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Current guidelines have limited consensus on the approach to portal venous thrombosis (PVT) in cirrhotic patients. While there is rising interest in direct oral anticoagulants (DOACs) use for PVT, current evidence is limited by small sample size and lack of comparisons to traditional anticoagulants. Thus, a network meta-analysis was conducted to compare the use of DOACs with traditional anticoagulants. Medline and Embase were searched for articles about anticoagulation use in cirrhotic patients with nontumorous PVT for articles on DOACs, warfarin, low-molecular weight heparin (LMWH) or antithrombin III. A network analysis was conducted using risk ratios (RR) with surface under the cumulative ranking curve (SUCRA). A single-arm meta-analysis was used to summarize the outcomes of DOAC treatment. A total of 10 articles were included in the study. 79.5% (CI 38.8–95.9) of DOACs patients achieved complete or partial recanalization and 9.80% (CI 4.50–20.0) experienced a bleeding event. DOACs were superior to LMWH (RR 2.299, CI 1.037–5.093, p = 0.040), warfarin (RR 1.762, CI 1.017–3.053, p = 0.043) and no treatment (RR 3.489, CI 1.394–8.733, p = 0.008) in complete recanalization. For partial recanalization, while DOACs were not superior to any treatment, they had the highest probability in achieving partial recanalization in SUCRA analysis. Bleeding risk and mortality were similar compared to other treatments. The network analysis supports the use of DOACs in cirrhotic patients, with significant rates of complete recanalization compared to other treatments without increasing bleeding risk. DOACs can potentially be considered for nontumorous PVT in cirrhosis.

BACKGROUND Endoscopic submucosal dissection (ESD) has shown to be effective in management of colorectal neoplasm in the Asian countries, while its implementation in Western countries where endoscopic mucosal resection (EMR) is preferred is still debatable. AIM To compare the surgical, histological, and oncological outcomes between ESD and EMR in the treatment of colorectal polyps, with subgroup analysis comparing the efficacy of ESD and EMR between Japan and the rest of the world. METHODS Embase and Medline databases were searched from inception to October 2020 in accordance with PRISMA guidelines for studies comparing en bloc, complete resection, margin involvement, resection time, need for additional surgery, complications, and recurrence rate of ESD with EMR. RESULTS Of 281344 colorectal polyps from 21 studies were included. When compared to EMR, the pooled analysis revealed ESD was associated with higher en bloc and complete resection rate, and lower lateral margin involvement and recurrence. ESD led to increased procedural time, need for additional surgery, and perforation risk. No significant difference in bleeding risk was found between the two groups. Meta-regression analysis suggested only right colonic polyps correlated with an increased perforation risk in ESD. Confounders including polyp size and invasion depth did not significantly influence the en bloc and complete resection rate, bleeding risk and recurrence. In subgroup analysis, Japan performed better than the rest of the world in both ESD and EMR with perforation risk of 4% and 0.0002%, respectively, as compared to perforation risk of 8% and 1%, respectively, in reports coming from rest of the world. CONCLUSION ESD resulted in better resection outcomes and lower recurrence compared to EMR. With appropriate training, ESD is preferred over EMR as the first-line therapy for resection of colorectal polyps, without restricting to lesions greater than 20 mm and those with high suspicion of submucosal invasion.

Conventional colectomy, and the Japanese Society for Cancer of the Colon and Rectum (JSCCR) D2 Lymphadenectomy (LND2), are currently considered standard of care for surgical management of colon cancer. Colectomy with complete mesocolic excision (CME) and JSCCR D3 Lymphadenectomy (LND3) are more radical alternative approaches and provide a greater degree of lymph nodal clearance. However, controversy exists over the long-term benefits of CME/LND3 over non-CME colectomies (NCME)/LND2. In this study, we performed a systematic review and meta-analysis to compare the surgical, pathological, and oncological outcomes of CME/LND3 with NCME/LND2. Embase, Medline and CENTRAL databases were searched from inception until May 15, 2020, in accordance with PRISMA guidelines. Studies were included if they compared curative intent CME/LND3 with NCME/LND2. Weighted mean differences (WMD) and odds ratios (OR) were estimated for continuous and dichotomous outcomes respectively. Out of 1310 unique citations, 106 underwent full-text review, and 30 were included for analysis. In total, 21,695 patients underwent resection for colon cancer. 11,625 received CME/LND3, and 10,070 underwent NCME/LND2. No significant differences were found in post-operative morbidity and mortality. Both overall and disease-free survival favored CME/LND3 (5-year OS: OR = 1.29; 95% CI 1.02 to 1.64, p = 0.03; 5-year DFS: OR = 1.61; 95% CI 1.14 to 2.28; p = 0.007). This is the first systematic review and meta-analysis to demonstrate that CME/LND3 has superior long-term survival outcomes compared to NCME/LND2.

