A hybrid ensemble approach to accelerate the classification accuracy for predicting malnutrition among under-five children in sub-Saharan African countries.

BACKGROUND: The proper intake of nutrients is essential to the growth and maturation of youngsters. In sub-Saharan Africa, 1 in 7 children dies before age 5 y, and more than a third of these deaths are attributed to malnutrition. The main purpose of this study was to develop a majority voting-based hybrid ensemble (MVBHE) learning model to accelerate the prediction accuracy of malnutrition data of under-five children in sub-Saharan Africa. METHODS: This study used available under-five nutritional secondary data from the Demographic and Health Surveys performed in sub-Saharan African countries. The research used bagging, boosting, and voting algorithms, such as random forest, decision tree, eXtreme Gradient Boosting, and k-nearest neighbors machine learning methods, to generate the MVBHE model. RESULTS: We evaluated the model performances in contrast to each other using different measures, including accuracy, precision, recall, and the F1 score. The results of the experiment showed that the MVBHE model (96%) was better at predicting malnutrition than the random forest (81%), decision tree (60%), eXtreme Gradient Boosting (79%), and k-nearest neighbors (74%). CONCLUSIONS: The random forest algorithm demonstrated the highest prediction accuracy (81%) compared with the decision tree, eXtreme Gradient Boosting, and k-nearest neighbors algorithms. The accuracy was then enhanced to 96% using the MVBHE model. The MVBHE model is recommended by the present study as the best way to predict malnutrition in under-five children.

Prevalence of acute respiratory infections among children in India: Regional inequalities and risk factors.

AIM: The high incidence of acute respiratory infection (ARI)-related morbidity and mortality is a major public health concern in developing countries. This study aimed to quantify regional inequalities and the degree of association between childhood ARI and background factors. METHODS: This study utilised information of 238 945 children aged below five years extracted from the Fourth Indian National Family Health Survey conducted in 2015-16. Inter-state and regional inequality in the prevalence of ARI were quantified and presented using a map of India and forest plot. The association of background characteristics and ARI was quantified using bivariate and multivariable binary logistic regression models. RESULTS: Significant inequalities in the prevalence of childhood ARI were observed across the six regions of India. Considering the children from north-east region as a reference, those from north, central and east regions were 0.68, 1.02 and 0.57 times more likely to suffer from ARI. Comorbidity, sex, age and nutritional status of children were significantly associated with the prevalence of ARI. CONCLUSIONS: ARI remains a significant public health concern among Indian children. The results of this study showed that significant regional disparities in the prevalence of ARI exist in India. This study adds value to the better understanding of inequality patterns and quantifies within- and intra-region inequalities in the prevalence of ARI in India.

Prophylactic Onlay Mesh Repair (POMR) Versus Primary Suture Repair (PSR) for Prevention of Incisional Hernia (IH) After Abdominal Wall Surgery: A Systematic Review and Meta-analysis.

BACKGROUND: With many different operative techniques in use to reduce the incidence of incisional hernias (IH) following a midline laparotomy, there is no consensus among the clinicians on the efficacy and safety of any particular repair technique. This meta-analysis compares the prophylactic onlay mesh repair (POMR) and primary suture repair (PSR) for the incidence of IH. METHODS: A meta-analysis and systematic review of MEDLINE, PubMed Central (via PubMed), Embase (via Ovid), SCOPUS, ScienceDirect, Google Scholar, SCI and Cochrane Library databases were undertaken. Seven randomized controlled trials assessing the outcomes of PSR and POMR were analyzed in accordance with the PRISMA statement. The risk of bias was assessed using the Rob2 tool. RESULTS: According to the pooled analysis, POMR significantly reduced the incidence of IH compared to the PSR (OR 5.82 [95% CI 2.69, 12.58] P < 0.01) with a significantly higher seroma formation rate post-surgery (OR 0.35 [95% CI 0.18, 0.67] P < 0.01). Furthermore, the length of hospital stay (WMD -0.78 [95% CI -1.58, 0.02] P = 0.05) was significantly shorter for PSR compared to POMR group. Comparable effects were noted for reintervention, postoperative ileus, postoperative hematoma, postoperative mortality, long-term intervention and long-term deaths between the two groups. CONCLUSIONS: POMR significantly reduces the risk of IH when compared to the PSR, with an increased risk of postoperative seroma formation and longer hospital stay. However, more RCTs with standardized protocols are needed for meaningful comparisons of the two interventions, along with longer duration of follow-up to assess the impact on the occurrence of IH.

