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Food insecurity which has been a global threat, forces researchers to develop crops with increased productivity even under varying climatic conditions. Rice, being a significant staple and strategic crop, helps ensure economic stability, food, and nutritional security globally. It meets 20% of the calorie requirement of people residing all over the world. Lately, rice cultivation and research have been facing hitherto unprecedented difficulties in the context of climate-induced water scarcity and dwindling resources of manpower, arable land, etc. In this regard, direct seeded rice (DSR) as a resource conservation technique is gaining popularity as a potential alternative to conventional transplanting with reduced input requirement, reduced methane and CO2 emission, increased adaptability to climate change, and increased economic returns. The weed menace in DSR prevents it from reaching its fruitful attainment to a significant level. DSR highly depends on herbicide for weed control as manual weeding and other cultural practices are labour intensive which again meets a setback of crop injury (non-selective herbicide) and resistant weeds (selective herbicides). Herbicide-tolerant (HT) rice could be an effective and long-term solution for weed management in DSR. Three HT rice systems, viz., imidazolinones, glyphosate, and glufosinate, have already been developed in this context. This review gives an insight into the need for HT rice in DSR, its production system, limitations, and stewardship guidelines for proper weed management in rice.

From the inception of artificial intelligence (AI) in optical coherence tomography (OCT) for glaucoma diagnosis, the emphasis has always been on models focusing on visual data. The visual signals are extrapolated from the optic disc and retinal nerve fibre layer (RNFL) region and are processed visually. This manuscript introduces a novel bimodal AI model that combines visual data from OCT with numerical metrics such as RNFL thickness, vCDR, rim area, and cup volume. Furthermore, our unique model utilises an algorithm that goes one step further than existing models in the literature by providing multi-classification (normal vs mild/moderate vs severe) as opposed to binary classification.

The practice of ophthalmology has advanced exponentially due to technology. This has raised the bar of medical care from acceptable visual acuity to the highest precision in acuity. In such an era, it is the need of the hour to be aware of the medico-legal implications in ophthalmology to avert any lawsuits. Lawsuits can be due to breach of confidentiality, inadequate consent, negligence, unmet expectations in a procedure, etc. The majority of lawsuits are related to cataract and corneal surgeries, but the instances of lawsuits related to retinal conditions are on the rise, especially those related to screening of Retinopathy of prematurity resulting in huge sums of compensations. The awareness of regulations can guide the healthcare professionals in such instances. These include the knowledge of laws governing every step of practice and the rights of both healthcare professionals and patients. In addition, clear communication regarding the risks, benefits, and outcomes of the procedure, strict adherence to guidelines, and meticulous documentation are effective tools to avoid litigations. This review article aims to describe various regulations governing the practice of ophthalmology, implications in everyday practice, and steps to safeguard against lawsuits.

Purpose: Impaired ocular blood flow is an important risk factor in the pathogenesis of open-angle glaucoma (OAG). Studies have reported that dorzolamide 2% may be effective in improving ocular blood flow (OBF) in OAG patients. The objective of this study was to determine the efficacy of dorzolamide 2% (DORZOX, Cipla Ltd.) in improving retrobulbar blood flow in an Indian setting. Methods: The study was conducted as an interventional pilot project in 24 healthy subjects and 19 OAG patients. Baseline OBF measurements were done for all glaucoma patients with color Doppler imaging (CDI). Baseline ocular perfusion pressure (OPP) was calculated for all participants. Glaucoma patients were given dorzolamide 2% thrice daily for 12 weeks. The primary efficacy endpoints were mean changes in the CDI parameters of the retrobulbar vessels and OPP posttreatment. The secondary endpoint was mean change in the intraocular pressure (IOP) and adverse events, if any. Results: In comparison to healthy subjects, glaucoma patients displayed significantly reduced baseline OPP (P = 0.002). Treatment with dorzolamide 2% for 12 weeks led to a significant increase in OPP (P < 0.001) and a significant increase in end diastolic velocity (EDV) in all major ophthalmic arteries like ophthalmic artery (OA), central retinal artery (CRA), and short posterior ciliary artery (SPCA) (P < 0.001, P = 0.04, and P = 0.0075, respectively). A significant reduction in the intraocular pressure (IOP; P = 0.007) was observed posttreatment, with no adverse events reported. Conclusion: Dorzolamide 2% significantly improved parameters such as the EDV and OPP in major ophthalmic arteries. This pilot study shows promising results on using dorzolamide for treating Indian patients with OAG.

Glaucoma is a chronic progressive optic neuropathy, characterised by retinal ganglion cell loss leading to optic nerve head changes and visual field defects. The control of intraocular pressure remains a key determinant factor in the management of glaucoma. Cyclodestructive procedures target the epithelium of ciliary processes, thereby reduces the aqueous formation. Cyclodestructive procedures have advanced from initial cyclodiathermy to micropulse diode laser cyclophotocoagulation (CPC). The various probes used in transscleral CPC (TSCPC) include G-probe delivery device and G-probe illuminate delivery device for continuous wave TSCPC and micropulse P3 probe for micropulse diode laser TSCPC. This review article provides details on design of probes and their technology.

