One-Year Outcomes in a Supervised Program of Swallowable Intragastric Balloon-Analysis of 486 Patients in a High-Volume Bariatric Centre in Malaysia.

INTRODUCTION: The swallowable intragastric balloon (IGB) has recently emerged as a popular alternative for weight loss in Malaysia. It can reduce total body weight loss (TBWL) by 6-15%. We aim to observe positive weight loss up to a year after the swallowable IGB is implanted. METHODS: A total of 486 consecutive patients with overweight or obesity who underwent swallowable IGB insertion were included in this prospective data collection. RESULTS: Out of 486 patients, 404 patients (83%) had complete data at the end of 4 and 12 months. Patients included in the study had a starting mean body mass index of 35.3 ± 7.2 kg/m2 which decreased to 31.5 ± 5.7 kg/m2 (p < 0.0001) at the end of 4 months and further reduced to 30.3 ± 5.4 kg/m2 (p < 0.0001) at the end of 12 months. At 4 months, the overall average weight loss was 9.8 kg, meanwhile, at 12 months, the average weight loss increased to 12.9 kg. At 4 months, the average TBWL was 10.5%, while at the end of 1 year, the combined %TBWL increased to 13.7%. CONCLUSION: Most weight loss is typically observed within the first 4 months following the procedure. However, it is important to note that patients can continue to experience ongoing weight loss for up to 1 year. The swallowable IGB is a safe and effective option for patients seeking weight loss solutions. It offers numerous advantages, especially its non-invasive procedureless nature, which makes it more appealing to individuals considering this treatment.

A rare presentation of retroperitoneal liposarcoma presented with jejunal intussusception: An interesting radiological findings.

A jejunal intussusception as a presentation of retroperitoneal liposarcoma (RLPS) is a rare occurrence. The majority of RLPS are presented as an abdominal mass, however, having a jejunal obstruction is an interesting case. The aim is to describe the management of jejunal intussusception secondary to atypical lipomatous tumours with concurrent RLPS. A 61-year-old lady presented with a sudden onset of intestinal obstruction with 1 month of constitutional symptoms and an enlarging right lumbar mass. Computed tomography showed a small bowel intussusception with diffuse peritoneal and retroperitoneal lipomatosis. Emergency exploratory laparotomy, segmental bowel resection, and partial excision of intraperitoneal mesenteric lipoma were performed. A stage En-bloc resection of the RLPS and right nephrectomy was done later. However, she refused for subsequent surgery. A complete resection is the gold standard in managing RLPS. In this report, the management is rendered not to the standard as the patient first presented with intestinal obstruction requiring emergency reduction with a piecemeal resection. A stage surgery was required to determine a promising prognosis, but the patient refused such surgery. A small bowel intussusception in adults is rare but is mostly caused by a tumor or neoplasm. Early recognition of the complexity of the case should be preempted and referred to the tertiary team for further definitive surgery. Patient exhaustion from the subsequent surgery might hamper the only management available for the case.

Association between dietary pattern and Helicobacter pylori infection at Queen Elizabeth Hospital, Kota Kinabalu: A case-control study.

BACKGROUND: Limited studies have reported the association between dietary patterns and Helicobacter pylori (H. pylori) infection in Sabah. OBJECTIVE: The purpose of this study was to assess the association between dietary pattern and H. pylori infection among patients aged 18 years and above that went for first esophagogastroduodenoscopy (OGDS) in 2021 at Queen Elizabeth Hospital (QEH), Kota Kinabalu. METHODS: Dietary intake of positive H. pylori was compared with healthy subjects by using questionnaire adapted from Malaysian Adult Nutrition Survey (MANS) 2014. Using logistic regression models, we evaluated the association between dietary pattern and H. pylori infection risk. FINDINGS: Our finding identified four dietary patterns, namely "high carbohydrate pattern", "high fiber pattern", "high fat/cholesterol pattern" and "high salt pattern". After adjustment for potential confounders, the highest quartile of "high salt pattern" showed greater odds of H. pylori infection (OR = 1.26; 95% Cl: 1.032-1.459; P = 0.045) than lowest quartile, while highest quartile of "high fiber pattern" demonstrated lower odd of the infection (OR = 0.69; 95% Cl: 0.537-0.829; P = 0.008) than those in lowest quartile. If compared with Recommended Nutrient Intake (RNI) 2017, positive H. pylori consumed high carbohydrates and sodium with insufficient fiber intake. CONCLUSION: To conclude, "high fiber pattern" lowers the risk of H. pylori infection while "high salt pattern" increases the infection risk. Our study also highlighted the importance of nutrient intake within daily allowances.

