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  1. Nurzazlin, B.Z.N., Shamsul, B.S., Yahya, N.H.M., Ruszymah, B.H.I., Abdul Rani, R., Chowdhury, S.R.
    Medicine & Health, 2018;13(1):77-87.
    MyJurnal
    Culture expanded chondrocytes isolated from non-load bearing region of osteoarthritic (OA) joint has been used to construct tissue engineered cartilage for treatment purposes. The aim of the study was to compare the histological properties of the cartilage tissue and morphological properties of the chondrocytes isolated from less and severely affected OA knee. Human articular cartilage was obtained as redundant tissue from consented patients with late-stage OA undergoing total knee replacement surgery at Universiti Kebangsaan Malaysia Medical Centre (UKMMC). Articular cartilage was graded according to Dougados and Osteoarthritis Research Society International (OARSI) classification. Articular cartilage was classified into less affected (LA; Grade 0-1) and severely affected (SA; Grade 2-3). Cartilage tissue from less and severely affected region was stained with Safranin O staining. Isolated chondrocytes from each group were cultured until passage 4 (P4). Their growth patterns, cell areas, and circularity were compared. LA-cartilage tissue shows uniform spread of safranin O staining indicating intact extracellular matrix (ECM) component. However, SA-cartilage shows significant reduction and unstable staining due to its degraded ECM. LA-chondrocytes showed an aggregated growth compared to SA-chondrocyte that remains monolayer. Moreover, LA-chondrocytes have significantly higher cell area with wider spreading at passage 0 and 4 compared to SA-chondrocytes. It was also found that chondrocyte circularity increased with passage, and circularity of LAchondrocytes was significantly higher than that of the SA-chondrocytes at passage 3. This study demonstrated the considerable difference in the cellular properties for less and severely affected chondrocytes and implication of these differences in cell-based therapy needed to be explored.
  2. Mohamed-Haflah NH, Abdullah S, Abdul-Rani R
    Malays Orthop J, 2021 Mar;15(1):16-20.
    PMID: 33880143 DOI: 10.5704/MOJ.2103.003
    The Coronavirus (COVID-19) pandemic and institution of the Movement Control Order (MCO) had resulted in the cancellation of a major orthopaedic exam in April 2020. The exam is known as the Malaysian Orthopaedic Specialist Committee (OSC) Part I Examinations. It is similar to the British Royal Colleges of Surgeons Membership (MRCS) exams and held twice annually in April and October. There are up to 200 candidates involved. With implementation of new guidelines and standard operating procedures (SOP), the OSC Part I exam was successfully held by Universiti Kebangsaan Malaysia (UKM) from 5th-9th October 2020. Here we highlight the challenges we faced whilst coordinating a major exam at a national level during the COVID-19 pandemic with recommendations for future exams.
  3. Lourdesamy Anthony AI, Abdul Rani R
    J R Coll Physicians Edinb, 2024 Mar;54(1):18-25.
    PMID: 38509698 DOI: 10.1177/14782715241239704
    BACKGROUND: The presence of sleep-disordered breathing (SDB) in congestive heart failure (CHF) is associated with poor prognosis and is underdiagnosed despite advances in CHF management. The prevalence of SDB in CHF remains understudied in South East Asia.

    METHODS: A prospective, observational single-centre study was conducted where 116 consecutive patients in a specialised heart failure clinic underwent level 1, attended polysomnography (PSG).

    RESULTS: The prevalence of SDB was 78% using the apnoea-hypopnea index (AHI), AHI ⩾ 5/h threshold, and 59% with the AHI ⩾ 15/h threshold. Obstructive sleep apnoea (OSA) was the predominant type of SDB and was associated with increased body mass index and neck circumference. STOP-BANG was predictive of SDB, especially in men. Central sleep apnoea (CSA) patients had worse sleep indexes and lower awake arterial carbon dioxide. SDB was also homogenously present in preserved ejection fraction (EF) CHF.

