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Background: Myth is widely held but false idea or a belief. It is usually backed by religious, traditional , customs and rituals which tries to manipulate public mindset. Since the spread of Covid-19 Pandemic, myths are being believed by people .In this review article I am providing information about Myths and its actual facts about COVID-19 which are essential to be known so as to stop the spread of Myths by some set of people for own gains or either due to lack of Scientific Information It takes too long to debunk a myth by presenting facts. Conclusion: Myths have been believed by common people at large whenever a new disease or virus is identified. These Myths have potential to spread more vigorously than the virus itself Myths can have detrimental effects on various aspects of physical, mental and social health. These myths should be curbed by providing evidence based information which can stop its spread. Therefore strict possible measures as discussed above should be taken by respective authorities.

COVID-19 had a lot of lessons to tell, and one of the most interesting was how difficult it is to manage a deadly, fast-moving disease in a community that is closely tied together by mass transportation, mass consumption, and mass media. As the largest pandemic to have occurred in the “digital-mass society” period, COVID-19 demonstrates how quickly a virus can spread through the "masses" despite the many steps taken by public health authorities to limit its spread. The primary measure most in use by health officials during COVID-19 pandemic is preventing person to person spread of disease by creating a firewall between uninfected and infected masses. COVID-19 had a lot of lessons to tell, and one of the most interesting was how difficult it is to manage a deadly, fast-moving disease in a community that is closely tied together by mass transportation, mass consumption, and mass media. As the largest pandemic to have occurred in the “digital-mass society” era, COVID-19 offers an insight on how quickly a virus can spread through the "masses" despite the many steps taken by public health authorities to limit its spread. The material required for the review was taken from the databases of Pub Med, Web of science, the from the website of World Health Organization and the patients data of SMHRC and DMMC Wanadongari Nagpur.

Research evaluating optimal repair techniques for the reduction of postpartum dyspareunia following obstetric laceration is severely limited. Prevailing guidelines from the American College of Obstetricians and Gynecologists (ACOG) are reliant on data from just nine clinical trials conducted from 1980 to 2012. While the literature on this topic is still limited today, this review aims to synthesize data from past and present studies to ensure that standing clinical recommendations are supported by current literature. A review was conducted per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. Medical Literature Analysis and Retrieval System Online (MEDLINE), Cochrane Library, and Google Scholar were searched. Included articles (1) compared continuous with interrupted repair techniques for subjects with episiotomies and/or second-degree tears, (2) were available in full length, and (3) reported dyspareunia as an outcome variable. Excluded articles were those (1) inclusive of first-, third-, or fourth-degree tears; (2) comparing suture material rather than technique; and (3) not available in English. A meta-analysis was conducted for both acute dyspareunia (3 months) and chronic dyspareunia (3 months) utilizing Meta-Essentials Microsoft Excel (Microsoft Corp., Redmond, WA) workbook. Bias was evaluated via Egger regression and Begg and Mazumdar rank correlation tests. Twelve articles met inclusion and exclusion guidelines, seven for acute dyspareunia and eight for chronic dyspareunia. All publications were randomized controlled trials and were inclusive of a total of 4,081 patients. Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random effect model. Analysis revealed no statistically significant difference between continuous and interrupted suture groups for acute dyspareunia (RR: 0.98; 95% CI: 0.89-1.08) or chronic dyspareunia (RR: 0.96; 95% CI: 0.83-1.12). Egger regression test (p-value=0.534) and Begg and Mazumdar rank correlation test (p-value=0.570) indicated minimal publication bias. Compiled data does not indicate a preferential suture technique for the reduction of postpartum dyspareunia. These findings are congruent with the ACOG guidelines; therefore, there is no supporting evidence for ACOG's recommendation of continuous suturing to be overturned.

Background Endoscopic full-thickness resection (eFTR) of the colon using the full-thickness resection device (FTRD) is a novel method for removing lesions involving, or tethered to, deeper layers of the colonic wall. The UK FTRD Registry collected data from multiple centres performing this procedure. We describe the technical feasibility, safety and early outcomes of this technique in the UK. Methods Data were collected and analysed on 68 patients who underwent eFTR at 11 UK centres from April 2015 to June 2019. Outcome measures were technical success, procedural time, specimen size, R0 resection, endoscopic clearance, and adverse events. Reported technical difficulties were collated. Results Indications for eFTR included non-lifting polyps (29 cases), T1 tumour resection (13), subepithelial tumour (9), and polyps at the appendix base or diverticulum (17). Target lesion resection was achieved in 60/68 (88.2%). Median specimen size was 21.7 mm (10-35 mm). Histologically confirmed R0 resection was achieved in 43/56 (76.8%) with full-thickness resection in 52/56 (92.9%). Technical difficulties occurred in 17/68 (25%) and complications in 3/68 (5.9%) patients. Conclusion eFTR is a useful technique with a high success rate in treating lesions not previously amenable to endoscopic therapy. Whilst technical difficulties may arise, complication rates are low and outcomes are acceptable, making eFTR a viable alternative to surgery for some specific lesions.

Acute variceal bleeding (VB) remains a major cause of death in cirrhosis/portal hypertension. We aim to assess the characteristics, therapies delivered and outcomes of patients presenting with VB in a large teaching hospital. A retrospective analysis was performed on all patients presenting with acute UGIB who underwent a gastroscopy between March 2015 and February 2020. Data was collected where UGIB was deemed secondary to varices from electronic records to assess findings at endoscopy, therapy applied, rebleed rates and mortality. A total of 2324 patients presented with UGIB. 239 presentations involving 196 patients had varices reported. 155 cases underwent therapy for acute VB as cause for UGIB, with varices felt not to be the primary cause in the remaining 84. Median age was 54 years(IQR 46–67). 65%(n=100) were male. Clinical presentations were haematemesis only 35%(n=55), melaena only 26%(n=41) or both 38%(n=59). 56%(n=87) gastroscopies were undertaken ‘out of hours’. The commonest endoscopic finding was oesophageal varices in 98%(n=152). Treatment was undertaken at first endoscopy in 93%(n=144), comprising banding(86%) and glue injection(7%). 17%(n=27) of patients required insertion of Sengstaken-Blakemore tube. The remaining 7%(n=11) underwent their first treatment at further gastroscopy (within 7 days). 32%(n=49) of patients had repeat gastroscopy within 7 days, where 90% were due to clinical evidence of rebleed. 23 patients required repeat endoscopic therapy and 10 patients underwent Sengstaken-Blakemore tube insertion. 30%(n=70) of patients required ICU admission. 16%(n=25)underwent TIPS procedure. 30-day rebleeding rate was 24%(n=37). 30-day mortality was 17%(n=27) with 67% attributable to UGIB or subsequent decompensated cirrhosis with multi-organ failure. On subgroup analysis, ICU admission was significantly associated with increased mortality (OR 3.46, 95% CI 1.46 to 8.22, p Receiver operating characteristic (ROC) curves showed better predictive ability of MELD score than Child-Pugh score for 30-day mortality (AUC 0.92 vs 0.72), with MELD score of > 18 significantly associated with increased mortality (OR 7.70, 95% CI 0.04 to 0.35, p Mortality and rebleed rates following acute VB is in keeping with national data. More than half of patients undergo gastroscopy out of hours emphasizing the need for 24/7 access to therapeutic endoscopy. MELD score of >18 appears to be a strong predictor of mortality and can be used in clinical practice to consider early critical care involvement.