BACKGROUND: Reverse Total Shoulder Arthroplasty is commonly performed for elective indications, such as cuff tear arthropathies, salvage arthropathies and tumours with excellent outcomes. However, its use in treating acute conditions such as 3- and 4-part proximal humeral fractures in the elderly has been more controversial. The aim of our study is to directly compare the short-term intra-operative and post-operative outcomes of RTSA for traumatic proximal humeral fractures as compared to elective shoulder arthroplasty. METHODS: We retrospectively identified 78 consecutive patients who had undergone RTSA from 2009 to 2018 at a tertiary hospital. These patients were classified by etiology as either elective or trauma cases. Comparative analysis of the baseline demographics, as well as post-operative surgical, functional and range-of-movement outcomes between the two groups was performed. RESULTS: 57 Patients made up the elective cohort and 14 patients made up the trauma cohort. The elective cohort was significantly older compared to the traumatic fracture cohort (73.2 vs 78.6, p = 0.026). No significant differences were observed when comparing post-operative surgical outcomes. At 6 months, the elective cohort demonstrated greater forward flexion (105.8° vs 127.2°, p = 0.041), as well as higher SF-36 PCS (27.85 vs 43.99, p = 0.018) and ASES scores (35.5 vs 76.31, p = 0.009). However, these differences resolved by 1-year post-op and no significant differences were noted comparing functional and range-of-movement outcomes at 1-year post-op. CONCLUSIONS: Our study suggests that the application of reverse total shoulder arthroplasty in the management of traumatic humeral fractures may produce similarly favourable 1-year outcomes to that performed for elective etiologies. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-022-00625-4.

PHENOMENON: Research literacy remains important for equipping clinicians with the analytical skills to tackle an ever-evolving medical landscape and maintain an evidence-based approach when treating patients. While the role of research in medical education has been justified and established, the nuances involving modes of instruction and relevant outcomes for students have yet to be analyzed. Institutions acknowledge an increasing need to dedicate time and resources towards educating medical undergraduates on research but have individually implemented different pedagogies over differing lengths of time. APPROACH: While individual studies have evaluated the efficacy of these curricula, the evaluations of educational methods and curriculum design have not been reviewed systematically. This study thereby aims to perform a systematic review of studies incorporating research into the undergraduate medical curriculum, to provide insights on various pedagogies utilized to educate medical students on research. FINDINGS: Studies predominantly described two major components of research curricula—(1) imparting basic research skills and the (2) longitudinal application of research skills. Studies were assessed according to the 4-level Kirkpatrick model for evaluation. Programs that spanned minimally an academic year had the greatest proportion of level 3 outcomes (50%). One study observed a level 4 outcome by assessing the post-intervention effects on participants. Studies primarily highlighted a shortage of time (53%), resulting in inadequate coverage of content. INSIGHTS: This study highlighted the value in long-term programs that support students in acquiring research skills, by providing appropriate mentors, resources, and guidance to facilitate their learning. The Dreyfus model of skill acquisition underscored the importance of tailoring educational interventions to allow students with varying experience to develop their skills. There is still room for further investigation of multiple factors such as duration of intervention, student voluntariness, and participants’ prior research experience. Nevertheless, it stands that mentoring is a crucial aspect of curricula that has allowed studies to achieve level 3 Kirkpatrick outcomes and engender enduring changes in students. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s40670-020-01183-w.