The trends and hotspots of immunotherapy for metastatic colorectal cancer from 2013 to 2022: A bibliometric and visual analysis.

An increasing body of research indicates that immunotherapy has demonstrated substantial effectiveness in the realm of metastatic colorectal cancer(mCRC), especially among patients with deficient mismatch repair (dMMR) or microsatellite instability-high (MSI-H) (dMMR/MSI-H mCRC). This study constitutes the inaugural bibliometric and visual analysis of immunotherapy related to mCRC during the last decade. Between 2013 and the conclusion of 2022, we screened 306 articles from Web of Science and subjected them to analysis using CiteSpace and VOSviewer. The United States stood out as the primary contributor in this area, representing 33.33% of the publications, with China following closely at 24.51%. The most prolific institution has the lowest average citation rate. Sorbonne University were the most highly cited institutions. Notably, Frontiers In Oncology published the largest quantity of articles. Andre, Thierry, and Overman, Michael J. were prominent authors known for their prolific output and the high citation rates of their work. The focus areas in this field encompass "tumor microenvironment," "liver metastasis," "tumor-associated macrophages," "combination therapy" and "gut microbiota." Some keywords offer promise as potential biomarkers for evaluating the effectiveness of immunotherapeutic interventions.

Holes can be perilous: A rare presentation of intestinal obstruction - Herniation through the broad ligament.

A 57-year-old lady presented with symptoms of intestinal obstruction preceded by a 2-day history of lower abdomen pain. Clinically, she had a distended abdomen with tenderness in her lower abdomen. Laboratory investigations were unremarkable. An abdominal radiograph showed a dilated small bowel with no extensive bowel gas. A computed tomography (CT) scan showed suspected intestinal obstruction secondary to herniation into the right broad ligament. The decision was made to proceed with surgery, and the intraoperative results confirmed the CT results. The literature review is outlined here, and this instance illustrates a surprising discovery.

Ectopic Papillary Thyroid Carcinoma of the Posterior Pharynx.

Introduction: Ectopic thyroid is an uncommon condition resulting from the aberrant development of the normal thyroid gland and is usually found along the thyroglossal tract: lingual, submandibular, thyroglossal cysts, intra-tracheal and mediastinal, or, on rare occasions, in the adrenal gland, gallbladder, gastrointestinal tract, pancreas, and struma ovarii. Case Reports: We describe a novel case where primary papillary thyroid carcinoma (PTC) was found after a trans-oral excision of a tumor containing ectopic thyroid tissue at the posterior pharynx, an area not known to be a location for ectopic thyroid. Delays due to the COVID-19 pandemic resulted in regional cervical metastases and multifocal PTC. The female patient successfully underwent total thyroidectomy, selective cervical and central lymph node dissection, followed by adjuvant radioactive iodine ablation, with no evidence of distant metastases. Conclusions: Ectopic thyroid tissue is uncommon and may be in the posterior pharynx. The principles of management remain those of differentiated thyroid malignancy: complete surgical resection of any tumor focus, total thyroidectomy, and node dissection of involved lymph nodes, followed by adjuvant radioactive iodine in iodine-sensitive tumors.

Psychiatric illness and pregnancy: A literature review.

Background: Women of reproductive age frequently suffer from psychiatric disorders. The risk of developing anxiety, bipolar, and depressive disorders is especially significant during the perinatal period. Objectives: This article aims to identify and discuss the different psychiatric conditions that might affect pregnant women and update the mother's carers about the recent and updated bidirectional relationship between psychiatric disease and adverse pregnancy outcomes, As well as the most updates in diagnostic and management strategies. Methods: A thorough analysis of the literature was conducted using database searches in EMBASE, Science Direct, Google Scholar, Scopus, and PubMed to obtain the objectives and aim of the study. Results: The presence of maternal mental illness during pregnancy has been linked to preterm delivery, newborn hypoglycemia, poor neurodevelopmental outcomes, and disturbed attachment. Placental anomalies, small-for-gestational-age foetuses, foetal discomfort, and stillbirth are among more undesirable perinatal outcomes. Conclusions: Pregnancy-related psychiatric disorders are frequent. The outcomes for pregnant women, infants, and women's health are all improved by proper diagnosis and treatment of psychiatric problems.

