Adherence to COVID-19 preventive measures among residents in selected townships, Yangon Region, Myanmar: a community-based cross-sectional study.

BACKGROUND: To fight the current coronavirus disease (COVID-19) pandemic, many countries have implemented various mitigation measures to contain the spread of the disease. By engaging with health service providers, the community's participation in adherence to preventive measures is certainly required in the implementation of COVID-19 mitigation strategies. Therefore, this study aimed to assess the level of adherence to COVID-19 preventive measures and its associated factors among the residents, Yangon Region, Myanmar. METHODS: A community-based cross-sectional study was carried out among 636 residents in Yangon Region, Myanmar, from October to December 2021. A multistage non-probability sampling method, purposively selected for three townships in Yangon Region and convenience sampling for 212 participants from each township, was applied and the data were collected by face-to-face interviews using structured and pretested questionnaires. Data were entered, coded, and analyzed using IBM SPSS version 25.0. Simple and multiple logistic regression analysis were performed to identify the significant variables of adherence to COVID-19 preventive measures. RESULTS: As a level of adherence to COVID-19 preventive measures, the proportion of residents who had good adherence was 39.3% (95% CI 35.5-43.2%), moderate adherence was 37.6% (95% CI 33.8-41.5%), and poor adherence was 23.1% (95% CI 19.9-26.6%). The age group of 31-40 years (AOR: 3.13, 95% CI 1.62-6.05), 30 years and younger (AOR: 3.22, 95% CI 1.75-5.92), Burmese ethnicity (AOR: 2.52, 95% CI 1.44-4.39), own business (AOR: 3.19, 95% CI 1.15-8.87), high school education level and below (AOR: 1.64, 95% CI 1.02-2.69), less than 280.90 USD of monthly family income (AOR: 1.51, 95% CI 1.01-2.29), low knowledge about COVID-19 (AOR: 1.90, 95% CI 1.26-2.88) were significantly associated with poor adherence to COVID-19 preventive measures. CONCLUSIONS: In this study, nearly one-fourth of the residents were experiencing poor adherence to COVID-19 preventive measures. Therefore, building up the risk communication through the community using widely used mainstream media, the continuation of disease surveillance and announcement of updated information or advice for the public to increase awareness towards COVID-19, and enforcement to follow the recommended directions and regulations of health institutions are vital to consider for improving the adherence to preventive measures against COVID-19 among the residents.

Molecular markers of artemisinin resistance during falciparum malaria elimination in Eastern Myanmar.

BACKGROUND: Artemisinin resistance in Plasmodium falciparum threatens global malaria elimination efforts. To contain and then eliminate artemisinin resistance in Eastern Myanmar a network of community-based malaria posts was instituted and targeted mass drug administration (MDA) with dihydroartemisinin-piperaquine (three rounds at monthly intervals) was conducted. The prevalence of artemisinin resistance during the elimination campaign (2013-2019) was characterized. METHODS: Throughout the six-year campaign Plasmodium falciparum positive blood samples from symptomatic patients and from cross-sectional surveys were genotyped for mutations in kelch-13-a molecular marker of artemisinin resistance. RESULT: The program resulted in near elimination of falciparum malaria. Of 5162 P. falciparum positive blood samples genotyped, 3281 (63.6%) had K13 mutations. The prevalence of K13 mutations was 73.9% in 2013 and 64.4% in 2019. Overall, there was a small but significant decline in the proportion of K13 mutants (p < 0.001). In the MDA villages there was no significant change in the K13 proportions before and after MDA. The distribution of different K13 mutations changed substantially; F446I and P441L mutations increased in both MDA and non-MDA villages, while most other K13 mutations decreased. The proportion of C580Y mutations fell from 9.2% (43/467) before MDA to 2.3% (19/813) after MDA (p < 0.001). Similar changes occurred in the 487 villages where MDA was not conducted. CONCLUSION: The malaria elimination program in Kayin state, eastern Myanmar, led to a substantial reduction in falciparum malaria. Despite the intense use of artemisinin-based combination therapies, both in treatment and MDA, this did not select for artemisinin resistance.

