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Background and Aim: Endoscopic ultrasound (EUS) is the most sensitive method for evaluation of pancreatic lesions but is limited by significant operator dependency. Artificial intelligence (AI), in the form of computer-aided detection (CADe) systems, has shown potential in increasing accuracy and bridging operator dependency in several endoscopic domains. However, the complexity of integrating AI into EUS is far more challenging. This aims to develop and test the basis for a CADe system for real-time detection and segmentation of all pancreatic lesions., Methods: In this single-center study EUS studies of pancreatic findings were included. Lesions were outlined by two expert (>5 years performing EUS) endoscopists, and the two leading types of models were benchmarked. The models' performance was evaluated through per-pixel intersection over union (IoU)., Results: A total of 1497 EUS images from 165 patients were evaluated. The dataset included malignancies, neuroendocrine tumors, benign cysts, chronic and acute pancreatitis, normal fatty pancreas, and benign lesions. The best model demonstrated detection and segmentation on the test set with a mean IoU of 0.73, achieving a PPV, NPV, total accuracy, and ROC of 0.82, 0.96, 0.95, and 0.95, respectively. The algorithm is adaptable for real-time processing., Conclusions: We developed and tested deep learning models for real-time detection and segmentation of pancreatic lesions during EUS with promising results. This constitutes the basis for a CADe system for EUS, which could be valuable in future detection and evaluation of pancreatic lesions. Further studies for validation and generalization are underway., (© 2024 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Studies on the effect of computer-aided detection (CAD) in a daily clinical screening and surveillance colonoscopy population practice are scarce. The aim of this study was to evaluate a novel CAD system in a screening and surveillance colonoscopy population., Methods: This multicentre, randomised, controlled trial was done in ten hospitals in Europe, the USA, and Israel by 31 endoscopists. Patients referred for non-immunochemical faecal occult blood test (iFOBT) screening or surveillance colonoscopy were included. Patients were randomomly assigned to CAD-assisted colonoscopy or conventional colonoscopy; a subset was further randomly assigned to undergo tandem colonoscopy: CAD followed by conventional colonoscopy or conventional colonoscopy followed by CAD. Primary objectives included adenoma per colonoscopy (APC) and adenoma per extraction (APE). Secondary objectives included adenoma miss rate (AMR) in the tandem colonoscopies. The study was registered at ClinicalTrials.gov, NCT04640792., Findings: A total of 916 patients were included in the modified intention-to-treat analysis: 449 in the CAD group and 467 in the conventional colonoscopy group. APC was higher with CAD compared with conventional colonoscopy (0·70 vs 0·51, p=0·015; 314 adenomas per 449 colonoscopies vs 238 adenomas per 467 colonoscopies; poisson effect ratio 1·372 [95% CI 1·068-1·769]), while showing non-inferiority of APE compared with conventional colonoscopy (0·59 vs 0·66; p<0·001 for non-inferiority; 314 of 536 extractions vs 238 of 360 extractions). AMR in the 127 (61 with CAD first, 66 with conventional colonoscopy first) patients completing tandem colonoscopy was 19% (11 of 59 detected during the second pass) in the CAD first group and 36% (16 of 45 detected during the second pass) in the conventional colonoscopy first group (p=0·024)., Interpretation: CAD increased adenoma detection in non-iFOBT screening and surveillance colonoscopies and reduced adenoma miss rates compared with conventional colonoscopy, without an increase in the resection of non-adenomatous lesions., Funding: Magentiq Eye., Competing Interests: Declaration of interests HN reports equipment from Magentiq Eye. AAB is a consultant for Boston Scientific Corp. SN is a consultant for Boston Scientific Corp, Olympus, and Neptune Medical. HJ reports consultancy fees from Magentiq Eye, and stock options from Magentiq Eye from activities before the clinical trial. PDS reports research support from Pentax, The eNose company, Lucid Diagnostics, Micro Tech, Motus GI, Magentiq Eye, Norgine, and Endo Tools Therapeutics, and consultancy fees from Motus GI and Magentiq Eye. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Purpose: Obesity and pregnancy are strictly related: on the one hand, obesity-one of the most common comorbidities in women of reproductive age-contributes to infertility and obesity-related pregnancy complications, whereas pregnancy is a condition in which, physiologically, the pregnant woman undergoes weight gain. Endoscopic sleeve gastroplasty (ESG) may be used for the treatment of obesity in women of childbearing age., Materials and Methods: A retrospective analysis was conducted to evaluate weight trajectories, the evolution of obesity-related comorbidities, and lifestyle modification in women who became pregnant after ESG. A comparison was made between childbearing-age women who became pregnant after ESG and non-pregnant women., Results: A total of 150 childbearing-age women underwent ESG at a large tertiary medical center. Of these, 11 patients (33.4 ± 6.2 years) became pregnant after the procedure, following a mean time interval of 5.5 ± 3.9 months. Three women (two affected by polycystic ovary syndrome) reported difficulty getting pregnant before undergoing ESG. The mean preconception BMI was 31.9±4.0 kg/m 2 (-7.24 ± 4.0 kg/m 2 after ESG). Total body weight loss (TBWL, %) was 18.08 ± 8.00, 11.00 ± 11.08, and 12.08 ± 8.49, at the beginning of pregnancy, at the delivery, and at the first follow-up (19.6 ± 7.8 months after ESG). TBWL of at least 5% was achieved before pregnancy in all patients (73% reached a TBWL ≥ 10%). No significant differences in weight loss and QoL were found between the pregnancy and non-pregnancy groups up to 24 months after ESG., Conclusions: Endoscopic sleeve gastroplasty allows for adequate weight loss before and after pregnancy in patients with obesity., (© 2023. The Author(s).)