Venous thromboembolism and pregnancy: A review of the literature.

This review aims to provide the mother carers with the most recent evidence-based guidelines in the context of managing of pregnancy-associated VTE, where an extensive search through the medical journals addressing the topic including the medical database such as Pubmed, Medline, Sience direct,Embase and others using the title and key-words in order to gather the most concerned as well as the up-to-date publications concerned with the problem under research, the search resulted in recognising pregnancy as a significant risk factor for the development of VTE, both during the prenatal and postnatal periods, with an estimated increased likelihood risk of five and sixty times, respectively and concluded that venous thromboembolism (VTE) is one of the leading causes of maternal mortality hence, all pregnant women should be assessed for the risk of developing the condition as early as possible (when scheduling a booking antenatal appointment) or even in the pre-pregnancy clinic.

Post-thoracotomy paraplegia after oxidized cellulose spinal compression.

Post-thoracotomy paraplegia after non-aortic surgery is an extremely uncommon complication. A 56-year-old woman presented with a 1-year history of progressive shortness of breath. Computed tomography revealed a locally advanced posterior mediastinal mass involving the ribs and the left neural foramina. Tumor excision with a left pneumonectomy was performed. Post-resection, bleeding was noted in the vicinity of the T4-T5 vertebral body, and the bleeding point was packed with oxidized cellulose gauze (Surgicel®). Postoperatively, the patient complained of bilateral leg numbness extending up to the T5 level, with bilateral paraplegia. An urgent laminectomy was performed, and we noted that the spinal cord was compressed by two masses of Surgicel® with blood clots measuring 1.5 × 1.5cm at T4 and T5 levels. The paraplegia did not improve despite the removal of the mass, sufficient decompression, and aggressive postoperative physiotherapy. Surgeons operating in fields close to the intervertebral foramen should be aware of the possible threat to the adjacent spinal canal as helpful hemostatic agents can become a preventable threat.

Performance and diagnostic accuracy of scoring systems in adult patients with suspected appendicitis.

BACKGROUND: This study aims to determine the most accurate appendicitis scoring system and optimal cut-off points for each scoring system. METHODS: This single-centred prospective cohort study was conducted from January-to-June 2021, involving all patients admitted on suspicion of appendicitis. All patients were scored according to the Alvarado score, Appendicitis Inflammatory Response (AIR) score, Raja Isteri Pengiran Anak Saleha (RIPASA) score and Adult Appendicitis score (AAS). The final diagnosis for each patient was recorded. Sensitivity and specificity were calculated for each system. Receiver operating characteristic (ROC) curve was constructed for each scoring system, and the area under the curve (AUC) was calculated. Optimal cut-off scores were calculated using Youden's Index. RESULTS: A total of 245 patients were recruited with 198 (80.8%) patients underwent surgery. RIPASA score had higher sensitivity and specificity than other scoring systems without being statistically significant (sensitivity 72.7%, specificity 62.3%, optimal score 8.5, AUC 0.724), followed by the AAS (sensitivity 60.2%, specificity 75.4%, optimal score 14, AUC 0.719), AIR score (sensitivity 76.7%, specificity 52.2%, optimal score 5, AUC 0.688) and Alvarado score (sensitivity 69.9%, specificity 62.3%, optimal score 5, AUC 0.681). Multiple logistic regression revealed anorexia (p-value 0.018), right iliac fossa tenderness (p-value 0.005) and guarding (p-value 0.047) as significant clinical factors independently associated with appendicitis. CONCLUSION: Appendicitis scoring systems have shown moderate sensitivity and specificity in our population. The RIPASA scoring system has shown to be the most sensitive, specific and easy-to-use scoring system in the Malaysian population whereas the AAS is most accurate in excluding low-risk patients.

Veno-Venous Surgical Bypass for Central Vein Occlusion in a Child: The First in the Literature.