Introduction Formalin therapy is an established method for the treatment of radiation proctopathy (RP). Emerging data suggests a potential role for Purastat application in the treatment of RP; however, no comparison to conventional treatment has been made to date. The aim of this study was to assess the safety and efficacy of Purastat for the treatment of RP compared to conventional treatment. Methods Consecutive patients with RP referred between January 2018 and December 2019 were treated with either conventional formalin or Purastat, based on endoscopist preference. Patients symptoms were scored with the subjective, objective management analysis (SOMA) scale, and the endoscopic severity of RP was graded by Zincola score. These measures were taken pre-treatment and prior to any subsequently planned treatments if clinically warranted, typically at 6-week intervals up to a maximum of 4 sessions. Results Of 17 patients (all male) referred for treatment, 11 patients underwent conventional Formalin instillation and 6 patients Purastat. Table 1 shows demographic and treatment outcomes. There was no statistical difference between the 2 groups in patient demographics, baseline symptom severity and Zincola score. Post-treatment protocol SOMA score reduction was significantly greater in the formalin group v Purastat group (8 to 1 v 8.2 to 4, p=0.01 respectively), and Zincola score reduction ( 4–2 v 4–3, p= 0.04 respectively). There was 1 case of mild anaphylaxis with facial flushing with Formalin, which settled with observation. Conclusions Formalin instillation is still a cheap and effective treatment of RP. Although Purastat has a beneficial adverse event profile, its limited effect in this small cohort does not yet warrant widespread usage.

Introduction The gastroduodenal full thickness resection device (FTRD®) is a new device that allows resection of tethered epithelial or subepithelial lesions (SELs) in the stomach and duodenum, but data on outcomes are limited1. Here we present first UK experience of this technique, including technical feasibility, safety and early outcomes. Methods Data on consecutive patients who underwent endoscopic full thickness resection (eFTR) at two UK teaching hospitals in November - December 2019 were analysed. The procedure was undertaken using the endoscope mounted gastroduodenal FTRD®. Main outcome measures were technical success (target lesion resection with FTRD®), total procedural time, specimen size, R0 resection, and adverse events. Need for dilatation to facilitate passage of device past cricopharyngeus or the pylorus was also documented. Results All cases were undertaken under general anaesthetic. It was possible to insert the device to the lesion in all cases; in two, dilatation of the pylorus with a 20 mm through the scope balloon was required to facilitate passage of the device to the duodenum. Technical success and histological diagnosis were achieved in 5/5 (100%) cases. Median total procedural time was 23 minutes (range 18–65). Baseline and outcome data of the cases can be seen in table 1. Two patients were kept for overnight observation and three were discharge on same day as the procedure. One patient reported shivering post procedure, which was thought to be general anaesthesia related, otherwise there were no immediate or delayed complications. Conclusions eFTR of SELs or heavily scarred lesions in the stomach and duodenum is feasible and safe with the gastroduodenal FTRD®. It facilitates acquisition of definite histology aiding diagnosis and R0 resection is possible, providing treatment or avoiding need for ongoing surveillance in selected patients. The device can be challenging to insert and in particular, pre-dilatation of the pylorus to facilitate insertion into the duodenum may be required. References Meier B, Schmidt A, Glaser N, Meining A, Walter B, Wannhoff A, Riecken B, Caca K (2020) Endoscopic full-thickness resection of gastric subepithelial tumors with the gFTRD-system: a prospective pilot study (RESET trial). Surg Endosc 34:853–860

Introduction There have been no significant improvements in the outcomes of upper gastrointestinal (GI) bleeding over the last few years. The aim of this study was to determine whether the use of the OVESCOTMover the scope clip (OTSC) was associated with a lower rebleed-rate and mortality compared to conventional endoscopic therapy. Methods Consecutive episodes of upper GI haemorrhage treated with the OTSC were identified from a prospective database in a UK tertiary centre over a 3-year period. Treatment with OTSC was delivered for patients with high-risk features or failed conventional endoscopic therapy. Over the same time period, all patients with upper GI haemorrhage treated with conventional endoscopic therapy were retrospectively identified, and a propensity score-matched cohort was assembled. Patient demographics, 7-day re-bleed rate, 30-day re-bleed rate and 30-day mortality rates were compared. T-test and Pearson’s Chi-square statistic were used to statistically describe the results. Results 617 episodes of upper GI haemorrhage were identified requiring endoscopic intervention over three years. 71 high-risk lesions were treated in the OTSC group, vs 89 high-risk lesions in the matched control group (conventional endoscopic therapy). The sites of lesions treated with the OTSC included oesophagus (10%), stomach (22%) and duodenum (68%). The lesions were described as Forrest 1a-18%, 1b-33%, 2a-32%, 2b-17%. Pathology included ulcers (78.9%), Mallory-Weiss tears (9.6%) Dieulafoy (7.0%) post-angiographic coil ulcer (1.4%) post- EMR (1.4%) anastomotic bleed (1.4%). Compared to the control group, the OTSC group had lower 7-day re-bleeding rate (19.3% vs 2.8%, p Conclusions This is one of the largest series of patients treated with OTSC for upper GI haemorrhage, demonstrating a significant reduction in both early and late rebleeding in addition to haemorrhage related mortality and thus needs to part of the treatment armamentarium.

Introduction Capsule endoscopy (CE) is well established the investigation of small-bowel (SB) pathology. We compared the use of double-headed (DH) capsules, to conventional single-headed (SH), in a real-world patient cohort in the first multicentre British study. Methods Over 9 months, patients referred for routine SBCE at 4 tertiary referral centres in the UK underwent DH CE instead of conventional SH using MiroCamⓇ MC2000 as per local protocols. One head (L/R) was chosen at random and reported by an expert reviewer. The DH recordings, anonymised and randomised, reported by another expert or re-read after a 4-week interval. For each CE, numbers and types of findings and overall conclusion/diagnosis were compared between SH and DH examinations. Results 211 CEs were performed. 7 failed to reach the SB; 204 analysed. Indications were: SB bleeding (n = 94); ?SB inflammation or reassessment of known inflammatory bowel disease (IBD) (n = 84); ?SB neoplasia including suspicious radiological imaging (n = 15); and, others e.g. ?celiac disease (n = 11). For SB bleeding: 27/94 (28.7%) examinations reported differences between SH and DH readings. In 17 (18.1%) the findings were clinically significant. SH CE missed angiectasias (5 pts), SB inflammation (7 pts), oesophagitis (2 pts) and SB masses (2 pts). In 1 patient, the extent of angiectasias seen was greater on the DH reading. For IBD: findings differed in 30/84 (35.7%) of CEs; 11 (13.1%) were clinically significant. In 5, signs of active inflammation were missed by the SH reading. In 6, assessment of extent/severity differed. For?SB neoplasia findings differed in 2/15 (13.3%) of examinations. Both were clinically significant. For others: 1/11 (9.1%) examinations differed; however, not deemed clinically significant. Overall, use of DH CE impacted the diagnosis in 30/204 (14.7%). Conclusions The use of DH CE provides more information with the potential to change clinical diagnosis and therefore management. Therefore, the routine adoption of DH CE in SB assessment should be considered.

