Minimally invasive surgery for Inflammatory Bowel Disease: a systematic review and meta-analysis of robotic versus laparoscopic surgical techniques.

BACKGROUND: To evaluate outcomes of robotic versus conventional laparoscopic colorectal resections in patients with inflammatory bowel disease (IBD). METHODS: Comparative studies of robotic versus laparoscopic colorectal resections in patients with IBD were included. Primary outcome was total post-operative complication rate. Secondary outcomes included operative time, conversion to open surgery, anastomotic leaks, intra-abdominal abscess formation, ileus occurrence, surgical site infection, re-operation, re-admission rate, length of hospital stay, and 30-day mortality. Combined overall effect sizes were calculated using random-effects model and the Newcastle-Ottawa Scale was used to assess risk of bias. RESULTS: Eleven non-randomised studies (n=5,566 patients) divided between those undergoing robotic (n=365) and conventional laparoscopic (n=5,201) surgery were included. Robotic platforms were associated with a significantly lower overall post-operative complication rate compared with laparoscopic surgery (P=0.03).Laparoscopic surgery was associated with a significantly shorter operative time (P=0.00001). No difference was found in conversion rates to open surgery (P=0.15), anastomotic leaks (P=0.84), abscess formation (P=0.21), paralytic ileus (P=0.06), surgical site infections (P=0.78), re-operation (P=0.26), re-admission rate (P=0.48), and 30-day mortality (P=1.00) between the groups.Length of hospital stay was shorter following a robotic sub-total colectomy compared with conventional laparoscopy (P=0.03). CONCLUSION: Outcomes in the surgical management of IBD are comparable between traditional laparoscopic techniques and robotic-assisted minimally invasive surgery demonstrating the safety and feasibility of robotic platforms. Larger studies investigating the use of robotic technology in Crohn's disease and ulcerative colitis separately may be of benefit with specific focus on important IBD-related metrics.

Event-Related Spectral Perturbation, Inter Trial Coherence, and Functional Connectivity in motor execution: A comparative EEG study of old and young subjects.

INTRODUCTION: The motor-related bioelectric brain activity of healthy young and old subjects was studied to understand the effect of aging on motor execution. A visually cued finger tapping movement paradigm and high-density EEG were used to examine the time and frequency characteristics. METHODS: Twenty-two young and 22 healthy elderly adults participated in the study. Repeated trials of left and right index finger movements were recorded with a 128-channel EEG. Event-Related Spectral Perturbation (ERSP), Inter Trial Coherence (ITC), and Functional Connectivity were computed and compared between the age groups. RESULTS: An age-dependent theta and alpha band ERSP decrease was observed over the frontal-midline area. Decrease of beta band ERSP was found over the ipsilateral central-parietal regions. Significant ITC differences were found in the delta and theta bands between old and young subjects over the contralateral parietal-occipital areas. The spatial extent of increased ITC values was larger in old subjects. The movement execution of older subjects showed higher global efficiency in the delta and theta bands, and higher local efficiency and node strengths in the delta, theta, alpha, and beta bands. CONCLUSION: As functional compensation of aging, elderly motor networks involve more nonmotor, parietal-occipital, and frontal areas, with higher global and local efficiency, node strength. ERSP and ITC changes seem to be sensitive and complementary biomarkers of age-related motor execution.

Heartbeat classification based on single lead-II ECG using deep learning.

The analysis and processing of electrocardiogram (ECG) signals is a vital step in the diagnosis of cardiovascular disease. ECG offers a non-invasive and risk-free method for monitoring the electrical activity of the heart that can assist in predicting and diagnosing heart diseases. The manual interpretation of the ECG signals, however, can be challenging and time-consuming even for experts. Machine learning techniques are increasingly being utilized to support the research and development of automatic ECG classification, which has emerged as a prominent area of study. In this paper, we propose a deep neural network model with residual blocks (DNN-RB) to classify cardiac cycles into six ECG beat classes. The MIT-BIH dataset was used to validate the model resulting in a test accuracy of 99.51%, average sensitivity of 99.7%, and average specificity of 98.2%. The DNN-RB method has achieved higher accuracy than other state-of-the-art algorithms tested on the same dataset. The proposed method is effective in the automatic classification of ECG signals and can be used for both clinical and out-of-hospital monitoring and classification combined with a single-lead mobile ECG device. The method has also been integrated into a web application designed to accept digital ECG beats as input for analyses and to display diagnostic results.