Anterior Dor or Posterior Toupet with Heller Myotomy for Achalasia Cardia: A Systematic Review and Meta-Analysis.

BACKGROUND AND AIMS: Partial fundoplication is commonly performed in conjunction with Heller Myotomy. It is, however, controversial whether anterior Dor or posterior Toupet partial fundoplication is the antireflux procedure of choice. The aim was to perform a systematic review and meta-analysis of studies comparing these two procedures. MATERIAL AND METHODS: A search of PubMed, Cochrane database, Medline, Embase, Science Citation Index, Google scholar and current contents for English language articles comparing Dor and Toupet fundoplication following HM between 1991 and 2018 was performed. The outcome variables analyzed included operating time, length of hospital stay (LOHS), overall complication rate, quality of life (QOL), postoperative reflux, residual postoperative dysphagia, treatment failure and reoperations. The meta-analysis was prepared in accordance with the PRISMA-P statement. RESULTS: Seven studies totaling 486 patients (Dor = 245, Toupet = 241) were analyzed. LOHS was significantly shorter for Toupet repair compared to Dor procedure (WMD 0.73, 95% CI 0.47 to 0.99; P < 0.0001). Furthermore, patients after Toupet experienced significantly better QOL than those after Dor (WMD 1.68, 95% CI 0.68 to 2.73, P < 0.001). All other variables showed comparable effects for these two procedures. CONCLUSION: Our systematic review and meta-analysis revealed that Toupet fundoplication is superior to Dor in terms of LOHS and QOL following HM. For other variables such as postoperative reflux, postoperative dysphagia, complication rates and treatment failure, both Dor and Toupet fundoplication produced effective and equivalent results.

Meta-analysis of histopathological outcomes of laparoscopic assisted rectal resection (LARR) vs open rectal resection (ORR) for carcinoma.

BACKGROUND: We conducted a meta-analysis of the randomized evidence to determine the relative merits of histopathological outcomes of laparoscopic assisted (LARR) versus open rectal resection (ORR) for rectal cancer. DATA SOURCES: A search of PubMed and other electronic databases comparing LARR and ORR between Jan 2000 and June 2016 was performed. Histopathological variables analyzed included; location of rectal tumors; complete and incomplete TME; positive and negative circumferential resection margins (+/-CRM); positive distal resected margins (+DRM); distance of tumor from DRM; number of lymph nodes harvested; resected specimen length; tumor size and perforated rectum. RESULTS: Fourteen RCTs totaling 3843 patients (LARR = 2096, ORR = 1747) were analyzed. Comparable effects were noted for all these histopathological variables except for the variable perforated rectum which favored ORR. CONCLUSIONS: LARR compares favorably to ORR for rectal cancer treatment. However, there is significantly higher risk of rectal perforation during LARR compared to ORR.

Changes in Non-Diabetic Comorbid Disease Status Following Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-En-Y Gastric Bypass (LRYGB) Procedures: a Systematic Review of Randomized Controlled Trials.