Fractures of the femoral shaft in children are common. The rates of bone growth and remodeling in children vary according to their ages, which affect their respective management.This paper evaluates the incidence and patterns of pediatric femoral shaft fracture and the current concepts of treatments available.The type of fracture-closed or open; stable or unstable-needs to be taken into account. Child abuse should be suspected in fractures sustained by infants. For younger children, non-surgical management is preferred, which include Pavlik harness ( 6 months old) and early spica casting (6 months to 6 years old). Older children ( 6 years old) usually benefit from surgical treatments as outcomes of non-surgical alternatives are worse and are associated with prolonged recovery times. These operative measures for older children that are 6-12 years old include elastic stable intramedullary nailing and submuscular plating. Factors to be considered when devising an appropriate intervention include body mass, location of injury, and nature of fracture. For adolescent and skeletally mature teenagers ( 12 years old), rigid antegrade entry intramedullary fixation is indicated. In the event of open fractures or polytrauma, external fixation should be considered as a temporary treatment method for initial fracture stabilization.An age-based and evidence-based algorithm has been proposed to guide surgeons in the process of evaluating an appropriate treatment.

Background The role of perioperative or neoadjuvant chemotherapy for locally advanced colon cancer is unclear. Emerging evidence such as the FOXTROT trial is challenging the conventional norm of upfront operation for these patients. However, these trials have yet to reach statistical significance. Methods MEDLINE, Embase, Cochrane Library, China Knowledge Resource Integrated Database (CNKI) and ClinicalTrials.gov were searched. Randomized controlled trials (RCTs) and observational studies of patients with locally advanced colon cancer were included. The intervention arm was neoadjuvant chemotherapies while the comparator arm was adjuvant chemotherapies. Studies which reported outcomes of interests included overall survival, disease-free survival, R0 resection rate, perioperative complications and adverse effects of chemotherapy were chosen. Results We identified five eligible randomized trials and two observational studies, including 29,504 patients. Neoadjuvant therapies exhibited statistically significant improvement in overall survival [hazard ratio (HR) =0.76, 95% confidence interval (CI): 0.65-0.89, P=0.0005], and disease-free survival (HR =0.74, 95% CI: 0.58-0.95, P=0.02). R0 resection rate fell slightly short of significance [odds ratio (OR) =1.86, 95% CI: 0.95-3.62, P=0.07]. Risk of peri-operative complications did not differ between groups when examining abdominal infection [risk ratio (RR) =1.14, 95% CI: 0.59-2.18, P=0.70] and anastomotic leakage (RR =0.83, 95% CI: 0.53-1.31, P=0.42). No statistical differences in complications from chemotherapy were reported. Conclusions This meta-analysis highlights the potential survival benefit of neoadjuvant chemotherapy compared to adjuvant chemotherapy for locally advanced colon cancer, without an increase in surgical morbidity. Neoadjuvant or perioperative approaches may be considered an alternative to upfront surgery followed by chemotherapy for locally advanced colon cancer.

Background: Dementia is the decline in cognitive function sufficient to impair one’s accustomed functioning. Countries with aging populations, such as Singapore, face rising rates of dementia. Dementia patients and their caregivers endure great financial and emotional stress. With the broad aim of minimizing these stresses, this study provides a cross-sectional view of the knowledge, attitudes, and perceptions (KAP) towards dementia in middle-aged Singaporean residents. Objective: We aim to examine 1) the associations between demographic correlates and KAP; and 2) the effect of dementia knowledge on attitudes and perceptions towards dementia. Methods: An online anonymous cross-sectional questionnaire was administered to Singaporeans and Permanent Residents aged 45 to 65 years old in English, Mandarin, and Malay. Knowledge was evaluated across three domains: symptoms, risk factors, and management. Total and domain scores were dichotomized as good or poor knowledge using median cut-offs. Attitudes/perceptions across six domains were evaluated on Likert scales, and responses to each question were dichotomized into positive or negative attitudes/perceptions. Results: From 1,733 responses, 1,209 valid complete responses were accepted (mean age±SD 54.8±5.12 years old, females = 69.6%). Lower socioeconomic status was associated with poorer knowledge and greater barriers to risk-mitigating lifestyle modifications. Lack of personal experience with dementia and poor knowledge were also associated with erroneous attitudes/perceptions. Conclusion: Socioeconomic status and personal experience affect KAP towards dementia. Policy and education campaigns to address KAP towards dementia should account for baseline differences across demographics, for greater improvements in dementia incidence and support.