Glaucoma is the second leading cause of blindness in India. Despite advances in diagnosing and managing glaucoma, there is a lack of India-specific clinical guidelines on glaucoma. Ophthalmologists often refer to the European Glaucoma Society (EGS) and Asia-Pacific Glaucoma Society (APGS) guidelines. A group of glaucoma experts was convened to review the recently released EGS guideline (fifth edition) and the APGS guideline and explore their relevance to the Indian context. This review provides the salient features of EGS and APGS guidelines and their utility in Indian scenario. Glaucoma diagnosis should be based on visual acuity and refractive errors, slit-lamp examination, gonioscopy, tonometry, visual field (VF) testing, and clinical assessment of optic nerve head, retinal nerve fiber layer (RNFL), and macula. The intraocular pressure target must be individualized to the eye and revised at every visit. Prostaglandin analogues are the most effective medications and are recommended as the first choice in open-angle glaucoma (OAG). In patients with cataract and primary angle-closure glaucoma (PACG), phacoemulsification alone or combined phacoemulsification and glaucoma surgery are recommended. Trabeculectomy augmented with antifibrotic agents is recommended as the initial surgical treatment for OAG. Laser peripheral iridotomy and surgery in combination with medical treatment should be considered in high-risk individuals aged

Clinical skills training in Glaucoma is an intergral for the Glaucoma specialist of tomorrow. We discuss the various modalities and resources for glaucoma skills training.

Severe acute respiratory syndrome- coronavirus-2 is an enveloped, single-stranded RNA virus that causes novel coronavirus disease 2019 (COVID-19). It is highly transmissible and has a significant fatality rate, especially in the elderly and those with comorbidities such as immunosuppression, respiratory disease, and diabetes mellitus. The purpose of this brief review is to summarize those published studies as of early May 2020 on COVID in ophthalmology and to present a review of various national and international ophthalmological society guidelines, hoping to make a contribution for protecting ophthalmologists and patients.

Primary open-angle glaucoma is a condition with multiple risk factors. Although intraocular pressure is the most established among them, vascular factors and ocular blood flow (OBF) also play a significant role, especially in patients of normal tension glaucoma. This review article discusses the various vascular factors and the various methods of measurement of OBF with their clinical importance.

All across the globe, India is considered as an agricultural nation because its agro products drive the economy. An increase in population growth and a hike in food demands lead to the use of hazardous chemicals in farm fields. An in-depth field survey in Northern India was conducted to understand the types of agrochemicals that were used, farmers' knowledge about their safe handling, and their practices on its usage. Ninety-two responders (primarily farmers) from 37 districts of 12 states were interviewed to collect the information. The library containing 58 compounds as toxic spray constituents were developed and further screened in-silico for ADMET, drug-likeness, toxicity prediction, and molecular docking against their target actions in the human system. Glutathione S-transferases (GSTs) was selected as target protein showing the best-docked score with Bordeaux, Indoxacarb, Cyphenothrin, Deltamethrin, and Beta-cyfluthrin. The study revealed various adverse effects on human health and advocated provisions of alternative solutions such as using GST as a binding agents to hold the toxic chemicals out of living system and eventually saves valuable lives of the farmers.

Aim: The aim was to study the normative pattern of ocular blood flow (OBF) using color Doppler imaging. Materials and Methods: It was a prospective study including healthy volunteers without any ocular pathology. Results: We analyzed ocular blood flow for 25 eyes of consecutive normal patients. Our study had 14 males and 11 females. The standard deviation of the resistive index of Ophthalmic artery, Central retinal artery and short posterior ciliary artery were 0.07, 0.08 and 0.12 respectively. Discussion: Ischemia to the optic nerve and dysfunctional vascular regulation are likely responsible for glaucomatous damage. Ocular hemodynamics, though complex, can be assessed to an extent by many ways. The quantification of blood flow in these vessels can give great lengths of information with regard to the pathological processes behind retinal and optic nerve head diseases such as glaucoma. Lower ocular perfusion pressure, vascular dysregulation, and lower OBF can worsen glaucoma. Conclusion: To our knowledge, there are no South Indian studies showing the normative data.

Autoperimetry is a very important investigation for glaucoma diagnosis and management. This article deals with the basics and terminologies used in humphrey visual field analysis and deals with the interpretation of humphrey visual field analysis printout.