Hyperactive STAT5 hijacks T cell receptor signaling and drives immature T cell acute lymphoblastic leukemia.

T cell acute lymphoblastic leukemia (T-ALL) is an aggressive immature T cell cancer. Mutations in IL7R have been analyzed genetically, but downstream effector functions such as STAT5A and STAT5B hyperactivation are poorly understood. Here, we studied the most frequent and clinically challenging STAT5BN642H driver in T cell development and immature T cell cancer onset and compared it with STAT5A hyperactive variants in transgenic mice. Enhanced STAT5 activity caused disrupted T cell development and promoted an early T cell progenitor-ALL phenotype, with upregulation of genes involved in T cell receptor (TCR) signaling, even in absence of surface TCR. Importantly, TCR pathway genes were overexpressed in human T-ALL and mature T cell cancers and activation of TCR pathway kinases was STAT5 dependent. We confirmed STAT5 binding to these genes using ChIP-Seq analysis in human T-ALL cells, which were sensitive to pharmacologic inhibition by dual STAT3/5 degraders or ZAP70 tyrosine kinase blockers in vitro and in vivo. We provide genetic and biochemical proof that STAT5A and STAT5B hyperactivation can initiate T-ALL through TCR pathway hijacking and suggest similar mechanisms for other T cell cancers. Thus, STAT5 or TCR component blockade are targeted therapy options, particularly in patients with chemoresistant clones carrying STAT5BN642H.

Can Computerized Simulation be Used to Assess Surgical Proficiency in Laparoscopic Colorectal Surgeries? A Systematic Review.

INTRODUCTION: Computerized simulation (CS) of surgery in virtual reality (VR), augmented reality (AR) and mixed reality (MR) settings are used to teach foundational skills, but its applicability in advanced training is to be determined. This review aims to summarize the types of CS available for laparoscopic colorectal surgery (CRS) and its utility in assessment of proficiency. METHODS: A systematic review of CS in laparoscopic CRS was done on PubMed, Embase, Scopus and Cochrane Library databases. RESULTS: Eleven relevant observational studies were identified. The most common procedure simulated was laparoscopic colectomy. Assessment using performance metrics measured by the simulator such as path length moved by laparoscopic tools, procedure time and number of discrete movements had the most consistent differentiating ability between expert and non-expert cohorts. Surgeons fared similarly in proficiency scores in assessment with CS compared to assessment with traditional cadaveric or porcine models. CONCLUSION: CS of laparoscopic CRS may be used in assessment of proficiency using performance metrics measuring economy of movement. CS may be a viable assessment tool in advanced surgical training, but further studies should assess utility of incorporating it as a formal assessment tool in training programs.

Establishing the Learning Curve of Laparoscopic and Robotic Distal Gastrectomy: a Systematic Review and Meta-Regression Analysis.

BACKGROUND: Minimally invasive distal gastrectomy (MIDG) is non-inferior compared with open distal gastrectomy for gastric cancer. However, MIDG bears a learning curve (LC). This study aims to evaluate the number of cases required to surmount the LC (i.e. NLC) in MIDG. METHODS: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched from inception to August 2022 for studies which reported NLC in MIDG. NLC on reduced-port/single-port MIDG only were separately analysed. Poisson mean (95% confidence interval (CI)) was used to determine NLC. Negative binomial regression was used to compare NLC between laparoscopic distal gastrectomy (LDG) and robotic distal gastrectomy (RDG). RESULTS: A total of 45 articles with 71 data sets (LDG n=47, RDG n=24) were analysed. There were 7776 patients in total (LDG n=5516, RDG n=2260). Majority of studies were conducted in East Asia (n=68/71). Majority (76.1%) of data sets used non-arbitrary methods of analyses. The overall NLC for RDG was significantly lower compared to LDG (RDG 22.4 (95% CI: 20.4-24.5); LDG 46.7 (95% CI: 44.1-49.4); incidence rate ratio 0.48, p<0.001). The median number of laparoscopic gastrectomy (LG) cases prior was 0 (interquartile range (IQR) 0-105) for LDG and 159 (IQR 101-305.3) for RDG. Meta-regression analysis did not show a significant impact prior experience in LG, extent of lymphadenectomy and intracorporeal vs extracorporeal anastomosis had on overall NLC for LDG and RDG. CONCLUSION: NLC for RDG is shorter compared to LDG, but this may be due to prior experience in LG and ergonomic advantages of RDG.