PURPOSE: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG) have been proposed as cost-effective strategies to manage obesity-related chronic disease. The aim of this systematic review was to study the peer review literature regarding postoperative nondiabetic comorbid disease resolution or improvement reported from randomized controlled trials (RCTs) comparing LVSG and LRYGB procedures. MATERIAL AND METHODS: RCTs comparing postoperative comorbid disease resolution such as hypertension, dyslipidemia, obstructive sleep apnea, joint and musculoskeletal conditions, gastroesophageal reflux disease, and menstrual irregularities following LVSG and LRYGB were included for analysis. The studies were selected from PubMed, Medline, EMBASE, Science Citation Index, Current Contents, and the Cochrane database and reported on at least one comorbidity resolution or improvement. The present work was undertaken according to the Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA). The Jadad method for assessment of methodological quality was applied to the included studies. RESULTS: Six RCTs performed between 2005 and 2015 involving a total of 695 patients (LVSG n = 347, LRYGB n = 348) reported on the resolution or improvement of comorbid disease following LVSG and LRYGB procedures. Both bariatric procedures provide effective and almost comparable results in improving or resolving these comorbidities. CONCLUSIONS: This systematic review of RCTs suggests that both LVSG and LRYGB are effective in resolving or improving preoperative nondiabetic comorbid diseases in obese patients. While results are not conclusive at this time, LRYGB may provide superior results compared to LVSG in mediating the remission and/or improvement in some conditions such as dyslipidemia and arthritis.

Diabetes improvement and resolution following laparoscopic vertical sleeve gastrectomy (LVSG) versus laparoscopic Roux-en-Y gastric bypass (LRYGB) procedures: a systematic review of randomized controlled trials.

BACKGROUND: The prevalence of type 2 diabetes is growing in both developed and developing countries and is strongly linked with the prevalence of obesity. Bariatric surgical procedures such as laparoscopic vertical sleeve gastrectomy (LVSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are increasingly being utilized to manage related comorbid chronic conditions, including type 2 diabetes. METHODS: A systematic review of randomized controlled trials (RCTs) was undertaken using the PRISMA guidelines to investigate the postoperative impact on diabetes resolution following LVSG versus LRYGB. RESULTS: Seven RCTs involving a total of 732 patients (LVSG n = 365, LRYGB n = 367) met inclusion criteria. Significant diabetes resolution or improvement was reported with both procedures across all time points. Similarly, measures of glycemic control (HbA1C and fasting blood glucose levels) improved with both procedures, with earlier improvements noted in LRYGB that stabilized and did not differ from LVSG at 12 months postoperatively. Early improvements in measures of insulin resistance in both procedures were also noted in the studies that investigated this. CONCLUSIONS: This systematic review of RCTs suggests that both LVSG and LRYGB are effective in resolving or improving preoperative type 2 diabetes in obese patients during the reported 3- to 5-year follow-up periods. However, further studies are required before longer-term outcomes can be elucidated. Areas identified that need to be addressed for future studies on this topic include longer follow-up periods, standardized definitions and time point for reporting, and financial analysis of outcomes obtained between surgical procedures to better inform procedure selection.

Postoperative Early Major and Minor Complications in Laparoscopic Vertical Sleeve Gastrectomy (LVSG) Versus Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) Procedures: A Meta-Analysis and Systematic Review.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic vertical sleeve gastrectomy (LVSG) have been proposed as cost-effective strategies to manage obesity-related chronic disease. The aim of this meta-analysis and systematic review was to compare the "early postoperative complication rate i.e. within 30-days" reported from randomized control trials (RCTs) comparing these two procedures. METHODS: RCTs comparing the early complication rates following LVSG and LRYGB between 2000 and 2015 were selected from PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane database. The outcome variables analyzed included 30-day mortality, major and minor complications and interventions required for their management, length of hospital stay, readmission rates, operating time, and conversions from laparoscopic to open procedures. RESULTS: Six RCTs involving a total of 695 patients (LVSG n = 347, LRYGB n = 348) reported on early major complications. A statistically significant reduction in relative odds of early major complications favoring the LVSG procedure was noted (p = 0.05). Five RCTs representing 633 patients (LVSG n = 317, LRYGB n = 316) reported early minor complications. A non-statically significant reduction in relative odds of 29 % favoring the LVSG procedure was observed for early minor complications (p = 0.4). However, other outcomes directly related to complications which included reoperation rates, readmission rate, and 30-day mortality rate showed comparable effect size for both surgical procedures. CONCLUSIONS: This meta-analysis and systematic review of RCTs suggests that fewer early major and minor complications are associated with LVSG compared with LRYGB procedure. However, this does not translate into higher readmission rate, reoperation rate, or 30-day mortality for either procedure.