Purpose: To compare the visual outcomes and complications between the eyes receiving retropupillary iris claw intraocular lens (IOL) and scleral-fixated IOL (SFIOL) for post-cataract aphakia. Methods: Medical records of consecutive patients who had iris claw IOL and SFIOL surgery from January 2010 to March 2015, with > 1 year of follow up were retrospectively analyzed. The surgical technique was based on individual surgeon preference. The best-corrected distance visual acuity (BCDVA), previous surgery, surgical technique, and complications were analyzed. Results: Retropupillary iris claw IOL was fixated in 48 eyes (46%) and SFIOL was performed in 56 eyes. Iris claw was performed more frequently at the time of primary cataract surgery (56%) compared to SFIOL (14%) (P < 0.001). At 1 month postoperative, BCDVA was significantly better in the SFIOL group [0.7 ± 0.5 logarithm of minimum angle of resolution (logMAR) in iris claw vs. 0.3 ± 0.2 logMAR in SFIOL, P < 0.001] but this difference did not persist at 1 year (0.4 ± 0.4 logMAR in iris claw vs. 0.3 ± 0.2 logMAR in SFIOL, P = 0.56). Eyes with iris claw IOL experienced significantly more postoperative iritis (17%), intraocular pressure spikes (10%), and ovalization of the pupil (16%). Conclusion: Retropupillary iris claw IOL fixation is as safe as SFIOL for visual rehabilitation of post-cataract aphakia. Visual rehabilitation following iris claw IOL might take longer than SFIOL. Ovalization of the pupil is the commonest adverse effect reported with this type of IOL design.

Glaucoma is a progressive disease which can lead to blindness. Early detection is crucial to prevent further damage. Though glaucoma is more a clinical diagnosis but investigative tools like optical coherence tomography can help us diagnose suspicious cupping and early glaucoma. The newer modalities help us to prognostigate the disease by seeing for progression. This article will help the reader interpret OCT with better understanding.

Molecular mimicry is an evolutionary strategy adopted by viruses to exploit the host cellular machinery. We report that SARS-CoV-2 has evolved a unique S1/S2 cleavage site, absent in any previous coronavirus sequenced, resulting in the striking mimicry of an identical FURIN-cleavable peptide on the human epithelial sodium channel α-subunit (ENaC-α). Genetic alteration of ENaC-α causes aldosterone dysregulation in patients, highlighting that the FURIN site is critical for activation of ENaC. Single cell RNA-seq from 66 studies shows significant overlap between expression of ENaC-α and the viral receptor ACE2 in cell types linked to the cardiovascular-renal-pulmonary pathophysiology of COVID-19. Triangulating this cellular characterization with cleavage signatures of 178 proteases highlights proteolytic degeneracy wired into the SARS-CoV-2 lifecycle. Evolution of SARS-CoV-2 into a global pandemic may be driven in part by its targeted mimicry of ENaC-α, a protein critical for the homeostasis of airway surface liquid, whose misregulation is associated with respiratory conditions.

Fungal sinusitis poses a great diagnostic and treatment challenge to the otorhinolaryngologist. The increasing incidence of the disease, wide spectrum of clinical features, possibility of recurrence, invasion to vital structures such as orbit and brain, and treatment challenges make it a major health burden today. Often attributed to an immunoglobulin E-specific reaction or cell-mediated immune response to the fungal filaments, fungal sinusitis can be diagnosed by fungal stain and culture and histopathology (gold standard). Radiological studies help in assessing the disease extent and in planning management. We present our series of various forms of fungal sinusitis and the difficulties we faced in the management and the outcome. Each form of fungal sinusitis has distinctly different medical and surgical treatment which needs to be individualized, most often requiring radical surgical debridement along with adjunct long-term antifungals (polyene and triazole) playing an equally important role.

Ocular pyogenic granulomas (PG) are common benign tumors seen by general ophthalmologists. Topical beta-blockers can be an effective noninvasive treatment for them. It is particularly very useful in the pediatric population where both surgical excision or steroid use can be risky. We present this case to report yet another use of timolol in ophthalmology.

A 27-year-old male patient, with family history of glaucoma was diagnosed to have iridocorneal endothelial syndrome in the left eye. He was treated initially with topical medications and subsequently underwent trabeculectomy with the express implant. Postoperatively, the bleb was found to be well functioning for few months and later became flat and he was given subconjunctival (SC) 0.1 ml 5-Flourouracil (FU) injection with bleb needling. As the bleb did not form despite these measures, he underwent a second surgery with an Ahmed glaucoma valve (FP7) implantation. On review after 4 weeks, the patient had developed a large encysted bleb. Needling was done again and another dose of SC 5-FU 0.1 ml was given. The bleb became encysted again after 6 weeks, hence bleb wall excision was done, and the cyst wall was sent for histopathological analysis which revealed presence of loculated cysts and goblet cells but no inflammation. To the best of our knowledge, there have been very few histopathological case reports of encysted bleb published in peer-reviewed literature.

Herein, we report a case of acquired optic nerve pit in a 46-year-old Indian male, a known case of primary angle closure glaucoma (PACG) compatible with treatment for the past 15 years. He presented to our clinic with complaints of recent decrease in vision; on examination, his visual acuity was found correctable to 6/6 and 6/12 in the right and left eye, respectively. Fundoscopy revealed glaucomatous cupping in both the eyes and subretinal fluid in macula of the left eye. Swept-source optical coherence tomography macula and retinal nerve fiber layer disclosed acquired pit of the optic nerve (APON) in the left eye. The patient was under continuous follow-up and maculopathy spontaneously resolved. An APON may indicate progression of glaucoma and was more commonly reported in cases of primary open-angle glaucoma; we aimed to report an unusual presence of APON in a case of PACG.