A Comprehensive Research Schema for the Characterization of Aortic Aneurysms.

A robust, accurate, and standardized approach to measurement of the aorta is critical to improve the predictive accuracy of these aortic measurements, and to investigate other aortic imaging biomarkers. Developing a comprehensive and generic schema for characterization of the aorta to enable investigators to standardize data that are collected across all aorta research. A systematic review of the literature was conducted to identify and assess schemata of aortic measurement and description. The schemata were reported and discussed to guide the synthesis of a comprehensive schema. We propose the International College of Angiology Aortic Research Schema as a comprehensive design that fills the gaps left behind by previously reported schemata. It is intended to be applicable for all clinically relevant purposes, including endograft development for aneurysm repair and for the accurate characterization of the aortic anatomy. This schema divides the aorta into 14 segments and 2 sections (thoracic and abdominal aortas). The segmentation proposed can be used in addition to specific measurements taken for any aneurysm including the neck, and maximal and minimal diameters of the aneurysm.

A case of prune belly syndrome: Experience from a regional hospital in Togo.

INTRODUCTION AND IMPORTANCE: Prune Belly syndrome is a rare congenital condition first reported in 1939. It is a malformative disease associated with high mortality. We report a neonatal case in a regional hospital in Togo. PRESENTATION OF CASE: A 4-month-old male infant was brought to the hospital by his uncle because of a "deformity of the abdomen and absence of testicles". The examination revealed hypoplasia of the abdominal wall associated with bilateral cryptorchidism. Abdominal and urinary tract ultrasound revealed a left pyelocaliceal dilatation and a right megaureter. All these data allowed the diagnosis of Prune Belly syndrome. CONCLUSION: Prune Belly syndrome is a rare and complex disease with a high mortality rate.

Impact of intravenous access site on attenuation for thoracic computed tomographic angiography: A time-matched, nested, case-control study.

BACKGROUND: The objective of this study was to evaluate whether the choice of intravenous access (IVA) site affects aortic attenuation during thoracic computed tomographic angiography (T-CTA) and any associated risks with intravenous device placement. METHODS: All T-CTA exams performed between 1/1/2013 and 8/14/2015 were retrospectively reviewed to identify those performed with contrast media injection via alternative (i.e. non-antecubital) IVA (n = 1769). Using time matching, antecubital IVA exams (n = 1769) were selected as controls. For each exam, attenuation was measured in the ascending aorta. Patient and technical data was subsequently collected from all 3538 patients included in this study. Multiple linear regression was used to determine if IVA site affected attenuation. Lastly, data related to extravasations for the entire T-CTA cohort were collected and compared. RESULTS: Hand/wrist, arm, and central venous access device IVA were all equivalent to antecubital IVA in terms of attenuation (P = 0.579, P = 0.599, and P = 0.522 respectively). Forearm and intraosseous IVA had significantly higher attenuation (P = 0.010 and P = 0.002, respectively) than antecubital IVA. Right-sided IVA was associated with a small attenuation increase of 11 Hounsfield Units (P < 0.001) compared to left-sided IVA. In terms of extravasation, antecubital IVA was equivalent to hand/wrist, forearm, and upper arm IVA (P = 0.778, P = 0.060, and P = 0.090 respectively). CONCLUSIONS: Satisfactory aortic attenuation achieved with non-antecubital IVA is equivalent to attenuation achieved with antecubital IVA for T-CTA imaging. The risk of contrast media extravasation in peripheral IVA devices was relatively low, however, appropriate IVA site selection should be considered an important factor for successful administration of contrast media for future imaging studies. This prevents undue harm to patients through preventable device failures when using a peripheral IV device in areas of high flexion/range of movements undergoing pressure injection for contrast media.

Enhanced Arithmetic Optimization Algorithm for Parameter Estimation of PID Controller.