In the present study, additive main effects and multiplicative interactions (AMMI) biplot analyses was used to dissect genotype x environment interaction (GEI) and to identify location specific and widely adapted genotypes for root branches, diameter and length in ashwagandha [Withania somnifera (L.) Dunal]. Trials were conducted in randomized complete block design (RCBD) with two replications over three consecutive years at three different locations. ANOVA analysis revealed environment, G×E interaction and genotype effects to contribute significantly (p less than 0.001) towards total sum of squares for root branches (61.00%, 22.18% and 14.00%); root diameter (51.06%, 24.26% and 15.34%) and root length (65.67%, 20.82% and 11.39%). Further, the GEI for these traits was mostly explained by the first, second and third principal component axis (IPCA1, IPCA2 and IPCA3). AMMI1 and AMMI2 biplot analyses showed differential stability of genotypes for root branches, diameter and length with few exceptions. Environmental contribution towards the genotypic performance from AMMI1 and AMMI2 analysis for root traits except environment Bhi16 contribution for root diameter and root length. AMMI1 biplots and simultaneous selection index (SSI) statistics identified SKA-11 as the most desirable genotype for root branches and length while SKA-26 and SKA-27 for root diameter. The ashwagandha genotypes identified for root attributes could be advocated either for varietal recommendation or in varietal development program.

Diallel analysis excluding reciprocals, comprised of ten parents and their hybrids was carried out to identify high heterotic crosses and their relationship in terms of general and specific combining ability (GCA and SCA) in Indian mustard in year 2013-14. Analysis of variance for GCA and SCA signify differences for all the traits. Ratio of GCA and SCA variances was below unity for all the characters except days to flowering, plant height and harvest index, which suggested superior role of non-additive genetic variance in the inheritance of these traits. Out of 45 specific crosses, the highest economic heterosis was observed in case of five crosses viz., SKM 815 x RGN-303 (30.26 %), GDM 4 x RH-0555 (27.72 %), GDM 4 x RGN-303 (26.67 %), GDM 4 x RGN-282 (25.06 %) and GDM 4 x SKM 518 (18.63 %). The parents GM 3, GDM 4, RH-0555 and RSK-29 were good combiners for seed yield and its component characters. Parents RGN-303 and RSK-29 were good general combiners for oil content. Similarly, GM 3 and RGN-282 for oleic acid.

Endoscopic resections and radiofrequency ablation (RFA) are the established treatments for Barrett's-associated dysplasia and early esophageal neoplasia. The UK RFA Registry collects patient outcomes from 24 centers treating patients in the United Kingdom and Ireland. Learning curves for treatment of Barrett's dysplasia and the impact of center caseload on patient outcomes is still unknown.We examined outcomes of 678 patients treated with RFA in the UK Registry using risk-adjusted cumulative sum control chart (RA-CUSUM) analysis to identify change points in complete resolution of intestinal metaplasia (CR-IM) and complete resolution of dysplasia (CR-D) outcomes. We compared outcomes between those treated at high-volume (100 enrolled patients), medium-volume (51-100), and low-volume (50) centers.There was no association between center volume and CR-IM and CR-D rates, but recurrence rates were lower in high-volume versus low-volume centers (log rank P = .001). There was a significant change point for outcomes at 12 cases for CR-D (reduction from 24.5% to 10.4%; P .001) and at 18 cases for CR-IM (30.7% to 18.6%; P .001) from RA-CUSUM curve analysis.Our data suggest that 18 supervised cases of endoscopic ablation may be required before competency in endoscopic treatment of Barrett's dysplasia can be achieved. The difference in outcomes between a high-volume and low-volume center does not support further centralization of services to only high-volume centers.

Introduction Endoscopic resection of adenomas involving the appendiceal base is challenging and often technically impossible with resultant necessity for surgery. Endoscopic full thickness resection (eFTR) using the full thickness resection device (FTRD) is a novel technique for removing lesions in the colo-rectum unresectable by conventional methods. We report use of this technique and outcomes for adenomas involving the appendiceal base. Methods Data was collected and analysed on patients who underwent eFTR of adenomas involving the appendix base in the UK from April 2015 – January 2019. Main outcome measures were technical success, procedural time, specimen size, R0 resection, endoscopic clearance, and adverse events including appendicitis, and need for surgery. Results 10 cases were identified across 4 sites where eFTR was attempted for adenoma at the appendix base. Mean patient age was 68 years (range 57–78). 3/10 had previous attempts at EMR and 2/10 had prior appendicectomy. In 9/10 patients the lesion was reached with the FTRD, with failure of insertion in 1/10 due to sigmoid diverticulosis. The procedure was technically successful in 9/9 patients. Median procedure time was 72 minutes (50–97) and median resection time 6 minutes (4–17). Antibiotics were given in all cases. Median hospital stay was 1 day (1–3). Median specimen size was 26 mm (15–35), and full thickness resection was achieved in 7/9 and R0 resection in 6/9. In those where R0 resection was not achieved, 2/3 had residual lesion at follow up; one residual lesion removed by snare, one had clip still in situ and awaiting use of clip cutter to facilitate residual polyp removal. Overall endoscopic clearance rate to date is 89% (8/9). One patient developed appendicitis at day 6 which required surgery to remove a gangrenous appendix. The patient made an uneventful recovery. Appendicitis rates for this cohort was therefore 14.2% (1/7) when those with prior appendicectomy were excluded. No other complications occurred. Conclusions Removal of adenomas at the appendix base by eFTR is technically feasible and can avoid the need for surgery. Rates of appendicitis in our cohort are significant and similar to published data1, suggesting the need for careful consent and close observation post procedure. Reference Schmidt A, et al. Gut 2018; 67: 1280–1289.

Introduction Gastrocutaneous fistulae (GF) are a rare, but difficult to manage complication after percutaneous endoscopic gastrostomy (PEG) tube removal. In cases, refractory to conventional medical management various approaches have been used for their treatment including; surgical closure, through the scope clipping and endoscopic suturing with variable results. The over-the-scope-clip (OTSC) has an emerging role in the endoscopic closure of gastrointestinal wall defects, including persistent GF. The aim of this study was to assess the efficacy and safety of the use of OTSC for the closure of persistent GF. Methods A prospectively kept database was analysedfrom September 2016 to January 2019 was undertaken of all persistent GF using an OTSC 12/6 GF clip. Prior to the deployment of an OTSC, the fistulous tract was disrupted using a wire brush, which also acted as a guide for placement. The use of ancillary techniques such as snare debulking or knife resection was utilised if needed. Primary outcome measures were; successful deployment of the OTSC, procedure time, complications and 30 day success. Secondary outcome measures were PEG dwell time prior to removal, time from diagnosis to closure and sedation type. Results A total of 22 procedures were performed, on 12 male & 10 female patients with a mean age of 47. Median PEG dwell time was 16 months prior to removal. 64% of the procedures were performed with conscious sedation, with 36% requiring enhanced sedation with anaesthetic support. Technical success was 100%, with 2 procedures requiring ancillary techniques to facilitate the deployment of the OTSC, resulting in 1 complication of intra-procedural bleeding (stopped endoscopically). The median procedure time was 14 mins (range 9–35). A 30 & 90 day success was reported in 96% cases, with only one fistula recurring. Discussion This is the largest cohort of patients with a persistent GF treated with an OTSC. This evolving procedure is an effective and safe method for the treatment of persistent GF. It has a much lower morbidity compared to surgery and shorter procedure times than more invasive endoscopic treatment options, such as endoscopic suturing.

