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Background and study aims Refractory variceal bleeding is associated with high mortality in patients with chronic liver disease. A fully-covered self-expanding metal stent (SEMS) has been reported to have excellent rates of technical success and initial bleeding control; however, studies to date are small and limited to Europe and Asia. Our aim was to evaluate the efficacy and safety of this SEMS for control of refractory variceal bleeding (VB). Patients and methods A retrospective analysis was undertaken of all patients who received the SX-ELLA Danis SEMS for management of VB at 9 tertiary centers across Australia and New Zealand. A total of 32 SEMS had been deployed in 30 patients (median age 53.3). Results Technical success of SEMS placement was achieved in 100 % of cases, resulting in immediate control of bleeding across 31 of 32 cases (96.9 %). Re-bleeding with SEMS in situ occurred in three of 32 cases (9.4 %). Mean SEMS in-dwelling time was 6.4 days. Delayed SEMS migration occurred in 6.3 % of cases. Interventional radiological therapy for management of varices within 6 weeks was performed in 12 of 30 patients (40 %). Death with SEMS in situ occurred in seven of 30 patients (23.3 %). Seven-day bleeding-related mortality was 16.7 %, 14-day mortality 23.3 %, and 6-week mortality 33.3 %. Three of 30 patients (10 %) received orthotopic liver transplantation following SEMS insertion, including two patients within 6 weeks. Conclusions SX-Danis Ella SEMS is highly effective for immediate control of refractory VB and bridging to definitive therapy because it has excellent technical success rates, appears to be relatively easy to use, and has low rates of serious adverse events.

BACKGROUND AND AIM: During COVID-19, restrictions to elective endoscopy were introduced worldwide. A reduction in procedures may impact trainees' endoscopy learning. This study aims to assess Australian advanced gastroenterology and general surgery trainees' self-perceived efficacy and knowledge in endoscopy during the pandemic. METHODS: All Australian gastroenterology and general surgery trainees in their last 2 years of accredited training were invited to participate through email (2020-2021 and 2021-2022 training cycles). The primary outcome was to assess trainees' self-efficacy and knowledge regarding gastrointestinal endoscopy. Secondary outcomes included subgroup analysis between gastroenterology and general surgery trainees. Self-perceived efficacy was assessed with Likert-scale questions on 20 endoscopy procedures and knowledge was assessed through 21 endoscopy-related multiple choice questions. RESULTS: Eighty-one trainees responded to a self-efficacy questionnaire and 77 responded to the knowledge questionnaire. Over 90% of the trainees were confident or extremely confident in diagnostic endoscopy, but only half demonstrated similar efficacy for therapeutic endoscopy. The efficacy for basic endoscopy procedures was higher for gastroenterology trainees (64.0% vs 51.1%, P < 0.001). Last-year trainee achievement of conjoint committee requirements for upper gastrointestinal endoscopy was achieved in 95.8% of gastroenterology trainees versus 22.2% of surgical trainees (P < 0.001). The median score on the knowledge questionnaire was also higher for the gastroenterology subset (90.5% vs 71.4%, P < 0.001). CONCLUSION: During COVID-19, endoscopy trainees' self-efficacy in endoscopic diagnostic procedures was achieved for most trainees. The differences in self-perceived efficacy and knowledge between gastroenterology and surgical trainees may be reflective of the different opportunities for learning between the two groups.

BACKGROUND: Anaesthetic care during upper gastrointestinal (GI) endoscopy has the unique challenge of maintaining ventilation and oxygenation via a shared upper airway. Supplemental oxygen is recommended by international society guidelines, however, the optimal route or rate of oxygen delivery is not known. Various oxygen delivery devices have been investigated to improve oxygenation during upper GI endoscopy, however, these are limited by commercial availability, costs and in some cases, the expertise required for insertion. Anecdotally at our centre, higher flows of supplemental oxygen can safely be delivered via an oxygenating mouthguard routinely used during upper GI endoscopic procedures. AIM: To assess the incidence of hypoxaemia (SpO2 < 90%) in patients undergoing upper GI endoscopy receiving supplemental oxygen using an oxygenating mouthguard at 20 L/min flow compared to standard nasal cannula (SNC) at 2 L/min flow. METHODS: A single centre, prospective, randomised clinical trial at two sites of an Australian tertiary hospital between October 2020 and September 2021 was conducted. Patients undergoing elective upper gastrointestinal endoscopy under deep sedation were randomised to receive supplemental oxygen via high-flow via oxygenating mouthguard (HFMG) at 20 L/min flow or SNC at 2 L/min flow. The primary outcome was the incidence of hypoxaemia of any duration measured by pulse oximetry. Intraprocedural-related, procedural-related, and sedation-related adverse events and patient-reported outcomes were also recorded. RESULTS: Three hundred patients were randomised. Eight patients were excluded after randomisation. 292 patients were included in the intention-to-treat analysis. The incidence of hypoxaemia was significantly reduced in those allocated HFMG. Six patients (4.4%) allocated to HFMG experienced an episode of hypoxaemia, compared to thirty-four (22.1%) patients allocated to SNC (P value < 0.001). No significant difference was observed in the rates of