The Proportional-Integral-Derivative (PID) controller is a key component in most engineering applications. The main disadvantage of PID is the selection of the best values for its parameters using traditional methods that do not achieve the best response. In this work, the recently released empirical identification algorithm that is the Arithmetic Optimization Algorithm (AOA) was used to determine the best values of the PID parameters. AOA was selected due to its effective exploration ability. Unfortunately, AOA cannot achieve the best parameter values due to its poor exploitation of search space. Hence, the performance of the AOA exploit is improved by combining it with the Harris Hawk Optimization (HHO) algorithm which has an efficient exploit mechanism. In addition, avoidance of trapping in the local lower bounds of AOA-HHO is enhanced by the inclusion of perturbation and mutation factors. The proposed AOA-HHO algorithm is tested when choosing the best values for PID parameters to control two engineering applications namely DC motor regulation and three fluid level sequential tank systems. AOA-HHO has superiority over AOA and comparative algorithms.

Unusual form of inguinal hernia: A case report of Littré's hernia strangled.

INTRODUCTION: Littré's hernia is a rare condition related to Meckel's diverticulum. Its diagnosis is per operative and its treatment is surgical. We report a case of Littre's hernia strangled, discovered in a 67-year-old adult in Togo. CASE REPORT: A 67-year-old farmer was seen in the emergency room for a painful right inguinoscrotal swelling. The diagnosis of strangulated right inguinoscrotal hernia was retained and a surgical indication was given. Intraoperatively, a Meckel's diverticulum was found in the hernia sac and an intraoperative diagnosis of Littre's hernia was made. The patient underwent a T-shaped resection with terminal ileo-ileal anastomosis. The postoperative course was simple. CONCLUSION: Littré's hernia is a rare and exceptional disease whose preoperative diagnosis is difficult. Surgery is the therapeutic modality for this condition.

Surgical Management of Perforated Peptic Ulcer: A Comparative Meta-analysis of Laparoscopic Versus Open Surgery.

BACKGROUND: Despite the widescale success of proton pump inhibitors to reducing the incidence of peptic ulcer disease, perforated peptic ulcer (PPU) remains a significant cause of severe complications and death. The implementation of open or surgical repair of PPU should be guided by reliable guidelines which are based on current systematic evidence. OBJECTIVES: To assess the comparative efficacy and safety of laparoscopic and open repair of PPU. METHODS: A systematic review and meta-analysis was conducted based on retrospective, prospective cohort studies, and randomized clinical trials. Duration of surgery and postoperative complications and death were collected from eligible studies, and the outcomes were pooled using mean differences (MD) or relative risks (RRs) for numerical and binary outcomes, respectively. The estimated variance was expressed as 95% confidence intervals (95% CIs). RESULTS: Forty-five studies were included (8456 patients, 56.08% underwent open repair, 6 prospective studies, 7 randomized clinical trials, and 32 retrospective studies). Compared with open repair, laparoscopic surgeries were associated with longer operative times (MD=8.36, 95% CI, 0.49-16.22), shorter hospital stay (MD=-2.74, 95% CI, -3.70 to-1.79), a higher risk of suture leakage (RR=1.91, 95% CI, 1.04-3.49) and lower risks of mortality (RR=0.57, 95% CI, 0.47-0.70), septic shock (RR=0.69, 95% CI, 0.49-0.98), renal failure (RR=0.38, 95% CI, 0.18-0.79), and wound infection (RR=0.26, 95% CI, 0.19-0.37). CONCLUSION: Laparoscopic repair of PPU showed promising safety outcomes; however, future well-designed randomized studies are warranted to reduce the observed performance bias and possible selection bias in individual studies.

Esophageal Schwannoma: An Important Differential Diagnosis for Esophageal Subepithelial Lesions.

Esophageal schwannoma is a rare tumor and is classified as one of the esophageal subepithelial lesions (SELs). Endoscopic ultrasound (EUS) evaluation is the gold standard for evaluating subepithelial lesions. Differentiation through EUS-guided fine needle aspiration is sometimes important to exclude lesions with malignant potential. Immunohistochemistry differentiates schwannoma from other subepithelial lesions. Strong and diffuse positivity for S100 is characteristic. The decision for conservative management versus endoscopic or thoracoscopic intervention is made based on the tumor size, location, and symptoms.