Introduction Buried bumper syndrome (BBS) represents a rare, but potentially serious complication in percutaneous endoscopic gastrostomy (PEG) tubes. In BBS there is a growth of the gastric mucosa over the inner bumper of the PEG tube, affecting 0.–% of PEG tubes. Options for the management of BBS include the insertion of a jejunal extension, surgical or endoscopic removal. Endoscopic removal represents the most attractive option as it is the least invasive procedure to remove the buried bumper (BB). Several endoscopic techniques have been described including endoscopic dissection (ESD) of the overgrown tissue, a “Push-pull T technique”, or the use of a papillotome placed through the PEG tube to cut the overgrown tissue. The novel T-piece pull technique has been developed as a modification of the “Push-pull T technique” without the need for external support. Methods A prospectively kept database was analysed for all BBS patients undergoing the procedure between September 2016 to January 2019. Primary outcome measures were technical success, procedural times and adverse events. Secondary outcome measures were BB morphology based on Paris polyp classification and PEG dwell time. Description of technique (Figure 1) Following endoscopic assessment of the BB, the PEG tube is exposed and cleaned. The PEG tube is cut close to the abdominal wall. Biopsy forceps are passed through the PEG tube into the stomach under direct endoscopic vision. The forceps pull a 10mm snare passed down the biopsy channel of endoscope out of the stomach through the PEG tube. A 2cm piece of the redundant PEG tube is cut and placed through the snare and closed to create a t–piece. The snare is pulled firmly through the PEG into the stomach, removing the buried bumper. Results A total of 27 cases for BBS were undertaken with the T-Piece pull technique, on 18 females and 9 males with a mean age of 43 (range 1–8). The median PEG tubes dwell time was 14 months. Procedures were performed with conscious sedation in 19% and enhanced sedation with anaesthetic support in 81%. BB morphology was Paris 1s in 9, 2a in 16 and 2b in 2. The median procedure time was 18 minutes (range 1–5). The technical success was 93%. 2 failed procedures required surgical removal, both 2b lesions. Complications occurred in 2 cases, 1 episode of sepsis and 1 abdominal pain. Discussion This novel T-piece pull technique for the removal of BB is a simple endoscopic procedure, using equipment that is readily available in most endoscopy departments. The procedure time is much shorter than more complex endoscopic techniques, such as ESD. Lesions which have a 2b Paris classification indicate a deeply buried bumper and should be considered for a different approach to removal.

Introduction Capsule reading is a time-consuming process when in normal play, in which all captured images are analysed by the reader. MiroView™ client 4.0 video (Intromedic, Seoul) features a new express play function, introduced to reduce reading times by filtering out similar non-diagnostic images using an informatics algorithm. Our aim was to determine the positive and diagnostic finding concordance in Express Play compared with normal play. Methods A database of capsule procedures utilising the new software between March 2018 and January 2019 were retrospectively analysed. For each positive finding identified on normal play and captured with an image, the footage was cross-checked using express play to see if the positive finding was also captured. Out of these, the diagnostic findings from both normal and express views were determined. Results 313 CE procedures with Express Play available were performed in the study period and 224 had positive findings. The median age was 54 years with 55.2% females, the main indications were occult GI bleed (n=68), diarrhoea ± other symptoms (n=58) and overt GI bleed (n=32). A total of 368 positive findings were identified with normal play with an 88.3% (n=328) concordance on Express Play. Of the 43 missed findings, 9 were diagnostic: lymphangiectasia (n=3), angiodysplasia (n=2), polypoidal mass (n=1), varices (n=1), ulceration (n=1) and erosion (n=1). The diagnostic finding concordance in Express Play was 127/139= 91.4%. The negative predictive value for a diagnostic finding in Express Play was 88.1%. Conclusions Express Play, which allows a quicker reading of capsule endoscopy, detected a high proportion of pathologies and has good diagnostic concordance with normal play. However, a small number of diagnostic pathologies are still being missed and therefore express mode needs more development before it can be used in routine reporting. Further improvements to the software algorithm are currently being undertaken to bring diagnostic concordance even higher.

Introduction Advancements in capsule endoscopy (CE) have led to the introduction of double ended capsule endoscopes. With a second camera on the rear end, these capsules can collect double the number of images per second compared to single ended capsules, and provide a field of view of 340 degrees, potentially doubling the area of bowel mucosa visualised. This, however, comes at the cost of a greater size. The clinical benefit of this additional camera has not been confirmed. Methods Prospective randomised cohort study of single v double tip CE from March 2018 to January 2019. Capsule reading speed and reporting was done as per individual preferences. In double-tip studies, readers were advised to alternate between cameras based on which gave the best views. Primary outcome measures were the positive yield (PY) and diagnostic yield (DY). Secondary outcome measures were quality of bowel views, gastric transit time (GTT), small bowel transit time (SBTT) and completion rate (CR). Results 326 CE procedures were performed during the study period: 201 single-tip v 125 double-tip. There was no statistical difference between the PY and DY (147/201= 73.1% v 90/125= 72.0%, p=0.82 and 86/201= 42.8% v 59/125= 47.2%, p=0.44 respectively). Despite the size difference, the transit times and completion rates between the 2 capsules were also similar (Median GTT 25 min v 28 min, p=0.22, Median SBTT 259 min v 247 min, p=0.35, CR 177/201= 88.1% v 114/125= 91.2%, p=0.37). Bowel views was reported as poor in significantly fewer double-tip than single-tip capsules (4.7% v 27.3%, p Conclusions Although this study demonstrates that the double-tip capsule provides better views of the bowel mucosa than single-tip, due to the ability to alternate between camera sides, this did not translate into higher diagnostic yields. It may be that a different protocol for reading is required for the double-tip capsule to maximise use of the improved field of view, such as viewing both cameras simultaneously. The size of the capsule was not shown to affect the transit or completion rate.

Introduction Lesions detected at capsule endoscopy currently can only be viewed by a 2D image and size estimated by subjective image perception. The MiroCam MC4000 uses stereo matching technology to enable reconstruction of selected images in 3D format to enable size calculation. The aim of this study was to assess the reliability of this novel capsule to reconstruct 3D images, and its ability to accurately calculate lesion size within a phantom model. Methods The MC4000 capsule was mounted on a modified plastic shaft with the receiver circuitry system attached. In-vitro measurements at various distances were undertaken on a phantom model with static 2D and 3D lesions with sizes between 5–25 mm. In addition, dynamic movements resembling capsule movement through the bowel was performed. The ability to reconstruct images in a 3D format, in addition to the accuracy of the size calculations within ± 10%, was assessed. Results All lesions within the phantom model were successfully reconstructed in 3D format. For static lesions the MC4000 capsules estimated measurements correlated highly with the known sizes (table 1, 2D lesions). The effective distance for accurate size measurement for the MC4000 capsule was 10 mm to 25 mm. In total 2D & 3D objects, 5 mm to 20 mm in size, were measured with an overall accuracy of 88.4% within this effective distance. There was statistically significant correlation between 2D and 3D lesion size and measured size for each distance (correlation coefficient 0.98–1, p Conclusions The MiroCam MC4000 capsule provides reconstructive technology with good size calculations. This novel function may allow more accurate interpretation of lesions identified during capsule endoscopy either for index lesions or when looking for follow up lesion sizes. Further adjustment to the software may be required to bring accuracy to an optimum level to allow further in-vivo studies.

