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BACKGROUND & AIMS: Microscopic inflammation has significant prognostic value in ulcerative colitis (UC); however, its assessment is complex with high interobserver variability. We aimed to develop and validate an artificial intelligence (AI) computer-aided diagnosis system to evaluate UC biopsies and predict prognosis. METHODS: A total of 535 digitalized biopsies (273 patients) were graded according to the PICaSSO Histologic Remission Index (PHRI), Robarts, and Nancy Histological Index. A convolutional neural network classifier was trained to distinguish remission from activity on a subset of 118 biopsies, calibrated on 42 and tested on 375. The model was additionally tested to predict the corresponding endoscopic assessment and occurrence of flares at 12 months. The system output was compared with human assessment. Diagnostic performance was reported as sensitivity, specificity, prognostic prediction through Kaplan-Meier, and hazard ratios of flares between active and remission groups. We externally validated the model in 154 biopsies (58 patients) with similar characteristics but more histologically active patients. RESULTS: The system distinguished histological activity/remission with sensitivity and specificity of 89% and 85% (PHRI), 94% and 76% (Robarts Histological Index), and 89% and 79% (Nancy Histological Index). The model predicted the corresponding endoscopic remission/activity with 79% and 82% accuracy for UC endoscopic index of severity and Paddington International virtual ChromoendoScopy ScOre, respectively. The hazard ratio for disease flare-up between histological activity/remission groups according to pathologist-assessed PHRI was 3.56, and 4.64 for AI-assessed PHRI. Both histology and outcome prediction were confirmed in the external validation cohort. CONCLUSION: We developed and validated an AI model that distinguishes histologic remission/activity in biopsies of UC and predicts flare-ups. This can expedite, standardize, and enhance histologic assessment in practice and trials. ispartof: GASTROENTEROLOGY vol:164 issue:7 pages:1180-+ ispartof: location:United States status: published

Background and Aim: Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC-325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy. Methods: Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy. Results: One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7–12). The median Rockall score was 8 (IQR, 7–9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30-day rebleed, 20% of patients died within 30 days (all-cause mortality). There was a significant improvement in transfusion requirements following treatment (P

Objectives This study investigated benefits of routine panendoscopy in staging of oral squamous cell cancer patients. Materials and methods From 2013 to 2017, 194 oral squamous cell cancer patients were staged. Reports of routine flexible panendoscopy including oropharyngolaryngoscopy, bronchoscopy, and esophagogastroduodenoscopy were retrospectively analyzed for diagnoses of inflammation and second primary malignancies (carcinoma in situ or cancer) and compared to results of computed tomography. The effects of alcohol and tobacco history of 142 patients were assessed. Results Overall, a second primary malignancy was detected in seven patients. In four patients this discovery was only found by panendoscopy. One invasive carcinoma (esophagus) was detected as well as three carcinoma in situ. The second primary malignancies were located in the lung (3), esophagus (3), and stomach (1). In one patient index tumor therapy was modified after panendoscopy. Upper gastrointestinal inflammation was present in 73.2% of patients and 61.9% required treatment. About 91.8% of bronchoscopies and 34.5% of panendoscopies were without therapeutic consequences. Patients with higher risk from smoking were more likely to benefit from panendoscopy and to have a Helicobacter pylori infection. Conclusion We do not recommend routine panendoscopy for all oral squamous cell cancer patients. Esophagogastroduodenoscopy benefitted smoking patients primarily concerning the secondary diagnosis of inflammation of the upper digestive tract. Selective bronchoscopy, esophagogastroduodenoscopy, and oropharyngolaryngoscopy should be performed if clinical examination or medical history indicates risks for additional malignancies of the upper aerodigestive tract. Clinical relevance Routine panendoscopy is not recommended in all, especially not in low-risk oral cancer patients like non-smokers and non-drinkers.