'Forest malaria' in Myanmar? Tracking transmission landscapes in a diversity of environments.

BACKGROUND: In the Greater Mekong Subregion, case-control studies and national-level analyses have shown an association between malaria transmission and forest activities. The term 'forest malaria' hides the diversity of ecosystems in the GMS, which likely do not share a uniform malaria risk. To reach malaria elimination goals, it is crucial to document accurately (both spatially and temporally) the influence of environmental factors on malaria to improve resource allocation and policy planning within given areas. The aim of this ecological study is to characterize the association between malaria dynamics and detailed ecological environments determined at village level over a period of several years in Kayin State, Myanmar. METHODS: We characterized malaria incidence profiles at village scale based on intra- and inter-annual variations in amplitude, seasonality, and trend over 4 years (2016-2020). Environment was described independently of village localization by overlaying a 2-km hexagonal grid over the region. Specifically, hierarchical classification on principal components, using remote sensing data of high spatial resolution, was used to assign a landscape and a climate type to each grid cell. We used conditional inference trees and random forests to study the association between the malaria incidence profile of each village, climate and landscape. Finally, we constructed eco-epidemiological zones to stratify and map malaria risk in the region by summarizing incidence and environment association information. RESULTS: We identified a high diversity of landscapes (n = 19) corresponding to a gradient from pristine to highly anthropogenically modified landscapes. Within this diversity of landscapes, only three were associated with malaria-affected profiles. These landscapes were composed of a mosaic of dense and sparse forest fragmented by small agricultural patches. A single climate with moderate rainfall and a temperature range suitable for mosquito presence was also associated with malaria-affected profiles. Based on these environmental associations, we identified three eco-epidemiological zones marked by later persistence of Plasmodium falciparum, high Plasmodium vivax incidence after 2018, or a seasonality pattern in the rainy season. CONCLUSIONS: The term forest malaria covers a multitude of contexts of malaria persistence, dynamics and populations at risk. Intervention planning and surveillance could benefit from consideration of the diversity of landscapes to focus on those specifically associated with malaria transmission.

Malaria temporal dynamic clustering for surveillance and intervention planning.

BACKGROUND: Targeting interventions where most needed and effective is crucial for public health. Malaria control and elimination strategies increasingly rely on stratification to guide surveillance, to allocate vector control campaigns, and to prioritize access to community-based early diagnosis and treatment (EDT). We developed an original approach of dynamic clustering to improve local discrimination between heterogeneous malaria transmission settings. METHODS: We analysed weekly malaria incidence records obtained from community-based EDT (malaria posts) in Karen/Kayin state, Myanmar. We smoothed longitudinal incidence series over multiple seasons using functional transformation. We regrouped village incidence series into clusters using a dynamic time warping clustering and compared them to the standard, 5-category annual incidence standard stratification. RESULTS: We included 1115 villages from 2016 to 2020. We identified eleven P. falciparum and P. vivax incidence clusters which differed by amplitude, trends and seasonality. Specifically the 124 villages classified as "high transmission area" in the standard P. falciparum stratification belonged to the 11 distinct groups when accounting to inter-annual trends and intra-annual variations. Likewise for P. vivax, 399 "high transmission" villages actually corresponded to the 11 distinct dynamics. CONCLUSION: Our temporal dynamic clustering methodology is easy to implement and extracts more information than standard malaria stratification. Our method exploits longitudinal surveillance data to distinguish local dynamics, such as increasing inter-annual trends or seasonal differences, providing key information for decision-making. It is relevant to malaria strategies in other settings and to other diseases, especially when many countries deploy health information systems and collect increasing amounts of health outcome data. FUNDING: The Bill & Melinda Gates Foundation, The Global Fund against AIDS, Tuberculosis and Malaria (the Regional Artemisinin Initiative) and the Wellcome Trust funded the METF program.