Nanophthalmos is characterized by bilateral and symmetrical small eyes with shortened axial length of 20 mm or less (two standard deviation below average axial length), high lens-to-eye volume ratio with shallow anterior chamber, enophthalmos, and narrow palpebral fissures. All these features make it challenging for cataract surgery, in this case report, we suggest few necessary steps taken for an uncomplicated outcome.

Generic pharma products are inexpensive as compared to the original innovator branded drugs. True generics are not freely available in India. There have been concerns about efficacy and quality of generics that are available. This review outlines these issues and the legislation regarding the availability and use of generics in our practice.

Lobular capillary haemangioma also called as pyogenic granuloma is a hyperplastic vascular lesion generally found in mucus membranes of head and neck region especially the nasal and oral mucosae. It is rapidly growing and more common in paediatric age group, pregnancy and after surgery or trauma. Its occurrence involving caruncle is uncommon. Here we report a case of a 46 year old male who presented to us with caruncular nodular mass which on excision biopsy was diagnosed as lobular capillary hemangioma. The purpose of this case report is to make readers aware of its rare site of presentation and management. Pyogenic granuloma should be borne in mind as one of the differentials in cases like this and complete excision should be done to prevent recurrence and to rule out malignant entities.

Animals that require purposeful movement for survival are endowed with mechanosensory neurons called proprioceptors that provide essential sensory feedback from muscles and joints to spinal cord circuits, which modulates motor output. Despite the essential nature of proprioceptive signaling in daily life, the mechanisms governing proprioceptor activity are poorly understood. Here, we have identified distinct and nonredundant roles for two voltage-gated sodium channels (Na V s), Na V 1.1 and Na V 1.6, in mammalian proprioception. Deletion of Na V 1.6 in somatosensory neurons (Na V 1.6 cKO mice) causes severe motor deficits accompanied by complete loss of proprioceptive transmission, which contrasts with our previous findings using similar mouse models to target Na V 1.1 (Na V 1.1 cKO ). In Na V 1.6 cKO animals, loss of proprioceptive feedback caused non-cell-autonomous impairments in proprioceptor end-organs and skeletal muscle that were absent in Na V 1.1 cKO mice. We attribute the differential contribution of Na V 1.1 and Na V 1.6 in proprioceptor function to distinct cellular localization patterns. Collectively, these data provide the first evidence that Na V subtypes uniquely shape neurotransmission within a somatosensory modality., Competing Interests: Competing interests: All other authors declare they have no competing interests

With the global rise of cardiovascular disease including atherosclerosis, there is a high demand for accurate diagnostic tools that can be used during a short consultation. In view of pathology, abnormal blood flow patterns have been demonstrated to be strong predictors of atherosclerotic lesion incidence, location, progression, and rupture. Prediction of patient-specific blood flow patterns can hence enable fast clinical diagnosis. However, the current state of art for the technique is by employing 3D-imaging-based Computational Fluid Dynamics (CFD). The high computational cost renders these methods impractical. In this work, we present a novel method to expedite the reconstruction of 3D pressure and shear stress fields using a combination of a reduced-order CFD modelling technique together with non-linear regression tools from the Machine Learning (ML) paradigm. Specifically, we develop a proof-of-concept automated pipeline that uses randomised perturbations of an atherosclerotic pig coronary artery to produce a large dataset of unique mesh geometries with variable blood flow. A total of 1,407 geometries were generated from seven reference arteries and were used to simulate blood flow using the CFD solver Abaqus. This CFD dataset was then post-processed using the mesh-domain common-base Proper Orthogonal Decomposition (cPOD) method to obtain Eigen functions and principal coefficients, the latter of which is a product of the individual mesh flow solutions with the POD Eigenvectors. Being a data-reduction method, the POD enables the data to be represented using only the ten most significant modes, which captures cumulatively greater than 95% of variance of flow features due to mesh variations. Next, the node coordinate data of the meshes were embedded in a two-dimensional coordinate system using the t-distributed Stochastic Neighbor Embedding ( t -SNE) algorithm. The reduced dataset for t -SNE coordinates and corresponding vector of POD coefficients were then used to train a Random Forest Regressor (RFR) model. The same methodology was applied to both the volumetric pressure solution and the wall shear stress. The predicted pattern of blood pressure, and shear stress in unseen arterial geometries were compared with the ground truth CFD solutions on "unseen" meshes. The new method was able to reliably reproduce the 3D coronary artery haemodynamics in less than 10 s., Competing Interests: The 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., (© 2023 Morgan, Murali, Preston, Sima, Marcelo Chamorro, Bourantas, Torii, Mathur, Baumbach, Jacob, Karabasov and Krams.)