Introduction: During the past two decades, the incidence of chronic kidney disease (CKD) in children worldwide has steadily increased and, even in children, native arteriovenous fistula (AVF) remains the access of choice. Nevertheless, maintaining a well functioning fistula is limited by central venous occlusion due to the widespread use of central venous access devices before AVF creation. Report: A 10 year old girl with end stage renal failure dialysing through a left brachiocephalic fistula presented with left upper limb and facial swelling. She had previously exhausted the option of ambulatory peritoneal dialysis for recurrent peritonitis. A central venogram showed occlusion at the left subclavian vein, which was not amenable for angioplasty through either an upper limb or femoral approach. Given the precious fistula with concomitant worsening venous hypertension, an ipsilateral axillary vein to external iliac vein bypass was performed. Subsequently, her venous hypertension was significantly resolved. This report is the first in English literature on this surgical bypass in a child with central venous occlusion. Discussion: Central venous stenosis or occlusion rates are rising due to extensive central venous catheter use in the paediatric population with end stage renal failure. In this report, an ipsilateral axillary vein to external iliac vein bypass was used successfully as a safe temporary option to maintain AVF. Ensuring a high flow fistula pre-operatively and continued antiplatelet post-operatively will allow longer patency of the graft.

Forensic age estimation in living children: how accurate is the Greulich-Pyle method in Sabah, East Malaysia?

Background: The Greulich and Pyle's Radiographic Atlas of Skeletal Development of the Hand and Wrist (GP Atlas) is the most widely used method of determining the bone age (BA) of a child. It is also a widely accepted method for forensic age determination. As there is limited local bone age data for forensic age estimation, the purpose of this study was to assess the accuracy of the GP Atlas for forensic age determination in living Sabahan children. Method: This study recruited 182 children between the ages of 9 years to 18 years. BA estimation of the left-hand anteroposterior radiographs were performed by two experienced radiologists using the Greulich-Pyle method. Results: The BA estimates from two radiologists had very high interobserver reliability (ICC 0.937) and a strong positive interobserver correlation (r > 0.90). The GP method, significantly and consistently underestimated chronological age (CA) by 0.7, 0.6 and 0.7 years in overall children, boys and girls respectively with minimal errors. Mean absolute error and root of mean squared error for overall children was 1.5 and 2.2 years respectively, while mean absolute percentage error was 11.6%. This underestimation was consistent across all age groups but was statistically significant only at 13-13.9 and 17-18.9 years old age groups. Conclusion: Despite high interobserver reliability of BA estimation using the GP Atlas, this method consistently underestimates the age of the child in all children to a significant degree, for both boys and girls across all age groups, with an acceptably low level of error metrics. Our findings suggest that locally validated GP Atlas or other type of assessments (artificial intelligence or machine learning) are needed for assessment of BA to accurately predict CA, since current GP Atlas standards significantly underestimated chronological age with minimal error for children in Sabah. A larger population-based study would be necessary for establishing a validated atlas of a bone age in Malaysia.

A peculiar case of intususception in a pregnant woman: A diagnostic challenge.

Adult intussusception presents a diagnostic challenge given its non-specific symptoms. It is not as common as in infants and young children. Traditionally, diagnostic steps are invariably fit for normal adults, but not in pregnancy which faces certain limitations. A 40-year-old pregnant mother, gravida 9 para 8 at 34-week gestation, complained of intermittent epigastric pain for 2 days, requiring hospitalization. She soon developed minimal per rectal bleeding that was ruled out as hemorrhoid. Imaging was limited due to her pregnancy status. She later developed spontaneous delivery to a premature baby. Computed tomography (CT) revealed an ileocolic intussusception, which was confirmed via exploratory laparotomy. Histology was consistent with inflammatory fibroid polyp. Acute abdomen in pregnancy can be due to various causes, thus a high index of suspicion and early CT abdomen might help in early diagnosis and treatment. The benefit of doing CT on the mother and the risk of CT on the fetus is to be weighed as the timely diagnosis can prevent bowel ischemia and reduce maternal morbidity and mortality. Surgery remains the definite management in adult intussusception and an exact diagnosis can be made during the operation.

Improvement in Erectile Dysfunction Among Male Obese Patient, Following Bariatric Surgery in Hospital Canselor Tuanku Muhriz (HUKM).