Introduction Cardiac Implantable electronic devices (CIEDs) are seen to be a relative contraindication to capsule endoscopy (CE), due to concern that interaction between the 2 devices may lead to technical failure or interference to each device. Consequently, CE is performed infrequently in this cohort and hence significant pathology may be missed. The MiroCam capsule (Intromedic, Seoul) does not use the standard radiofrequency transmission, but a mechanism known as human body communication (HBC), considered to be safer. Our aim was to assess the safety and efficacy of CE in this cohort. Methods A retrospective analysis of a prospectively collected database of CE procedures between May 2014 and January 2019. All CIEDs were remotely checked on the day or by interrogation of log files post procedure for any technical disruption. All video footage from the CE was analysed to check for image degradation or signs of interference. The positive findings (PY), and those deemed to be diagnostic (DY) on capsule endoscopy were documented. Results 1018 CE procedures were performed during the study period. 45 of these were performed in patients with CIEDs (28 pacemakers, 6 implantable cardiac monitors, 5 defibrillators, 2 Cardiac Resynchronisation Therapy Pacemakers (CRT-P) and 4 CRT Defibrillators (CRT-D). The median age was 68 years with 62% females. The main indications were occult (n=21) and overt GI bleeding (n=15). Log files from all the implantable devices showed no signs of technical disruption. Video footage from CE showed no image degradation apart from one case which coincided with the use of a Microwave oven. The PY was 36/45= 80% v 332/641= 65.9% (p Conclusions CE with the MiroCam capsule has been shown to be safe within this large cohort of patients, with no incidences of any technical disruptions in patients with CIEDs. Considering the higher rate of positive and diagnostic findings in CIED patients, CE with the MiroCam capsule in patients with an CIEDs should not be considered a contraindication. Further studies are required to see if this translates to other capsule manufacturers.

Introduction Benign strictures in the upper GI tract are often treated endoscopically using Savary-Gillard bougie dilatators, which provide tactile feedback. However the drawback to this technique is the lack of direct optic feedback and the need for fluoroscopy during the procedure. A novel device, BougieCap (Ovesco, Germany), allows both tactile and optic feedback of the dilatation procedure without the need for fluoroscopy. The aim of this study was to assess the safety and efficacy of this device in a prospective cohort of patients. Methods Patients with benign strictures of the oesophagus and with clinical symptoms of dysphagia were recruited from 3 endoscopy centres in the UK and Germany for planned dilatation with the BougieCap. The device is a single use transparent conical cap which is fixed to the tip of the endoscope. It comes in different sizes to facilitate dilatation to varying diameters. Once in place, the endoscope is inserted and positioned in front of the stricture. Under direct vision, pushing forward and rotating with the endoscope enables the conical cap to dilate the mucosa in the area of the stricture by the conversion of longitudinal force into radial force vectors. Dilatation could be repeated sequentially with a larger sized cap if necessary. The primary outcome measure was technical success of dilatation. Secondary outcome measure was improvement in symptoms of dysphagia as assessed by the Dysphagia Handicap index (DHI) before and 14 day after the bougienage procedure and adverse events. Results 79 patients (M/F 41/38) with benign oesophageal strictures underwent the procedure between February 2018 to January 2019. Aetiology of strictures were peptic 52% (n=40), radiation 25% (n=19), anastomotic 10% (n=8), caustic 7% (n=5), EoE 4% (n=3), post-ESD 3% (n=2). Mean diameter of strictures was 6 mm (±2.9). Endoscopic bougienage was successful in 97.5%. In 2 cases, with a narrow long stricture, bougienage failed because of high resistance at the site of the stricture causing buckling of the endoscope in the pharynx. Symptoms of dysphagia improved after bougienage (53.6 points. d0 v 26.4 points d14, p Conclusions Endoscopic treatment of benign strictures using the BougieCap enables direct visual and tactile control of the bougienage procedure and therefore of mucosal damage within the area of strictures. This might help to adapt treatment even more precisely to the stricture. Symptoms of dysphagia are improved in short-term follow-up.

Introduction Capsule endoscopy (CE) is a well-established mode of investigation for small bowel (SB) pathology. This study examines the potential benefits of using double-headed capsules compared to conventional single-headed ones in a real-world cohort of patients referred for CE. We present initial results from the first multicentre British study. Methods Over a 9-month period, patients referred for routine SBCE at 4 tertiary referral centres in the UK underwent double-headed CE in lieu of conventional single-headed CE using MiroCam MC2000 capsules. CE was carried out as per routine protocols at each centre. Clinical data were anonymised. One head (L/R) was chosen at random and reported by an expert reviewer. The double-headed recordings, also anonymised and randomised, were reported by another expert reviewer. In centres with only one expert reviewer, double-headed CEs were read after a 4-week interval to minimise recall bias. For each CE, numbers and types of findings and overall conclusion/diagnosis were compared between single and double-headed examinations. Results 211 CE examinations were performed. 7 failed to reach the SB; 204 cases were analysed. Indications were (a) SB bleeding; (b) ?SB inflammation or reassessment of known inflammatory bowel disease (IBD); (c) ?SB neoplasia including suspicious radiological imaging and (d) others e.g. ?coeliac disease. Results are presented in table 1. Conclusions The use of double-headed CE provides more information which has the potential to change clinical diagnosis and therefore management. Therefore, the routine adoption of double-headed CE in SB assessment should be considered.

Objective To identify the methods employed within the UK practice prior to diagnostic gastroscopy and compare with published guidelines for patients undergoing general anaesthesia. Design National Health Service (NHS) endoscopy units were invited to take part in a structured telephone survey to determine the length of time patients are kept nil-by-mouth (NBM) for food and fluids prior to gastroscopy, and whether a preprocedure mucolytic drink was used. Methods 212 NHS Trusts providing endoscopy services were identified from the Joint Advisory Group on GI Endoscopy. Trusts were excluded if they were children9s hospitals (n=5). Results 207 NHS Trusts were telephoned. 193 completed the survey (93%), 11 Trusts declined and there was no response from 3 Trusts. 13 separate policies regarding NBM timings were identified. 51 Trusts (21%) used the timings ratified by Surgical and Anaesthetic Societies (6 h NBM for food, 2 h for clear fluid). 135 Trusts (70%) used a policy which starved patients in excess of the standard surgical guidelines. No Trust used a mucolytic drink prior to gastroscopy. Conclusions The survey revealed large variation in NHS Trust9s policies regarding the times patients were starved prior to gastroscopy. Results of surgical studies demonstrate increased risk of significant pulmonary aspiration with increased fluid-starvation periods, 68% of NHS endoscopy policy would be deemed excessive by surgical practice. There is no routine use of a mucolytic drink to improve mucosal visualisation in the UK practice.

Introduction Endoscopic full thickness resection (eFTR) of the colon using the full thickness resection device (FTRD) is a novel method for removing lesions involving, or tethered to, deeper layers of the colonic wall. The UK FTRD registry collects data from multiple centres performing this procedure. We describe the feasibility and early outcomes of this technique. Methods Registry data from April 2015 – January 2018 was analysed. Main outcome measures were technical success, procedural time, specimen size, R0 resection, endoscopic clearance, and adverse events. Reported technical difficulties were collated. Results 38 cases were performed across 8 centres (median 2 cases per centre, range 1–23). Mean patient age was 70 years (39–93). Indications for eFTR include non-lifting adenoma (18 cases), T1 tumour resection (10), submucosal tumour (7), and appendix base adenoma (3). In 97.4% (37/38) of patients the lesion was reached with the FTRD. One caecal lesion could not be reached due to sigmoid diverticulosis. The procedure was technically successful in 91.9% of patients (34/37). Median procedure time was 41 minutes (11–86), median resection time 6 minutes (2–36), and median specimen size 22mm (10–30). R0 resection was achieved in 76.5% of patients (26/34). R0 resection was not achieved in 8 patients, of which 5 had no residual lesion on follow up, giving a total endoscopic clearance rate of 91.2% (31/34). Technical difficulty occurred in 9 patients; 6 due to snare failure and 3 due to lesion slippage on clip deployment. Of these 9 cases, 7 achieved R0 resection by use of further snare. Of the 2 patients with R1 resection, one has had follow up at 4 months with no evidence of residual lesion. Resection was unsuccessful in 3 patients; 2 due to significant tethering restricting lesion capture, and one due to haemodynamic instability from atrial fibrillation whilst pulling lesion into cap. Complications occurred in 2 patients; one acute appendicitis at day 6 after resection of appendix base adenoma, and one with mild asymptomatic stricture at eFTR site at follow up. There were no cases of bleeding, perforation, or fistula. Conclusions eFTR has a high success rate in treating lesions not previously amenable to endoscopic therapy. Whilst technical difficulties may arise; complication rates are low and outcomes acceptable, making eFTR a viable alternative to surgery.