    CONCLUSION: Most of the CHF patients were found to have SDB with the utility of PSG. Local CHF guidelines should include sleep testing for all patients with CHF.The study is registered on ClinicalTrials.gov (NCT05332223) as 'The Epidemiological Characteristics of SDB in Patients with Reduced or Preserved EF CHF'.

  4. Aliaga Ramos J, Arantes V, Abdul Rani R, Yoshida N
    Endosc Int Open, 2020 Dec;8(12):E1741-E1747.
    PMID: 33269305 DOI: 10.1055/a-1265-6598
    Background and study aims  Submucosal (SM) injection is a critical step in endoscopic submucosal dissection (ESD). In Japan, use of viscous solutions such as sodium hyaluronate are recommended; the commercially product available is MucoUp (Seikagaku Co. and Boston Scientific Japan Co., Japan). Nevertheless, MucoUp is expensive and unavailable in many Western countries. For the past 8 years, we have been using low-cost sterile teardrops solution composed of 0.4 % sodium hyaluronate (Adaptis Fresh, Legrand Laboratory, Brazil). This solution is readily available in drugstores with a cost of approximately US$ 10.00 for each 10-cc bottle. The aim of this study was to present the clinical outcome with off-label sodium hyaluronate use for SM injection in gastric ESD. Patients and methods  A single-center retrospective study of collected data investigating consecutive patients that underwent gastric ESD between 2012 and 2019. ESD was performed using 0.4 % sodium hyaluronate teardrop for SM injection and Flush Knife BT 2.5 (Fujifilm Co., Japan). The following data were analyzed: clinical-pathological features, en-bloc, R0 and curative resection rate, procedure duration, adverse events, and clinical outcome. Results  ESD was performed with sodium hyaluronate for submucosal injection in 78 patients. The en-bloc resection rate and R0 resection rate were 96.1 % and 92.3 %, respectively. The curative resection rate for epithelial lesions was 83.8 %. Adverse events occurred in 5 cases (6.3 %): delayed bleeding (3.8 %, 3 cases) and perforation (2.5 %, 2 cases); all managed successfully by clipping and thermal coagulation. The mean volume of sodium hyaluronate solution used per patient was 10 cc (SD: ± 8 cc). During follow-up (mean: 17 months; SD: ± 14.5 months), two patients developed metachronous lesions (2.5 %). Conclusions  Off-label use of teardrops with 0.4 % sodium hyaluronate for submucosal injection was demonstrated to be safe and able to provide an effective submucosal cushion that facilitates SM dissection in gastric ESD procedures.
  5. Arantes V, Aliaga Ramos J, Abdul Rani R, Yoshida N
    Endosc Int Open, 2020 Dec;8(12):C3.
    PMID: 33304992 DOI: 10.1055/a-1328-0505
    [This corrects the article DOI: 10.1055/a-1265-6598.].
  6. Abdul Rani R, Raja Ali RA, Lee YY
    Intest Res, 2016 Oct;14(4):297-304.
    PMID: 27799880
    Irritable bowel syndrome (IBS), a common gastrointestinal disorder involving the gut-brain axis, and inflammatory bowel disease (IBD), a chronic relapsing inflammatory disorder, are both increasing in incidence and prevalence in Asia. Both have significant overlap in terms of symptoms, pathophysiology, and treatment, suggesting the possibility of IBS and IBD being a single disease entity albeit at opposite ends of the spectrum. We examined the similarities and differences in IBS and IBD, and offer new thoughts and approaches to the disease paradigm.
  7. Mohd Said MR, Abdul Rani R, Raja Ali RA, Ngiu CS
    Med J Malaysia, 2017 02;72(1):77-79.
    PMID: 28255151 MyJurnal