Exploring the learning curve in minimally invasive esophagectomy: a systematic review.

Minimally invasive esophagectomy (MIE) has been shown to be superior to open esophagectomy with reduced morbidity, mortality, and comparable lymph node (LN) harvest. However, MIE is technically challenging. This study aims to perform a pooled analysis on the number of cases required to surmount the learning curve (LC), i.e. NLC in MIE. PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 2022. Inclusion criteria were articles that reported LC in video-assisted MIE (VAMIE) and/or robot-assisted MIE (RAMIE). Poisson means (95% confidence interval [CI]) was used to determine NLC. Negative binomial regression was used for comparative analysis. There were 41 articles with 45 data sets (n = 7755 patients). The majority of tumors were located in the lower esophagus or gastroesophageal junction (66.7%, n = 3962/5939). The majority of data sets on VAMIE (n = 16/26, 61.5%) used arbitrary analysis, while the majority of data sets (n = 14/19, 73.7%) on RAMIE used cumulative sum control chart analysis. The most common outcomes reported were overall operating time (n = 30/45) and anastomotic leak (n = 28/45). Twenty-four data sets (53.3%) reported on LN harvest. The overall NLC was 34.6 (95% CI: 30.4-39.2), 68.5 (95% CI: 64.9-72.4), 27.5 (95% CI: 24.3-30.9), and 35.9 (95% CI: 32.1-40.2) for hybrid VAMIE, total VAMIE, hybrid RAMIE, and total RAMIE, respectively. NLC was significantly lower for total RAMIE compared to total VAMIE (incidence rate ratio: 0.52, P = 0.032). Studies reporting NLC in MIE are heterogeneous. Further studies should clearly define prior surgical experiences and assess long-term oncological outcomes using non-arbitrary analysis.

Learning curve of laparoscopic and robotic total gastrectomy: A systematic review and meta-analysis.

PURPOSE: Minimally-invasive total gastrectomy (MITG) is associated with lower morbidity in comparison to open total gastrectomy but requires a learning curve (LC). We aimed to perform a pooled analysis of the number of cases required to surmount the LC (NLC) in MITG. METHODS: A systematic review of PubMed, Embase, Scopus and the Cochrane Library from inception until August 2022 was performed for studies reporting the LC in laparoscopic total gastrectomy (LTG) and/or robotic total gastrectomy (RTG). Poisson mean (95% confidence interval [CI]) was used to determine the NLC. Negative binomial regression was performed as a comparative analysis. RESULTS: There were 12 articles with 18 data sets: 12 data sets (n = 1202 patients) on LTG and 6 data sets (n = 318 patients) on RTG. The majority of studies were conducted in East Asia (94.4%). The majority of the data sets (n = 12/18, 66.7%) used non-arbitrary analyses. The NLC was significantly smaller in RTG in comparison to LTG [RTG 20.5 (95% CI 17.0-24.5); LTG 43.9 (95% CI 40.2-47.8); incidence rate ratio 0.47, p < 0.001]. The NLC was comparable between totally-laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG) [LATG 39.0 (95% CI 30.8-48.7); TLTG 36.0 (95% CI 30.4-42.4)]. CONCLUSIONS: The LC for RTG was significantly shorter for LTG. However existing studies are heterogeneous.

Perceived effectiveness of an innovative mobile-based serious game on the improvement of soft skills in minimally invasive surgical training.