PURPOSE: Obesity is associated with multiple health-related complications and affects various aspects of life, including erectile dysfunction (ED). The aim of this study is to postulate that erectile dysfunction in male obese patients can be reversed following bariatric surgery. MATERIALS AND METHODS: We conducted a non-randomized quasi-experimental study (prospective) between 2 groups, those who underwent surgery with the control group. In this study, the resolution of erectile dysfunction following bariatric surgery comparing with the control group was evaluated in terms of International Index of Erectile Function (IIEF) score. IIEF score is taken by delivering validated questionnaire to participants that enrolled in this study, both the control and intervention group. RESULTS: A total of 25 patients were included in this study, 13 from the intervention group and 12 from the control group. From our study, we evaluated the resolution of IIEF score in both groups. We found that the resolution of erectile function is statistically significant in the intervention group compared to control group. Spearman rank correlation (rs) test was performed to identify the correlation between age and IIEF score. CONCLUSION: Statistically significant improvements in erectile function were found following bariatric surgery. This is evidenced by the improvements in the IIEF score post-surgery compared to control group.

Post-thoracotomy paraplegia after oxidized cellulose spinal compression

ABSTRACT Post-thoracotomy paraplegia after non-aortic surgery is an extremely uncommon complication. A 56-year-old woman presented with a 1-year history of progressive shortness of breath. Computed tomography revealed a locally advanced posterior mediastinal mass involving the ribs and the left neural foramina. Tumor excision with a left pneumonectomy was performed. Post-resection, bleeding was noted in the vicinity of the T4-T5 vertebral body, and the bleeding point was packed with oxidized cellulose gauze (Surgicel®). Postoperatively, the patient complained of bilateral leg numbness extending up to the T5 level, with bilateral paraplegia. An urgent laminectomy was performed, and we noted that the spinal cord was compressed by two masses of Surgicel® with blood clots measuring 1.5 × 1.5cm at T4 and T5 levels. The paraplegia did not improve despite the removal of the mass, sufficient decompression, and aggressive postoperative physiotherapy. Surgeons operating in fields close to the intervertebral foramen should be aware of the possible threat to the adjacent spinal canal as helpful hemostatic agents can become a preventable threat.

Children's eating behaviour: A comparison between normal, overweight and obese children.

Background: Childhood obesity has become a major global health concern and has been increasing dramatically over the years. Previous study has shown that specific eating behaviours may have been associated with obesity especially under-responsiveness to internal satiety cues and over-responsiveness to external food cues such as the taste, smell, availability and emotions. However, there is still inadequate number of studies present to describe the association between the children's body mass index (BMI) and their eating behaviours, especially in Sabah, Malaysia. Therefore, the objective of this study is to established the association between the children's eating behaviours with their nutritional status based on their body mass index. Materials and methods: A cross-sectional study involving 484 children aged 6-12 years old was conducted in Kota Kinabalu, which is a developing urban area in Sabah. The children were recruited from five primary schools that were selected based on multistage stratified and convenience sampling method. Sociodemographic details and anthropometric measures both parents and children, and eating behaviours of children were assessed using Children Eating Behaviour Questionnaires (CEBQ). Age-adjusted BMI z-scores were then calculated according to the World Health Organization recommendations to assess nutritional status. Results: The prevalence of childhood obesity among children aged 6-12 years old is 13.2%. The mean scores of 'Food Approach' subscales from the CEBQ showed higher mean score in overweight and obese groups as compared to the mean score in normal weight group. The mean scores of 'Food Avoidance' subscales showed lower mean score in overweight and obese groups as compared to mean score in normal weight group. Conclusion: This study provides evidence that childhood obesity is yet to be a prevalent health problem in a developing urban area considering the "Food approach" subscales were positively associated with the excess weight in children.

Sino-orbital metastasis as the initial presentation of advanced breast cancer.

A woman in her 70s presented with reduced vision in her left eye, progressive narrowing of right eye opening for 6 months and anosmia. On examination, she had right enophthalmos and pseudoptosis with inferior globe dystopia. Her visual acuity was 6/9 and nil light perception in the right and left eyes, respectively. Extraocular muscle examination showed limited right up gaze. Funduscopy showed a normal right optic disc and left optic disc atrophy. Systemic examination revealed left breast ulceration with skin tethering. CT revealed an infiltrative mass invading the ethmoidal sinuses, frontal sinuses and both orbits. A histological diagnosis of infiltrative ductal breast carcinoma was made after nasal endoscopic and left breast biopsy. She underwent palliative chemoradiotherapy and survived with good disease control after 1 year. Metastatic carcinoma is a differential diagnosis of a sino-orbital mass, and comprehensive clinical assessment is indicated for all patients presenting with non-acute eye injury.

Diagnostic Value of Preoperative Haemoglobin, Albumin, Lymphocyte and Platelet (HALP) Score in Predicting Tumour Budding in Colorectal Cancer.

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