Objectives: Dysregulation of hepcidin-iron axis is presumed to account for abnormal iron status in patients with chronic liver disease (CLD). Our aim is to determine the effect of specific etiologies of CLD and of cirrhosis on serum hepcidin levels., Methods: PubMed, Embase, Web of Science were searched for studies comparing serum hepcidin levels in patients with CLD to that in controls using enzyme-linked immunosorbent assay. The study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Guidelines. Statistical analysis was carried out with STATA using random effects model to calculate the mean difference (MD) between two groups., Results: Hepcidin levels were significantly lower in subjects with hepatitis C virus (16 studies) [MD -1.6 (95 % CI: -2.66 to -0.54), p<0.01] and alcoholic liver disease (3 studies) [MD -0.84 (95 % CI: -1.6 to -0.07), p=0.03] than controls. Serum hepcidin was significantly higher in subjects with non-alcoholic fatty liver disease (12 studies) [MD 0.62 (95 % CI: 0.21 to 1.03), p<0.01], but did not differ in subjects with hepatitis B and controls (eight studies) [MD -0.65 (95 % CI: -1.47 to 0.16), p=0.12]. Hepcidin levels were significantly lower in patients with cirrhosis of any etiology (four studies) [MD -1.02 (CI: -1.59 to -0.45), p<0.01] vs. controls (CI: confidence interval)., Conclusions: Serum hepcidin levels are altered in common forms of CLD albeit not in a consistent direction. Additional study is needed to determine how changes in hepcidin levels are related to dysregulation of iron metabolism in CLD., (© 2023 Walter de Gruyter GmbH, Berlin/Boston.)

Background: Porto-sinusoidal vascular disease (PSVD) is a novel nomenclature to describe non-cirrhotic portal hypertension and characteristic histology without portal vein thrombosis (PVT). It is a more inclusive definition than the previously well-recognized entity idiopathic non-cirrhotic portal hypertension. There is a paucity of data on PSVD patients., Methods: A total of 33 patients diagnosed with PSVD and portal hypertension (PH) between 2005 and 2021 were included. Data were retrieved from electronic medical record system and analyzed., Results: Of the 33 patients, 6 (18%) occurred in post-transplant allograft liver. After a median follow-up of 96 months (interquartile range, IQR [52, 139]), 14 deaths occurred (42%), 4 directly related to decompensated liver disease. The Kaplan-Meier survival estimates at 1, 5, and 10 years were 94%, 87% and 58%. PVT occurred in 10 patients (30%). The Nelson-Aalen cumulative risk estimate for PVT at 1, 5 and 10 years were 16%, 25% and 48%. The median model for end-stage liver disease and Child-Pugh score at initial presentation were 8 (IQR [7-12]) and 5 [5-6], and increased to 13 [8, 18] and 7 [5, 8], respectively, at the end of follow-up. Of the 11 patients who presented with splenomegaly and no specific sign of PH, 7 (64%) developed varices and 3 (27%) ascites at a median follow-up of 100 months., Conclusions: PSVD with PH is not a benign entity. Mortality, PVT and hepatic decompensation are common. Patients with PSVD must be closely monitored, including those who only have non-specific clinical signs (e.g., splenomegaly) of PH., (© 2023. Japanese Society of Gastroenterology.)

Background: The NAFLD decompensation risk score (the Iowa Model) was recently developed to identify patients with nonalcoholic fatty liver disease (NAFLD) at highest risk of developing hepatic events using three variables-age, platelet count, and diabetes., Aims: We performed an external validation of the Iowa Model and compared it to existing non-invasive models., Methods: We included 249 patients with NAFLD at Boston Medical Center, Boston, Massachusetts, in the external validation cohort and 949 patients in the combined internal/external validation cohort. The primary outcome was the development of hepatic events (ascites, hepatic encephalopathy, esophageal or gastric varices, or hepatocellular carcinoma). We used Cox proportional hazards to analyze the ability of the Iowa Model to predict hepatic events in the external validation (https://uihc.org/non-alcoholic-fatty-liver-disease-decompensation-risk-score-calculator). We compared the performance of the Iowa Model to the AST-to-platelet ratio index (APRI), NAFLD fibrosis score (NFS), and the FIB-4 index in the combined cohort., Results: The Iowa Model significantly predicted the development of hepatic events with hazard ratio of 2.5 [95% confidence interval (CI) 1.7-3.9, P < 0.001] and area under the receiver operating characteristic curve (AUROC) of 0.87 (CI 0.83-0.91). The AUROC of the Iowa Model (0.88, CI: 0.85-0.92) was comparable to the FIB-4 index (0.87, CI: 0.83-0.91) and higher than NFS (0.66, CI: 0.63-0.69) and APRI (0.76, CI: 0.73-0.79)., Conclusions: In an urban, racially and ethnically diverse population, the Iowa Model performed well to identify NAFLD patients at higher risk for liver-related complications. The model provides the individual probability of developing hepatic events and identifies patients in need of early intervention., (© 2022 Indian National Association for Study of the Liver. Published by Elsevier B.V. All rights reserved.)