Hypercontractile esophagus with concomitant esophagogastric junction outflow obstruction (EGJOO) is a rare entity that is characterized by both esophageal hypercontractility and lack of relaxation of the EGJ. The clinical characteristics of these patients are not well-described and there is no strict recommendation regarding the treatment of this condition. We report four cases of patients with hypercontractile esophagus and concomitant to EGJOO. All patients underwent upper gastrointestinal (GI) endoscopy, high-resolution esophageal manometry (HRM) and barium swallow and met the criteria of Chicago Classification for both EGJOO and hypercontractile esophagus. Patients were followed up to four years from diagnosis and clinical symptoms were recorded. Four patients, who underwent evaluation for dysphagia, were found to have both EGJOO and hypercontractile esophagus on HRM. Two of them had mild symptoms and did not undergo treatment with no progression of symptoms on follow-up. Of the two patients who underwent treatment, one had botulinum toxin injection to the EGJ via upper GI endoscopy and one underwent per-oral endoscopic myotomy. Symptoms in both patients improved. Patients with concomitant hypercontractile esophagus and EGJOO present with varying degrees of symptoms and the treatment approach should be personalized according to the degree of symptoms and general clinical condition., (© 2022. Indian Society of Gastroenterology.)

Background: The term Fetal Alcohol Spectrum Disorders (FASD) describes a range of neurodevelopmental conditions, the direct result of prenatal alcohol exposure. FASD encompasses a range of behavioural, cognitive and sleep patterns that are sometimes indiscernible from other neurodevelopmental conditions, one in particular being Autism Spectrum Disorders (ASD). This study aimed to provide a comparison of behavioural, cognitive, affect-related and sleep profiles in children aged between 6 and 15 years with diagnoses of FASD or ASD, in contrast to typically developing (TD) children., Methods: We compared 29 children with FASD, 21 children with ASD and 45 typically developing (TD) children on parental-reported questionnaires measuring behaviour and executive functioning: the Child Behaviour Checklist (CBCL), the Spence Children's Anxiety Scale (SCAS) and the Behaviour Rating Inventory for Executive Function (BRIEF). Additionally, parents completed the Children's Sleep Habits Questionnaire (CSHQ), and children wore actigraphy watches while sleeping to objectively capture their sleep habits. The three groups were compared using ANCOVA, controlling for age effects., Results: Children with FASD scored significantly higher than the other two groups on the CBCL subscales of attention problems, somatic complaints, social problems, delinquency, and aggressive behaviour, as well as the panic subscale of the SCAS. Children with FASD also scored higher on all measures of the BRIEF than the ASD and TD groups, indicating greater problems with working memory and more difficulty shifting between tasks, planning, organising, inhibiting their behaviour and exercising emotional control. Nocturnal sleep duration in children with FASD was reported as one hour less than TD children and 46 minutes less than children with ASD per night., Conclusions: The findings in this study highlight several syndrome specific features (shorter sleep duration, executive functioning difficulties, and higher levels of social and behavioural problems and panic) that potentially contribute to the unique phenotype of FASD. Whilst this research highlights the need for further work in this area, initial clinical screening for FASD should take such data on discernible characteristics, particularly the syndrome specificity of the BRIEF, into consideration., Competing Interests: The authors declare no conflict of interest. Dagmara Dimitriou is serving as one of the Guest editors of this journal. We declare that Dagmara Dimitriou had no involvement in the peer review of this article and has no access to information regarding its peer review. Full responsibility for the editorial process for this article was delegated to Gernot Riedel., (© 2023 The Author(s). Published by IMR Press.)

Background: Peroral endoscopic myotomy (POEM) is rapidly becoming the procedure of choice for treating esophageal achalasia. In most centers, contrast-enhanced swallow studies (CESS) are routinely performed postoperatively to confirm mucosal integrity. The aim of this study was to determine the necessity of performing these studies routinely after POEM., Methods: A retrospective review of a prospectively maintained database of patients who underwent POEM between December 2012 and November 2020 was performed. All patients underwent a CESS on the first postoperative day. Medical records including vital signs, complete blood count, and POD-1 CESS were evaluated., Results: One hundred thirty-four consecutive patients were included in the study. Sixty-nine (51.49%) CESS showed abnormal findings; while most findings did not change the postoperative course, five (7.2%) demonstrated tunnel leaks, which did alter the overall management. Screening patients for fever, tachycardia, or leukocytosis on POD-1 had a 100% sensitivity and a 62% specificity for finding a clinically significant complication on CESS., Conclusions: The study findings suggest that performing routine contrast-enhanced swallow studies on all patients is not necessary following POEM, as leaks can be screened for by clinical or laboratory abnormalities. Herein, we propose an algorithm based on objective measurable findings for the selection of patients who should undergo CESS., (© 2023. The Society for Surgery of the Alimentary Tract.)

Purpose: APC I1307K has a higher prevalence among Ashkenazi Jews (AJ), and a two-fold increased risk for colorectal cancer (CRC) compared to non-Jewish populations. We assessed CRC and extracolonic malignancies among I1307K carriers from AJ and non-AJ whites (NAW). Methods: We compared the rate of I1307K in cancer patients who underwent germline genetic testing via a multi-gene panel with healthy subjects retrieved from the gnomAD database. Cases undergoing testing were not selected and testing was undertaken through a commercial laboratory. Results: Overall, 586/7624 (7.6%) AJ with cancer carried I1307K compared to 342/4918 (6.9%) in the AJ control group (p = NS). In the NAW, 318/141,673 (0.2%) cancer patients and 73/58,918 (0.1%) controls carried the variant [OR = 1.8, (95% CI 1.41−2.35), p < 0.001]. I1307K in NAW was associated with an increased risk of CRC [OR = 1.95, (95% CI 1.39−2.73), p < 0.01], melanoma [OR = 2.54, (95% CI 1.57−3.98)], breast [females, OR = 1.73, (95% CI 1.18−2.65), p < 0.01], and prostate cancer [males, OR = 2.42, (95% CI 1.45−3.94), p < 0.01]. Among AJ, the variant increased the risk for CRC [OR = 1.67, (95% CI 1.36−2.05), p < 0.001] and renal cancer [OR = 1.64, (95% CI 1.04−2.47)]. AJ men had a higher risk for any cancer [OR = 1.32, (95% CI 1.05−1.66), p < 0.05] and melanoma [OR = 2.04, (95% CI 1.24−3.22); p < 0.05]. Conclusions: This is the most extensive study to date conducted on I1307K carriers, although it is amenable to selection bias. NAW carrying I1307K had a higher risk of any cancer and several specific cancer types, whereas AJ carrying the variant had a risk for only a few select cancers. Our data add to the research base on I1307 carriers concerning future risk management.

