The association between epidural labour analgesia and postpartum depression: a randomised controlled trial.

There is conflicting evidence regarding the association between epidural labour analgesia and risk of postpartum depression. Most previous studies were observational trials with limited ability to account for confounders. We aimed to determine if epidural analgesia was associated with a significant change in the incidence of postpartum depression in this randomised controlled trial. We enrolled women aged 21-50 years old with a singleton fetus ≥ 36 weeks gestation. Patients were advised regarding available labour analgesic modalities during enrolment (epidural block; intramuscular pethidine; nitrous oxide; or intravenous remifentanil). On request for analgesia, patients were offered the modality that they had been allocated randomly to first. Blinded investigators recorded patient and obstetric characteristics within 24 h of delivery and assessed for postpartum depression at 6-10 weeks following delivery using the Edinburgh Postnatal Depression Scale (score ≥ 13 considered positive for postpartum depression). The modified intention-to-treat population consisted of all patients who received any form of labour analgesia, while per-protocol consisted of patients who received their randomised modality as their first form of labour analgesia. Of 881 parturients allocated randomly (epidural n = 441, non-epidural n = 440), we analysed 773 (epidural n = 389, non-epidural n = 384); 62 (15.9%) of women allocated to epidural group developed postpartum depression compared with 65 (16.9%) women allocate to the non-epidural group. There were no significant differences in the incidence of postpartum depression between the two groups (adjusted risk difference (95%CI) 1.6 (-3.0-6.3%), p = 0.49). Similar results were obtained with per-protocol analysis (adjusted risk difference (95%CI) -1.0 (-8.3-6.3%), p = 0.79). We found no significant difference in the risk of postpartum depression between patients who received epidural labour analgesia and those who utilised non-epidural analgesic modalities.

Artificial intelligence for gastroenterology: Singapore artificial intelligence for Gastroenterology Working Group Position Statement.

BACKGROUND: Successful implementation of artificial intelligence in gastroenterology and hepatology practice requires more than technology. There are ethical, legal, and social issues that need to be settled. AIM: A group consisting of AI developers (engineer), AI users (gastroenterologist, hepatologist, and surgeon) and AI regulators (ethicist and administrator) formed a Working Group to draft these Positions Statements with the objective of arousing public and professional interest and dialogue, to promote ethical considerations when implementing AI technology, to suggest to policy makers and health authorities relevant factors to take into account when approving and regulating the use of AI tools, and to engage the profession in preparing for change in clinical practice. STATEMENTS: These series of Position Statements point out the salient issues to maintain the trust between care provider and care receivers, and to legitimize the use of a non-human tool in healthcare delivery. It is based on fundamental principles such as respect, autonomy, privacy, responsibility, and justice. Enforcing the use of AI without considering these factor risk damaging the doctor-patient relationship.

AN OUTBREAK OF TETRODOTOXIN POISONING FROM CONSUMING HORSESHOE CRABS IN SABAH.

The horseshoe crab (Carcinoscorpius rotundicauda) is consumed by those residing near the coastal areas of Kota Marudu District in Malaysia, as it is considered a delicacy. During June to August, 2011 thirty cases of tetrodotoxin poisoning were reported from Kota Marudu District following ingestion of horseshoe crabs caught in Kota Marudu Bay. The purpose of this study is to describe this case series in order to determine risk factors to prevent further outbreaks. There were six confirmed and 24 probable cases of tetrodotoxin poisoning identified in the study area during the study period as diagnosed by clinical presentation and laboratory findings. Symptoms included dizziness (80%), circumoral and lingual numbness (80%), hand and feet numbness (63.3%), nausea and vomiting (30%) and weakness and difficulty in breathing (26.6%). Three cases (10%) died while 27 cases recovered. Forty-seven percent of the cases had onset of symptoms within 30 minutes of ingestion and 14% 31-60 minutes after ingestion of horseshoe crab meat. Urine samples were collected from the cases, while horseshoe crabs, cockles and sea water from the epidemic area were also taken for analysis. Tetrodotoxin was detected in the urine of six cases; the highest concentrations recorded were among the three cases who died. High tetrodotoxin concentrations were found in the hepatic cecum and eggs of the tested horseshoe crabs. Dinoflagellates were not detected in the sea water or cockle samples. Intensive health education was initiated quickly to stop other members of the Marudu Bay community from consuming the horseshoe crabs. This is the first documented epidemic of tetrodotoxin poisoning in Sabah.