Suture Cruroplasty Versus Prosthetic Hiatal Herniorrhaphy for Large Hiatal Hernia: A Meta-analysis and Systematic Review of Randomized Controlled Trials.

OBJECTIVE: The aim was to conduct a meta-analysis of randomized controlled trials (RCTs) comparing 2 methods of hiatal closure for large hiatal hernia and to evaluate their strengths and flaws. METHODS: Prospective RCTs comparing suture cruroplasty versus prosthetic hiatal herniorrhaphy for large hiatal hernia were selected by searching PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1991 and October 2014. The outcome variables analyzed included operating time, complications, recurrence of hiatal hernia or wrap migration, and reoperation. These outcomes were unanimously decided to be important because they influence the practical approach toward patient management. Random effects model was used to calculate the effect size of both dichotomous and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran's Q statistic and I index. The meta-analysis was prepared in accordance with Preferred Reporting of Systematic Reviews and Meta-Analyses guidelines. RESULTS: Four RCTs were analyzed totaling 406 patients (Suture = 186, Prosthesis = 220). For only 1 of the 4 outcomes, ie, reoperation rate (OR 3.73, 95% CI 1.18, 11.82, P = 0.03), the pooled effect size favored prosthetic hiatal herniorrhaphy over suture cruroplasty. For other outcomes, comparable effect sizes were noted for both groups which included recurrence of hiatal hernia or wrap migration (OR 2.01, 95% CI 0.92, 4.39, P = 0.07), operating time (SMD -0.46, 95% CI -1.16, -0.24, P = 0.19) and complication rates (OR 1.06, 95% CI 0.45, 2.50, P = 0.90). CONCLUSIONS: On the basis of our meta-analysis and its limitations, we believe that the prosthetic hiatal herniorrhaphy and suture cruroplasty produces comparable results for repair of large hiatal hernias. In the future, a number of issues need to be addressed to determine the clinical outcomes, safety, and effectiveness of these 2 methods for elective surgical treatment of large hiatal hernias. Presently, the use of prosthetic hiatal herniorrhaphy for large hiatal hernia cannot be endorsed routinely and the decision for the placement of mesh needs to be individualized based on the operative findings and the surgeon's recommendation.

Laparoscopic anterior versus posterior fundoplication for gastro-esophageal reflux disease: a meta-analysis and systematic review.

OBJECTIVES: Although laparoscopic posterior fundoplication (LPF) i.e., Nissen or Toupet have the proven efficacy for controlling gastro-esophageal reflux surgically, there remain problems with postoperative dysphagia and gas bloat syndrome. To decrease some of these postoperative complications, laparoscopic anterior fundoplication (LAF) was introduced. The aim of this study was to conduct a meta-analysis and systematic review of randomized controlled trials (RCTs) to investigate the merits and drawbacks of LPF versus LAF for the treatment of gastro-esophageal reflux disease (GERD). DATA SOURCES, STUDY SELECTION, AND REVIEW METHODS: A search of Medline, Embase, Science Citation Index, Current Contents, PubMed, ISI Web of Science, and the Cochrane Database identified all RCTs comparing different types of LPF and LAF published in the English Language between 1990 and 2013. The meta-analysis was prepared in accordance with the Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) statement. Data was extracted and analyzed on ten variables which include dysphagia score, heartburn rate, redo operative rate, operative time, overall complications, rate of conversion to open, Visick grading of satisfaction, overall satisfaction, length of hospital stay, and postoperative 24-h pH scores. DATA SYNTHESIS: Nine trials totaling 840 patients (anterior = 425, posterior = 415) were analyzed. There was a significant reduction in the odds ratio for dysphagia in the LAF group compared to the LPF group. Conversely, significant reduction in the odds ratio for heartburn was observed for LPF compared to LAF. Comparable effects were noted for both groups for other variables which include redo surgery, operating time, overall complications, conversion rate, Visick's grading, patients' satisfaction, length of hospital stay, and postoperative 24-h pH scores. CONCLUSIONS: Based on this meta-analysis, LPF compared to LAF is associated with significant reduction in heartburn at the expense of higher dysphagia rate on a short- and medium-term basis. We therefore conclude that LPF is a better alternative to LAF for controlling GERD symptoms.