INTRODUCTION: With increasing advances in minimally invasive endoscopic therapies and endoscopic resection techniques for luminal disease, there is an increased risk of post-procedure bleeding. This can contribute to significant burden on patient’s quality of life and health resources when reintervention is required. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder licensed for gastrointestinal bleeding. The aim of this single-arm, prospective, non-randomised multicentre international study is to look at outcomes in patients with upper gastrointestinal bleeds following elective endoscopic therapy treated with Hemospray to achieve haemostasis. METHODS: Data was prospectively collected on the use of Hemospray from 16 centres (January 2016–November 2019). Hemospray was used during the presence of progressive intraprocedural bleeding post-endoscopic therapy as a monotherapy, dual therapy with standard haemostatic techniques or rescue therapy once standard methods had failed. Haemostasis was defined as the cessation of bleeding within 5 min of the application of Hemospray. Re-bleeding was defined as a sustained drop in haemoglobin (>2 g/l), haematemesis or melaena with haemodynamic instability after the index endoscopy. RESULTS: A total of 73 patients were analysed with bleeding post-endoscopic therapy. The median Blatchford score at baseline was five (interquartile range 0–9). The median Rockall score was six (interquartile range 5–7). Immediate haemostasis following the application of Hemospray was achieved in 73/73 (100%) of patients. Two out of 57 (4%) had a re-bleed post-Hemospray, one was following oesophageal endoscopic mucosal resection and the other post-duodenal endoscopic mucosal resection. Both patients had a repeat endoscopy and therapy within 24 h. Re-bleeding data was missing for 16 patients, and mortality data was missing for 14 patients. There were no adverse events recorded in association with the use of Hemospray. CONCLUSION: Hemospray is safe and effective in achieving immediate haemostasis following uncontrolled and progressive intraprocedural blood loss post-endoscopic therapy, with a low re-bleed rate.

A composite endoscopic-histologic remission is increasingly explored as an important endpoint in ulcerative colitis (UC). We investigated combined endoscopic-histologic remission for predicting clinical outcomes at 12 months compared with endoscopic remission alone using the high definition virtual chromoendoscopy (VCE) Paddington International virtual ChromoendoScopy ScOre (PICaSSO) and histology scores.Ulcerative colitis patients, prospectively enrolled from 11 international centres, underwent VCE with targeted biopsies and followed up for 12 months. Endoscopic activity was assessed by Mayo Endoscopic Score (MES), Ulcerative Colitis Endoscopic Index Severity (UCEIS) followed by VCE-PICaSSO. Robarts Histopathological Index|Robarts Histological index≤3 without neutrophils in mucosa, and Nancy Histological index (NHI)≤ 1 were used to define histologic remission. Combined endoscopic-histologic remission was compared with endoscopic remission alone by Cox proportional hazards model and by two- and three-proportion analysis using pre-specified clinical outcomes.307 patients were recruited and 302 analysed. There was no difference in survival without specified clinical outcomes between PICaSSO defined endoscopic remission alone and endoscopic plus histologic remission in the rectum (HR 0.42, 95%CI 0.16-1.11 and HR 1.03, 95%CI 0.42-2.52 for Robarts Histological index and NHI respectively) at 12 months. There was however a significant survival advantage without specified clinical outcome events for UCEIS combined with histology compared with UCEIS alone (HR 0.30, 95%CI 0.12-0.75, p = 0.02) at 12 months (but not combined with NHI). For MES there was no advantage for predicting specified clinical outcomes at 12 months for endoscopy alone versus endoscopy plus histology, but there were differences in two and three proportion analysis at 6 months.Endoscopic remission by VCE-PICaSSO alone was similar to combined endoscopic and histologic remission for predicting specified clinical outcomes at 12 months. Larger studies with specific therapeutic interventions are required to further confirm the findings.

Background and aim Acute gastrointestinal bleeding carries poor outcomes unless prompt endoscopic hemostasis is achieved. Mortality in these patients remains significant. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites. We report the largest dataset of patient outcomes after treatment with Hemospray from an international multicenter registry. Patients and methods Prospective data (Jan 2016-May 2018) from 12 centers across Europe were collected. Immediate hemostasis was defined as endoscopic cessation of bleeding within 5 min after application of Hemospray. Rebleeding was defined as subsequent drop in hemoglobin, hematemesis, persistent melena with hemodynamic compromise post-therapy. Results Three hundred and fourteen cases were recruited worldwide (231 males, 83 females). Median pretreatment Blatchford score was 11 (IQR: 8-14) and median complete Rockall score (RS) was 7 (IQR: 6-8) for all patients. Peptic ulcer disease (PUD) was the most common pathology (167/314 = 53%) and Forrest Ib the most common bleed type in PUD (100/167 = 60%). 281 patients (89.5%) achieved immediate hemostasis after successful endoscopic therapy with Hemospray. Rebleeding occurred in 29 (10.3%) of the 281 patients who achieved immediate hemostasis. Seven-day and 30-day all-cause mortality were 11.5% (36/314) and 20.1% (63/314), respectively (lower than the predicted rates as per the RS). Similar hemostasis rates were noted in the Hemospray monotherapy (92.4%), combination therapy (88.7%) and rescue therapy (85.5%) groups. Conclusions These data show high rates of immediate hemostasis overall and in all subgroups. Rebleeding and mortality rates were in keeping/lower than predicted rates.