A systematic review of local excision combined with chemoradiotherapy for early rectal cancer.

AIM: Local excision of early rectal cancer is a less morbid alternative to major abdominal surgery. This review evaluates the role of local excision with neoadjuvant or adjuvant chemoradiotherapy to identify a select group of patients where local excision is appropriate without significantly compromising the oncological outcome. METHOD: MEDLINE, PubMed and the Cochrane Central Register of Controlled Trials databases were searched to identify relevant articles investigating the role of local excision with adjuvant or neoadjuvant chemoradiotherapy in patients with T1/T2N0M0 disease. Eleven studies comprising 455 patients were selected. Oncological end-points included overall survival, disease-free and disease-specific survival, recurrence rates as well as perioperative morbidity and mortality. RESULTS: At a range of 30.5-115.2 months, median overall survival, disease-specific and disease-free survival were 75% (66-80.6%), 89% (75-93.3%) and 74% (64-85.2%), respectively. Median local, distant and overall recurrence rates were 10% (4.8-25%), 4.7% (4-11.8%) and 13.1% (10.7-23.5%), respectively. Mortality was 0% in all studies except one (2.9%). Most reported complications were minor and were treated conservatively. CONCLUSION: This systematic review provides data suggesting that selected patients with T1/T2N0M0 rectal cancer may undergo local excision without compromising the oncological outcome otherwise conferred by total mesorectal excision. It may be a particularly useful option in patients in whom radical surgery is contraindicated. Randomized trials comparing both management strategies to consolidate this finding may lead to a paradigm change in the management of early rectal cancer.

Postoperative bladder and sexual function in patients undergoing surgery for rectal cancer: a systematic review and meta-analysis of laparoscopic versus open resection of rectal cancer.

There have been conflicting opinions regarding the superiority of open and laparoscopic surgery in preserving bladder and sexual function after rectal cancer surgery. This systematic review and meta-analysis aims to pool the available data comparing the impact of surgical approaches on postoperative sexual and urinary function. A search of Pubmed, Medline, Cochrane and Embase was undertaken and studies from January 2000 to February 2013 were identified. We included, in our meta-analysis, both prospective and retrospective studies that compared laparoscopic surgery and open surgery for rectal cancer. A total of 876 patients undergoing rectal cancer surgery (lap n = 468, open n = 408) were examined. In men, postoperative ejaculatory function and erectile dysfunction evaluated from two studies comprising of 74 patients showed no difference between groups. The rate of overall sexual dysfunction evaluated from five studies comprising of 289 patients revealed a rate of 34 % in both the open and lap groups. Postoperative urinary function evaluated from five studies comprising of 312 patients showed no difference between groups. In women, postoperative sexual and urinary function were evaluated from five studies comprising of 321 patients. Three studies (n = 219) reported no difference in sexual function between groups. Postoperative urinary function evaluated from four studies comprising of 212 patients was found to be comparable. The available data are limited, but suggest that neither form of surgical approach be it laparoscopy or open surgery demonstrate superiority in preservation of sexual and bladder function. Further research into the technical aspects of surgery and evaluating newer minimally invasive technologies such as the robot may prove to be useful in improving functional outcomes of rectal cancer patients.

Impact of peritoneal carcinomatosis in the disease history of colorectal cancer management: a longitudinal experience of 2406 patients over two decades.