Background: Endoscopic ultrasound-guided rendezvous (EUS-RV) endoscopic retrograde cholangiopancreatography (ERCP) is an alternative to interventional radiology-guided rendezvous ERCP in patients who failed biliary cannulation with conventional ERCP. However, there is significant variation in reported rates of success and adverse events associated with EUS-RV-assisted ERCP. We performed a systematic review and a proportion meta-analysis to reliably assess the effectiveness and safety of the EUS-RV-assisted ERCP., Materials and Methods: We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through August 2020) to identify studies reporting EUS-RV-assisted ERCP in patients who failed biliary cannulation with conventional ERCP techniques. Using the random-effects model described by DerSimonian and Laird, we calculated the pooled rates of technical success, clinical success, and adverse events of EUS-RV-assisted ERCP., Results: Twelve studies reporting a total of 342 patients were included in the meta-analysis. The pooled rate of technical success (12 studies reporting a total of 342 patients) was 86.1% [95% confidence interval (CI): 78.4-91.3]. The pooled rate of clinical success (4 studies reporting a total of 94 patients) was 80.8% (95% CI: 64.1-90.8). The pooled rate of overall adverse events (12 studies; 42 events in 342 patients) was 14% (95% CI: 10.5-18.4). Low to moderate heterogeneity was noted in the analyses., Conclusions: EUS-RV-assisted ERCP appears to be effective and safe in patients who failed biliary cannulation with conventional ERCP. Given the risk of adverse events, it should be performed in centers with expertise in therapeutic endoscopic ultrasound., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Aims: Heterozygous alpha-1-antitrypsin (A1AT) Pi*MZ variant has been shown to increase the risk of developing liver cirrhosis in patients with non-alcoholic fatty liver disease (NAFLD). We aimed to determine the association between heterozygous Pi*MZ and Pi*MS variants and development of hepatic decompensation events in NAFLD patients., Methods: We included patients with NAFLD who also had A1AT genotyping performed from 2005 to 2020. We recorded demographic and clinical variables, and data on hepatic events (ascites, hepatic encephalopathy, esophageal variceal bleed, or hepatocellular carcinoma), if any. We performed binary logistic regression analysis to assess the association between A1AT variants and hepatic events, and calculated Odds ratio (OR) with their 95% confidence intervals (Cl)., Results: We included 1532 patients with NAFLD, of which 1249 patients had Pi*MM, 121 had Pi*MS, and 162 had Pi*MZ. Of the 1532 patients, hepatic events developed in 521 (34%) patients. The percentage of patients with Pi*MZ variant was significantly higher in patients with hepatic events as compared to patients without hepatic events (18.7 % vs 8.1%, p<0.0001). Pi*MZ variant was noted to significantly increase the odds of developing hepatic events in NAFLD patients, unadjusted OR: 1.82 (1.3-2.5, p<0.001), adjusted OR (for age, sex, body mass index, and diabetes mellitus) 1.76 (1.2-2.5, p = 0.002). Pi*MS variant did not increase the odds of hepatic events in NAFLD patients, OR: 0.92 (0.6-1.4, p = 0.70)., Conclusion: Patients with NAFLD and A1AT Pi*MZ variant are at increased risk for developing hepatic decompensation. NAFLD patients should be offered A1AT genotyping for risk stratification, counseling, and multidisciplinary intervention for NAFLD., Competing Interests: Disclosures Arvind Murali, Sameer Prakash, and Antonio Sanchez declare that they have no conflict of interest or other financial disclosures relevant to the subject matter. The study protocol was approved by the institutional review board., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Background: Controversy exists whether alpha-1 antitrypsin (A1AT) genotype testing should be performed as a first-line screening for A1AT heterozygous variants., Methods: We calculated the median and interquartile range of A1AT level for each genotype in 4378 patients with chronic liver disease and "miss rate" of MZ genotype identification at various cutoff levels., Findings: Significant overlap in A1AT level noted with Pi*MM, MZ, and MS variants. Miss rate of Pi*MZ at a cutoff level <100 was 29%, <110 was 18%, <120 was 8%, and <130 was 4%. We suggest simultaneous measurement of A1AT level and genotype in patients with chronic liver disease., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Study of Liver Diseases.)

Video 1Colonoscopy findings of cecal mass as a lead point causing intussusception., (© 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background and Aims: Colorectal cancer (CRC) is the third most common cause of cancer worldwide. Studies have shown a strong association between screening colonoscopy and a reduced risk of death from colorectal cancers. The incidence of poor bowel preparation has been reported in up to 25% cases. We conducted a systematic review and comprehensive meta-analysis to evaluate the effect of patient education using multimedia platforms on adenoma detection rate and adequacy of bowel preparation., Methods: Multiple databases were searched through May 2020 for studies that reported the efficacy of multimedia education (smartphone app and online audio-visual aids) in improving quality of bowel preparation and its effect on adenoma detection rate (ADR). Meta-analysis was performed to determine whether multimedia based patient education (MM) helps improve ADR and bowel preparation quality as compared to controls (CT)., Results: We included 13 randomized controlled trials with a total of 3754 patients. Eight studies reported outcomes on ADR and 12 reported on adequacy of bowel preparation. Overall ADR was higher in patients receiving multimedia based education as compared to CT (risk ratio (RR) 1.25, confidence interval (CI) 1.01-1.56, P = 0.04). A higher proportion of patients receiving multimedia based education achieved adequate bowel preparation (RR 1.2, CI 1.1-1.3, P = 0.001). In patients with mean age over 50 years, ADR was better in MM cohort as compared to controls (RR 1.3, CI 1.1-1.6, P = 0.001)., Conclusion: Pre-colonoscopy patient education using multimedia based platforms seems to improve ADR and the adequacy of bowel preparation., (© 2020 Japan Gastroenterological Endoscopy Society.)