Contains fulltext : 205162.pdf (Publisher’s version ) (Open Access) BACKGROUND AND AIMS: Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy still occur. An increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device includes a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics, and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing the ADR. METHODS: In this randomized, controlled, international, multicenter study (11 centers), patients (aged >/=50 years) referred to colonoscopy for screening, surveillance, or changes in bowel habits were randomized to undergo either balloon-assisted colonoscopy by using an insufflated balloon during withdrawal or standard high-definition colonoscopy. The primary endpoint was the ADR. RESULTS: One thousand patients were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (standard colonoscopy n = 396; balloon-assisted colonoscopy n = 407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the standard colonoscopy group (28% increase; P = .0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (P = .0033) flat adenomas (P < .0001) and sessile serrated adenomas/polyps (P = .0026). CONCLUSION: Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat, and sessile serrated adenomas/polyps when compared with standard colonoscopy. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates and consequently reducing interval cancer incidence. (Clinical trial registration number: NCT01917513.).

Sintering is a process of agglomeration of fine particles into porous sinters for blast furnaces. During the sintering process, high volumes of sinter plant gas containing high loads of dust, SO2 and NOX and toxic pollutants, such as heavy metals (e.g., Hg, Pb, Cr and Cd) and PCDD/F, are emitted. The objective of this study was to characterize dusts of different plants as the basis for suggestions of reutilization and treatment options. Dusts, eluates and residues were produced and DOC, T-N, ions and heavy metals were analyzed. The results show that dusts from different plants are very similar in terms of DOC, T-N, Mg, Ca and many heavy metals and only differ in criteria such as suspended solids and ions such as K, Na, Cl and SO4. Based on the high levels of alkalis and low levels of iron, direct recycling into the sinter or furnace process is not recommended. The dissolution of the soluble substances in water reduces the MEROS dust by 90% of the weight and extracts the alkalis. The remaining wastewater needs to be treated to reduce DOC, T-N and some heavy metals. The solid residues can be recycled into the sinter to reduce potential PCDD/F, which are attached to the activated carbon.

BACKGROUND & AIMS: Endoscopic and histologic remission are important goals in the treatment of ulcerative colitis (UC). We investigated the correlation of the recently developed Paddington International Virtual ChromoendoScopy ScOre (PICaSSO) and other established endoscopic scores against multiple histological indices and prospectively assessed outcomes. METHODS: In this prospective multicenter international study, inflammatory activity was assessed with high-definition and virtual chromoendoscopy in the rectum and sigmoid using the Mayo Endoscopic Score (MES), UC Endoscopic Index of Severity (UCEIS), and PICaSSO. Targeted biopsies were taken for assessment using Robarts Histological Index (RHI), Nancy Histological index (NHI), ECAP (Extent, Chronicity, Activity, Plus score), Geboes, and Villanacci. Follow-up data were obtained at 6 and 12 months after colonoscopy. RESULTS: A total of 307 patients were recruited. There was strong correlation between PICaSSO and histology scores, significantly superior to correlation coefficients of MES and UCEIS with histology scores. A PICaSSO score of ≤3 detected histologic remission by RHI (≤3 + absence of neutrophils) with area under the receiver operating characteristic curve (AUROC) 0.90 (95% confidence interval [CI] 0.86-0.94) and NHI (≤1) AUROC 0.82 (95% CI 0.77-0.87). The interobserver agreement for PICaSSO was 0.88 (95% CI 0.83-0.92). At 6- and 12-months follow-up, PICaSSO score ≤3 predicted better outcomes than PICaSSO >3 (hazard ratio [HR] 0.19 [0.11-0.33] and 0.22 [0.13-0.34], respectively),} as well as PICaSSO 4-8 (HR 0.25 [0.12-0.53] and 0.22 (0.12-0.39), respectively) and similar to histologic remission. CONCLUSION: In this first real-life multicenter study, the PICaSSO score correlated strongly with multiple histological indices. Furthermore, PICaSSO score predicted specified clinical outcomes at 6 and 12 months, similar to histology. Thus, PICaSSO can be a useful endoscopic tool in the therapeutic management of UC. ispartof: GASTROENTEROLOGY vol:160 issue:5 pages:1558-+ ispartof: location:United States status: published