BACKGROUND: Recent therapeutic developments demand for an update of information on natural history, risk factors and prognosis of peritoneal carcinomatosis (PC) of colorectal origin. Therefore, prospective registry data should provide information about incidence, predictors and outcome. METHODS: From a prospectively expanded single-institutional database with 2406 consecutive patients with colorectal cancer (CRC), clinical, histological and survival data were analysed for independent risk factors and prognosis. Findings were then stratified to the era of treatment without chemotherapy, 5-Fluorouracil-only and contemporary systemic chemotherapy, respectively. RESULTS: Overall, 256 (10.6%) patients were diagnosed with PC thereof 141 (5.85%) with metachronous PC. Independent risk factors for the development of metachronous PC were age <62 years, N2-status, T4-status, location of the primary in the left colon or appendix. In the era of contemporary systemic chemotherapy, prognosis for PC improved only not-significantly (median survival of 17.9 months vs 7.03 months, P=0.054). CONCLUSION: Despite improvement in the overall outcome with prolonged median survival for the complete patient cohort with CRC, those patients with PC have not experienced the same benefit. In the era of contemporary systemic chemotherapy, progress in treatment resulted in only limited survival benefit. Thus, continuous efforts for further therapeutic advancements should be undertaken in these patients diagnosed with PC.

Palliative resection of the primary tumour in patients with Stage IV colorectal cancer: systematic review and meta-analysis of the early outcome after laparoscopic and open colectomy.

AIM: Resection of the primary tumour in patients with Stage IV colorectal cancer may be performed to avoid future tumour-related complications whilst on systemic treatment. We compared the safety and efficacy of laparoscopic and open colectomy in this patient group. METHOD: PubMed, MEDLINE and the Cochrane Library were searched in the English literature for studies between January 2000 and October 2012 dealing with laparoscopic resection of the primary tumour in Stage IV disease. Single-arm laparoscopic studies were systematically reviewed. Prospective and retrospective studies were included for meta-analysis. End-points include safety, complications, mortality and cancer specific outcome including 5-year and median survival. RESULTS: Eleven studies comprising 1165 patients undergoing palliative laparoscopic colectomy for Stage IV colorectal cancer were included. Five studies were comparative studies of laparoscopic and open colectomy. The former took longer (pooled mean difference (MD) = 41.52, 95% CI = 11.47-71.56, Z = 2.71, P = 0.007), but resulted in a shorter length of stay (pooled MD = -2.41, 95% CI = -3.84 to -0.99, Z = 3.32, P = 0.0009), with fewer postoperative complications (pooled odds ratio = 0.53, 95% CI = 0.32-0.87, Z = 2.51, P = 0.01) and lower estimated blood loss (pooled MD = -47.71, 95% CI = -80.00 to -15.42, Z = 2.90, P = 0.004). Median survival ranged between 11.4 and 30.1 months. CONCLUSION: Palliative colectomy performed laparoscopically is associated with a better perioperative outcome than open colectomy. Survival is dependent on the response to systemic chemotherapy.

Importance of gender in diffuse malignant peritoneal mesothelioma.

BACKGROUND: Combined therapy involving cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy has been shown to improve survival outcomes for patients with diffuse malignant peritoneal mesothelioma (DMPM). The present study aims to investigate gender as a potential prognostic factor on overall survival. PATIENTS AND METHODS: Over a period of two decades, 294 patients who underwent CRS and perioperative intraperitoneal chemotherapy were selected from a large multi-institutional registry to assess the prognostic significance of gender on overall survival. RESULTS: Female patients were shown to have a significantly improved survival outcome than male patients (P < 0.001). Staging according to a recently proposed tumor-node-metastasis categorization system was significant in both genders. Older female patients had significantly worse survival than younger female patients (P = 0.019), a finding that was absent in male patients. Female patients with low-stage disease were found to have a very favorable long-term outcome after combined treatment. CONCLUSIONS: Gender has demonstrated a significant impact on overall survival for patients with DMPM after CRS and perioperative intraperitoneal chemotherapy. An improved understanding of the role of estrogen in the pathogenesis of DMPM may improve the prognostication of patients and determine the role of adjuvant hormonal treatment in the future.

Hyoscine butylbromide administered at the cecum increases polyp detection: a randomized double-blind placebo-controlled trial.