    Percutaneous Endoscopic Gastrostomy (PEG) tubes were often offered to patients requiring long term enteral feeding. Even though the procedure is relatively safe, it is associated with various complications such as peritonitis or even death.1 We presented a case of a 54-year-old gentleman with underlying ischemic stroke and pus discharges from a recently inserted PEG tube. Computed Topography (CT) scan confirmed abdominal wall necrotising fasciitis complicated with hyperosmolar hyperglycaemia state (HHS) and later succumbed after 48 hours of admission. Our case illustrated the rare complication related to the insertion of PEG tube; abdominal wall necrotising fasciitis that was associated with mortality.
  8. Aliaga Ramos J, Yoshida N, Abdul Rani R, Arantes VN
    Arq Gastroenterol, 2023;60(2):208-216.
    PMID: 37556747 DOI: 10.1590/S0004-2803.20230222-168
    •This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Retrospective observational study, enrolling patients that underwent EESD from 2009 to 2021, divided in 2 groups. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). The learning curve in esophageal ESD could be overcomed effectively and safely by an adequately trained Western endoscopist. Background - Esophageal endoscopic submucosal dissection (EESD) is a complex and time-consuming procedure at which training are mainly available in Japan. There is a paucity of data concerning the learning curve to master EESD by Western endoscopists. Objective - This study aimed to assess the learning curve effect on patient's clinical outcome for EESD. Methods - This is a retrospective observational study. Enrolling patients that underwent EESD from 2009 to 2021. The analysis was divided into two periods; T1: case 1 to 49 and T2: case 50 to 98. The following features were analyzed for each group: patients and tumors characteristics, en-bloc, complete and curative resection rates, procedure duration and adverse events rate. Results - Ninety-eight EESD procedures were performed. Mean procedure time was 111.8 min and 103.6 min for T1 and T2, respectively (P=0.004). En bloc resection rate was 93.8% and 97.9% for T1 and T2, respectively (P=0.307). Complete resection rate was 79.5% and 85.7% for T1 and T2, respectively (P=0.424). Curative resection rate was 65.3% and 71.4% for T1 and T2, respectively (P=0.258). Four patients had complications; three during T1 period and one during T2 period. Overall mortality rate: 0%. Conclusion - The esophageal endoscopic submucosal dissection could be performed effectively and safely by an adequately trained Western endoscopist.
  9. Abdul Rani R, Hussin FR, Hamzaini AH, Isa MR, Raja Ali RA
    Med J Malaysia, 2016 02;71(1):37-8.
    PMID: 27130745
    Cronkhite-Canada Syndrome (CCS) is a syndrome characterised by a constellation of signs including but not limited to onychodystrophy of the finger and toe nails, skin hyperpigmentation and alopecia. Endoscopic features showed hamartomatous polyps involving all segments of the gastrointestinal tract with the characteristic exception of being oesophageal sparring. These polyps show confirmation by the presence of eosinophils and mast cells at the lamina propria upon histological studies.
  10. Chua KW, Muthuvadivelu S, Abdul Rani R, Ong SC, Hussin N, Cheah WK
    Curr Ther Res Clin Exp, 2021;95:100641.
    PMID: 34539939 DOI: 10.1016/j.curtheres.2021.100641
    Background: In Malaysia, knowledge regarding the clinical efficacy of tenecteplase (TNK), a fibrin-specific tissue-plasminogen activator, is limited.