Acute ST-Elevation Myocardial Infarction Presenting With Persistent Vomiting.

Atypical presentations of acute coronary syndrome (ACS) have been commonly known to occur but are often excluded in the differential when other diagnoses seem more likely. Female gender, patients with diabetes, hypertension, age greater than 55, and a history of smoking are some of the risk factors that have been associated with noncharacteristic presentations of ACS. This often leads to misdiagnosis and overall increased mortality. Patients with risk factors for atypical presentations of myocardial infarctions should mandate a low threshold for suspicion and undergo evaluation with EKG and troponins for prompt diagnosis and early intervention.

Pancreatic Plasmacytoma: A Case of Recurrent Disease.

Pancreatic plasmacytoma is a rare entity of extramedullary plasmacytomas (EMP). It is important to consider pancreatic plasmacytoma in patients diagnosed with multiple myeloma (MM) presenting with obstructive jaundice. We present a case of pancreatic plasmacytoma in a patient with previously diagnosed multiple myeloma and extramedullary plasmacytoma in remission. Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) were of great diagnostic and therapeutic value for acute management.

Human Activity Recognition Based on Embedded Sensor Data Fusion for the Internet of Healthcare Things.

Nowadays, the emerging information technologies in smart handheld devices are motivating the research community to make use of embedded sensors in such devices for healthcare purposes. In particular, inertial measurement sensors such as accelerometers and gyroscopes embedded in smartphones and smartwatches can provide sensory data fusion for human activities and gestures. Thus, the concepts of the Internet of Healthcare Things (IoHT) paradigm can be applied to handle such sensory data and maximize the benefits of collecting and analyzing them. The application areas contain but are not restricted to the rehabilitation of elderly people, fall detection, smoking control, sportive exercises, and monitoring of daily life activities. In this work, a public dataset collected using two smartphones (in pocket and wrist positions) is considered for IoHT applications. Three-dimensional inertia signals of thirteen timestamped human activities such as Walking, Walking Upstairs, Walking Downstairs, Writing, Smoking, and others are registered. Here, an efficient human activity recognition (HAR) model is presented based on efficient handcrafted features and Random Forest as a classifier. Simulation results ensure the superiority of the applied model over others introduced in the literature for the same dataset. Moreover, different approaches to evaluating such models are considered, as well as implementation issues. The accuracy of the current model reaches 98.7% on average. The current model performance is also verified using the WISDM v1 dataset.

Low Turnover Renal Osteodystrophy With Abnormal Bone Quality and Vascular Calcification in Patients With Mild-to-Moderate CKD.

Introduction: Limited information is available on renal osteodystrophy (ROD) and vascular calcification (VC) during early chronic kidney disease (CKD). This study was designed to evaluate ROD and VC in 32 patients with CKD stages II to IV. Methods: Patients underwent dual-energy X-ray absorptiometry (DXA) for assessment of bone mineral density (BMD) and trabecular bone score (TBS), thoracic computed tomography for VC scoring using the Agatston method, and anterior iliac crest bone biopsy for mineralized bone histology, histomorphometry, and Fourier transform infrared spectroscopy (FTIR). Classical and novel bone markers were determined in the blood. Results: Mean estimated glomerular filtration rate (eGFR) was 44 ± 16 ml/min per 1.73 m2. Of the patients, 84% had low bone turnover. In Whites, eGFR correlated negatively with the turnover parameter activation frequency (Ac.f) (r -0.48, P = 0.019) and with parameters of bone formation. Most patients had VC (>80%) which correlated positively with levels of phosphorus, c-terminal fibroblast growth factor-23, and activin. Aortic calcifications (ACs) correlated negatively with bone formation rate (BFR) and Ac.f (rho -0.62, -0.61, P < 0.001). TBS correlated negatively with coronary calcification (rho -0.42, P = 0.019) and AC (rho -0.57, P = 0.001). These relationships remained after adjustment of age. The mineral-to-matrix ratio, an FTIR metric reflecting bone quality, was negatively related to Ac.f and positively related to AC. Conclusion: Low bone turnover and VC are predominant in early stages of CKD. This is the first study demonstrating mineral abnormalities indicating reduced bone quality in these stages of CKD.