BACKGROUND AND STUDY AIMS: Removal of colonic polyps prevents progression of colonic neoplasia. Miss rates of polyps range from 5 % to 32 %. The effect of colonic contractility on polyp detection has not been studied adequately. Hyoscine butylbromide results in colonic spasmolysis and may improve polyp detection. PATIENTS AND METHODS: Patients undergoing colonoscopy for standard indications were included and randomized to receive either 20  mg hyoscine butylbromide or placebo at cecal intubation. Operators were blind to the intervention. Data on indication, preparation, sedation, colonoscope type, times of insertion/withdrawal, polyps, and failure were recorded. The primary end point was the number of polyps detected per patient. Secondary endpoints were adenoma detection rate and polyp detection rate. RESULTS: A total of 303 patients received hyoscine butylbromide and 298 received placebo. More polyps per patient were identified in the hyoscine group than in the placebo group (0.91 vs. 0.70; P = 0.044). Adenoma detection rate and polyp detection rate were higher in the hyoscine arm but not significantly different (27.1 % vs. 21.8 % [P = 0.13] and 43.6 % vs. 36.6 % [P = 0.08], respectively). After adjusting for confounding variables, the odds of detecting any polyp were 1.56 higher in the hyoscine than the placebo group (95 % confidence interval [CI] 1.09 - 2.21, P = 0.014). The adjusted odds of detecting any adenoma were 1.62 higher in the hyoscine group compared with the placebo group (95 %CI 1.09 - 2.42, P = 0.017). There were no differences in baseline characteristics between the groups. No adverse colonoscopy-related events were recorded. One patient experienced transient tachycardia without sequelae. CONCLUSIONS: Hyoscine butylbromide administered at the cecum aids polyp detection. Further studies are required to determine the contribution of colonic spasm to polyp miss rates.

New techniques in imaging in Barrett's esophagus.

The presence of dysplasia in patients with Barrett's esophagus identifies who is at increased risk for the development of esophageal adenocarcinoma and who may most benefit from intervention. Several technologies have emerged as potent tools to identify subtle or occult neoplasia in the gastrointestinal tract. Detailed inspection of the mucosa with high resolution white light endoscopy is the most critical tool to detect subtle neoplasia. This review also chromoendoscopy, narrow band imaging, autofluorescence imaging, optical coherence tomography, confocal laser endomicroscopy, and spectroscopy in the context of detection of neoplasia in Barrett's esophagus.

First detection of Babesia sp. in Bornean sun bear (Helarctos malayanus euryspilus Horsfield) in Sabah, Malaysia.

The Bornean sun bear, a subspecies of the endangered Malayan sun bear, resides only on Borneo Island and little is known about diseases or parasites that may impact their health. In 2019, blood and ticks were collected from 46 captive bears held at the Bornean Sun Bear Conservation Centre in Sabah, Malaysia during annual health examinations in response to previous blood smear analysis that revealed presumptive haemoparasites in more than half the resident bears. Polymerase chain reaction detected a unique Babesia sp. in one of the bears. Disease surveillance of mosquitoes trapped along the outer perimeter of the bears' outdoor enclosure did not reveal any malaria parasites. This research marks the first documented case in Bornean sun bears of both a Babesia sp. and the Ixodes tick Haemaphysalis nr koningsbergeri. More research on incriminating the vector and the effects of Babesia infection on the health of Bornean sun bears is needed. Due to the zoonotic nature of babesiosis, mitigative actions should be taken to protect any humans that work with or come into close contact with these captive bears or their enclosures.

Impact of surgical ventricular restoration on ventricular shape, wall stress, and function in heart failure patients.

Surgical ventricular restoration (SVR) was designed to treat patients with aneurysms or large akinetic walls and dilated ventricles. Yet, crucial aspects essential to the efficacy of this procedure like optimal shape and size of the left ventricle (LV) are still debatable. The objective of this study is to quantify the efficacy of SVR based on LV regional shape in terms of curvedness, wall stress, and ventricular systolic function. A total of 40 patients underwent magnetic resonance imaging (MRI) before and after SVR. Both short-axis and long-axis MRI were used to reconstruct end-diastolic and end-systolic three-dimensional LV geometry. The regional shape in terms of surface curvedness, wall thickness, and wall stress indexes were determined for the entire LV. The infarct, border, and remote zones were defined in terms of end-diastolic wall thickness. The LV global systolic function in terms of global ejection fraction, the ratio between stroke work (SW) and end-diastolic volume (SW/EDV), the maximal rate of change of pressure-normalized stress (dσ*/dt(max)), and the regional function in terms of surface area change were examined. The LV end-diastolic and end-systolic volumes were significantly reduced, and global systolic function was improved in ejection fraction, SW/EDV, and dσ*/dt(max). In addition, the end-diastolic and end-systolic stresses in all zones were reduced. Although there was a slight increase in regional curvedness and surface area change in each zone, the change was not significant. Also, while SVR reduced LV wall stress with increased global LV systolic function, regional LV shape and function did not significantly improve.