INTRODUCTION: Soft skills have a pertinent role for the quality and efficient outcomes in minimally invasive surgical procedures that are difficult to practice due to time constraints, limited resources, and other logistical reasons. The literature says that serious games serve as better resources for learning soft skills but needs evaluation from stakeholders. This study explores the perceived effectiveness of serious gaming intervention as a learning tool to improve communication, collaborative skills among the residents in surgery, house officers and junior doctors. METHOD: A total of nine participants volunteered to take part in the exploratory study. During the study, the participants responded to a pre-test quiz, followed by exploration of the game and a post-test quiz. The perceived perceptions on the effectiveness of the gaming intervention were collected on a five-point Likert scale questionnaire with open-ended questions. RESULTS: There was no significant difference in pre-test and post-test scores on communication and collaborative skills. Among the three themes, there was significant effect of usefulness of the application of improvement of soft skills (90% response); however, technicalities should be addressed (50% of responses). The qualitative feedback renders that, better graphics, tutorial run, user-friendly interface and controls, and enhanced 3D environment would enhance the efficacy of the prototype. CONCLUSION: An innovative mobile-based serious gaming intervention was developed and tested for its effectiveness as a resource to develop soft skills among surgeons in training. The results indicate that gamified interventions can serve as educational resources and supplement the self-directed learning in surgical education.

Outcomes of Intraoperative Pyloric Drainage on Delayed Gastric Emptying Following Esophagectomy: A Systematic Review and Meta-analysis.

BACKGROUND: Intraoperative pyloric drainage in esophagectomy may reduce delayed gastric emptying (DGE) but is associated with risk of biliary reflux and other complications. Existing evidence is heterogenous. Hence, this meta-analysis aims to compare outcomes of intraoperative pyloric drainage versus no intervention in patients undergoing esophagectomy. METHODS: PubMed/MEDLINE, Embase, Web of Science, and the Cochrane were searched from inception up to July 2022. Exclusion criteria were lack of objective evidence (e.g., symptoms of nausea or vomiting) of DGE. The primary outcome was incidence of DGE. Secondary outcomes were incidence of pulmonary complications, bile reflux, anastomotic leak, operative time, and mortality. RESULTS: There were nine studies including 1164 patients (pyloric drainage n = 656, no intervention n = 508). Intraoperative pyloric drainage included pyloroplasty (n = 166 (25.3%)), pyloromyotomy (n = 214 (32.6%)), botulinum toxin injection (n = 168 (25.6%)), and pyloric dilatation (n = 108 (16.5%)). Pyloric drainage is associated with reduced DGE (odds ratio (OR): 0.54, 95% confidence interval (CI): 0.39-0.74, I2 = 50%). There was no significant difference in incidence of pulmonary complications (OR: 0.74, 95% CI: 0.51-1.08; I2 = 0%), biliary reflux (OR: 1.43, 95% CI: 0.80-2.54, I2 = 0%), anastomotic leak (OR: 0.79, 95% CI: 0.48-1.29; I2 = 0%), operative time (MD: + 22.16 min, 95% CI: - 13.27-57.59 min; I2 = 76%), and mortality (OR: 1.13, 95% CI: 0.48-2.64, I2 = 0%) between the pyloric drainage and no intervention groups. CONCLUSIONS: Pyloric drainage in esophagectomy reduces DGE but has similar post-operative outcomes. Further prospective studies should be carried out to compare various pyloric drainage techniques and its use in esophagectomy, especially minimally-invasive esophagectomy.

Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair.

Introduction: The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population. Methods: This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups. Results: There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable. Conclusion: Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

Open versus laparoscopic intraperitoneal on-lay mesh repair: A comparison of outcomes in small ventral hernia.