Introduction Mucosal healing (MH)is an important goal in the treatment of ulcerative colitis (UC). The newly published PICaSSO score characterises subtle mucosal and vascular changes and defines MH. We aimed to validate in real-life the PICaSSO score and assess its ability to predict relapse. Methods Patients with UC were prospectively recruited from 11 international centres. Participating endoscopists experienced in IBD received training on PICaSSO before starting the study. The rectum and sigmoid were examined using iScan 1,2&3 (Pentax, Japan) and inflammatory activity was assessed using Mayo, UCEIS and PICaSSO. Biopsies were taken for histological assessment using Robarts Histological Index (RHI), Nancy, ECAP, Geboes and Villanacci. Follow up data was obtained at 12 months. Results A total of 307 patients were recruited.The interobserver agreement for the PICaSSO score was 0.879 (95% CI 0.826–0.924). The PICaSSO total and PICaSSO mucosal scores strongly correlated with histology scores and was statistically better than MES and UCEIS as show in figure 1. When using a PICaSSO total score of ≤3 the AUROC to predict MH by RHI (≤3 + absence of neutrophils) was 0.90 (95% CI 0.86–0.94) and when we compare the AUROC of Picasso vs Mayo p was =0.06. When using the Nancy score (≤1) the AUROC was 0.816 (95% CI 0.77–0.87). A Kaplan-Meier curve shows a significant favourable survival probability without relapse with a PICASSO score of ≤3 Likelihood ratio test=26.41, p Conclusions This real-life validation study shows the electronic chromoendoscopy score, PICaSSO, can predict accurately histological healing and long-term remission and can be a useful tool in the management of UC.

We analyze the effect of the geographic expansion of banks across U.S. states on the co-movement of economic activity between states. To identify the causal effect of financial integration on business cycle synchronization, we exploit the staggered timing of the removal of restrictions to interstate banking to construct time-varying instrumental variables at the state-pair level. We find a strong positive effect of bilateral banking integration on the synchronization of economic activity between states, conditional on national shocks and state pair heterogeneity. This effect is stronger for states experiencing periods of financial turmoil and for industries that rely more on external financing. Furthermore, we find that integration increases the similarity of fluctuations in bank lending between states. Our findings are consistent with theories highlighting the role of banks in transmitting financial shocks across regions, and show that integration has increased output synchronization between U.S. states.

Introduction Lower Gastrointestinal bleeding (LGIB) accounts for 20% of GI bleeds, with significant mortality in the elderly and those with comorbidities. There is limited data on the use of Hemospray in LGIB’s. The primary aim was to look at its safety and efficacy in the treatment of LGIB’s. Methods Data was prospectively collected on the use of Hemospray in LGIB’s in 16 Centres in the UK, USA, Germany, France and Spain (January 2016 – November 2019). Hemospray was used as a monotherapy, combination therapy or rescue therapy. Haemostasis was defined as the cessation of bleeding within 5 minutes of Hemospray application. Results 24 patients with LGIB’s were recruited (16 male, 8 female). The cause of bleeding included malignancy (6/24,25%), post procedure (polypectomy/ESD)(5/24,21%), inflammation/angiodysplasia (7/24, 29%). The median lesion diameter was 20 mm (IQR, 25–50). 9/24 (38%) patients were on antiplatelets/anticoagulants. Immediate haemostasis was achieved in 22/24 (92%) patients. 2/19 (11%) had a re-bleed within 7 days, 4/19 (21%) had a re-bleed within 30 days. 2/21 (10%) died within 30 days (all cause mortality). The two patients that failed treatment had surgery. In combination Hemospray was always used as a second or third modality. There was a 78% haemostasis rate in patients on anticoagulants/antiplatelets, 100% immediate haemostasis on patients on no anticoagulants. There were no adverse events associated with Hemospray. Outcomes in the Hemospray treatment subgroups (table 1). Conclusions Hemospray is safe and effective in LGIB’s with 92% haemostasis rates, with better outcomes as a Monotherapy. Anticoagulants have an effect on haemostasis rates (78% vs 100%). Lower GI bleeds are difficult to treat. Hemospray is an effective alternative in situations where access is difficult and there is a large surface of bleeding.

