Vincent Tee

Background: High‐resolution manometry (HRM) is increasingly used to assess risk of gastroesophageal reflux disease (GERD). The Milan Score (MS) integrates four HRM variables—EGJ morphology, EGJ contractile integral (EGJ‐CI), ineffective esophageal motility (IEM), and straight leg raise (SLR) response—to predict pathological esophageal acid exposure. The inter‐observer reproducibility of the MS and its components has never been formally assessed. Methods: A total of 50 consecutive HRM plots from patients undergoing evaluation for suspected GERD at a tertiary referral center were distributed to a multicenter pool of esophageal experts for blind review. Participants assessed EGJ type, EGJ‐CI, IEM, and SLR response; the MS and corresponding GERD risk were automatically calculated. Inter‐observer variability was evaluated using Fleiss' κ for categorical variables and Kendall's coefficient for continuous variables. MS accuracy was assessed by comparing calculated scores against MII‐pH results. Results: Twenty‐three esophageal experts from 16 international institutions reviewed all 50 plots. Agreement was fair for EGJ morphology ( κ = 0.321), moderate for SLR ( W = 0.531), and good for IEM ( κ = 0.638), EGJ‐CI ( W = 0.675) and the final MS ( W = 0.641). Median plot‐level concordance between MS and pH‐impedance study was 71.74% [IQR 51.08%]; median reader accuracy for Milan Score was 64% [IQR 12%], ranging from 54% to 80%. Conclusions: Inter‐observer variability of the Milan Score is good across a diverse international cohort of esophageal experts, supporting its reproducibility as a clinical tool. However, agreement for individual parameters was heterogeneous, and the assessment of EGJ morphology and the SLR maneuver achieved only fair‐to‐moderate agreement, highlighting the need for improved standardization.

Introduction: According to Lyon 2.0, laryngopharyngeal symptoms (LPS) should undergo upfront pathophysiologic tests. The novel Milan score integrates esophagogastric junction (EGJ) morphology, ineffective esophageal motility, EGJ‐contractile integral (EGJ‐CI), and straight leg raise (SLR) response. It has been demonstrated to predict abnormal AET. The aim of this study was to assess the value of the Milan score in predicting GERD in these patients. Methods: We prospectively enrolled patients with suspected GERD who underwent HRM and MII pH from 12 referral centers. Patients with isolated LPS (reflux symptom index > 13) were compared with typical GERD symptoms (GERD‐HRQL ≥ 10). A Milan score > 137 was considered positive. The effectiveness of the Milan score in the identification of patients with pathologic GERD was assessed. Results: Of 570 patients (49% females, median age 49 years, BMI 24 kg/m ² ), isolated LPS was found in 30 patients and isolated typical symptoms in 154. An AET > 6% was found in 23% of the LPS group and 43% of the typical symptom group ( p = 0.034). The Milan score was higher in the typical symptoms group, with higher scores for EGJ‐CI ( p = 0.039) and SLR response ( p = 0.038) components. The likelihood of concordance of the Milan score and AET on reflux monitoring was similar (83.3% vs. 84.4%, p = 0.532). Conclusions: Patients with isolated LPS demonstrated a lower likelihood of EGJ disruption, pathologic GERD, and abnormal Milan score. The Milan score performed similarly well in the identification of GERD in both LPS and typical symptoms and could therefore be used as an upfront test in LPS patients.

The Traditional Asian Diet (TAD) is characterised by high dietary fibre and functional foods. This study investigated TAD’s effects on meeting fibre requirements, gut microbiome, and faecal and urine metabolomes. A four-week randomised controlled trial was conducted among healthy Asian women allocated into the TAD group (n = 11) following a newly developed TAD program and the control group (n = 11). Assessments included dietary intake, gut health (symptoms, faecal form, frequency), serum fatty acids binding protein-2 (FABP-2) levels, faecal microbiome via 16s rRNA sequencing, and faecal and urine metabolites which were analysed using gas chromatography-mass spectrometry (GC-MS) and nuclear magnetic resonance (NMR), respectively. The TAD group showed significant increases in dietary fibre ( ), reduced fat ( ), and improved faecal form ( ) compared to the control group. The TAD group was enriched with Parabacteroides merdae , while Bacteroides uniformis was more abundant in the control group. Individuals with baseline Prevotella copri showed its enrichment following TAD and higher butyrate levels, unlike the control group. The TAD led to lower urine levels of creatinine, dimethylamine, and phenethylamine compared to the control diet. In conclusion, the TAD program has proven beneficial effects in achieving dietary fibre, enriching the beneficial microbiota and metabolites, reducing harmful metabolites, and improving faecal form compared to a control diet. Clinical trial registration: NCT04885959, clinicaltrials.gov

