Martin Tze Wah Kueh

Objective: Although body mass index (BMI)-defined non-obesity metabolic dysfunction-associated steatotic liver disease (MASLD) predicts poor prognosis, the role of visceral adiposity and weight-based phenotypes is unclear. This study aimed to examine the clinical correlates of four unique MASLD phenotypes based on BMI and waist-to-height ratio (WHtR) and to assess the prognostic value of this classification with respect to mortality. Design: Population-based cross-sectional study with prospective mortality follow-up. Setting: Nationally representative US population derived from the National Health and Nutrition Examination Survey (NHANES), 2007–2018. Participants: 6300 adults with MASLD, sampled from NHANES 2007 to 2018. Methods: Participants were allocated into four phenotypes based on obesity/lean and central adiposity status. Obesity was defined as BMI≥30 kg/m², while those without obesity were determined as lean. High central adiposity was defined as WHtR≥0.6. Primary outcome measure: The primary outcome was all-cause mortality. This was ascertained through National Death Index linkage with follow-up censored at 31 December 2019. Results: Among adults with MASLD, 72.1% had obesity with high central adiposity (mean follow-up: 6.9±3.5 years). The non-obesity, high central adiposity phenotype (9.6%) exhibited the highest rates of hypertension (60.2%), type 2 diabetes (31.8%) and chronic kidney disease (23.3%). This phenotype portended the poorest 6-year survival (p<0.001) and was independently associated with higher all-cause mortality (adjusted HR (aHR) 3.1, 95% CI 1.3 to 7.7). A J-shaped association was observed between BMI and mortality, with increasing WHtR linked to elevated risk. Conclusion: Non-obesity MASLD with high central adiposity confers the poorest survival and cardiometabolic burden.

Opportunities for structured, hands-on surgical skills training during undergraduate medical education remain variable, particularly in resource-limited settings where access to equipment, funding, and faculty support may be constrained. This study explored medical students’ experiences of a stepwise extracurricular surgical skills training series and their perceptions of its educational value and sustainability. A qualitative exploratory study design was used, involving focus group discussions with 22 medical students in their clinical years who had completed a three-part training program: basic, advanced, and introductory laparoscopic surgical skills. Thematic analysis revealed four interconnected areas. Students highlighted challenges related to sustainability, particularly the cost of materials and limited faculty availability, while proposing practical alternatives such as peer-led teaching and low-cost simulation approaches. The progressive, hands-on structure of the workshops was widely valued, allowing learners to build confidence through repetition, feedback, and self-directed practice. Emotional aspects of learning were also evident, with students describing both motivation and performance anxiety, often alleviated by a supportive and low-pressure environment. In addition, the workshops played a meaningful role in career exploration, helping students better understand their interest and suitability for surgical training. Overall, the stepwise simulation-based approach was perceived as beneficial in strengthening confidence, learning behaviours, and career insight. These findings suggest that structured, resource-conscious training models may be both feasible and valuable, with potential for broader integration into undergraduate curricula and adaptation across diverse healthcare and educational settings, particularly where traditional simulation resources are limited.

As the global population ages, Enhanced Recovery After Surgery (ERAS) protocols have gained increasing importance for improving recovery, pain control, and

Introduction: Esophageal cancer represents a major global health challenge. Multimodality treatment, involving esophagectomy with chemotherapy, radiotherapy, or immunotherapy, remains the standard of care for locally advanced esophageal cancers. Objectives: Unplanned hospital readmission has emerged as a key indicator of surgical quality and long-term patient outcomes after esophageal cancer surgery. This meta-analysis aims to provide a comprehensive review of predictors of unplanned readmission following esophagectomy. Methods: A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. A literature search for studies reporting readmission following esophagectomy up to November 2024 was conducted for PubMed and Embase. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported for the risk factors in question. Random-effects meta-analysis models were applied accordingly. Results: A total of 43 studies with 164 948 participants were included, with a pooled readmission rate of 16.4%. Comorbidities, particularly diabetes mellitus, chronic obstructive pulmonary disease, and cardiovascular disease, were associated with increased risk of readmission. A higher risk of readmission was also observed among women [OR 1.12 (95% CI 1.02, 1.23) P = 0.02]. Both higher American Society of Anesthesiologists (ASA) (III/IV) and longer length of index stay (>10 days) were important indicators of higher readmission rates [OR 2.27 (1.05, 4.89), P < 0.004] and [OR 1.35 (1.14, 1.61), P < 0.0007]. In contrast, neoadjuvant therapy was a protective factor for readmission [0.74 (95% CI 0.59, 0.92) P = 0.008]. Postoperative complications, especially anastomotic leak, wound-related, pulmonary, and thromboembolic events, were associated with readmission. Readmission was not significantly associated with mortality [OR 1.65 (95% CI 0.82, 3.33), P = 0.16]. Conclusion: This review provides a comprehensive overview of readmission after esophageal cancer surgery, a major indicator fof quality care. Our findings identified several potential risk factors of readmission following esophagectomy. These included comorbidities, ASA III/IV status, postoperative complications, and prolonged hospital stay. Neoadjuvant therapy may have potential benefits on unplanned readmission. By identifying modifiable risk factors, future optimization of health outcomes and preventive measures can be achieved.