Introduction Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity. The aim was to look at outcomes in patients with non-variceal UGIBs of all causes treated with Hemospray. Methods Data was collected prospectively (Jan’ 16- Nov’19) from 16 centres in the USA, UK, Germany, France and Spain. Hemospray was used during endoscopy as a monotherapy, dual therapy or rescue therapy. Haemostasis was defined as cessation of bleeding within 5 minutes of Hemospray application. Results 512 patients with non-variceal UGIBs were recruited (343 male, 169 female). The most common cause was peptic ulcers (236/512, 46%). Immediate haemostasis was achieved in 473/512 (92%) patients. Median Blatchford was 11 (IQR, 8–14), median Rockall was 7 (IQR, 6–8). Re-bleeding occurred in 59/404 (15%) patients. There was a 7-day mortality (all cause) of 9% (42/444), 30-day mortality (all cause) was 19% (85/444). The highest haemostasis rates were in the Hemospray monotherapy group (95%). 39 patients did not achieve haemostasis (69% were peptic ulcer related). 14/39 (36%) of these patients had CT embolization, 7/39 (18%) managed conservatively and 3/39 (8%) had surgery. Outcomes in different UGI pathologies (table 1). Conclusion There were high immediate haemostasis rates following treatment of non-variceal UGIBs. The better outcomes were when Hemospray was used in UGIB’s post endotherapy, malignancy and Angiodysplasia. In malignancies it can bridge towards surgery/chemoradiotherapy, and post endotherapy it can provide definitive haemostasis with low re-bleed rates.

Introduction Early treatment for variceal bleeding is recommended within 12 hours to improve outcomes. Endoscopic therapy in acute variceal bleeding can be technically difficult and not always successful and a bridge is sometimes required towards definitive therapy. Aim of this study was to look at outcomes in patients with upper gastrointestinal bleeds (UGIB’s) secondary to varices. Methods Data was collected prospectively (Jan’16- Nov’19) from 16 centres in the USA, UK, Germany, France and Spain. Hemospray was used during emergency endoscopy for a variceal UGIB as a monotherapy, dual therapy or rescue therapy once standard methods have failed. Haemostasis was defined as cessation of bleeding within 5 minutes. Results 12 patients had Hemospray treatment following a variceal UGIB (10 male, 2 female). 10 oesophageal varices, 2 gastric varices. The median Rockall was 8 (IQR, 7–8). The median Blatchford was 15 (IQR, 13–17). The immediate haemostasis rate was 75%. There were no re-bleeds. 4 patients were treated with Hemospray monotherapy, 3 with combination therapy and 5 with rescue therapy. Hemospray was always given after oesophageal banding/injection sclerotherapy in the combination/rescue therapy cohorts. 4/9 patients died within 7 days, 3 out of these 4 patients did not achieve initial haemostasis with Hemospray. Outcomes in the Hemospray subgroups (table 1). Conclusions The immediate haemostasis rate was 75% in variceal UGIBs following treatment with Hemospray. In this cohort there is no re-bleeding. This suggests that Hemospray may play a role as bridging therapy in variceal bleeds which are difficult to control, towards repeat definitive therapy.

We evaluate the role of insider ownership in shaping banks’ equity issuances in response to the global financial crisis. We construct a unique dataset on the ownership structure of U.S. banks and their equity issuances and discover that greater insider ownership leads to less equity issuances. Several tests are consistent with the view that bank insiders are reluctant to reduce their private benefits of control by diluting their ownership through equity issuances. Given the connection between bank equity and lending, the results stress that ownership structure can shape the resilience of banks—and hence the entire economy—to aggregate shocks. Institutional subscribers to the NBER working paper series, and residents of developing countries may download this paper without additional charge at www.nber.org.

Background Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % – 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy. Methods Data were collected prospectively (January 2016 – March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist’s discretion. Results 202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) experienced rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P Conclusions This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers.

Complete esophageal obstruction (CEO) is a rare complication after radiochemotherapy that dramatically impairs quality of life. Within this study, we assessed the outcome of two different endoscopic techniques for lumen restoration in patients with CEO. 17 patients were included. Esophageal recanalization was performed in an antegrade approach (Group A) or through combined antegrade and retrograde recanalization and dilatation (CARD, Group B). Technical success, complications, and dysphagia development during follow-up (FU) were compared between the groups. In Group A (n = 6), esophageal recanalization was performed by a single endoscopist with a median duration of 47 min. In two patients, antegrade recanalization led to formation of a false lumen (i.e., submucosal tunneling) followed by mediastinitis. In Group B, 21 CARD procedures were performed in 11 patients with a technical success rate of 100%. Procedure time was longer compared to Group A; however, no intra- or postprocedural complications were observed in Group B. In our experience and cohort, CARD was a successful procedure for recanalization of CEO, which exhibits a more favorable safety profile over antegrade recanalization. Further randomized studies to evaluate the treatment of CEO with CARD are needed.