Introduction: High‐resolution manometry (HRM) allows assessment of esophagogastric junction (EGJ) disruption. While type 3 EGJ predicts definitive gastroesophageal reflux disease (GERD), type 2 EGJ is less clearly implicated in GERD pathogenesis. This study aimed to characterize physiologic findings in type 2 EGJ to determine if the HRM‐based Milan Score can define GERD within type 2 EGJ. Methods: 535 patients with suspected GERD who underwent HRM and reflux monitoring were retrospectively analyzed. Clinical, HRM, and reflux study data were compared between the EGJ morphology subtypes, with objective GERD defined according to Lyon Consensus 2.0. The Milan Score, a novel metric that integrates ineffective esophageal motility, EGJ‐contractile integral, EGJ morphology, and straight leg raise response, was abnormal when ≥ 137 (risk rate 50% for GERD). Receiver operating characteristic (ROC) curve analysis was performed to assess the accuracy of the Milan Score to predict objective GERD. Results: Type 3 EGJ was associated with the highest rate of objective GERD, followed by type 2 and type 1 EGJ ( p < 0.001), with a corresponding stepwise increase in AET from type 1 to 3 EGJ (p < 0.001). Type 2 EGJ with Milan Score < 137 resembled type 1 EGJ (objective GERD in 23.6% vs. 33.2%, p = 0.09), and type 2 EGJ with score ≥ 137 resembled type 3 EGJ (objective GERD in 88.2% vs. 78.8%, p = 0.11). On ROC analysis, the Milan Score had an area under the curve of 0.858. Conclusion: While type 2 EGJ includes varying GERD severity, the Milan Score can segregate patients at risk for objective GERD.

Objectives The emergence of “green endoscopy” arises from the increasing global need to reform environmental sustainability due to climate change. Our review aimed to provide current evidence surrounding green endoscopy on sustainable issues including environmental impact, innovations, guidelines, policies, future directions, and recommendations. Materials and Methods A scoping review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews guidelines. Full-text English articles from established databases were screened for eligibility criteria and analyzed. Results Out of 7,892 identified articles, 28 met all the eligibility criteria. Key findings include (1) the significant environmental impact of single-use items in current endoscopic practices; (2) there are emerging green innovations in endoscopy, such as reusable instruments, eco-friendly sterilization methods, and energy-efficient technologies; (3) guidelines and green policies are increasingly available to provide clinical guidance and framework for health care facilities; (4) model institutions can provide case studies and examples of implementing green endoscopy; and (5) unified efforts from all stakeholders are needed to address challenges, including cost-effectiveness. Conclusion A paradigm shift toward green endoscopy is clearly in place and should be driven by the need to reduce environmental impact, be cost-effective, and not sacrifice patient safety.

Background: Chatbots have the potential to increase people’s access to quality health care. However, the implementation of chatbot technology in the health care system is unclear due to the scarce analysis of publications on the adoption of chatbot in health and medical settings. Objective: This paper presents a protocol of a bibliometric analysis aimed at offering the public insights into the current state and emerging trends in research related to the use of chatbot technology for promoting health. Methods: In this bibliometric analysis, we will select published papers from the databases of CINAHL, IEEE Xplore, PubMed, Scopus, and Web of Science that pertain to chatbot technology and its applications in health care. Our search strategy includes keywords such as “chatbot,” “virtual agent,” “virtual assistant,” “conversational agent,” “conversational AI,” “interactive agent,” “health,” and “healthcare.” Five researchers who are AI engineers and clinicians will independently review the titles and abstracts of selected papers to determine their eligibility for a full-text review. The corresponding author (ZN) will serve as a mediator to address any discrepancies and disputes among the 5 reviewers. Our analysis will encompass various publication patterns of chatbot research, including the number of annual publications, their geographic or institutional distribution, and the number of annual grants supporting chatbot research, and further summarize the methodologies used in the development of health-related chatbots, along with their features and applications in health care settings. Software tool VOSViewer (version 1.6.19; Leiden University) will be used to construct and visualize bibliometric networks. Results: The preparation for the bibliometric analysis began on December 3, 2021, when the research team started the process of familiarizing themselves with the software tools that may be used in this analysis, VOSViewer and CiteSpace, during which they consulted 3 librarians at the Yale University regarding search terms and tentative results. Tentative searches on the aforementioned databases yielded a total of 2340 papers. The official search phase started on July 27, 2023. Our goal is to complete the screening of papers and the analysis by February 15, 2024. Conclusions: Artificial intelligence chatbots, such as ChatGPT (OpenAI Inc), have sparked numerous discussions within the health care industry regarding their impact on human health. Chatbot technology holds substantial promise for advancing health care systems worldwide. However, developing a sophisticated chatbot capable of precise interaction with health care consumers, delivering personalized care, and providing accurate health-related information and knowledge remain considerable challenges. This bibliometric analysis seeks to fill the knowledge gap in the existing literature on health-related chatbots, entailing their applications, the software used in their development, and their preferred functionalities among users. International Registered Report Identifier (IRRID): PRR1-10.2196/54349