These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques—including stents—will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop­ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.

Examination of the upper gastrointestinal tract by a standard endoscope is often thought as a daunting experience to many who have undertaken or are about to undergo the procedure. The overall perceived size of the gastroscope, unpleasantness of stimulation of the gag reflex and the need often for sedation is discouraging to many. A method to visualise the upper gastrointestinal mucosa which negates the need for sedation, the associated expensive decontamination costs and the possibility of having a community based examination would be particularly welcoming to this endoscopy field. Since the first swallow of a capsule endoscope by a human volunteer in 1999, their usage for examining the small bowel has exponentially grown to that of over a million patients worldwide. More recently, innovation in this field have shown plausibility for its use to visualise the upper gastrointestinal tract, with the integration of magnets within the capsule the most promising method.

BACKGROUND AND STUDY AIM Mucosal neoplasia arising in Barrett's esophagus can be successfully treated with endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA). The aim of the study was to compare clinical outcomes of patients with high grade dysplasia (HGD) or intramucosal cancer (IMC) at baseline from the United Kingdom RFA registry. PATIENTS AND METHODS Prior to RFA, visible lesions and nodularity were removed entirely by EMR. Thereafter, patients underwent RFA every 3 months until all visible Barrett's mucosa was ablated or cancer developed (end points). Biopsies were taken at 12 months or when end points were reached. RESULTS A total of 515 patients, 384 with HGD and 131 with IMC, completed treatment. Prior to RFA, EMR was performed for visible lesions more frequently in the IMC cohort than in HGD patients (77 % vs. 47 %; P

Evidence for management of asthma comes from closely monitored efficacy trials done in highly selected patient groups. There is a need for randomised trials that are closer to usual clinical practice.We did an open-label, randomised, controlled, two-arm effectiveness trial at 74 general practice clinics in Salford and South Manchester, UK. Patients aged 18 years or older with a general practitioner's diagnosis of symptomatic asthma and on maintenance inhaler therapy were randomly assigned to initiate treatment with a once-daily inhaled combination of either 100 μg or 200 μg fluticasone furoate with 25 μg vilanterol or optimised usual care and followed up for 12 months. The primary endpoint was the percentage of patients who achieved an asthma control test (ACT) score of 20 or greater or an increase in ACT score from baseline of 3 or greater at 24 weeks (termed responders), in patients with a baseline ACT score less than 20 (the primary effectiveness analysis population). All effectiveness analyses were done according to the intention-to-treat principle. This study is registered with ClinicalTrials.gov, number NCT01706198.Between Nov 12, 2012, and Dec 16, 2016, 4725 patients were enrolled and 4233 randomly assigned to initiate treatment with fluticasone furoate and vilanterol (n=2114) or usual care (n=2119). 1207 patients (605 assigned to usual care, 602 to fluticasone furoate and vilanterol) had a baseline ACT score greater than or equal to 20 and were thus excluded from the primary effectiveness analysis population. At week 24, the odds of being a responder were higher for patients who initiated treatment with fluticasone furoate and vilanterol than for those on usual care (977 [71%] of 1373 in the fluticasone furoate and vilanterol group vs 784 [56%] of 1399 in the usual care group; odds ratio [OR] 2·00 [95% CI 1·70-2·34], p0·0001). At week 24, the adjusted mean ACT score increased by 4·4 points from baseline in patients initiated with fluticasone furoate and vilanterol, compared with 2·8 points in the usual care group (difference 1·6 [95% CI 1·3-2·0], p0·0001). This result was consistent for the duration of the study. Pneumonia was uncommon, with no differences between groups; there was no difference in other serious adverse events between the groups.In patients with a general practitioner's diagnosis of symptomatic asthma and on maintenance inhaler therapy, initiation of a once-daily treatment regimen of combined fluticasone furoate and vilanterol improved asthma control without increasing the risk of serious adverse events when compared with optimised usual care.GlaxoSmithKline.

Introduction Attempts to endoscopically resect non-lifting adenomas, subepithelial tumours, and T1 cancers are very challenging and are traditionally in the realm of surgery. Here we report the first multi-centre UK experience of colonic resections of these lesions using a novel endoscopic full thickness resection device (FTRD) Method Data on consecutive patients who underwent endoscopic full thickness resection (eFTR) at 6 UK institutions from April 2015 – February 2017 were prospectively analysed. The procedure was undertaken using the, over-the-scope FTRD. Main outcome measures were technical success, total procedure times, histological confirmation of full thickness, R0 resection, technical failures and adverse events. Results A total of 29 patients underwent eFTR, of which 14 were non-lifting adenomas, 8 T1 polyps and 7 subepithelial tumours. Procedure was technically successful in 89.7% (26/29) cases. The mean age was 68.7 years (39–93 years), median procedure time 38 min (10–80 mins), and median specimen size of 22 mm (13–30 mm). Histology confirmed full thickness resection in 96.2% (25/26) cases, with an R0 resection in 73.1% (19/26) cases. The institution with the greatest number of FTRD cases had a R0 resection of 81.3% (13/16). Technical difficulties occurred in 38.5% (10/26) cases; 5 due to snare failure (R0 still achieved in 4/5 by use of further snare after deployment of device clip), 2 lesions could not be introduced into the FTRD cap, 2 lesions slipped from forceps during clip deployment, and 1 lesion could not be reached with FRTD device, due to sigmoid diverticular segment. There were no cases of immediate or delayed bleeding or perforation. Conclusion eFTR using the FTRD system is a promising technique allowing full thickness resection of difficult polyps that would otherwise require surgery. Our data demonstrates that it is a safe and effective technique requiring a short but significant learning curve before outcomes similar to European case series are achieved. Reference . Arthur Schmidt, et al. Endoscopic full-thickness resection in the colorectum with a novel over-the-scope device: first experience. Endoscopy2015; 47(08): 719–725 Disclosure of Interest None Declared