Backgrounds/aims: The soft texture of the pancreas parenchyma may influence the incidence of pancreatic leakage after pancreaticoduodenectomy (PD). One possible method to assess pancreatic texture and atrophy, is via computed tomography (CT) scan of the abdomen. The purpose of our study was to evaluate the relation between the preoperative CT scan and the incidence of pancreatic fistula after PD., Methods: A retrospective single-center study including patients who underwent PD for a benign and malignant tumor of the periampullary region between the years 2000 and 2016. Demographic and imaging data were analysed and a correlation with the post-operative leak was evaluated., Results: Pancreatic leak was documented in 34 out of 154 (22.1%) patients. All the leakage cases occurred in the preserved pancreas group (33.1% of the total preserved pancreas group alone). No leak was documented in the atrophic pancreas group. This difference between the two groups was found to be statistically significant ( p ≤ 0.00001)., Conclusions: Atrophic pancreas in the preoperative CT scan may be protective against leakage after PD. These findings may help the surgeon to risk stratify patients accordingly. In addition, the findings suggest that patients with a preserved pancreas may require more protective methods to prevent leakage.

Background and Aims: There is conflicting evidence regarding the association between proton pump inhibitors (PPI) and the risk of acquisition and severity of acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Aim: To evaluate the association between PPI exposure and infection and development of severe disease in patients infected with SARS-CoV2in a large population-based historical cohort. Methods: Data were extracted from a health maintenance organization database in Israel that insures over 1,200,000 individuals from across the country. All patients who underwent SARS-CoV-2 testing between March and November 2020 were included. Logistic regression and matched analyses were used to compare patients prescribed and exposed to PPIs to those not prescribed PPIs regarding SARS-CoV-2 positivity. In addition, among SARS-CoV-2 positive patients (n = 44,397) the likelihood of developing severe disease, defined by a composite endpoint of death, ICU admission and prolonged hospitalization, was compared in those exposed and not exposed to PPIs. Results: Among 255,355 adult patients who underwent SARS-CoV-2 testing by PCR, 44,397 (17.4%) were positive for SARS-CoV-2 and 12,066 (4.7%) patients were prescribed PPIs in the 3 months before testing. In a multivariable logistic regression model controlling for age, gender, smoking status, BMI, diabetes mellitus, hypertension, COPD, history of ischemic heart disease and fasting blood glucose (FBG) levels, no significant association was found between PPIs and SARS-CoV-2 positivity ( p = 0.09 aOR 0.94, 95% CI - 0.88-1.01). Among SARS-CoV-2 positive patients, 910 (2%) had a severe infection. Multivariate logistic regression controlling for the abovementioned confounders, showed no such association between PPIs and severe COVID-19 ( p = 0.28). Elevated FBG levels were significantly associated with both PPI exposure ( p < 0.001) and severe COVID-19 infection ( p < 0.001). These results were reinforced by a matched analysis (n = 655 pairs). Conclusion: PPIs are spuriously associated with severe COVID-19 due to the presence of elevated FBG as a confounder. Our study accounted for the FBG levels of patients and known risk factors for severe COVID-19 infection, which may be the reason for the discrepancy in prior studies. These results may aid in understanding potential confounders when evaluating potential associations of PPIs with other respiratory or viral diseases., Competing Interests: Authors AS and MB were employed by the company Meuhedet Health Medical Organization. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Shafrir, Benson, Katz, Hershcovici, Bitan, Paltiel, Calderon-Margalit, Safadi and Shauly-Aharonov.)

Competing Interests: There are no conflicts of interest.

Background: Synthetic cannabinoids (SC) are chemical substances which activate cannabinoid receptors similarly to tetrahydrocannabinol, but with a higher efficacy. These substances are used as illicit recreational drugs, often smoked as herbal mixtures. The continuing availability and rapid evolution of SC is an ongoing health risk. The adverse effects of SC are wide ranging, and span from mild behavioral changes to death. Knowledge regarding gastrointestinal (GI) manifestations of SC use is sparse., Methods: Single tertiary-care referral medical center retrospective study., Results: The medical records of patients presented to hospital emergency care due to SC use between January 2014 and February 2018 were retrieved from Hadassah Mount Scopus Hospital's computerized database. The records were reviewed for clinical outcomes and laboratory tests. Fifty-five (55) patients were identified with a hospital presentation due to SC use. Twenty-one (21) out of 55 patients (38%) reported gastrointestinal complaints. The most common complaints were abdominal pain and vomiting. Of those, 28% had recurrent emergency department presentations due to abdominal pain and 66% presented with leukocytosis. Serum lactate was elevated in 66% of patients with GI manifestations. One patient had an abnormal computerized tomography (CT) abdominal angiography scan, which was compatible with intestinal ischemia., Conclusions: The clinical spectrum of gastrointestinal manifestations in SC intoxication ranges from mild symptoms, such as abdominal pain and vomiting, to even more severe symptoms suggestive of intestinal ischemia. Clinicians should be aware that abdominal pain and other gastrointestinal complaints can be associated with SC use.

When choosing between options, such as food items presented in plain view, people tend to choose the option they spend longer looking at. The prevailing interpretation is that visual attention increases value. However, in previous studies, 'value' was coupled to a behavioural goal, since subjects had to choose the item they preferred. This makes it impossible to discern if visual attention has an effect on value, or, instead, if attention modulates the information most relevant for the goal of the decision-maker. Here, we present the results of two independent studies-a perceptual and a value-based task-that allow us to decouple value from goal-relevant information using specific task-framing. Combining psychophysics with computational modelling, we show that, contrary to the current interpretation, attention does not boost value, but instead it modulates goal-relevant information. This work provides a novel and more general mechanism by which attention interacts with choice., Competing Interests: PS, MU, ND, AB, PO, BD No competing interests declared, (© 2020, Sepulveda et al.)