Does an increase in competition increase or decrease bank stability? I use a novel way to capture changes in banking competition by exploring how the exogenous state-specific process of banking deregulation gradually lowered entry barriers into urban banking markets. I find that the increase in market contestability significantly improves bank stability. This result is robust to the inclusion of additional fixed effects and other influences, such as mergers and acquisitions, or geographic expansion. Moreover, I find that greater competition reduces banks’ failure probability, share of non-performing loans and increases profitability. These findings suggest that competition increases stability, as it improves bank profitability and asset quality.

Introduction: Endoscopy is a key technique for the surveillance of patients with inflammatory bowel diseases (Crohn's disease (CD) and ulcerative colitis). Indication to perform endoscopy for surveillance includes assessment of response to therapy, postoperative surveillance, and surveillance for intraepithelial neoplasia. Methods: In addition to personal experience, a literature search was performed and the guidelines were consulted. Results and Conclusion: Endoscopy is the gold standard in the long-term assessment of mucosal healing and in the short-term control of response to intensified therapy. For postoperative surveillance in CD, mucosal changes (as graded by the Rutgeerts score) are predictive of clinical recurrence. For neoplasia surveillance, virtual chromoendoscopy has not (yet) replaced conventional chromoendoscopy. Surveillance can be optimized by the use of high-definition endoscopes as well as (pan-)chromoendoscopy and requires time to scrutinize the mucosa. This approach seems to be superior to random biopsies.

Diagnostic imaging of jejuno-ileal neuroendocrine tumors (NETs) has been described as challenging. Follow-up requires the detection of metastatic spread as well as screening for local recurrence. Multimodal imaging concepts must often be applied.We report the case of a 45-year-old man with a history of ileal NET. At 2 points in follow-up of our patient, information provided by high-end ultrasound changed prognosis and treatment considerably: when positron emission tomography/computed tomography newly detected suspected hepatic metastases, contrast-enhanced ultrasound correctly identified the lesions as intrahepatic vascular shunts. Moreover, profound B-mode ultrasound solely detected ileal recurrence, leading to early removal of the tumor.Diagnostische Bildgebung bei jejuno-ilealen neuroendokrinen Tumoren (NETs) stellt gemeinhin eine Herausforderung dar. In der Nachsorge ist sowohl auf die Detektion möglicher Metastasen als auch auf das Auftreten von Lokalrezidiven zu achten. Oft sind hierfür multimodale bildgebende Ansätze notwendig.Wir berichten über den Fall eines 45-jährigen Patienten mit einem ilealen NET in der Vorgeschichte. An zwei Punkten in der Nachsorge des Patienten lieferte high-end Ultraschall Informationen, die sowohl die Prognose als auch das Behandlungskonzept des Patienten maßgeblich beeinflussten. Im PET/CT neu aufgetretene und als hoch metastasensuspekt beschriebene Läsionen wurden im CEUS korrekt als intrahepatische vaskuläre Shunts erkannt. Des Weiteren detektierte fundierter B-Bild-Ultraschall als einziger ein ileales Rezidiv des NET, was eine frühe Resektion des Tumors ermöglichte.

Management of intestinal strictures associated with Crohn's disease (CD) is clinically challenging despite advanced medical therapy directed toward mucosal healing to positively influence the natural course of CD-associated complications. Although medical therapy is available for inflammatory strictures, therapy of fibrostenotic strictures is the domain of surgery and endoscopy. Endoscopic balloon dilation (EBD) has been recognized as a well-established first-line procedure in terms of safety and efficacy. Although surgery is a valuable treatment modality for the management of CD-related strictures, EBD can help prevent multiple surgical interventions, which might in the long-term lead to a risk of short bowel syndrome. In this review we discuss requirements, techniques, safety, short- and long-term outcomes, as well as combinations of this procedure with surgical and medical treatment in CD-associated intestinal strictures.