Background and study aims Evidence from recent trials comparing conventional endoscopic mucosal resection (EMR) to underwater EMR (UEMR) have matured. However, studies comparing UEMR to endoscopic submucosal dissection (ESD) are lacking. Hence, we sought to conduct a comprehensive network meta-analysis to compare the efficacy of UEMR, ESD, and EMR. Methods Embase and Medline databases were searched from inception to December 2020 for articles comparing UEMR with EMR and ESD. Outcomes of interest included rates of en bloc and complete polyp resection, risk of perforation and bleeding, and local recurrence. A network meta-analysis comparing all three approaches was conducted. In addition, a conventional comparative meta-analysis comparing UEMR to EMR was performed. Analysis was stratified according to polyp sizes ( Results Twenty-two articles were included in this study. For polyps ≥ 10 mm, UEMR was inferior to ESD in achieving en bloc resection (P = 0.02). However, UEMR had shorter operating time for polyps ≥ 10 mm (P Conclusions UEMR has demonstrated technical and oncological outcomes comparable to ESD and EMR, along with a desirable safety profile. UEMR appears to be a safe and effective alternative to conventional methods for resection of polyps ≥ 10 mm.

Introduction Conventional colectomy, and the Japanese Society for Cancer of the Colon and Rectum (JSCCR) D2 Lymphadenectomy (LND2), are the standards of care for the surgical management of colon cancer. Colectomy with complete mesocolic excision (CME) and JSCCR D3 Lymphadenectomy (LND3) are alternative, and more radical procedures, that provide greater lymph nodal clearance. However, controversy exists over the long-term survival benefits of CME/LND3 over non-CME colectomies (NCME)/LND2. Method In this study, we performed a meta-analysis to compare the survival outcomes of CME/LND3 with NCME/LND2. Medline and Embase databases were searched for articles reporting survival outcomes of both CME/LND3 and NCME/LND2, with comparisons presented using odds ratios (OR). Results Ten studies were included in this analysis. Overall and disease-free survival favored CME/LND3 (3-year OS: OR = 1.56; CI 1.22-2.00; p = 0.0004, 5-year OS: OR = 1.29; CI 1.02-1.64, p = 0.03, 3-year DFS: OR = 1.45; CI 1.12-1.88; p = 0.005, 5-year DFS: OR = 1.61; CI 1.14-2.28; p = 0.007). Overall and disease-free survival rates at five years were 79.8% and 85.9%, and 74.6% and 78.0%, in the CME/LND3 and NCME/LND2 groups respectively. Conclusions This is the first meta-analysis to demonstrate that CME/LND3 has superior long-term survival outcomes compared to NCME/LND2, hence a strong case can be made for incorporating CME/LND3 into standard care practice.

Introduction Learning research in medical school can be daunting and difficult with many lacking appropriate guidance. Particularly, research in surgery can be difficult with most clinicians tied to long hours from clinical duties, leaving medical students lost to learn the ropes for medical research. Method We started a surgical research group in January of 2020 under a shepherd sheep model. Shepards were senior medical students who had previous experience in research and were provided resources from consultants on statistics and research designs. Thereafter, each Shepard were paired with junior medical students (sheep) and a resident to provide clinical background. Research was then carried out small teams with minimal guidance from consultants. Results To date, the group has published 11 articles (median impact factor: 2.41, range: 1.89 - 3.42), 3 articles in revision and 9 articles in review. Conclusions We provide preliminary evidence of a successful model for building medical student research in surgery. While current analysis was limited to meta-analysis and systematic review due to the availability of data, current expansion is currently underway to expand to observational studies.