Background: Few studies describe the radiological and laboratory characteristics of patients with Crohn's disease (CD) with intra-abdominal fistulae., Objectives: We aimed to describe a cohort of CD patients with intra-abdominal fistulae and determine characteristics associated with complex fistulae., Methods: Data were gathered from medical records and imaging studies of patients. Evaluation included type of fistula, number of fistulae, and radiological characteristics., Results: A total of 205 fistulae in 132 patients were identified with an average patient age of 31 (±12) years. The average time from CD diagnosis to fistula development was 7 years. The most common type of fistula was entero-enteric (53%). Patients with an extra-intestinal fistula presented with an average of 1.96 fistulae, compared with an average of 1.28 fistulae for those with a fistula limited to the bowel (p =0.01). Except for the number of fistula no other significant differences were observed in radiological characteristics of patients who were diagnosed with a fistula at time of CD diagnosis compared to those diagnosed with a fistula later., Conclusions: The most common CD-associated intra-abdominal fistulae are entero-enteric and entero-colonic fistulae. An extra-intestinal fistula and diagnosis of a fistula subsequent to diagnosis of CD were associated with an increased number of fistulae per patient., (© 2019 S. Karger AG, Basel.)

Purpose: Portal vein thrombosis (PVT) is a common condition in cirrhotic patients and mostly attributed to portal hypertension. The objective of our study was to examine the association of PVT with hepatocellular carcinoma (HCC) in cirrhotic patients., Methods: A retrospective study was performed to identify cirrhotic patients with thrombosis of the portal system. Clinical and laboratory characteristics were collected and analyzed., Results: Thirty-nine patients were identified. Twenty-four out of 39 patients with PVT did not develop HCC (group A) after follow-up time of 38.5 months from the diagnosis of PVT. Eight patients (20.5%) were diagnosed with HCC within two weeks following diagnosis of PVT (group B). Seven patients (17.9%) were diagnosed with tumor thrombus (group C) at time of PVT diagnosis. The average age was 53.5, 66.5, and 69 years for groups A, B, and C respectively. Most patients (75 and 87.5% for groups B and C respectively) diagnosed with PVT and HCC were males. The most common cause of cirrhosis in groups B and C was chronic hepatitis B virus infection (HBV) in 62.5% and 50% respectively. The most common clinical presentation of PVT in group A was abdominal pain in 55.5% compared to new/worsening ascites in 43% and 37.5% for groups B and C respectively. The platelet count in groups B and C was higher as compared to that in group A (126 and 125 vs. 107 thousand, P = NS)., Conclusion: In 38.4% of cases, new diagnosis of PVT was associated with concomitant diagnosis of HCC. Identifiable risk factors were chronic HBV infection and higher platelet count.

Background and Aims: A majority of acutely ill Crohn's disease [CD] patients who present to Emergency Department [ED] will undergo an abdominal CT to rule out disease complications. We aimed to generate a simple non-invasive scoring model to predict the presence of an intra-abdominal abscess in CD patients in the ED., Methods: We performed a retrospective case-control study at four Israeli hospitals from January 1, 2010 to May 30, 2018. Inclusion criteria included patients with an established diagnosis of CD that had cross-sectional abdominal imaging performed. A total of 322 patients were included, and 81 [25%] were diagnosed with an intra-abdominal abscess., Results: In univariate analysis, ileo-colonic location (odds ratio [OR] 1.88, p = 0.0148), perianal CD [OR 7.01, p = 0.0004], fever [OR 1.88, p = 0.0247], neutrophil-to-lymphocyte ratio [OR 1.12, p < 0.0001], and C-reactive protein [OR 1.10, p < 0.0001] were significantly associated with abscess formation, whereas current use of corticosteroids was negatively associated with abscess formation [OR 0.46, 95% CI, 0.2-0.88, p = 0.0192]. We developed a diagnostic score that included five parameters that were significant on multivariate regression analysis, with assignment of weights for each variable according to the coefficient estimate. A low cut-off score of ≤7 was associated with a negative predictive value [NPV] of 93% for abscess formation, whereas a high cut-off score of >9 was associated with a positive predictive value of 65%. We validated this score with an independent cohort [area under the curve of 0.881 and NPV of 98.5%]., Conclusion: We recommend incorporating this score as an aid for stratifying acutely ill CD patients in the ED with low or high probability of the presence of an intra-abdominal abscess., (Copyright © 2019 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background: Colonoscopy is the standard of care for the diagnosis and treatment of many colonic disorders. Over the past few years, endoscopic closure of colonoscopy-related perforation has become more common. Endoscopic closure of perforation secondary to colonoscopy has been undertaken in patients in the hospital setting and often during the same colonoscopic procedure in which the perforation itself occurred. The aim of our study was to analyze our experience with emergency endoscopic closure of colonoscopy-related perforation with over-the-scope clip (OTSC) technique., Methods: We report five cases of colonic perforation that occurred during colonoscopy in an outpatient facility remotely located from our hospital and then referred as an emergency to our institution for endoscopic closure., Results: Bowel preparation was reported to be adequate in all cases. Prior to attempting endoscopic closure of colonic perforation, all patients were in stable clinical condition, early broad-spectrum antibiotic coverage was initiated, and a surgical consult was obtained. All patients had sigmoidoscopy and were found to have sigmoid colon perforations. In three cases, the perforations were closed successfully using an OTSC clip device 14 mm type t. Two patients were found to have greater than 4-cm sigmoid perforations with irregular margins, incompatible with OTSC closure, and were referred for emergency surgery. All patients had an uneventful course following either OTSC closure or surgery., Conclusions: Based on the characteristics of the five cases and a review of the literature, we suggest a practical approach for undertaking closure of colonic perforations occurring during colonoscopy in the outpatient setting, focusing on clinical criteria to determine eligibility of patients for attempted endoscopic closure and outlining required therapeutic and monitoring steps needed to optimize outcomes.

Background: Hydatid cyst is a zoonotic disease caused by Echinococcus genera. Surgery is needed in most cases. We aimed to describe our center's experience in the surgical management of hepatic hydated cysts (HHC)., Methods: Data was retrospectively collected for patients who underwent operative management for HHC between the years 1994-2014., Results: Sixty-nine underwent surgical treatment for HHC. Group A included 34 treated with an unroofing procedure, group B included 24 patients who underwent hepatectomy and group C included 11 patients who underwent peri-cystectomy. The median ± (range) age for groups A, B and C were 39.5 (6.5-69), 40 (17-74) and 32 (20-62), respectively (P > 0.1). Post-operative complications occurred in 16, 11 and 5 patients in group A, B and C, respectively, as assessed by clavien-dindo classification (CDC). The average CDC was significantly higher in the hepatectomy group as compared to the unroofing group (2.3 vs.1.5, P = 0.04). Recurrence was significantly higher after the unroofing procedure as compared to the hepatectomy group (P = 0.05)., Conclusion: Surgery remains the mainstay of treatment for HHC, once surgery is pursued, the results are satisfactory., (Copyright © 2018. Published by Elsevier Taiwan LLC.)