Introduction We have the largest UK experience (17 cases) with the novel endoscopic full thickness resection device (FTRD), which allows endoscopic resection of non-lifting adenomas, subepithelial tumours, and T1 cancers. Here we report and demonstrate the use of a Hybrid resection technique that combines traditional EMR with endoscopic full thickness resection (eFTR) for large scarred polyps where traditionally surgery would be required. Method In our series of endoscopic full thickness resections (eFTR) from April 2015 – February 2017, 4 scarred polyps were too large for traditional eFTR with a diameter larger than the limit of the FTRD device of around 30 mm. These patients were assessed as high risk for surgery, but had good life expectancy and wanted the polyp to be removed. We developed a strategy of resecting the polyps in 2 stages. Stage 1 involved traditional EMR of the non-scarred/lifting segment of the polyp. Stage 2 involved resecting the remaining scarred part of the polyp with eFTR. Outcomes were success of eradication of polyp and adverse events. Results All 4 cases underwent the hybrid eFTR resection. Median size of referred polyp was 50 mm (30–60 mm), 2 were laterally spreading tumour (LST) non-granular type with Paris classification 0-2a/b and 2 were LST granular type 0-1s+2 a/b. All cases initially underwent traditional EMR with a median procedural time of 90 min (60–130 min). 3 months later eFTR took place successfully in all 4 patients; median procedural time 56.5mins (41-71mins), and median specimen size 22.5 mm (18–25 mm). Histology confirmed full thickness resection in all 4 cases, and R0 resection in 2/4. 3 month follow up is complete in all 4 cases; 2 mm residual adenoma was found in 1 patient and treated by biopsy and argon therapy to scar with site clear of adenoma at 1 year follow up. In all cases, the polyp was eradicated with no adverse events, including no post procedural complications of bleeding or perforation. The video illustrates the technique used in a patient referred with an extensive and heavily scarred polyp (60 mm LST-G, 0-1s+2 a/b). Conclusion Hybrid eFTR of large scarred colonic polyps is a feasible alternate to surgery in selected cases with good outcomes and favourable safety profile. Disclosure of Interest None Declared

The fast-evolving process of urbanization will transform Africa’s future. Urbanization can be harnessed to build an effective urban platform for the continent’s social and economic development, but this requires the right policies to capture the benefits of urban growth. The scope and scale of urban growth requires a fundamentally different approach to the current practice of making sporadic, large-scale infrastructure investments. Cities must be enabled to facilitate and finance ongoing investment programs, in partnership with local businesses and communities. This article puts forward an agenda for achieving the 2050 vision that focuses on unlocking a more systematic approach to urban development and management. This requires the development of new partnerships for urban development and management, between tiers of government, with the private sector and citizens. It requires a greater focus on using local resources to leverage the financing needed to support urban growth. And it requires strengthened capacity for city planning and management to meet projected demand for land and services. National governments will need to play a leading role in repositioning and strengthening local city managers to meet the challenges of urban growth.

Objectives Diagnostic gastroscopy provides a unique opportunity to diagnose early oesophagogastric neoplasia; however, intraluminal mucus and bile can obscure mucosal visualization. The aim of this study was to determine whether the use of a premedication solution containing the mucolytic agent N-acetylcysteine and the surfactant simethicone improves mucosal visualization within a UK diagnostic gastroscopy service. Materials and methods A total of 75 consecutive patients were recruited from a single (S.J.) endoscopist's diagnostic gastroscopy list. They were randomized into three treatment groups: (a) standard control=clear fluids only for 6 h, nil by mouth for 2 h; (b) water control=standard control+100 ml sterile water (given 20 min before gastroscopy); and (c) solution=standard control+100 ml investigated solution (20 min before gastroscopy). The endoscopist was blinded to patient preparation. Inadequate mucosal visualization was defined as fluid/mucus during gastroscopy that could not be suctioned and required flushing with water. The volume of flush, the site at which it was used and the total procedure times were recorded. Results All three groups showed no statistical difference for age, sex ratio, procedure priority or indication. The mean volume of flush required to obtain clear mucosa was significantly less in the solution group compared with the other groups. The mean overall procedure time was also less in the solution group compared with the other groups. Discussion Premedication with N-acetylcysteine and simethicone markedly improves mucosal visibility during gastroscopy. It also reduces the time taken for the procedure. This low-cost and well-tolerated intervention may improve detection of early neoplasia.

Leukotriene (LT) B(4) is a lipid inflammatory mediator implicated in tumorigenesis in animal models of Barrett's oesophagitis, but little is known about the cysteinyl-leukotrienes (LTC(4), LTD(4), LTE(4)), which have distinct inflammatory and tumorigenic actions in other tissues. We recently showed that the terminal enzymes for the synthesis of both LT families are highly expressed in human oesophageal adenocarcinoma (OA) tissues. This study therefore examined the capacity of Barrett's metaplasia (BM) and OA tissues to synthesise LTs in vitro.Oesophageal biopsies from patients with BM (n = 14), high-grade dysplasia (n = 2), OA (n = 11), and squamous control tissues (n = 11) were cultured with calcium ionophore A32187 (2 μM) for 60 min. LTB(4) and cysteinyl-leukotrienes were extracted and measured by specific enzyme immunoassays.Levels of LTB(4) and cysteinyl-leukotrienes were 8.6-fold (P 0.01) and 2.4-fold (P 0.02) higher, respectively, in OA tissues than in squamous control tissues, but levels in BM tissues (n = 14) were not altered. Production of the two LT families correlated across all tissue types (r = 0.62, p 0.00005).Increased synthesis of LTB(4) and cysteinyl-leukotrienes has not previously been shown in human OA tissue and our results may indicate a role of these lipids in Barrett's disease progression.

Boger P C, Shutt J D, Neale J R, Wilson S J, Bateman A C, Holloway J W, Patel P & Sampson A P (2012) Histopathology 61, 509–517 Increased expression of the 5-lipoxygenase pathway and its cellular localization in Barrett’s adenocarcinoma Aims: Up-regulation of the 5-lipoxygenase (5-LOX) leukotriene pathway is evident in numerous tumour types, and has been linked to the promotion of cancer cell growth. The aim of this study was to evaluate the immunohistochemical expression of 5-LOX pathway proteins in oesophageal adenocarcinoma and its premalignant lesion, Barrett’s metaplasia. Methods and results: Tissue samples were collected at endoscopy from 16 patients with Barrett’s metaplasia and from seven with oesophageal adenocarcinoma; five proximal squamous oesophagus samples were used as controls. Immunohistochemical analyses were performed on stromal and epithelial areas with optimized concentrations of primary antibodies for 5-LOX, 5-LOX-activating protein (FLAP), and the distal enzymes leukotriene (LT) A4 hydrolase (LTA4H) and LTC4 synthase (LTC4S). the diagnosis was histologically confirmed from adjacent sections by a gastrointestinal pathologist. Striking increases in the stromal immunoexpression of 5-LOX (P = 0.041), FLAP (P = 0.038), LTA4H (P = 0.0008) and LTC4S (P = 0.036) were seen in adenocarcinoma tissue. Stromal FLAP and LTA4H immunostaining correlated with elevated neutrophil counts (P

The follow-up of inflammatory bowel disease (IBD) patients is challenging due to the relapsing remitting nature of the diseases, the wide spectrum of severity and complexity as well as the need for monitoring of long-term complications and drug treatments. Conventional outpatient follow-up lacks flexibility for patients and there are competing pressures for clinic time. Alternative follow-up pathways include telephone clinics, self-management programmes or discharging patients. The IBD virtual clinic (VC) is a further option. Patients with an established diagnosis for >2 years, who have been stable for >1 year, do not have primary sclerosing cholangitis and who give their consent, are entered into the VC system. Two months before their annual follow-up is due patients are sent blood test forms and a simple questionnaire with an information sheet. If they meet any of the criteria on the questionnaire, they are asked to contact the IBD specialist nursing team to discuss their situation. The blood test results and the patient's database entry are reviewed to ensure that they are not due surveillance investigations. The patients and their GPs then receive a letter informing them of their management plan. We currently follow-up 20% of the Southampton IBD cohort using the VC. The VC system is an innovative, efficient and patient-responsive method for following up mild to moderate IBD. It is well liked by patients but is dependent on a well-maintained database with good integration of IT systems and requires both clerical and IBD nurse specialist support.

