocal regarding the associations between caregiver QoL and the level/quality of care in AD.