PURPOSE: The ideal surgical treatment of small ventral hernias (defect less than 4 cm) is still debatable. In our study, we sought to compare the outcomes of open versus laparoscopic intraperitoneal on-lay mesh (IPOM) repair in small ventral hernias. METHODS: Patients with a single ventral hernia defect of less than 4 cm undergoing surgical mesh repair between January 2016 and September 2018 were prospectively registered for this study. The minimum follow-up duration was 12 months. Patient demographics, operative findings and regular post-operative follow-up details including recurrence rates and complications were recorded and analysed. RESULTS: 41 patients underwent laparoscopic IPOM repair and 47 patients underwent open IPOM repair. The mean age for both groups is similar with no significant difference. The mean hernia defect size for the laparoscopic group is 2.8 cm (±0.8) whereas the mean hernia defect size for the open repair group is 2.1 cm (±0.4). The mean surgery duration for open IPOM repair was significantly shorter (59 min (±17) vs 74 min (±26); p = 0.001). There was no significant difference in the incidence of seroma formation and surgical site infections post-operatively. There was also no significant difference in both groups in terms of chronic pain and recurrence at 1-year follow-up. CONCLUSION: Open IPOM repair for small ventral hernias may be superior to laparoscopic IPOM repair due to the shorter operative duration, single incision, and no additional risk of port-site hernias. There was no difference in chronic pain, wound infection and recurrence rate between the two groups.

A systematic review and meta-analysis comparing postoperative outcomes of laparoscopic versus open omental patch repair of perforated peptic ulcer.

BACKGROUND: The mainstay of surgical management of perforated peptic ulcer is omental patch repair. Advances in minimally invasive techniques have shown feasibility of laparoscopic omental patch repair (LOPR). Laparoscopic omental patch repair is limited by learning curve (LC), but there is a lack of reporting of LC in LOPR. This study aims to compare outcomes following LOPR versus open omental patch repair (OOPR) with reporting of LC. METHODS: PubMed, Embase, The Cochrane Library, and Scopus were systematically searched from inception till January 2022 for randomized controlled trials (RCTs) and non-RCTs comparing LOPR and OOPR in perforated peptic ulcer. Exclusion criteria were primary repair without use of omental patch repair. Primary outcomes were 30-day mortality, postoperative leak, and LC analysis. RESULTS: There were a total of 29 studies including 5,311 patients (LOPR, n = 1,687; OOPR, n = 3,624), with 4 RCTs with 238 patients (LOPR, n = 118; OOPR, n = 120). Majority of ulcers were located in the duodenum (57.0%) followed by stomach (30.7%). Mean ulcer size ranged from 5 to 16.2 mm in LOPR and 4.7 to 15.8 mm in OOPR. Laparoscopic omental patch repair was associated with lower 30-day mortality (odds ratio [OR], 0.57; 95% confidence interval [CI], 0.35-0.92; p = 0.02), overall morbidity (OR, 0.31; 95% CI, 0.18-0.53; p < 0.0001), surgical site infection (OR, 0.27; 95% CI, 0.18-0.42; p < 0.00001), and length of stay (mean difference, -2.84 days; 95% CI, -3.63 to -2.06; p < 0.00001). Postoperative leakage (OR, 1.06; 95% CI, 0.43-2.61; p = 0.90) was comparable between LOPR and OOPR. Only three studies analyzed the proportion of consultants to trainees; LOPR was performed mainly by consultants (range, 82.4-91.4%), while OOPR was mainly performed by trainees (range, 52.8-96.8%). One study showed that consultants who performed open conversion had shorter operating time compared with chief residents (85 vs. 186.6 minutes, p < 0.003). CONCLUSION: Laparoscopic omental patch repair has lower mortality, overall morbidity, length of stay, intraoperative blood loss, and postoperative pain compared with OOPR. More prospective studies should be conducted to evaluate LC in LOPR. LEVEL OF EVIDENCE: Systematic Review and Meta-Analysis; Level IV.

Learning Curve of Laparoscopic Common Bile Duct Exploration: A Systematic Review.