Early versus traditional postoperative feeding in patients undergoing resectional gastrointestinal surgery: a meta-analysis.

BACKGROUND: A meta-analysis evaluating surgical outcomes following nutritional provision provided proximal to the anastomosis within 24 hours of gastrointestinal surgery compared with traditional postoperative management was conducted. METHODS: Databases were searched to identify randomized controlled trials comparing the outcomes of early and traditional postoperative feeding. Trials involving gastrointestinal tract resection followed by patients receiving nutritionally significant oral or enteral intake within 24 hours after surgery were included for analysis. RESULTS: Fifteen studies involving a total of 1240 patients were analyzed. A statistically significant reduction (45%) in relative odds of total postoperative complications was seen in patients receiving early postoperative feeding (odds ratio [OR] 0.55; confidence interval [CI], 0.35 -0.87, P = .01). No effect of early feeding was seen with relation to anastomotic dehiscence (OR 0.75; CI, 0.39-1.4, P = .39), mortality (OR 0.71; CI, 0.32-1.56, P = .39), days to passage of flatus (weighted mean difference [WMD] -0.42; CI, -1.12 to 0.28, P = .23), first bowel motion (WMD -0.28; CI, -1.20 to 0.64, P = .55), or reduced length of stay (WMD -1.28; CI, -2.94 to 0.38, P = .13); however, the direction of clinical outcomes favored early feeding. Nasogastric tube reinsertion was less common in traditional feeding interventions (OR 1.48; CI, 0.93-2.35, P = .10). CONCLUSIONS: Early postoperative nutrition is associated with significant reductions in total complications compared with traditional postoperative feeding practices and does not negatively affect outcomes such as mortality, anastomotic dehiscence, resumption of bowel function, or hospital length of stay.

Meta-analysis of randomized clinical trials comparing open and laparoscopic anti-reflux surgery.

OBJECTIVES: The aim of this study was to conduct a meta-analysis of randomized evidence to determine the relative merits of laparoscopic anti-reflux surgery (LARS) and open anti-reflux surgery (OARS) for proven gastro-esophageal reflux disease (GERD). METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents, and PubMed databases identified all randomized clinical trials that compared LARS and OARS and that were published in the English language between 1990 and 2007. A meta-analysis was carried out in accordance with the QUOROM (Quality of Reporting of Meta-Analyses) statement. The six outcome variables analyzed were operating time, hospital stay, return to normal activity, perioperative complications, treatment failure, and requirement for further surgery. Random-effects meta-analyses were carried out using odds ratios (ORs) and weighted mean differences (WMDs). RESULTS: Twelve trials were considered suitable for the meta-analysis. A total of 503 patients underwent OARS and 533 had LARS. For three of the six outcomes, the summary point estimates favored LARS over OARS. There was a significant reduction of 2.68 days in the duration of hospital stay for the LARS group compared with that for the OARS group (WMD: -2.68, 95% confidence interval (CI): -3.54 to -1.81; P<0.0001), a significant reduction of 7.75 days in return to normal activity for the LARS group compared with that for the OARS group (WMD: -7.75, 95% CI: -14.37 to -1.14; P=0.0216), and finally, there was a statistically significant reduction of 65% in the relative odds of complication rates for the LARS group compared with that for the OARS group (OR: 0.35, 95% CI: 0.16-0.75; P=0.0072). The duration of operating time was significantly longer (39.02 min) in the LARS group (WMD: 39.02, 95% CI: 17.99-60.05; P=0.0003). Treatment failure rates were comparable between the two groups (OR: 1.39, 95% CI: 0.71-2.72; P=0.3423). Despite this, the requirement for further surgery was significantly higher in the LARS group (OR: 1.79, 95% CI: 1.00-3.22; P=0.05). CONCLUSIONS: On the basis of this meta-analysis, the authors conclude that LARS is an effective and safe alternative to OARS for the treatment of proven GERD. LARS enables a faster convalescence and return to productive activity, with a reduced risk of complications and a similar treatment outcome, than an open approach. However, there is a significantly higher rate of re-operation (79%) in the LARS group.