    Objectives: To evaluate the effectiveness and tolerability of TNK in patients with ST-segment-elevation myocardial infarction in a secondary referral Malaysian hospital.

    Methods: This was a single-center retrospective case series based on the medical records of patients with ST-segment-elevation myocardial infarction admitted to the cardiac care unit between January 2016 and May 2019. Data regarding the mortality status and date of death were collected from the database of the National Registration Department of Malaysia.

    Results: Data for 30 patients with ST-segment-elevation myocardial infarction, who received weight-adjusted doses of TNK, were analyzed. The patients' mean (SD) age was 62 (14) years, and 77% were men. The median time to treatment was 265 minutes (interquartile range = 228-660 minutes), and the clinical success rate of thrombolysis was 79%. The overall all-cause in-hospital mortality rate was 33%. The 1-year survival rates were higher in patients achieving a time to treatment ≤360 minutes (P = 0.03), with a trend toward greater survival in this group at 30 days. Similarly, a trend toward lower in-hospital all-cause mortality was observed in this group (21% vs 50%; P = 0.12). Only 1 patient (3%), who had a HAS-BLED score based on hypertension, abnormal liver/renal function, stroke history, bleeding history or predisposition, labile international normalized ratio, old age, drug/alcohol use of 5, developed major bleeding that required blood transfusion. No cases of ischemic stroke, nonmajor bleeding, in-hospital reinfarction, or TNK-induced allergic reaction were identified.

    Conclusions: We hypothesized that the mortality-related outcomes of TNK in patients with ST-segment-elevation myocardial infarction were influenced by TTT, with TTT ≤360 minutes indicating a better prognosis than TTT >360 minutes. TNK-induced bleeding-related complications were minimal in low-risk patients. Further local studies are needed to compare TNK's profile with that of streptokinase, which is a common agent currently used in clinical practice in Malaysian public hospitals. (Curr Ther Res Clin Exp. 2021; 82:XXX-XXX).

  11. Mohd Said MR, Wong Z, Abdul Rani R, Ngiu CS, Raja Ali RA, Lee YY
    J Gastroenterol Hepatol, 2021 May;36(5):1244-1252.
    PMID: 33002243 DOI: 10.1111/jgh.15284
    BACKGROUND AND AIM: Variations in the Chicago 3.0 normative metrics may exist with different postures and with different provocative swallow materials in a healthy Asian population.

    METHOD: Eligible healthy Malay volunteers were invited to undergo the high-resolution esophageal manometry (inSIGHT Ultima, Diversatek Healthcare, Milwaukee, WI, USA). In recumbent and standing positions, test swallows were performed using liquid, viscous, and solid materials. Metrics including integrated relaxation pressure 4 s (IRP-4 s, mmHg), distal contractile integral (DCI, mmHg s cm), distal latency (DL, s), and peristaltic break (PB, cm) were reported in median and 95th percentile.

    RESULTS: Fifty of 57 screened participants were recruited, and 586 saline, 265 viscous, and 261 solid swallows were analyzed. Per-patient wise, in the recumbent position, 95th percentile for IRP-4 s, DCI, DL, and PB were 16.5 mmHg, 2431 mmHg s cm, 8.5 s, and 7.2 cm, respectively. We observed that with each posture, the use of viscous swallows led to changes in DL, but the use of solid swallows led to more changes in the metrics including DCI and length of PB. Compared with a recumbent posture, anupright posture led to lower IRP-4 s and DCI values. Both per-patient analysis and per-swallow analyses yielded almost similar results when comparing the different postures and types of swallows. No major motility disorders were observed in this cohort of asymptomatic population. However, more motility disorders were reported in the upright position.

    CONCLUSIONS: Variations in metrics can be observed in different postures and with different provocative swallow materials in a healthy population. The normative Chicago 3.0 metrics are also determined for the Malay population.

  12. Mokhtar NM, Jaafar NM, Alfian E, Mohd Rathi ND, Abdul Rani R, Raja Ali RA
    Acta Gastroenterol Belg, 2021 12 30;84(4):585-591.
    PMID: 34965040 DOI: 10.51821/84.4.009
    Background: Gut dysbiosis is linked with the pathophysiology of irritable bowel syndrome (IBS). Manipulation of intestinal microbiota using cultured milk drinks may stimulate the immune system, hence providing beneficial support in IBS treatment. This study aimed to investigate the effects of cultured milk drink on clinical symptoms, intestinal transit time (ITT), fecal pH and cytokines in constipation-predominant IBS (IBS-C) as compared to non-IBS participants.