After liver transplantation (LT), the role of ursodeoxycholic acid (UDCA) is not well characterized. We examine the effect of UDCA after LT in the prophylaxis of biliary complications (BCs) in all-comers for LT and the prevention of recurrent primary biliary cholangitis (rPBC) in patients transplanted for PBC. Two authors searched PubMed/MEDLINE and Embase from January 1990 through December 2018 to identify all studies that evaluate the effectiveness of UDCA prophylaxis after LT for BCs in all LT recipients and rPBC after LT in patients transplanted for PBC. Odds ratios (ORs) were calculated for endpoints of the BC study. Pooled recurrence rates were calculated for rPBC. The study was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. A total of 15 studies were included, comprising 530 patients in the analysis for BCs and 1727 patients in the analysis for rPBC. UDCA was associated with decreased odds of BCs (OR, 0.70; 95% confidence interval [CI], 0.52-0.93; P = 0.01) and biliary stones and sludge (OR, 0.49; 95% CI, 0.24-0.77; P = 0.004). Prophylactic use of UDCA did not affect the odds of biliary stricture. For patients transplanted for PBC, the rate of rPBC was lower with the prophylactic use of UDCA (IR 16.7%; 95% CI, 0.114%-22.0%; I2 = 36.1%) compared with not using prophylactic UDCA (IR 23.1%; 95% CI, 16.9%-29.3%; I2 = 86.7%). UDCA after LT reduces the odds of BC and bile stones and sludge in all-comer LT recipients and reduces or delays the incidence of rPBC in patients transplanted for PBC. UDCA use after LT could be considered in all LT recipients to reduce the odds of BC and may be particularly beneficial for patients transplanted for PBC by reducing the incidence of rPBC., (Copyright © 2020 by the American Association for the Study of Liver Diseases.)

Background and Aims: Several criteria have been described to noninvasively predict the presence of high-risk esophageal varices in patients with compensated advanced chronic liver disease (cACLD). However, a recent study showed that treatment with β blockers could increase decompensation-free survival in patients with clinically significant portal hypertension, thereby making it important to predict the presence of any esophageal varices. We aimed to develop a simple scoring system to predict any esophageal varices., Methods: We retrospectively reviewed patients who had vibration-controlled transient elastography (VCTE) at Cook County Hospital, Chicago, USA. Patients with cACLD and liver stiffness measurement (LSM) ≥ 10 kPa with esophagogastroduodenoscopy performed within one year of VCTE were analyzed. We generated a novel score to predict esophageal varices, using the beta coefficient of predictive variables. The score was validated in an external cohort at the University of Iowa Hospital, USA., Results: There were 372 patients in the development cohort and 200 patients in the validation cohort. LSM, platelet count, and albumin were identified as predictors of esophageal varices and were included for generating the Cook County score as "platelet count * - 0.0155872 + VCTE score * 0.0387052 + albumin * - 0.8549209." The area under receiver operating curve for our score was 0.86 for any varices and 0.85 for high risk varices and avoided more endoscopies than the expanded Baveno VI criteria while maintaining a very low miss rate (negative predictive value > 99%)., Conclusion: We propose a new, highly accurate, and easy-to-use scoring system to predict the presence of not only high-risk but any esophageal varices in patients with cACLD.