We thank you for your observations and comments about the role of surgical treatment for acid reflux in maintaining long-term disease remission after successful endoscopic therapy. We share your observations that although, in most patents, with combined endoscopic resection and radiofrequency ablation (RFA), we are able to clear the mucosal neoplasia and intestinal metaplasia that is Barrett’s esophagus, we do not reverse the persisting reflux insult that drives the biological transformation to Barrett’s esophagus and neoplasia. The ongoing requirement for acid suppression after successful endoscopic treatment may well reduce the quantity of acid exposure to the distal esophagus but this has little impact on the number of reflux events overall [1]. Toxic compounds within the refluxate that can lead to persistent damage to squamous mucosa include duodenogastric contents such as bile, pepsin, and pancreatic proteolytic enzymes [2]. Furthermore, the mechanical clearance of refluxate after endotherapy might also be impaired as has been shown in patients with mucosal esophagitis when compared to those with endoscopy-negative reflux disease [3], a concept yet to be explored in the context of refractory Barrett’s esophagus. Shaheen at al. [4] showed from data derived from the US registry that in patients undergoing endoscopic therapy for Barrett’s neoplasia prior antireflux surgery made no difference to the outcome. The authors examined 5537 patients undergoing RFA, of which 301 (5.4 %) had had a prior fundoplication. Complete eradication of intestinal metaplasia and dysplasia were achieved in 71 % and 87 %, respectively, of patients with a fundoplication, and 73 % and 87 %, respectively, of patients without a fundoplication (P = non-significant for both). Therefore the authors concluded that prior antireflux surgery made no difference to the outcome. However, there was little emphasis on the selection criteria for antireflux surgery or on the manometric and reflux characteristics that led to the surgical decision-making. The role of surgery after successful endoscopic treatment has yet to be examined and may well find a place in carefully selected patients in whom significant reflux is more likely after successful therapy – for example those with a large hiatus hernia and significant exposure to acid (or exposure to weak acid/non-acids such as bile) despite maximum medical therapy.

Methods to assess, access and treat pathology within the gastrointestinal tract continue to evolve with video endoscopy replacing radiology as the gold standard. Whilst endoscope technology develops further with the advent of newer higher resolution chips, an array of adjuncts has been developed to enhance endoscopy in other ways; most notable is the use of magnets. Magnets are utilised in many areas, ranging from endoscopic training, lesion resection, aiding manoeuvrability of capsule endoscopes, to assisting in easy placement of tubes for nutritional feeding. Some of these are still at an experimental stage, whilst others are being increasingly incorporated in our everyday practice.

Background: in the UK, oesophagectomy is the current recommendation for patients with persistent high-grade dysplasia in Barrett’s oesophagus. Radiofrequency ablation is an alternative new technology with promising early trial results. Aim: to undertake a cost–utility analysis comparing these two strategies. Methods: we constructed a Markov model to simulate the natural history of a cohort of patients with high-grade dysplasia in Barrett’s oesophagus undergoing one of two treatment options: (i) oesophagectomy or (ii) radiofrequency ablation followed by endoscopic surveillance with oesophagectomy for high-grade dysplasia recurrence or persistence. Results: in the base case analysis, radiofrequency ablation dominated as it generated 0.4 extra quality of life years at a cost saving of £1902. For oesophagectomy to be the most cost-effective option, it required a radiofrequency ablation treatment failure rate (high-grade dysplasia persistence or progression to cancer) of >44%, or an annual risk of high-grade dysplasia recurrence or progression to cancer in the ablated oesophagus of >15% per annum. There was an 85% probability that radiofrequency ablation remained cost-effective at the NICE willingness to pay threshold range of £20 000–30 000. Conclusion: radiofrequency ablation is likely to be a cost-effective option for high-grade dysplasia in Barrett’s oesophagus in the UK.

The purpose of the Africa Emerging Markets Forum is to discuss the continent’s economic and social challenges and to share ideas for better results on the ground. This article focuses on the performance and potential contribution of agricultural development, first looking at the current constraints and then setting out some suggestions for the way forward. Over the past 50 years, the normal structural decline in the share of agriculture in the economy and accompanying convergence of incomes in the agricultural and non-agricultural sectors, has not yet happened in sub-Saharan Africa. The economy, in terms of sector shares in total output, has been practically frozen, as has the structure of production within agriculture itself, its technology, and its mode of growth primarily via area expansion. As a consequence, African agriculture remains extremely under-capitalized, and the number of poor and hungry has increased in both the rural and urban areas. Encouraging signs for a new beginning for agriculture discussed in this article include the resumption of economic growth, the reduction in agricultural dis-protection, the end of the secular downward trend in agricultural prices, growing domestic and regional demand for food, improvements in the institutional environment for rural development, and a growing commitment of African Governments to agricultural development. While there is much talk about another structural transformation in Africa toward large scale commercial farming, there appear to be diseconomies of scale in farming, while the success rate of large scale farming has been very limited in Africa. The family farm model therefore remains an appropriate model for most of African agricultural development. To seize opportunities underlying the above-mentioned encouraging signs, sub-Saharan Africa will need to support economic growth by (a) continued sound macroeconomic policies, (b) removing of the remain-ing agricultural taxation that still disadvantages African farmers relative to all other farmers in the world, (c) improving services for small farmers, (d) significantly increasing investment in agricultural technology and its dissemination, (e) empowering local governments, communities, and farmer organizations for their own development, and (f) strengthening the already existing regional agricultural institutions. An overall conclusion emanating from this article is for individual countries to adapt and customize the above broad goals into country-specific action plans to enhance the performance and contribution of the agriculture sector, in line with the CAADP (Comprehensive Africa Agriculture Development Programme) compacts on which they are already working.

Myocardial infarction in young adults is, in practice, a diagnosis of exclusion. Given the fact that most of the patients with sickle cell disease are young and have predisposition to painful crisis, they are often overlooked for myocardial infarction. These patients often have few or no traditional risk factors for coronary artery disease, and risk stratification tools such as the Thrombolysis in Myocardial Infarction (TIMI) and Global Registry of Acute Coronary Events (GRACE) models place these patients at low risk. Nonspecific changes on electrocardiogram are of little diagnostic value. Myocardial infarction is very often a missed diagnosis in patients with sickle cell disease. Diagnostic criteria, potential mechanisms, and management for acute myocardial infarction in patients with sickle cell disease are discussed.

Background and study aims: Capsule endoscopy is well tolerated but control of its movement is needed in order to visualize the whole gastric surface. Technological developments have produced an external magnet to allow manipulation of the capsule within the gastric cavity. The aim of this study was to compare magnetically steerable gastric capsule endoscopy (MSGCE) with flexible endoscopy for the detection of beads in a porcine stomach. Materials and methods: Beads were sewn onto the mucosal surface of 12 ex vivo porcine stomachs. Each model was examined by flexible endoscopy and MSGCE by two blinded investigators. MSGCE was performed according to a protocol using positional changes and magnetic steering. Outcome measures were number and location of beads identified, and duration of procedure. Results: Flexible endoscopy identified 79 /90 beads (88 %), and MSGCE identified 80 /90 (89 %). The difference in sensitivities was 1.11 (95 % confidence interval 0.06 – 28.26). Thus, MSGCE was noninferior to flexible endoscopy. Mean examination times for flexible endoscopy and MSGCE were 3.34 minutes and 9.90 minutes, respectively. Conclusion: MSGCE was equivalent to conventional flexible endoscopy in the detection of beads in a porcine stomach model.