Meta-analysis of laparoscopic and open distal gastrectomy for gastric carcinoma.

OBJECTIVES: The aim was to conduct a meta-analysis of the randomized evidence to determine the relative merits of laparoscopic assisted (LADG) and open (ODG) distal gastrectomy for proven gastric cancer. DATA SOURCES AND REVIEW METHODS: A search of the Medline, Embase, Science Citation Index, Current Contents, and PubMed databases identified all randomized clinical trials (RCTs) that compared LADG and OGD and were published in the English language between January 1990 and the end of June 2007. The meta-analysis was prepared in accordance with the Quality of Reporting of Meta-analyses (QUOROM) statement. The eight outcome variables analysed were operating time, blood loss, retrieval of lymph nodes, oral intake, hospital stay, postoperative complications, tumor recurrence, and mortality. Random effects meta-analyses were performed using odds ratios (OR) and weighted mean differences (WMD). RESULTS: Four trials were considered suitable for meta-analysis. A total of 82 patients underwent LADG and 80 had ODG. For only one of the eight outcomes, the summary point estimates favoured LADG over ODG; there was a significant reduction of 104.26 ml in intraoperative blood loss for LADG (WMD, -104.26, 95% confidence interval (CI) -189.01 to -19.51; p = 0.0159). There was however a 83.08 min longer duration of operating time for the LADG group compared with the ODG group (WMD 83.08, 95% CI 40.53 to 125.64; p = 0.0001) and significant reduction in lymph nodes harvesting of 4.34 lymph nodes in the LADG group (WMD -4.3, 95% CI -6.66 to -2.02; p = 0.0002). Other outcome variables such as time to commencement of oral intake (WMD -0.97, 95% CI -2.47 to 0.54; p = 0.2068), duration of hospital stay (WMD -3.32, 95% CI -7.69 to 1.05; p = 0.1365), rate of complications (OR 0.66, 95% CI 0.27 to 1.60; p = 0.3530), mortality rates (OR 0.94, 95% CI 0.21 to 4.19; p = 0.9363), and tumor recurrence (OR 1.08, 95% CI 0.42 to 2.79; p = 0.8806) were not found to be statistically significant for either group. However, for commencement of oral intake, duration of hospital stay, and complication rate, the trend was in favor of LADG. CONCLUSION: LADG was associated with a significantly reduced rate of intraoperative blood loss, at the expense of significantly longer operating time and significantly reduced lymph node retrieval compared to its open counterpart. Mortality and tumor recurrence rates were similar between the two groups. Furthermore, time to commencement of oral intake, postprocedural discharge from hospital, and perioperative complication rate, although not significantly different between the two groups, did suggest a positive trend toward LADG. Based on this meta-analysis, the authors cannot recommend the routine use of LADG over ODG for the treatment of distal gastric cancer. However, significant limitations exist in the interpretation of this data due to the limited number of published randomised control trials, the small sample sizes to date, and the limited duration of follow up. Further large multicentre randomized controlled trials are required to delineate significantly quantifiable differences between the two groups.