Complete postsurgical left ventricular-aortic discontinuity and pseudoaneurysm formation.

BACKGROUND: Left ventricular outflow tract pseudoaneurysm is a rare but potentially fatal complication of aortic valve replacement, infective endocarditis (IE), and suture dehiscence. Left ventricular-aortic discontinuity is a severe and uncommon manifestation of IE. For patients who have a long-standing history of endocarditis, periannular lesions in the aortic valve may rupture, leading to the rare occurrence of complete, or total, left ventricular-aortic discontinuity. METHODS: We present a case of complete postoperative left ventricular-aortic discontinuity and massive circumferential left ventricular outflow tract pseudoaneurysm discovered during a 3-month follow-up visit. Appropriate consent was obtained from all parties before submission of this case report. RESULTS: Postoperative cardiac computed tomography of a patient demonstrated dehiscence of a recently placed surgical aortic valve from the left ventricular outflow tract, with massive circumferential pseudoaneurysm formation. Only a small remnant of the membranous interventricular septum connected the aortic root to the heart, informing the diagnosis of complete left ventricular-aortic discontinuity. CONCLUSION: The clinical presentation of a left ventricular outflow tract pseudoaneurysm with concomitant left ventricular-aortic discontinuity is commonly nonspecific or clinically silent; thus, it requires a high index of suspicion and use of multimodality imaging for diagnosis and management.

Sickle Cell Intrahepatic Cholestasis: Extremely Rare but Fatal Complication of Sickle Cell Disease.

Sickle cell intrahepatic cholestasis (SCIC) is a rare but potentially fatal complication of sickle cell disease (SCD), with high mortality, observed mainly in patients with homozygous sickle cell anemia. Herein, we have reported a case of severe SCIC with a poor outcome despite aggressive measures including exchange transfusion and use of vasopressors. The patient was admitted with generalized weakness, confusion, rigors, chills, and signs of hepatic failure, such as hyperbilirubinemia, hypoalbuminemia, and coagulopathy. There was no evidence of viral hepatitis or biliary obstruction. The patient received two exchange transfusions, but he continued to deteriorate clinically despite exchange transfusion and developed hemorrhagic shock and multiorgan failure. The patient was made comfort care as per family wishes. This case emphasizes the importance of early diagnosis of sickle cell intrahepatic cholestasis and poor prognosis despite aggressive measures.

Predictors of type-2 diabetes remission following bariatric surgery after a two-year follow-up.

PURPOSE: Bariatric surgery is evolving as a successful tool for managing morbid obesity and T2DM. This study aimed to identify predictors of diabetes remission after two types of bariatric procedures. METHODS: This prospective study enrolled 172 patients with morbid obesity associated with T2DM scheduled for bariatric surgery. Two laparoscopic bariatric procedures were done; single anastomosis gastric bypass (SAGB, n = 83) and sleeve gastrectomy (LSG, n = 68). Lipid accumulation product index (LAP) and quantitative insulin sensitivity check index (QUICKI) were used to evaluate lipid profile and insulin sensitivity. Two years after surgery condition of DM was evaluated as complete remission (CR), partial remission (PR), or improvement. The primary outcome measure was predictors of diabetes remission. RESULTS: Two years after surgery, 151 patients were available for evaluation, where 75 patients (49.7%) achieved CR, while PR was found in 36 (23.8%). CR was significantly associated with younger age, shorter duration of DM (p < 0.001, for both), higher C-peptide and GLP-1 levels (p < 0.001 and p = 0.002, respectively), and bypass surgery (p = 0.027). On multivariate analysis, shorter duration of DM, lower BMI, and higher C-peptide levels were the independent factors predicting CR. CONCLUSION: Complete remission of T2DM can be achieved in nearly half of the patients two years after SG or SAGB. The duration of diabetes and preoperative BMI and C-peptide levels are the independent factors predicting complete remissions.

Negative Appendicectomy Rate: Incidence and Predictors.