BACKGROUND Chatbots have the potential to increase people’s access to quality health care. However, the implementation of chatbot technology in the health care system is unclear due to the scarce analysis of publications on the adoption of chatbot in health and medical settings. OBJECTIVE This paper presents a protocol of a bibliometric analysis aimed at offering the public insights into the current state and emerging trends in research related to the use of chatbot technology for promoting health. METHODS In this bibliometric analysis, we will select published papers from the databases of CINAHL, IEEE Xplore, PubMed, Scopus, and Web of Science that pertain to chatbot technology and its applications in health care. Our search strategy includes keywords such as “chatbot,” “virtual agent,” “virtual assistant,” “conversational agent,” “conversational AI,” “interactive agent,” “health,” and “healthcare.” Five researchers who are AI engineers and clinicians will independently review the titles and abstracts of selected papers to determine their eligibility for a full-text review. The corresponding author (ZN) will serve as a mediator to address any discrepancies and disputes among the 5 reviewers. Our analysis will encompass various publication patterns of chatbot research, including the number of annual publications, their geographic or institutional distribution, and the number of annual grants supporting chatbot research, and further summarize the methodologies used in the development of health-related chatbots, along with their features and applications in health care settings. Software tool VOSViewer (version 1.6.19; Leiden University) will be used to construct and visualize bibliometric networks. RESULTS The preparation for the bibliometric analysis began on December 3, 2021, when the research team started the process of familiarizing themselves with the software tools that may be used in this analysis, VOSViewer and CiteSpace, during which they consulted 3 librarians at the Yale University regarding search terms and tentative results. Tentative searches on the aforementioned databases yielded a total of 2340 papers. The official search phase started on July 27, 2023. Our goal is to complete the screening of papers and the analysis by February 15, 2024. CONCLUSIONS Artificial intelligence chatbots, such as ChatGPT (OpenAI Inc), have sparked numerous discussions within the health care industry regarding their impact on human health. Chatbot technology holds substantial promise for advancing health care systems worldwide. However, developing a sophisticated chatbot capable of precise interaction with health care consumers, delivering personalized care, and providing accurate health-related information and knowledge remain considerable challenges. This bibliometric analysis seeks to fill the knowledge gap in the existing literature on health-related chatbots, entailing their applications, the software used in their development, and their preferred functionalities among users. INTERNATIONAL REGISTERED REPORT PRR1-10.2196/54349

Foul-smelling vaginal discharge in adolescents often stems from infectious origin, foreign body insertion, neoplasm, congenital anomaly, and sexual abuse. Diagnosing the causes of the discharge remains challenging, especially in cases where sexual and reproductive health awareness is relatively low in the population from marginalized ethnographies and socio-cultural backgrounds. Suspicion of sexual abuse must be explored carefully and sensitively. A history of sexual exposure might not be forthcoming in adolescents where premarital sex is frowned upon. The process of eliciting the causation may be a challenge to healthcare professionals, delaying the diagnosis and subsequent management. In rare circumstances, imaging studies may help confirm the origin of the infection, giving insight into the presentation’s aetiology. We describe a case of Obstructed Hemivagina and Ipsilateral Renal Anomaly (OHVIRA) Syndrome presented with foul-smelling vaginal discharge in a newly attained menarche girl in the North-East region of Peninsular Malaysia. We also discussed the theories and reasons behind the occurrence of such a presentation, along with the diagnostic dilemma in this current case.

Background: Nab-paclitaxel is formulated to address several limitations of paclitaxel. Methods: A systematic review was done of several databases and a meta-analysis with a random-effects model was... Graphical abstract A systematic review and meta-analysis estimates the efficacy and safety of nab-paclitaxel in metastatic gastric cancer.

Summary: Background: The prevalence of irritable bowel syndrome (IBS) is now known to be similar in various geographical regions, but there has been no study directly comparing characteristics of patients with IBS between populations.Aims: To evaluate clinical and psychological differences between adults with IBS seen in secondary care in the United Kingdom (UK) and Malaysia.Methods: Age‐ and sex‐matched patients with IBS from a single centre in the UK (Leeds) and two centres in Malaysia (Kuala Lumpur and Kota Bharu), who fulfilled Rome III criteria, were recruited prospectively. Demographic characteristics and gastrointestinal and psychological symptoms were compared between both groups.Results: A total of 266 (133 UK and 133 Malaysian) age‐ and sex‐matched patients with Rome III IBS were recruited (mean age: 45.1 years Malaysia, vs. 46.5 years UK; 57.9% female). UK patients were more likely to consume alcohol than Malaysian patients (54.1% vs. 10.5%, p < 0.001). Compared with Malaysian patients, UK patients had more frequent abdominal pain, abdominal bloating, meal‐related symptoms (p < 0.001 for all), higher symptom scores (mean 268.0 vs 166.0; p < 0.001), greater limitation of activities due to IBS (p = 0.007) and were more likely to report abnormal anxiety scores (p < 0.001). Higher perceived stress (mean 21.3 vs. 19.1, p = 0.014) and gastrointestinal symptom‐specific anxiety scores (mean 50.8 vs. 43.0, p < 0.001) were also observed in UK patients. Finally, UK patients had higher somatoform symptom‐reporting scores (mean 8.9 vs. 6.9, p < 0.001).Conclusions: IBS is more severe and is associated with a higher level of psychological symptoms in the UK compared with Malaysian patients in secondary care.