Introduction The role and optimal regimen of radiotherapy in curative-intent treatment of metastatic rectal cancer is unclear and hence a single arm meta-analysis was performed. Method Medline, Embase and Cochrane Library databases were searched up to 16 May 2020. A Meta-analysis of binomial data was performed using a Freeman-Tukey double arcsine transformation, and pooled estimates were used to construct risk ratios and confidence intervals via the Katz-logarithmic method. Additionally, comparative meta-analysis was performed with the Mantel Haenszel model. Results 18 studies were included. Rectal pathological complete response (pCR) was observed in 14% of tumours treated with radiotherapy (n = 57/388, CI 0.07 to 0.23). Comparative meta-analysis of cohort studies showed that treatment regimens including radiotherapy were associated with higher pT1 tumour and better oncological outcomes compared to regimens without radiotherapy. Katz-logarithmic method showed that neoadjuvant radiotherapy had a higher proportion of pN0 staging (RR = 1.81, 95% CI 1.06 to 3.09, p = 0.029) and better oncological outcomes compared to adjuvant radiotherapy, and that short course radiotherapy (SCRT) had a lower proportion of pT3 tumours (RR = 0.778, 95% CI 0.609 to 0.994, p = 0.044) and similar oncological outcomes compared to long course radiotherapy (LCRT). Conclusions This study supports the evidence that radiotherapy should be used in curative intent metastatic rectal cancer.

Background: This extensive meta-analysis sought to compare the surgical, histological, and oncological outcomes between endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) in the treatment of colorectal polyps, with subgroup analysis comparing the efficacy of ESD and EMR between Japan and the rest of the world. Methods: Embase and Medline databases were searched from inception to October 2020 in accordance with PRISMA guidelines for studies comparing en bloc, complete resection, margin involvement, resection time, need for additional surgery, complications, and recurrence rate of ESD with EMR. Results: 281,344 colorectal polyps from 21 studies were included. When compared to EMR, the pooled analysis revealed ESD was associated with higher en bloc and complete resection rate, and lower lateral margin involvement and recurrence. ESD led to increased procedural time, need for additional surgery, and perforation risk. No significant difference in bleeding risk was found between the two groups. Meta-regression analysis suggested only right colonic polyps correlated with an increased perforation risk in ESD. Confounders including polyp size and invasion depth did not significantly influence the en bloc and complete resection rate, bleeding risk and recurrence. In subgroup analysis, Japan performed better than the rest of the world in both ESD and EMR with perforation risk of 4% and 0.0002%, respectively, as compared to perforation risk of 8% and 1%, respectively, in reports coming from rest of the world.Conclusions: This meta-analysis demonstrated increased safety and efficacy of ESD and EMR done in Japan as compared with the rest of the world.

To examine risk factors that might be associated with thyroid eye disease (TED) in patients with Graves' disease (GD), which may guide physicians in the prevention and management of TED.Medline and Embase were searched for articles discussing risk factors of TED. Comparisons were made between GD patients with and without TED, and between active and inactive TED GD patients. Weighted mean differences (WMDs) and odds ratios (ORs) were determined for continuous and dichotomous outcomes, respectively. Results were pooled with random effects using the DerSimonian and Laird model.Fifty-six articles were included in the analysis. Smoking, inclusive of current and previous smoking status, was a significant risk factor for TED (OR: 2.401; CI: 1.958-2.945; P.001). Statistical significance was found upon meta-regression between male sex and the odds of smoking and TED (β = 1.195; SE = 0.436; P = .013). Other risk factors were also examined, and patients with TED were significantly older than those without TED (WMD: 1.350; CI: 0.328-2.372; P = .010). While both age (WMD: 5.546; CI: 3.075-8.017; P.001) and male sex (OR: 1.819; CI: 1.178-2.808; P = .007) were found to be significant risk factors for active TED patients compared to inactive TED patients, no statistical significance was found for family history, thyroid status, cholesterol levels, or body mass index.Factors such as smoking, sex, and age predispose GD patients to TED, and TED patients to active TED. A targeted approach in the management of GD and TED is required to reduce the modifiable risk factor of smoking.