ObjectiveEndoscopic full-thickness resection (EFTR) is a novel treatment of colorectal lesions not amenable to conventional endoscopic resection. The aim of this prospective multicentre study was to assess the efficacy and safety of the full-thickness resection device.Design181 patients were recruited in 9 centres with the indication of difficult adenomas (non-lifting and/or at difficult locations), early cancers and subepithelial tumours (SET). Primary endpoint was complete en bloc and R0 resection.ResultsEFTR was technically successful in 89.5%, R0 resection rate was 76.9%. In 127 patients with difficult adenomas and benign histology, R0 resection rate was 77.7%. In 14 cases, lesions harboured unsuspected cancer, another 15 lesions were primarily known as cancers. Of these 29 cases, R0 resection was achieved in 72.4%; 8 further cases had deep submucosal infiltration >1000 µm. Therefore, curative resection could only be achieved in 13/29 (44.8%). In the subgroup with SET (n=23), R0 resection rate was 87.0%. In general, R0 resection rate was higher with lesions ≤2 cm vs >2 cm (81.2% vs 58.1%, p=0.0038). Adverse event rate was 9.9% with a 2.2% rate of emergency surgery. Three-month follow-up was available from 154 cases and recurrent/residual tumour was evident in 15.3%.ConclusionEFTR has a reasonable technical efficacy especially in lesions ≤2 cm with acceptable complication rates. Curative resection rate for early cancers was too low to recommend its primary use in this indication. Further comparative studies have to show the clinical value and long-term outcome of EFTR in benign colorectal lesions.Trial registration numberNCT02362126; Results.

Background Mucosal healing is an important goal in the treatment of ulcerative colitis (UC). The newly published PICaSSO score characterises subtle mucosal and vascular changes and defines mucosal healing. We aimed to validate in real-life the PICaSSO score and assess its ability to predict relapse. Methods Patients with UC were prospectively recruited from 11 international centres. Participating endoscopists experienced in IBD received training on PICaSSO before starting the study. The rectum and sigmoid were examined using iScan 1,2 and 3 (Pentax, Japan) and inflammatory activity was assessed using UCEIS and PICaSSO. Biopsies were taken for the histological assessment using Robarts Histological Index (RHI) and Nancy. Follow-up was obtained at 12 months. Results A total of 278 patients were recruited (Table 1). The diagnostic performance in predicting histologic healing is shown in Table 2. When using PICaSSO score of ≤3 for mucosal and vascular architecture the AUROC to predict healing by RHI is 0.79 (95% CI 0.74–0.85) and 0.73 (95% CI 0.68–0.80) respectively and when using the Nancy score the AUROC is 0.78 (95% CI 0.72–0.84) and 0.77 (0.71–0.84). A total PICaSSO score of ≤8 and UCEIS score of ≤1 predicts remission at 12 months with an AUROC of 0.73 (0.65–0.80) and 0.71 (0.64–0.79). A Kaplan–Meier curve shows a favourable survival probability without relapse with a PICASSO score of ≤8 (Figure 1). Conclusion This real-life validation study shows the PICaSSO score can predict accurately histological healing and long-term remission and can be a useful tool in the management of UC.

Background and aims Endoscopic retrograde cholangiopancreatography (ERCP) is rarely performed in newborns, and the risk of post-ERCP pancreatitis (PEP) has not been defined in this age group. We therefore performed a European multicentre analysis of PEP rates and risk factors in children aged ≤1 year. Patients and methods Based on a sample size estimation, 135 consecutive ERCPs in 126 children aged ≤1 year were evaluated from five European centres, and the first ERCP per child analysed. All ERCPs and clinical reports were reviewed manually for PEP and associated risk factors. All ERCPs were performed by endoscopists with high ERCP expertise. Results No PEP was observed (0/126, 0.0%, CI 0–2.9%) despite the formal presence of multiple risk factors and despite lack of PEP prophylaxis (except one patient having received a pancreatic duct stent). The PEP rate was significantly lower than the PEP rate expected in adults with similar risk factors. Conclusions ERCP in children aged ≤1 year is safe in terms of PEP. The PEP risk is significantly lower in children aged ≤1 year than in adults, therefore no PEP prophylaxis seems to be needed in young children. Risk factors from adults may not apply to children under 1 year. Reluctance to perform diagnostic ERCP in suspected biliary anomalies should not be based on presumed PEP risk.