Jugular venous valve incompetence has no long-term remedy and symptoms of transient global amnesia and/or intracranial hypertension continue to discomfort patients. During this study, we interrogate the synergy of the collagen and elastin microstructure that compose the bi-layer extracellular matrix (ECM) of the jugular venous valve. In this study, we investigate the jugular venous valve and relate it to tissue-level mechanical properties, fibril orientation and fibril composition to improve fundamental knowledge of the jugular venous valves toward the development of bioprosthetic venous valve replacements. Steps include: (1) multi loading biaxial mechanical tests; (2) isolation of the elastin microstructure; (3) imaging of the elastin microstructure; and (4) imaging of the collagen microstructure, including an experimental analysis of crimp. Results from this study show that, during a 3:1 loading ratio (circumferential direction: 900 mN and radial direction: 300 mN), elastin may have the ability to contribute to the circumferential mechanical properties at low strains, for example, shifting the inflection point toward lower strains in comparison to other loading ratios. After isolating the elastin microstructure, light microscopy revealed that the overall elastin orients in the radial direction while forming a crosslinked mesh. Collagen fibers were found undulated, aligning in parallel with neighboring fibers and orienting in the circumferential direction with an interquartile range of -10.38° to 7.58° from the circumferential axis (n = 20). Collagen crimp wavelength and amplitude was found to be 38.46 ± 8.06 µm and 4.51 ± 1.65 µm, respectively (n = 87). Analyzing collagen crimp shows that crimp permits about 12% true strain circumferentially, while straightening of the overall fibers accounts for more. To the best of the authors' knowledge, this is the first study of the jugular venous valve linking the composition and orientation of the ECM to its mechanical properties and this study will aid in forming a structure-based constitutive model.

Background: Percutaneous endoscopic gastrostomy (PEG) tubes are routinely used as an effective method for providing enteral nutrition. The need for their exchange is common., Goals: We aimed to examine the comparative safety and cost-effectiveness of PEG percutaneous counter-traction "pulling" approach or by endoscopically guided retrieval., Study: A prospective 215 consecutive patients undergoing PEG tube insertion were included. Fifty patients in total were excluded. The patients were examined for demographics, indications for PEG replacement, as well as procedure-related complications and procedural costs., Results: Group A included 70 patients (42%) with PEG tubes replaced endoscopically, whereas group B included 95 patients (58%) with PEG tubes replaced percutaneously. Baselines characteristics were similar between the 2 groups (P=NS). Group A and group B had similar immediate complication rates including 4 patients in group B (4.2%), and 2 patients in group A (2.8%) (P=0.24). Complications included a conservatively managed esophageal perforation, and self-limited mild bleeding groups A and group B, respectively. The mean procedure cost was significantly higher in the endoscopic PEG replacement group compared with the percutaneous PEG replacement group ($650 vs. $350, respectively)., Conclusion: Percutaneous PEG replacement appears as safe as endoscopic PEG replacement, however, percutaneous tube exchange is less costly.

There are limited efficacious therapeutic options for management of gastric variceal bleeding. Treatment modalities include transjugular intrahepatic portosystemic shunt, surgical shunts, and endoscopic interventions, including the recent advancement of endoscopic ultrasound (EUS)-guided coiling. We present a case series of 10 patients with portal hypertension (7 with liver cirrhosis and 3 without cirrhosis), complicated by gastric varices (GV) with bleeding. All cases were treated successfully with EUS-guided coiling leading to variceal eradication. There were 10 occurrences of minimal self-limited bleeding at the puncture site during the procedure, and only one occurrence of major bleeding that necessitated cyanoacrylate glue injection for homeostasis. There were no other adverse events within a mean follow-up time of 9.7 months (range, 1-28 months). Conclusion: In our series, EUS-guided angiotherapy was effective for GV eradication with a high safety profile.

Psychosocial factors greatly impact the course of patients throughout the liver transplantation process. A retrospective chart review was performed of patients who underwent liver transplantation at Hadassah-Hebrew University Medical Center between 2002 and 2012. A composite psychosocial score was computed based on the patient's pre-transplant evaluation. Patients were divided into two groups based on compliance, support and insight: Optimal psychosocial score and Non-optimal psychosocial score. Post-liver transplantation survival and complication rates were evaluated. Out of 100 patients who underwent liver transplantation at the Hadassah-Hebrew University Medical Center between 2002 and 2012, 93% had a complete pre-liver transplant psychosocial evaluation in the medical record performed by professional psychologists and social workers. Post-liver transplantation survival was significantly higher in the Optimal group (85%) as compared to the Non-optimal group (56%, p = .002). Post-liver transplantation rate of renal failure was significantly lower in the Optimal group. No significant differences were observed between the groups in other post-transplant complications. A patient's psychosocial status may impact outcomes following transplantation as inferior psychosocial grades were associated with lower overall survival and increased rates of complications. Pre-liver transplant psychosocial evaluations are an important tool to help predict survival following transplantation.

Hepatocellular carcinoma (HCC) is among the leading causes of cancer-related mortality. The principal treatment is surgical resection or liver transplantation, depending on whether the patient is a suitable transplant candidate. However, in most patients with HCC the diagnosis is often late, thereby excluding the patients from definitive surgical resection. Medical treatment includes sorafenib, which is the most commonly used systemic therapy; although, it has been shown to only minimally impact patient survival by several months. Chemotherapy and radiotherapy are generally ineffective. Due to the poor prognosis of patients with HCC, newer treatments are needed with several being in development, either in pre-clinical or clinical studies. In this review article, we provide an update on the current and future medical and surgical management of HCC., Competing Interests: The authors have no conflict of interests related to this publication.