Background: Single-stage laparoscopic common bile duct exploration (LCBDE) with cholecystectomy has superior outcomes over two-stage endoscopic retrograde cholangiopancreatogram with interval cholecystectomy. With decreasing trend of LCBDE, this study aims to summarize the literature on learning curve (LC) in LCBDE. Materials and Methods: PubMed, Embase, Scopus, and the Cochrane Library were systematically searched for articles from inception to June 3, 2022 (PROSPERO Ref No: CRD42022328451). Basic clinical demographics were collected. Poisson means (95% confidence interval [95% CI]) was used to determine the number of cases required to surmount the LC (NLC). Results: Eight articles (n = 2071 patients) reported LC outcomes in LCBDE with mean study period of 5.9 ± 2.8 years. Majority of studies (62.5%) used arbitrary methods of LC analysis. Most common outcomes reported were complications (any or major) (75%), open conversion (75%), length of stay (62.5%), and operating time (50%). Mean CBD diameter was 11.3 ± 4.8 mm (n = 1122 patients). Incidence of acute cholecystitis, acute cholangitis, and acute pancreatitis were 13.9% (n = 232/1668), 7.8% (n = 128/1629), and 13.7% (n = 229/1668), respectively. Pooled analysis of all the included studies showed NLC of 78.8 cases (95% CI: 71.9-86.3). Studies that used cumulative sum control chart analysis, nonarbitrary methods, and arbitrary-based LC had NLC of 152.0 (95% CI: 135.4-170.1), 108.0 (95% CI: 96.6-120.4), and 49.7 (95% CI: 42.0-58.3) cases, respectively. NLC was 37.0 cases (95% CI: 29.1-46.5) for single surgeon LC, and 99.8 cases (95% CI: 90.2-110.0) for institutional LC. Conclusion: Studies reporting NLC in LCBDE are heterogeneous. Further studies should use nonarbitrary methods of analysis for patient-reported outcome measures and procedure-specific morbidity.

Elective incisional hernia repair: lower risk of postoperative wound infection with laparoscopic versus open repair

INTRODUCTION@#The superiority of laparoscopic repair over open repair of incisional hernias (IHs) in the elective setting is still controversial. Our study aimed to compare the postoperative outcomes of laparoscopic and open elective IH repair in an Asian population.@*METHODS@#This retrospective study was conducted in an acute general hospital in Singapore between 2010 and 2015. Inclusion criteria were IH repair in an elective setting, IHs with diameter of 3-15 cm, and location at the ventral abdominal wall. We excluded patients who underwent emergency repair, had recurrent hernias or had loss of abdominal wall domain (i.e. hernia sac containing more than 30% of abdominal contents or any solid organs). Postoperative outcomes within a year such as recurrence, pain, infection, haematoma and seroma formation were compared between the two groups.@*RESULTS@#There were 174 eligible patients. The majority were elderly Chinese women who were overweight. Open repair was performed in 49.4% of patients, while 50.6% underwent laparoscopic repair. The mean operation time for open repair was 116 minutes (116 ± 60.6 minutes) and 139 minutes (136 ± 64.1 minutes) for laparoscopic repair (P = 0.079). Within a year after open repair, postoperative wound infection occurred in 15.1% of the patients in the open repair group compared to 1.1% in the laparoscopic group (P = 0.0007). Postoperative pain, recurrence and haematoma/seroma formation were comparable.@*CONCLUSION@#Elective laparoscopic IH repair has comparable outcomes with open repair and may offer the advantage of reduced postoperative wound infection rates.

High Efficacy and Drug Synergy of HDAC6-Selective Inhibitor NN-429 in Natural Killer (NK)/T-Cell Lymphoma.