Introduction Patients with tumour related upper gastrointestinal bleeds (UGIBs) are challenging to treat. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder for GI bleeding. The primary aim was to look at outcomes of UGIBs secondary to tumours who had Hemospray therapy in 13 centres. Methods Data was prospectively collected on the use of hemospray from specialist centres in the UK, France, Germany (Jan’16-September’18). Hemospray was used for UGIBs secondary to tumours as a monotherapy, dual-therapy with standard haemostatic techniques or rescue therapy. Haemostasis was defined as the cessation of bleeding within 5 minutes of the application of hemospray. Results 75 patients with tumoural UGIBs were recruited (51 males, 24 females, 22/75 (29%) oesophageal, 49/75 (65%) gastric, 4/75 (5%) doudenal). The median rockall score was 8 (IQR,7–9). Immediate haemostasis was achieved in 73/75 (97%) of patients, 7/65 (11%) had a rebleed, 12/65 (18%) died within 30 days (all-cause mortality). Based on the baseline average total rockall score, the expected rebleed rate is 25–40%, and expected mortality rate was 40–45% in our cohort. 100% immediate haemostasis was achieved in duodenal and gastric tumours, and 91% in oesophageal tumours. Outcomes with mono/combination therapy and rescue therapy (table 1) Conclusions Hemospray is effective for achieving immediate haemostasis in UGIBs secondary to upper GI tumours, which are considered difficult to treat. When considering average rockall score the rebleed and mortality rate is better than predicted rates. Haemostasis is achieved in the majority allowing for patient stabilization and providing time for surgery/radiotherapy.

Introduction Peptic ulcers are the commonest cause of upper Gastrointestinal bleeding (UGIB). Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder aimed to treat UGIB. The aim of this study is to look at outcomes in patients with peptic ulcer GI bleeds treated with hemospray in 13 centres. Methods Data was prospectively collected on hemospray use in UGIBs in the UK, France and Germany (Jan’16-Sept’18). Hemospray was used for peptic ulcer UGIBs as a monotherapy, dual-therapy with standard haemostatic techniques or rescue therapy. Haemostasis was defined as cessation of bleeding within 5 minutes of hemospray application. Results 196 patients with UGIBs secondary to peptic ulcers were recruited (133 M, 63 F, 123/196(63%) duodenal, 44/196(22%) gastric, 29/196(15%) oesophageal). Immediate haemostasis was achieved in 171/196(87%) patients. The median rockall score was 7 (IQR, 6–8). Rebleeding rates were significantly lower in forrest 2a relative to current predicted rebleeding rates based on forrest classifications, 2/21(10%, P Outcomes with different Forrest classifications (table 1) Conclusions Hemospray is effective in achieving immediate haemostasis in peptic ulcer UGIBs. The baseline Blatchford/rockall scores in our cohort are high with patients recruited from tertiary centres with high-risk cases. The rebleeding and mortality rates are in keeping/below the predicted rate based on the scores. The best outcome with hemospray was with forrest 2a ulcers.

Background/aims Ustekinumab is effective in active Crohn's disease. In a retrospective study we assessed the clinical outcome in nonresponders to anti-tumor necrosis factor therapy, and/or conventional therapy and/or the α4β7-integrin inhibitor vedolizumab. As approval study populations do not always reflect the average "real world" patient cohort, we assessed weather patients who would not have qualified for approval studies show similar outcomes. Methods Forty-one patients with mild to severe active Crohn's disease were treated with ustekinumab (intravenous 6 mg per kg/body weight) followed by subcutaneous ustekinumab (90 mg) at week 8. Depending on the clinical response maintenance therapy was chosen every 8 or 12 weeks. Clinical response was defined by Crohn's Disease Activity Index (CDAI) decline, decline of stool frequency or clinical improvement. Inclusion criteria for approval studies were assessed. Results The 58.5% (24/41) showed clinical response to ustekinumab. The 58.3% of this group (14/24) achieved clinical remission. Clinical response correlated significantly with drop of stool frequency and improvement of CDAI score. The 39 out of 41 patients had no side effects and we observed no serious infections. About a third of our patients would not have met ustekinumab approval study criteria. However, patients who did not meet study criteria showed clinical improvement numerically in the same range compared to patients who would have qualified for approval studies. Conclusions Ustekinumab is effective, safe and well tolerated in a highly therapy refractory patient cohort. Even though a reasonable number of patients did not meet ustekinumab approval study criteria, approval study results seem to be representative to the overall patient cohort.

Exploiting heterogeneity in U.S. firms' exposure to an unconventional monetary policy shock that reduced debt financing costs, I identify the impact of financing conditions on firms' toxic emissions. I find robust evidence that lower financing costs reduce toxic emissions and boost investments in emission reduction activities, especially capital-intensive pollution control activities. The effect is stronger for firms in noncompliance with environmental regulation. Examining the ability of regaining regulatory compliance by implementing pollution control activities I find that only capital-intensive activities help firms regaining compliance. These findings underscore the impact of firms' financing conditions for emissions and the environment.