Background: Percutaneous endoscopic gastrostomy (PEG) tubes are commonly utilized as a method of enteral feeding in patients unable to obtain adequate oral nutrition. Although some studies have shown improved mortality in select populations, the safety and effectiveness of PEG insertion in patients with dementia compared with those with other neurological diseases or head and neck malignancy remains less well defined., Objective: To evaluate the nutritional effectiveness, rate of rehospitalization, and risk of mortality among patients with dementia compared with patients with other neurological diseases or head and neck cancers who undergo PEG placement., Materials and Methods: We conducted a retrospective analysis from a prospective database of patients who underwent PEG placement at an academic tertiary center between 2008 and 2013. The following data were collected: indication for PEG, patient demographics, biochemical markers of nutritional status rehospitalization, and survival rates., Results: During the study period, 392 patients underwent PEG tube placement. Indications for PEG were dementia (N=165, group A), cerebrovascular accident (N=124, group B), and other indications such as oropharyngeal cancers and motor neuron disease (N=103, group C). The mean follow-up time after PEG was 18 months (range, 3 to 36 mo). No differences in baseline demographics were noted. PEG insertion in the dementia (group A) neither reduced the rehospitalization rate 6 months' postprocedure compared with groups B and C (2.45 vs. 1.86 and 1.65, respectively; P=0.05), nor reduced the mortality rate within the first year post-PEG placement (75% vs. 58% and 38% for groups A, B, and C, respectively, P=0.001), as well, it did not improve survival at 1 month after the procedure (15% vs. 3.26% and 7.76%, for groups A, B, C, respectively, P<0.01). The presence of dementia was also associated with shorter mean time to death (7.2 vs. 8.85 and 8 mo for groups A, B, C, respectively, P<0.05). The rate of improvement of the nutritional biomarker albumin was lower in the dementia group [3.1. to 2.9 vs. 3.2 to 3.3 and 3 to 3.3 g/dL for groups A, B, and C, respectively (P<0.02)]. Multivariate regression analysis showed that the presence of dementia was an independent predictor for mortality rate within the first year and 1-month mortality rate in patients undergoing PEG insertion with odds ratio 3.22 (95% confidence interval, 1.52-4.32) and odds ratio 2.52 (95% confidence interval, 1.22-3.67)., Conclusions: PEG insertion in patients with dementia neither improve both short-term and long-term mortality nor rehospitalization rate as compared with patients who underwent PEG placement for alternate indications such as other neurological diseases or head and neck malignancy and even was associated with shorter time to death. Furthermore, PEG insertion in patients with dementia did not improve albumin. Therefore, careful selection of patients with dementia is warranted before PEG placement weighing the risks and benefits on a personalized basis.

Background: Temozolomide (TMZ) is an alkylating agent used for treatment of brain neoplasms and levetiracetam (LEV) is a commonly used antiepileptic. When administered separately each medication has few negative side effects impacting the liver., Aims: We sought to determine the risk of liver injury associated with the co-administration of TMZ and LEV., Methods: A case-control study was performed comparing patients who received combination therapy of TMZ and LEV (group A) with matched controls (group B) who received monotherapy with one of either TMZ or LEV. We assessed patient demographics, laboratory results including presence of liver injury, and mortality., Results: Twenty-six patients were included in group A and 68 patients were included in group B. Both groups were similar with respect to demographics and baseline liver function tests (P>0.05). There was a significant elevation in liver enzymes in 73%, 46%, 19%, 31% and 27% of ALT, AST, ALK-P, GGT and bilirubin, respectively, in group A, as compared to elevations of 10.3%, 19%, 1.5%, 7% and 1.5%, respectively in group B (P<0.05). One patient in group A died as a result of acute liver failure while no deaths from acute liver failure occurred in group B (P=0.05). Univariate analysis identified combination therapy as a risk factor for liver injury. Multivariate regression showed that only co-treatment with TMZ and LEV was an independent risk factor for liver injury with an odds ratio of 19.1 (95 CI, 2.16-160)., Conclusions: Combination therapy with TMZ and LEV may precipitate acute liver injury and even death., (Copyright © 2016 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.)

Drug-induced liver injury (DILI) is a rare but potentially life threatening adverse drug reaction. DILI may mimic any morphologic characteristic of acute or chronic liver disease, and the histopathologic features of DILI may be indistinguishable from those of other causes of liver injury, such as acute viral hepatitis. In this review article, we provide an update on causative agents, clinical features, pathogenesis, diagnosis modalities, and outcomes of DILI. In addition, we review results of recently reported genetic studies and updates on pharmacological and invasive treatments.

Trends in concentrations and radiocarbon content of pyrogenic PAHs and perylene were determined 20 years after a previous study by Mcveety and Hites (1988). Pyrogenic PAH fluxes to sediments were observed to continue to decrease over the period from 1980 to 2000 at this remote site in contrast to observations in more urban areas. Radiocarbon analysis of pyrogenic PAHs showed a 50% decrease in the proportion of pyrogenic PAH derived from fossil fuel combustion over the past 50 years, consistent with decreasing emissions from regional coal-fired power-generating plants. Fluxes of pyrogenic PAHs related to biomass burning were consistent over this same period and found to exceed fossil fuel sources in the most recent samples. Fluxes of biomass-derived pyrogenic PAHs were similar in magnitude to total pyrogenic PAH fluxes in early 1900, suggesting that these fluxes may represent wildfire inputs. Not only did perylene concentrations in these sediments increase with depth as previously observed but also concentrations from the same sedimentary layers analyzed 20 years previously showed large increases in perylene concentrations. Radiocarbon analysis of perylene indicated that 70-85% of perylene observed in the deeper sediments could be explained by production from total organic carbon.

Unlabelled: Maintaining consistency and fairness when grading in a clinical setting can be difficult with the best method of clinical evaluation remaining unclear. Therefore, it is important to develop methods to ensure that instructors are scoring their students fairly within professional allied health programs., Objective: The purpose of this study was to determine the accuracy of scoring students in real-time compared to video., Methods: Subjects consisted of 27 students enrolled in an allied health professional program. Students were taught a psychomotor clinical skill (PCS) and subsequently performed the skill while being graded in both real-time and videotape., Results: Investigators provided higher scores when assessing students in real-time versus videotaped evaluation (p = 0.006, 1-b = 0.812). There was a trend (p = 0.074; 1-b = 0.514) toward students' classification (sophomore, junior, or graduate) affecting scoring accuracy., Conclusion: These findings indicate students receive higher performance scores during real-time scoring as opposed to videotape scoring. Inaccurate PCS evaluations are perhaps especially noted in students from lower academic classifications who tended to make more mistakes.