    Methods: Each recruited participant was given three bottles of 125 ml cultured milk drink containing 109 cfu Lactobacillus acidophilus LA-5 and Lactobacillus paracasei L. CASEI-01 consumed daily for 30 days. At pre- and post-30-day consumption, fecal pH, ITT, clinical symptoms, IL-6, IL-8 and TNF-α levels were assessed. Seventy-seven IBS-C and 88 non-IBS were enrolled.

    Results: Post-consumption, 97.4% of IBS-C experienced improvements in constipation-related symptoms supported by the significant reduction of ITT and decreased fecal pH (p<0.05). All pro-inflammatory cytokines were significantly lower in post as compared to pre-consumption of cultured milk drinks in IBS-C (p<0.05). There was significant reduction in the IL-8 and TNF-α levels in post- as compared to pre-consumption for the non-IBS (p<0.05).

    Conclusion: Cultured milk drink taken daily improved clinical symptoms and reduced cytokines, hence should be considered as an adjunctive treatment in IBS-C individuals.

  13. Aliaga Ramos J, Pedrosa MS, Yoshida N, Abdul Rani R, Arantes VN
    J Clin Gastroenterol, 2023 Jan 01;57(1):74-81.
    PMID: 33883515 DOI: 10.1097/MCG.0000000000001541
    BACKGROUND: The standard of practice when a superficial lesion was identified during upper GI endoscopy is to take an endoscopic forceps biopsy (EFB) of the lesion. The histopathologic findings then will determine the management plan. Endoscopic submucosal dissection (ESD) enables en-bloc resection for early neoplasms of the gastrointestinal tract and provides an adequate specimen that permits a more reliable histopathologic assessment. The objective of this study was to determine the rate of histopathologic discrepancy between EFB and specimens resected by ESD, and to identify the predisposing risk factors for this discordance.

    MATERIALS AND METHODS: This is a retrospective study, enrolling patients with superficial gastric neoplasms that underwent EFB followed by ESD. We divided cases to concordant or discordant group according to the histopathologic diagnosis of EFB and ESD specimens. We also analyzed the features that may have influenced the occurrence of histopathologic discordance and the association between discordant samples of adenocarcinoma and neoplastic invasion to deeper layers.

    RESULTS: A total of 115 gastric ESD procedures were performed with 84 patients meeting the inclusion criteria. Histopathologic discordance between EFB and ESD specimens were observed in 35.8% of cases (30/84 lesions). The univariant-bivariant analysis and multivariate logistic regression analysis showed that histologic discordance was closely related to the size of the lesions ( P =0.028).

    CONCLUSION: Histopathologic discrepancy between EFB and ESD specimens may occur in approximately one-third of cases, particularly for lesions over 20 mm, which may lead to crucial delays in gastric cancer precise diagnosis and treatment.

  14. Mahdzir ANK, Mat S, Seow SR, Abdul Rani R, Che Hasan MK, Mohamad Yahaya NH
    World J Clin Cases, 2023 Oct 16;11(29):7043-7052.
    PMID: 37946758 DOI: 10.12998/wjcc.v11.i29.7043
    BACKGROUND: The study sought to understand the self-management strategies used by patients during the postponement of their total knee arthroplasty (TKA) procedure, as well as the associations between the length of waiting time, pain, and physical frailty and function. The study focused on individuals aged 50 years and above, as they are known to be more vulnerable to the negative impacts of delayed elective surgery and rehabilitation. This study hypothesizes that delayed TKR due to coronavirus disease 2019 (COVID-19) will bear negative effect in self-management, pain, and physical frailty and function in older adults.

    AIM: To investigate the effects of COVID-19 pandemic on self-management, pain, and physical function in older adults awaiting TKA in Malaysia.

    METHODS: This cross-sectional study has the data of participants, who matched the criteria and scheduled for TKA for the first time, extracted from the TKA registry in the Department of Orthopaedics and Traumatology, Hospital Canselor Tuanku Mukhriz. Data on pain status, and self-management, physical frailty, and instrumental activities daily living were also collected. Multiple linear regression analysis with a significant level of 0.05 was used to identify the association between waiting time and pain on physical frailty and functional performance.