Introduction Acute appendicitis is a common emergency surgical presentation. The gold standard treatment is surgery. Like any surgical procedure, appendicectomy is associated with complications. Negative appendicectomy (NA) can occur, and its incidence is 15%-39%. This study aimed to evaluate the rate and predictors of NA in a cohort. Patients and methods A retrospective study over a year through which data of patients who underwent emergency appendicectomies were collected and analyzed. The absence of inflammatory process and/or other significant pathology in the appendix was considered negative for appendicitis. An utter definition of NA was the absence of inflammatory cells in the appendix. The NA rate (NAR) was calculated using the standard criteria (NAR-SDC) and the strict criteria (NAR-STC). The routine laboratory parameters for diagnosing acute appendicitis on admission were collected. Increased inflammatory markers in the form of leucocytosis of total WBC > 11,000 per mm, elevated CPR > 5 mg/L, and isolated elevated total serum bilirubin > 20 µmol/L, were suggestive of acute appendicitis. Results Three hundred and seventy-two patients were included, 179 males and 193 females with a median age were 27 (5-94) years. The median duration of symptoms and waiting time to surgery were two days and one day, respectively. The mean admission WBC, C-reactive protein (CRP) and serum bilirubin levels were 12,600 (3,000-38,000)/mm3, 66.9 (1-323) mg/L and 12.7 (4-38) µmol/L respectively. Laparoscopic appendicectomy was performed in 93.5% of patients with a conversion rate of 4.6%. NAR-SDC was 10.2% and NAR-STC was 25.8%. NAR was significantly higher in females than males (39.4% versus 11.1%; p-value 0.0001). Patients with NA were younger (p-value 0.0001), had lower mean total WBC (p-value 0.014), CRP (p-value 0.0001) and total serum bilirubin (p-value 0.0001) levels on admission. Conclusion NA is still a major problem in the management of patients with acute right lower abdominal pain. Our NAR compared favourably with reported rates. Female gender, duration of symptoms more than three days, and lower total WBC were independent predictors of NA.

Swiss cheese interventricular septum presenting with catastrophic stroke: the potential role of ECG-gated CTA.

Ventricular septal defect is a common congenital cardiac condition that presents in a variety of morphologies. Less commonly, when an individual patient is found to have multiple ventricular septal defects, the term "Swiss cheese ventricular septal defect" is applied. Although not routinely utilized in clinical practice, electrocardiogram (ECG)-gated computed tomographic angiography (CTA) has been shown to provide utility in detecting intracardiac shunts, demonstrating promise in preventing acute strokes secondary to a paradoxical embolus from occurring; this is especially important when atypical cardiac septa are suspected. This case seeks to illustrate how usage of ECG-gated CTA can assist in early detection and prevention of adverse outcomes resulting from an atypical presentation of a ventricular septal defect.

Secondary Hyperparathyroidism Before and After Bariatric Surgery: a Prospective Study with 2-Year Follow-Up.

PURPOSE: Secondary hyperparathyroidism (SHPT) is linked to obesity. Bariatric surgery may be associated with calcium and vitamin D deficiencies leading to SHPT. This study aimed to detect the prevalence of SHPT before and after bariatric surgery. METHODS: This prospective study assessed the prevalence of SHPT after sleeve gastrectomy (SG, n = 38) compared to one-anastomosis gastric bypass (OAGB, n = 86). All patients were followed up for 2 years. Bone mineral density (BMD) was assessed using dual-energy X-ray absorptiometry. RESULTS: Of the 124 patients, 71 (57.3%) were females, and 53 (42.7%) were males, with a mean age of 37.5 ± 8.8 years. Before surgery, 23 patients (18.5%) suffered from SHPT, and 40 (32.3%) had vitamin D deficiency. The prevalence of SHPT increased to 29.8% after 1 year and 36.3% after 2 years. SHPT was associated with lower levels of vitamin D and calcium and higher reduction of BMD in the hip but not in the spine. After 2 years, SHPT was associated with a significantly lower T-score in the hip. SHPT and vitamin D deficiency were significantly more common in patients subjected to OAGB compared to SG (p = 0.003, and p < 0.001, respectively). There is a strong negative correlation between vitamin D levels and parathormone levels before and after surgery. CONCLUSION: Prevalence of SHPT is high in obese patients seeking bariatric surgery, especially with lower vitamin D levels. Bariatric surgery increases the prevalence of SHPT up to 2 years. Gastric bypass is associated with a higher risk of developing SHPT compared to SG.