Multi-institutional experience of diffuse intra-abdominal multicystic peritoneal mesothelioma.

BACKGROUND: This study was undertaken to measure survival of patients with multicystic peritoneal mesothelioma treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy through a multi-institutional collaboration. METHODS: A multi-institutional data registry, established by the Peritoneal Surface Oncology Group, was used to identify patients with peritoneal mesothelioma and the subgroup with multicystic tumours, treated by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. Outcomes for this subgroup are reported. The primary endpoint was overall survival. A secondary endpoint was the incidence of treatment-related complications. RESULTS: Of 405 patients with peritoneal mesothelioma, 26 (6·4 per cent) had multicystic tumours. There were 20 women and six men with a mean(s.d.) age of 42(12) years. The median peritoneal carcinomatosis index (PCI) was 14 (range 6-39). There was no perioperative mortality. Six patients developed grade III or IV complications. After a median follow-up of 54 (range 5-129) months, all 26 patients were still alive. CONCLUSION: Multicystic peritoneal mesothelioma appears to be a distinct subtype of peritoneal mesothelioma, where long-term survival may be achieved through cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

Analysis of variables associated with surgery versus observation in patients with pancreatic cystic lesions referred for endoscopic ultrasound.

BACKGROUND AND STUDY AIM: Endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) for cyst fluid analysis (CFA) is often requested for pancreatic cystic lesions, to determine whether to operate or to observe. If this decision is not influenced by the EUS findings, the procedure may be unjustifiable. We aimed to determine whether EUS-CFA results predict surgery or observation in patients with pancreatic cysts referred for EUS. PATIENTS AND METHODS: Consecutive patients referred to a quaternary pancreaticobiliary center for EUS evaluation of pancreatic cysts were eligible. Clinical data, computed tomography (CT) results, EUS findings, and CFA results were reviewed retrospectively. Statistical analysis was performed to determine variables associated with surgery versus observation. RESULTS: Over 33 months, data on 194 consecutive patients referred for EUS for evaluation of pancreatic cysts were analyzed. Of these, 136 (70 %) patients had EUS-FNA. After the initial workup (including EUS with/without CFA), 35 (18 %) underwent surgery. Predictors of surgery were: younger age (< 65 years) (P = 0.0027), malignant appearance at EUS (P = 0.02), and history of EUS-FNA (P = 0.012). Cyst fluid appearance, and carcinoembryonic antigen (CEA), carbohydrate antigen 19­9 (CA 19­9), and amylase levels were not significant determinants of surgery. In 14/50 (28 %) of cases where EUS-CFA clearly suggested benign serous lesions, surgery was still performed and in 9/11 (82 %) of cases with malignant EUS-CFA findings, surgery was not done. CONCLUSIONS: In patients with pancreatic cysts referred for EUS, age and EUS appearance independently predict surgery. The "perceived need for EUS-CFA" also predicts surgery, but not the EUS-CFA results. The clinical value of EUS-CFA requires further study.

Chylopericardium associated with constrictive pericarditis assessed by multimodality imaging.

Acute-onset presentation with breathlessness and calcific pericardial thickening encapsulating the heart. Extremely chylous pericardium, which is by itself rare, in combination with constriction assessed with multiple imaging modalities.

Long-term outcome of image-guided percutaneous radiofrequency ablation of lung metastases: an open-labeled prospective trial of 148 patients.