    RESULTS: Out of 180 had deferred TKA, 50% of them aged 50 years old and above, 80% were women with ethnic distribution Malay (66%), Chinese (22%), Indian (10%), and others (2%) respectively. Ninety-two percent of the participants took medication to manage their pain during the waiting time, while 10% used herbs and traditional supplements, and 68% did exercises as part of their osteoarthritis (OA) self-management. Thirty-six participants were found to have physical frailty (strength, assistance with walking, rising from a chair, climbing stairs, and falls questionnaire score > 4) which accounted for 72%. Increased pain was associated with physical frailty with odds ratio, odds ratio (95% confidence interval): 1.46 (1.04-2.05). This association remained significant even after the adjustment according to age and self-management.

    CONCLUSION: While deferring TKA during a pandemic is unavoidable, patient monitoring for OA treatment during the waiting period is important in reducing physical frailty, ensuring the older patients' independence.

  15. Sellvam SA, Raghu S, Leong JF, Hafni F, Abdul Rani R
    Cureus, 2023 Aug;15(8):e43173.
    PMID: 37692627 DOI: 10.7759/cureus.43173
    Macrodystrophia lipomatosa (MDL) is a rare congenital variant of focused gigantism that is non-hereditary. Typically, MDL presents with localized gigantism in either the hand or foot. In this case report, we present the unique instance of a 12-year-old girl who has experienced enlargement of the first and second toes on her right foot since birth. Plain radiographs and MRI findings revealed the accumulation of fatty tissue around the first and second toes, medial and lateral aspects of the first metatarsal, extending up to the medial plantar arch of the foot. To enhance foot functionality and alleviate any issues with wearing footwear, a successful reconstruction surgical intervention was performed. As a result, the patient can now wear shoes without any difficulties. MDL is a very uncommon kind of congenital localised gigantism, and surgical consultation is frequently performed for cosmetic reasons.
  16. Bahrudin MF, Abdul Rani R, Tamil AM, Mokhtar NM, Raja Ali RA
    Dig Dis Sci, 2020 Feb;65(2):541-549.
    PMID: 31209720 DOI: 10.1007/s10620-019-05695-3
    BACKGROUND: This study aimed to objectively investigate whether the addition of polydextrose to sterilized probiotic containing Lactobacillus helveticus will confer benefits to constipation-predominant irritable bowel syndrome patients.

    METHODS: A total of 163 patients were randomized into two groups: Group A to consume 350 mL of sterilized probiotic with 5.85 g polydextrose daily for 1 week and Group B without polydextrose. Intestinal transit time, fecal pH, fecal weight, and modified Garrigues questionnaires for pre- and post-consumption were assessed.

    RESULTS: Median intestinal transit time was significantly reduced from 58 (IQR 43-72) to 45 (IQR 24-59) hours and 48 (IQR 31-72) to 30 (IQR 24-49) hours for Groups A and B, respectively (p 