NK/T-cell lymphoma (NKTCL) and γδ T-cell non-Hodgkin lymphomas (γδ T-NHL) are highly aggressive lymphomas that lack rationally designed therapies and rely on repurposed chemotherapeutics from other hematological cancers. Histone deacetylases (HDACs) have been targeted in a range of malignancies, including T-cell lymphomas. This study represents exploratory findings of HDAC6 inhibition in NKTCL and γδ T-NHL through a second-generation inhibitor NN-429. With nanomolar in vitro HDAC6 potency and high in vitro and in cellulo selectivity for HDAC6, NN-429 also exhibited long residence time and improved pharmacokinetic properties in contrast to older generation inhibitors. Following unique selective cytotoxicity towards γδ T-NHL and NKTCL, NN-429 demonstrated a synergistic relationship with the clinical agent etoposide and potential synergies with doxorubicin, cytarabine, and SNS-032 in these disease models, opening an avenue for combination treatment strategies.

Academy of Medicine, Singapore clinical guideline on endoscopic surveillance and management of gastric premalignant lesions.

Gastric cancer (GC) has a good prognosis, if detected at an early stage. The intestinal subtype of GC follows a stepwise progression to carcinoma, which is treatable with early detection and intervention using high-quality endoscopy. Premalignant lesions and gastric epithelial polyps are commonly encountered in clinical practice. Surveillance of patients with premalignant gastric lesions may aid in early diagnosis of GC, and thus improve chances of survival. An expert professional workgroup was formed to summarise the current evidence and provide recommendations on the management of patients with gastric premalignant lesions in Singapore. Twenty-five recommendations were made to address screening and surveillance, strategies for detection and management of gastric premalignant lesions, management of gastric epithelial polyps, and pathological reporting of gastric premalignant lesions.

Surveillance to achieve malaria elimination in eastern Myanmar: a 7-year observational study.

BACKGROUND: The collection and utilization of surveillance data is essential in monitoring progress towards achieving malaria elimination, in the timely response to increases in malaria case numbers and in the assessment of programme functioning. This paper describes the surveillance activities used by the malaria elimination task force (METF) programme which operates in eastern Myanmar, and provides an analysis of data collected from weekly surveillance, case investigations, and monitoring and evaluation of programme performance. METHODS: This retrospective analysis was conducted using data collected from a network of 1250 malaria posts operational between 2014 and 2021. To investigate changes in data completeness, malaria post performance, malaria case numbers, and the demographic details of malaria cases, summary statistics were used to compare data collected over space and time. RESULTS: In the first 3 years of the METF programme, improvements in data transmission routes resulted in a 18.9% reduction in late reporting, allowing for near real-time analysis of data collected at the malaria posts. In 2020, travel restrictions were in place across Karen State in response to COVID-19, and from February 2021 the military coup in Myanmar resulted in widescale population displacement. However, over that period there has been no decline in malaria post attendance, and the majority of consultations continue to occur within 48 h of fever onset. Case investigations found that 43.8% of cases travelled away from their resident village in the 3 weeks prior to diagnosis and 36.3% reported never using a bed net whilst sleeping in their resident village, which increased to 72.2% when sleeping away from their resident village. Malaria post assessments performed in 82.3% of the METF malaria posts found malaria posts generally performed to a high standard. CONCLUSIONS: Surveillance data collected by the METF programme demonstrate that despite significant changes in the context in which the programme operates, malaria posts have remained accessible and continue to provide early diagnosis and treatment contributing to an 89.3% decrease in Plasmodium falciparum incidence between 2014 and 2021.

Paraconduit hiatal hernia following minimally invasive oesophagectomy in an emergent setting.

Paraconduit hiatal hernia (PHH) remains a rare complication from oesophagectomies. Although minimally invasive oesophagectomies (MIO) for oesophageal cancer offer many advantages over open oesophagectomies (OO), the incidence of PHH appears to buckle this trend. As such, there is paucity in the current literature on the preferred approach as well as the management of PHH post-MIO. We present 2 emergent cases of post-MIO PHH. The laparoscopic approach of PHH repair appears feasible and safe even in the emergent setting. However, most advocate for the avoidance of emergent surgery altogether by astute care and prevention of PHH formation, or with early repair, if found asymptomatic PHH during surveillance scan.