BACKGROUND: Image-guided percutaneous radiofrequency ablation (RFA) has been proposed as an efficacious local therapy for lung metastases in nonsurgical candidates. Reports of long-term outcome from this treatment have been limited. METHODS: A prospective open-labeled trial of RFA was initiated in November 2000 for treatment of lung metastases in nonsurgical candidates. RFA was carried out under fluoroscopic computed tomography. Treatment complications and survival parameters were analyzed. RESULTS: Of 148 patients treated, 66 patients (46%) had a complete response, 38 patents (26%) had a partial response, 57 patients (39%) had stable disease and 23 patients (16%) had progressive disease. The median progression-free survival was 11 months [95% confidence interval (CI) 9-14]. The median overall survival and 3- and 5-year survivals were 51 months (95% CI 19-83) and 60% and 45%, respectively. Disease-free interval (P = 0.013) and response to treatment (P = 0.002) were independent predictors for overall survival. Complications occurred in up to 45% of patients, of which 45 patients (30%) required chest tube placement. CONCLUSION: This analysis confirms that RFA of lung metastases may achieve long-term survival in nonsurgical candidates with an acceptable complication rate hence supporting its incorporation into the oncosurgical management of lung metastases for the purposes of cure, stabilization and disease prolongation.

Accuracy and clinical relevance of computed tomography scan interpretation of peritoneal cancer index in colorectal cancer peritoneal carcinomatosis: a multi-institutional study.

BACKGROUND: Evaluation of peritoneal metastases by computed tomography (CT) scans is challenging and has been reported to be inaccurate. METHODS: A multi-institutional prospective observational registry study of patients with peritoneal carcinomatosis from colorectal cancer was conducted and a subset analysis was performed to examine peritoneal cancer index (PCI) based on CT and intraoperative exploration. RESULTS: Fifty-two patients (mean age 52.6 ± 12.4 years) from 16 institutions were included in this study. Inaccuracies of CT-based assessment of lesion sizes were observed in the RUQ (P = 0.004), LLQ (P < 0.0005), RLQ (P = 0.003), distal jejunum (P = 0.004), and distal ileum (P < 0.0005). When CT-PCI was classified based on the extent of carcinomatosis, 17 cases (33%) were underestimations, of which, 11 cases (21%) were upstaged from low to moderate, 4 cases (8%) were upstaged from low to severe, and 2 cases (4%) were upstaged from moderate to severe. Relevant clinical discordance where an upstage occurred to severe carcinomatosis constituted a true inaccuracy and was observed in six cases (12%). CONCLUSIONS: The actual clinical impact of inaccuracies of CT-PCI was modest. CT-PCI will remain as a mandatory imaging tool and may be supplemented with other tools including positron emission tomography scan or diagnostic laparoscopy, in the patient selection for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy.

A randomised controlled trial of low-dose misoprostol and dinoprostone vaginal pessaries for cervical priming.

OBJECTIVE: We studied the efficacy of 25-microg misoprostol pessaries as either single or double dose compared with a 3-mg dinoprostone pessary for cervical priming. DESIGN AND SETTING: A randomised controlled trial in Singapore. POPULATION: One hundred and seventy-one women with term pregnancies and modified Bishop scores (mBS) < or =6 from 2003 to 2004. METHOD: Patients were randomised to single misoprostol dose, double misoprostol dose or the current dinoprostone regimen. MAIN OUTCOME MEASURES: Primary outcome was number of women who achieved favourable mBS >6 or active labour by day 2. Secondary outcomes were time interval from insertion to delivery, cardiotocographic abnormalities, delivery and neonatal outcome. RESULTS: More women in the misoprostol double-dose group (96.6%) and dinoprostone group (93%) achieved the primary outcome compared with the single-dose group (77.8%) (P = 0.003 and P = 0.03, respectively). There was no difference in secondary outcomes. More multiparous women achieve primary outcome compared with nulliparous women (odds ratio 0.21, 95% confidence interval 0.06-0.77). CONCLUSION: Double-dose misoprostol 25 microg is as effective as dinoprostone 3 mg inserts for cervical priming; both are more efficacious than a single-dose misoprostol pessary. Parity prognosticates the success of induction.