  17. Basri KN, Yazid F, Mohd Zain MN, Md Yusof Z, Abdul Rani R, Zoolfakar AS
    PMID: 38394882 DOI: 10.1016/j.saa.2024.124063
    Dental caries has high prevalence among kids and adults thus it has become one of the global health concerns. The current modern dentistry focused on the preventives measures to reduce the number of dental caries cases. The employment of machine learning coupled with UV spectroscopy plays a crucial role to detect the early stage of caries. Artificial neural network with hyperparameter tuning was employed to train spectral data for the classification based on the International Caries Detection and Assesment System (ICDAS). Spectra preprocessing namely mean center (MC), autoscale (AS) and Savitzky Golay smoothing (SG) were applied on the data for spectra correction. The best performance of ANN model obtained has accuracy of 0.85 with precision of 1.00. Convolutional neural network (CNN) combined with Savitzky Golay smoothing performed on the spectral data has accuracy, precision, sensitivity and specificity for validation data of 1.00 respectively. The result obtained shows that the application of ANN and CNN capable to produce robust model to be used as an early screening of dental caries.
  18. Mokhtar NM, Bahrudin MF, Abd Ghani N, Abdul Rani R, Raja Ali RA
    Front Psychol, 2020;11:1936.
    PMID: 32849137 DOI: 10.3389/fpsyg.2020.01936
    Patients suffering from irritable bowel syndrome (IBS) may have some form of affective disorders that may worsen their symptoms. Lack of screening among IBS patients is one of the reasons for depression unawareness among healthcare providers. The present study was conducted to evaluate the prevalence of depression among patients with constipation-predominant IBS (IBS-C). A total of 240 IBS patients who fulfilled Rome III criteria were enrolled. The psychiatric assessment was evaluated using the Center for Epidemiologic Studies Depression Scale Revised (CESD-R). Twenty items in CESD-R scale measured symptoms of depression in nine separate groups. Patients were categorized into five different subgroups: major depressive episode, probable major depressive episode, possible major depressive episode, subthreshold depressive symptoms, and without clinical significance of depression. Out of the 240 patients with IBS-C, the majority (n = 161, 67.1%) had no clinical significance of depression. Seventy seven (32.1%) had subthreshold depression and only two (0.83%) patients were regarded as having probable a major depressive episode. No patient was categorized into a major or possible major depressive episode. The prevalence of subthreshold depression was the highest among female (72.3%) patients with 51.1% being single, 44.7% were married, and 4.3% were divorcees. When stratified according to ethnicity, subthreshold depression was highly prevalent among Malays (76.6%), followed by Chinese (19.2%), and Indians (2.1%). A high percentage of the patients were found to be non-smokers (93.6%) and had lower income of less than RM 5000 (USD 1250) per month (89.4%). The moderately high prevalence of subthreshold depression among patients with IBS, justifies psychological evaluation in all patients with functional gastrointestinal disorders.
  19. Matheen FIA, Leong JF, Abdul Rani R, Hayyun MF, Mohamad Yahaya NH
    Cureus, 2024 Sep;16(9):e68482.
    PMID: 39364451 DOI: 10.7759/cureus.68482
    Extra-articular deformities (EAD) can pose a challenge to surgeons during a total knee arthroplasty (TKA) surgery. Obtaining an acceptable post-operative hip-knee-ankle (HKA) angle may be difficult, especially in a limb with multiplanar deformities of both the femur and the tibia.  Our case is about a 66-year-old gentleman with a long-term deformity of his right lower limb secondary to malunion of the right femoral shaft and tibial shaft fractures. He initially presented with a right floating knee injury, 45 years ago, which was managed with conservative measures. He subsequently presented to us with ipsilateral knee osteoarthritis and underwent a robotic-assisted total knee arthroplasty surgery. Robotic- or computer-assisted total knee arthroplasty is an actively developing area and is gaining popularity among arthroplasty surgeons. In cases with severe extra-articular deformities such as in this case, robotic-assisted surgery can be superior to conventional surgery.
  20. Yoshida N, Naito Y, Murakami T, Hirose R, Ogiso K, Inada Y, et al.
    Ann Transl Med, 2017 Apr;5(8):185.
    PMID: 28616400 DOI: 10.21037/atm.2017.03.33
    In Japan, endoscopic submucosal dissection (ESD) becomes one of standard therapies for large colorectal tumors. Recently, the efficacy of ESD has been reported all over the world. However, it is still difficult even for Japanese experts in some situations. Right-sided location, large tumor size, high degree of fibrosis, difficult manipulation is related with the difficulty. However, improvements on ESD devices, suitable strategies, and increase of operators' experiences enable us to solve these problems. In this chapter, we introduce recent topics about various difficult factors of colorectal ESD and the tips such as strategy, devices, injection, and traction method [Pocket-creation method (PCM) etc.].
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