Nonhepatotropic viruses such as adenovirus, herpes simplex virus, flaviviruses, filoviruses, and human herpes virus, and bacteria such as Coxiella burnetii, can cause liver injury mimicking acute hepatitis. Most of these organisms cause a self-limited infection. However, in immunocompromised patients, they can cause severe hepatitis or in some cases fulminant hepatic failure requiring an urgent liver transplant. Hepatic dysfunction is also commonly seen in patients with severe acute respiratory syndrome coronavirus-2 infection. Patients with preexisting liver diseases are likely at risk for severe coronavirus disease 2019 (COVID-19) and may be associated with poor outcomes., Competing Interests: Disclosure A.R. Murali receives research grants from Arrowhead and Eiger. None of the other authors have disclosures., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background and study aims  With the advent of deep neural networks (DNN) learning, the field of artificial intelligence (AI) is rapidly evolving. Recent randomized controlled trials (RCT) have investigated the influence of integrating AI in colonoscopy and its impact on adenoma detection rates (ADRs) and polyp detection rates (PDRs). We performed a systematic review and meta-analysis to reliably assess if the impact is statistically significant enough to warrant the adoption of AI -assisted colonoscopy (AIAC) in clinical practice. Methods  We conducted a comprehensive search of multiple electronic databases and conference proceedings to identify RCTs that compared outcomes between AIAC and conventional colonoscopy (CC). The primary outcome was ADR. The secondary outcomes were PDR and total withdrawal time (WT). Results  Six RCTs (comparing AIAC vs CC) with 5058 individuals undergoing average-risk screening colonoscopy were included in the meta-analysis. ADR was significantly higher with AIAC compared to CC (33.7 % versus 22.9 %; odds ratio (OR) 1.76, 95 % confidence interval (CI) 1.55-2.00; I 2  = 28 %). Similarly, PDR was significantly higher with AIAC (45.6 % versus 30.6 %; OR 1.90, 95 %CI, 1.68-2.15, I 2  = 0 %). The overall WT was higher for AIAC compared to CC (mean difference [MD] 0.46 (0.00-0.92) minutes, I 2  = 94 %). Conclusions  There is an increase in adenoma and polyp detection with the utilization of AIAC., Competing Interests: Competing interests The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Background and Aims: EUS-guided FNA primarily provides cytologic samples. EUS-guided fine-needle biopsy (FNB) with needles that provide histologic specimens may enhance diagnostic yield and facilitate accessory tissue staining. Several different needle designs are currently available and design superiority is unknown. We designed a randomized controlled trial to compare 2 commonly used EUS-FNB needles in their ability to provide histologic tissue samples (primary endpoint) and to reach an accurate diagnosis (secondary endpoint)., Methods: A total of 150 lesions from 134 patients (November 2018 to June 2019) were randomized 1:1 between biopsy with a Franseen needle and a Fork-tip needle. The groups were compared regarding the quality of the tissue samples and diagnostic accuracy., Results: Of 150 lesions, 75 were pancreatic and 75 were other solid lesions in and around the GI tract. There was no statistically significant difference between the Franseen needle and the Fork-tip needle in the yield of adequate histologic samples, 71 of 75 (94.7%) versus 72 of 75 (96%), (P = 1.00), an absolute difference of -1.3% (95% confidence interval [CI], -8.1% to 5.4%). The 2 groups were similar in the diagnostic accuracy of histologic analysis, 64 of 75 (85.3%) versus 68 of 75 (90.7%) (P = .45), absolute difference -5.4% (95% CI, -15.7% to 5%); and in the diagnostic accuracy of combined cytologic and histologic analysis, 65 of 75 (86.7%) versus 69 of 75 (92%) (P = .43), absolute difference -5.3% (95% CI, -15.2% to 4.5%)., Conclusions: There was no significant difference in the performance of the Franseen needle versus the Fork-tip needle. Both needles achieved a high yield of histologic tissue samples and high diagnostic accuracy. (Clinical trial registration number: NCT03672032.)., (Copyright © 2021 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Introduction: Eosinophilic Esophagitis (EoE) is an immune-mediated, chronic inflammatory disorder of the esophagus. Topical steroids have been used in the management of EoE for over 15 years. However, there are no Food and Drug Administration (FDA) approved drug therapies for EoE., Areas Covered: This review discusses the current understanding of EoE and the role of topical steroids in the induction and maintenance of remission in patients with EoE. We performed a comprehensive review of the literature, summarized randomized control trials from 2006 to 2020, and provided a simplified management algorithm for EoE., Expert Opinion: In patients with EoE, topical steroids are effective in inducing clinical and histologic remission. Formulations of topical steroids that maximize the exposure to esophageal mucosa have the highest efficacy. A majority of patients who achieve remission with topical steroids develop clinical and histologic relapse off therapy within a year. Current evidence suggests that maintenance therapy with long-term topical steroids decreases the risk of relapse and progression to fibrostenotic disease. While uncertainty over the dose and duration of maintenance topical steroids and their potential side effects exists, long-term maintenance therapy with topical steroids appears to be the way forward to improve long-term outcomes in patients with EoE.

Background: Endoscopic mucosal resection (EMR) is used for the treatment of early esophageal cancer (EEC)., Methods: This a retrospective study aimed to study the efficacy, safety, and the recurrence rate of EEC following EMR., Results: Seventy-nine patients who had undergone EMR for early EEC (T1a andT1b lesions) from 2006 to 2015 were included. EMR alone was considered curative in 51 patients who had T1a lesion. Complete remission was achieved in 50 (98%) patients. Mean number of sessions of EMR was 1.14. Cancer recurred locally in 6 (12%) of 50 patients at a median follow-up of 48 (18-72) months. Endoscopic treatment alone achieved complete remission at last follow up in 47 of 50 patients (94%) who had initial EMR with complete remission, or in 47 of all 51 patients (92%) in whom EMR was considered curative for EC. The Kaplan-Meier cancer-free survival following complete remission with EMR was 94.2% at 1 year and 88.4% at 5 years. Patients with complete eradication of Barrett's had lower risk of recurrence of adenocarcinoma (AC) compared with patients who had persistent Barrett's (p = 0.01). EMR alone was not considered curative in 19 patients, 16 with T1b AC and 3 with T1a squamous cell carcinoma (SCC) invading the muscularis mucosa (m3). Two major adverse events were noted: delayed bleeding requiring hospitalization, and perforation that was closed endoscopically., Conclusion: EMR is effective and safe for the management of early EC. The risk of cancer recurrence, albeit small, warrants surveillance. Complete eradication of Barrett's should be attempted in all patients after EMR of AC.