Vitamin D plays key roles in innate and adaptive immunity through the stimulation of Toll-like receptors, increasing pro-inflammatory cytokine production, and possibly enhancing T helper type 2 responses. These mechanisms may explain the growing body of evidence connecting vitamin D to allergic diseases, including asthma, food allergies, and allergic rhinitis. The data relating vitamin D to allergic skin diseases are equivocal with studies linking both high and low vitamin D levels to an increased risk of developing atopic dermatitis. In this paper, we describe the role of vitamin D in the immunopathogenesis of atopic dermatitis and other allergic skin diseases., (© 2011 John Wiley & Sons A/S.)

I provide here a glimpse of my involvement with different isotopes of carbon. In my 65 years of synthetic work with C-12, I had experience working with C-11 (one year, 1942-1943), C-13 (one year, 1999) and C-14 (67 years, 1943-2009). I have also included a postscript dealing with my 1951 communication on the 5-carbon intermediate in photosynthesis., (© Springer Science+Business Media B.V. 2011)

Govindjee, the founding editor of the Historical Corner of Photosynthesis Research, invited me 3 years ago to tell the story of why I left Melvin Calvin's laboratory in the mid 1950s long before the 1961 Nobel Prize in Chemistry was awarded to Calvin for the path of carbon in photosynthesis. I have already written my scientific perspective on this topic (see Benson (Photosynth Res 73:29-49, 2002); also see Bassham (Photosynth Res 76:35-52, 2003) as he was also a major player in this research). Here, I present my recollections of my last days in the old radiation laboratory (ORL) at Berkeley, California. References have been added by Govindjee for the benefit of the readers.

The subject of endoscopic sedation continues to generate controversy and debate. This article provides a critical analysis of several key issues related to sedation that have recently been the focus of intense interest. Monitored anesthesia care (MAC) is currently the dominant method of endoscopic sedation for approximately one third of all US gastroenterologists. The benefits and cost-effectiveness of this approach remain unclear, as outlined in this article. An alternative to MAC is the administration of propofol by a specially trained nurse or endoscopy assistant, working under the direction of an endoscopist. The scientific merits of the arguments presented by both those in favor of, and those opposed to, this practice are evaluated. In addition, the clinical experience with endoscopist-directed propofol and the challenges associated with its implementation are presented. Other options for endoscopic sedation may soon be available. One approach is computer-assisted delivery of propofol, which is performed by a physician/nurse team. The clinical studies related to this device, along with several other novel methods of sedation, are described., (Copyright © 2009, Gastro-Hep Communications, Inc.)

Background/aims: Data are scarce on endoscopic sedation practices outside the United States and Western Europe, particularly from developing nations. An Internet survey was used to assess endoscopic sedation practices in developing and developed countries., Methods: Responses to a Web-based survey of sedation practices from 165 expert endoscopists from 81 countries were analyzed. The most common sedation method was defined as that used for >50% of endoscopies within a country., Results: Responses were received from 84 endoscopists practicing in 46 countries (51% response rate; 32 responses from 22 developing countries and 52 responses from 24 developed countries). A combination of benzodiazepine and opioid was the most common method for esophagogastroduodenoscopy (EGD) in 40% of the countries and for colonoscopy in 56% of the countries. For propofol and unsedated endoscopy, the corresponding figures were 8% and 19% for EGD and 18% and 10% for colonoscopy. No single sedation method accounted for >50% of EGD and colonoscopy cases in 32% and 17% of the countries, respectively. There were no significant differences in the proportions of developing and developed countries using combined benzodiazepine and opioid, propofol, or unsedated endoscopy., Conclusions: Sedation is used for most endoscopic procedures worldwide, with sedation practice not differing significantly between developing and developed countries.

The effectiveness of low-dose omeprazole as primary prevention of gastrointestinal adverse events due to episodic use of non-selective NSAIDs was evaluated. Healthy adults aged 50-75 who did not take chronic NSAIDs were randomized to a 6.5-day treatment of naproxen 500 mg twice daily plus omeprazole 20 mg daily or naproxen 500 mg twice daily plus placebo. Seventy subjects were enrolled (mean age 58.6 years, proportion >60 = 41.4%). Subjects receiving naproxen plus omeprazole developed fewer gastroduodenal ulcers compared to subjects receiving naproxen plus placebo (11.8% vs. 46.9%, P = 0.002). Likewise, naproxen plus omeprazole was associated with a decreased risk of ulceration and/or >5 erosions (38.2% vs. 81.3%, P < or = 0.001), and a smaller change in dyspepsia score. Considering their relatively low cost, ready availability, and favorable safety profile, low-dose PPI co-prescription in healthy adults requiring short-term therapy with non-selective NSAIDs may be reasonable.

Aim: Temporary epicardial pacing wires (TEPW) which are routinely used after coronary bypass grafting may result in significant complications. We sought to identify variables that predict TEPW implantation and thereby limit their use., Methods: This prospective study enrolled 564 patients (296 underwent coronary artery bypass grafting with cardiopulmonary bypass [ONCAB] and 268 underwent off-pump coronary artery bypass grafting, OPCAB). TEPW were placed in patients with the intraoperative presence of one or more of the following criteria: sinus bradycardia, sinus arrest, nodal/junctional rhythms, atrioventricular block, bundle branch block, ventricular tachycardia, or onset of atrial fibrillation., Results: Only 31 (5.5%) patients [ONCAB: 20 (6.8%) (ventricular: 14, bichamber: 6); OPCAB: 11 (4.1%) (ventricular: 9, bichamber: 2)] had temporary epicardial pacing wires implanted intraoperatively. Indications for using temporary epicardial pacing wires for ONCAB were sinus bradycardia (8), nodal/junctional rhythms (3), atrioventricular block (3), atrial fibrillation (4), and bundle branch block (2), and for OPCAB were sinus bradycardia (8), nodal/junctional rhythms (2), and atrioventricular block (1). Mean duration for pacing was 22.4 h for the ONCAB group and 11.3 h for the OPCAB group. There were no temporary epicardial pacing wires associated complications. One paced OPCAB patient required a permanent pacemaker and 2 non-paced OPCAB patients required transvenous pacing wires. Univariate and multivariate analyses were also conducted to determine risk factors for TEPW., Conclusion: TEPW implantation is overused in cardiac surgery and by identifying independent predictors for pacing we conclude that TEPW use should be limited to a select few.