Background: Choline (Ch) deprivation causes kidney injury and dysfunction, and diabetic nephropathy is also known to be a complication of diabetes; thus, this interplay could potentially aggravate diabetic kidney disease. Aim: This study aims to examine the effect of Ch-deprivation on the severity of kidney injury in streptozotocin (STZ)-induced diabetic rats. Methods: Twenty-four adult male Wistar rats were divided into four groups: control (C), nondiabetic Ch-deprived (CD), diabetic (DM), and diabetic Ch-deprived (DM + CD). Diabetes was induced by the intraperitoneal administration of 50 mg/kg body weight STZ; Ch-deprivation was induced through a choline-deficient diet. Rats were euthanized at week 5 of the study. Biochemical tests, renal histopathology, immunohistochemistry of the kidney injury molecule-1 (KIM-1), and vascular endothelial growth factor-A (VEGF-A) expression were assessed. Results: DM + CD and DM groups demonstrated significant increases in glucose levels and in the homeostasis model of insulin resistance (HOMA IR). Creatinine and blood urea nitrogen levels significantly increased in the DM + CD group compared to the control, and homocysteine levels were higher in the CD group. Kidney histopathology revealed that renal tubular necrosis, mesangial matrix expansion, and renal fibrosis substantially increased in the DM + CD group compared to all other groups, and KIM-1 and VEGF-A expressions were most pronounced in the DM + CD and DM groups, respectively. Conclusions: Ch deprivation affected kidney function and structure in STZ-induced diabetic rats. Choline deficiency and diabetes seem to have a synergistic effect, as evidenced by kidney biochemistry, histopathology, and immunohistochemistry. These findings could highlight the important role of choline in therapeutic strategies for the treatment and, potentially, prevention of chronic diabetic kidney disease.

Objective: This network meta‐analysis evaluates the efficacy and safety of tirzepatide compared to glucagon‐like peptide‐1 receptor agonists (GLP‐1 RA) and other weight loss drugs in the treatment of overweight and obesity.Methods: MEDLINE, Embase, and Cochrane CENTRAL were searched for randomized controlled trials on tirzepatide, GLP‐1 RA, and weight loss drugs approved by the US Food and Drug Administration. A network meta‐analysis was performed, drawing direct and indirect comparisons between treatment groups. Network diagrams and surface under the cumulative ranking curve analysis were performed for primary (≥5%, ≥10%, ≥15%, absolute weight loss) and secondary outcomes and adverse effects.Results: Thirty‐one randomized controlled trials, involving more than 35,000 patients, were included in this study. Tirzepatide 15 mg ranked in the top three across weight‐related parameters, glycemic profile (glycated hemoglobin), lipid parameters (total cholesterol, high‐density lipoprotein cholesterol, low‐density lipoprotein cholesterol, triglycerides), and blood pressure. Tirzepatide 15 mg had the highest efficacy compared with placebo for achieving ≥15% weight loss (risk ratio 10.24, 95% CI: 6.42–16.34). As compared to placebo, tirzepatide and GLP‐1 RA across all doses had significant increases in gastrointestinal adverse effects.Conclusions: The superiority of tirzepatide and GLP‐1 RA in inducing weight loss and their ability to target multiple metabolic parameters render them promising candidates in the treatment of patients with overweight and obesity.

Obesity, a chronic low-grade inflammatory disease represented by multifactorial metabolic dysfunctions, is a significant global health threat for adults and children. The once-held belief that type 1 diabetes is a disease of people who are lean no longer holds. The mounting epidemiological data now establishes the connection between type 1 diabetes and the subsequent development of obesity, or vice versa. Beyond the consequences of the influx of an obesogenic environment, type 1 diabetes-specific biopsychosocial burden further exacerbates obesity. In the course of obesity management discussions, recurring challenges surfaced. The interplay between weight gain and escalating insulin dependence creates a vicious cycle from which patients struggle to break free. In the absence of weight management guidelines and regulatory approval for this population, healthcare professionals must navigate the delicate balance between benefits and risks. The gravity of this circumstance highlights the importance of bringing these topics to the forefront. In this Review, we discuss the changing trends and the biopsychosocial aspects of the intersection between type 1 diabetes and obesity. We highlight the evidence supporting the therapeutic means (i.e., exercise therapy, nutritional therapy, adjunct pharmacotherapy, and bariatric surgery) and directions for establishing a more robust and safer evidence-based approach.