Background: Atrial fibrillation (AF) after coronary artery bypass graft surgery constitutes the most common sustained arrhythmia and results in many complications. The purpose of this study was to assess the effects of prophylactic use of beta-blockers against atrial fibrillation in off-pump surgery patients in the early postoperative period., Methods: From 2002 to 2005, 78 patients were enrolled and 41 patients received 50 mg metoprolol succinate daily, which was initiated minimum four days before surgery. Preoperative beta-blocking therapy was continued until the morning of surgery. Thirty-seven patients were free of beta-blocker therapy. Esmolol was used within same range of doses in both groups during operations. Both groups received metoprolol succinate following operations. The frequency of AF occurrence was analysed from the operation time to the sixth postoperative day., Results: Sixteen patients developed AF with an overall incidence of 22.5%. Four patients from the study group and three patients from the control group were excluded from the study because of transfer to on-pump surgery. There was no difference with regard to the number of grafts carried out, duration of operations and ventilation, intensive care unit stay and inotropic need among groups. Length of hospital stay did not differ among groups either. There was a higher incidence of postoperative AF in patients without beta-blocker prophylaxis (11.7-32.4% P=0.049)., Conclusion: Low-dose postoperative beta-adrenergic blockade is valuable for patients who receive these medications before off-pump coronary artery bypass grafting procedures and may be beneficial against AF in all patients.

It is very rare for heart tissue to give rise to a primary paraganglioma. Here, we report the observation of such a tumour in a 34-year-old woman who presented with symptoms of pulmonary venous congestion. The findings from echocardiography were consistent with the diagnosis of a myxoma that was partially occluding the left atrium. Surgery was performed in which a large (6 cm x 5 cm x 3 cm), non-lobulated solid tumour was resected from the posterior wall of the atrium. Upon histologic evaluation, this was determined to be a cardiac paraganglioma.

Background: The incidence of coronary artery bypass graft surgery (CABG) performed in elderly patients has been increasing over recent years. We sought to evaluate clinical outcomes of octogenarians undergoing CABG using an audited state-wide mandatory database., Methods: New York State Department of Health's Cardiac Reporting System was analyzed from 1998 to 2002. In all, 88,154 patients undergoing isolated CABG were identified. Patients were divided into four age groups: less than 50 years (group 1, n = 6,527), 50 to 64 years (group 2, n = 30,088), 65 to 79 years (group 3, n = 43,369), and 80 years and above (group 4, n = 8,170)., Results: Of all patients, 9.3% were octogenarians. In addition to marginally worse coronary artery disease, octogenarians generally manifested a higher incidence of preoperative risk factors such as cerebrovascular disease, peripheral vascular disease, and congestive heart failure compared with younger patients at baseline. Both length of hospital stay and in-hospital mortality rate were significantly higher among octogenarians. The incidence of postoperative complications was higher among octogenarians. Multivariate analysis demonstrated renal failure requiring dialysis (odds ratio [OR] = 4.4), myocardial infarction within 6 hours before surgery (OR = 3.6), chronic obstructive pulmonary disease (OR = 1.7), congestive heart failure at admission (OR = 1.7), emergent operation (OR = 1.6), Canadian Cardiovascular Society functional class IV (OR = 1.5), hypertension (OR = 1.4), and low ejection fraction (OR = 0.98) to be significant independent predictors of in-hospital mortality of octogenarians. Discharge to home rates were significantly lower for octogenarians., Conclusions: Although early outcomes in octogenarians are acceptable, these factors alone are not sufficient to reflect overall success of CABG in these patients, given the strikingly lower discharge to home rates. Attention to full functional recovery in octogenarians is essential.

The Publisher regrets that this article is an accidental duplication of an article that has already been published in Heart Lung Circ, 16 (2007) 116-117, doi:10.1016/j.hlc.2006.12.002. The duplicate article has therefore been withdrawn.

Objectives: The introduction of new sedative agents as well as a desire for improved patient satisfaction and greater efficiency has changed the practice of endoscopic sedation. This survey was designed to provide national and regional data on endoscopic sedation and monitoring practices within the United States., Methods: A 22-item survey regarding current practices of endoscopy and sedation was mailed to 5,000 American College of Gastroenterology physician members nationwide., Results: A total of 1,353 questionnaires (27.1%) were returned. Respondents performed an average of 12.3 esophagogastroduodenoscopies (EGDs) and 22.3 colonoscopies per wk. Endoscopic procedures were performed within a hospital setting (55.2) more often than at an ambulatory center (35.8%) or private office (8.8%). The vast majority of EGDs and colonoscopies (>98%) were performed with endoscopic sedation. Almost three quarters (74.3%) of the respondents used a narcotic and benzodiazepine for sedation, while propofol was preferred by 25.7%. Sedation practices varied considerably within different geographic regions of the United States. Respondents routinely monitored vital signs and pulse oximetry (99.2% and 98.6%, respectively), and supplemental oxygen was administered to all patients during EGD by 72.7% of endoscopists. Endoscopist satisfaction with sedation was greater among those using propofol than conventional sedation (10 vs 8, p < 0.0001)., Conclusions: During the past 15 yr, the volume of procedures performed by endoscopists in the United States has increased two- to fourfold. Propofol is currently being used for sedation in approximately one quarter of all endoscopies in the United States. The findings from this survey may help in the formulation of updated policies and practice guidelines pertaining to endoscopic sedation.

Chronological recognition of the intermediates and mechanisms involved in photosynthetic carbon dioxide fixation is delineated. Sam Ruben and Martin Kamen's development of application of radioactive carbon for the study of carbon dioxide fixation provided impetus and techniques for following the path of carbon in photosynthesis. Discovery The identity of the primary carboxylation enzyme and its identity with the major protein of photosynthetic tissues ('Fraction 1' protein of Sam Wildman) is reviewed. Memories are dimmed by sixty years of exciting discoveries exploration in newer fields [see Benson 2002 (Annu Rev Plant Biol 53: 1-25), for research and perspectives beyond the early Berkeley days].