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for drainage in malignant biliary obstruction. However, ERCP is not always successful, due to difficulties with selective biliary cannulation or gastroduodenal obstruction preventing access to the ampulla of Vater. Although percutaneous transhepatic biliary drainage has traditionally been the preferred approach in these circumstances, endoscopic ultrasound-guided biliary drainage (EUS-BD), using a novel lumen-apposing metal stent (LAMS) with an electrocautery-enhanced delivery system, has shown a technical success rate of 95% in overseas studies. This multicenter study aimed to evaluate the efficacy and safety of EUS-BD using LAMS (Hot AXIOS; Boston Scientific) in an Australian cohort. Method(s): Patients in whom a LAMS was used for biliary drainage across 11 tertiary Australian hospitals from October 2016 to June 2020 were retrospectively identified. Patient and procedural data were collected from the electronic medical records of each hospital. The primary outcome measure was technical success, defined as successful EUS-BD. Secondary outcomes included adverse events and 30-day mortality. Result(s): A total of 41 patients (median age, 72 years [range, 45-94]; 22 [54%] male) had attempted EUS-BD across the 11 hospitals. Etiology of biliary obstruction included pancreatic adenocarcinoma (n = 30), ampullary carcinoma (n = 3), cholangiocarcinoma (n = 1), duodenal cancer (n = 1), and metastatic disease (n = 6). Initial ERCP drainage failed due to inability to access the papilla as a result of malignant duodenal obstruction (n = 8), inability to locate the papilla due to tumor infiltration (n = 11), and failed cannulation (n = 22). The median common bile duct (CBD) diameter was 18 mm (IQR, 16-19.5), with access obtained through the duodenum in all but two procedures (95%), in which the stent was inserted through the gastric antrum. Fluoroscopic guidance was used in two-thi

Background and Aim: Percutaneous cholecystostomy tube (PC) drainage of the gall bladder (GB) has long been the preferred alternative to laparoscopic cholecystectomy in patients who are deemed too high risk or not appropriate for surgical intervention. Although PC has proven effective in resolving acute sepsis, reintervention for tube dysfunction is required in up to 28% of cases. Recently, endoscopic ultrasound (EUS)-guided transluminal drainage using a novel lumen-apposing metal stent (LAMS) with an electrocautery-enhanced delivery system has gained favor as another means of providing GB drainage. A meta-analysis of the overseas literature demonstrated a technical success rate of 95.2% and a procedure mortality rate of 0.02%. This multicenter study aimed to evaluate the efficacy and safety of EUS-guided GB drainage using LAMS (Hot AXIOS; Boston Scientific) in an Australian cohort. Method(s): Patients in whom a LAMS was used for GB drainage across eight tertiary Australian hospitals from October 2016 to June 2020 were retrospectively identified. Patient and procedural data were collected from the electronic medical records of each respective hospital. Primary outcome measures were technical success, defined as successful initial deployment of the LAMS, and clinical success, defined as resolution of symptoms at 72 h after the procedure. Secondary outcomes included adverse events and 30-day mortality. Result(s): A total of 37 patients (median age, 76 years [range, 39-94]; 26 [70%] male) across the eight hospitals had attempted EUS-guided GB drainage. Indications for proceeding to cholecystostomy drainage, as opposed to surgical management, included advanced age and comorbidities (n = 18), incurable malignancy (n = 13), poor functional state (n = 4), and clinically significant portal hypertension (n = 2). Visible GB calculi were seen in 24 patients (65%), with the remaining patients having acalculous cholecystitis, largely due to malignant obstruction. Most patients (9

Background and Aim: Endoscopic retrograde cholangiopancreatography (ERCP) remains the gold standard for drainage in malignant biliary obstruction. However, ERCP is not always successful, due to difficulties with selective biliary cannulation or gastroduodenal obstruction preventing access to the ampulla of Vater. Although percutaneous transhepatic biliary drainage has traditionally been the preferred approach in these circumstances, endoscopic ultrasound-guided biliary drainage (EUS-BD), using a novel lumen-apposing metal stent (LAMS) with an electrocautery-enhanced delivery system, has shown a technical success rate of 95% in overseas studies. This multicenter study aimed to evaluate the efficacy and safety of EUS-BD using LAMS (Hot AXIOS; Boston Scientific) in an Australian cohort. Method(s): Patients in whom a LAMS was used for biliary drainage across 11 tertiary Australian hospitals from October 2016 to June 2020 were retrospectively identified. Patient and procedural data were collected from the electronic medical records of each hospital. The primary outcome measure was technical success, defined as successful EUS-BD. Secondary outcomes included adverse events and 30-day mortality. Result(s): A total of 41 patients (median age, 72 years [range, 45-94]; 22 [54%] male) had attempted EUS-BD across the 11 hospitals. Etiology of biliary obstruction included pancreatic adenocarcinoma (n = 30), ampullary carcinoma (n = 3), cholangiocarcinoma (n = 1), duodenal cancer (n = 1), and metastatic disease (n = 6). Initial ERCP drainage failed due to inability to access the papilla as a result of malignant duodenal obstruction (n = 8), inability to locate the papilla due to tumor infiltration (n = 11), and failed cannulation (n = 22). The median common bile duct (CBD) diameter was 18 mm (IQR, 16-19.5), with access obtained through the duodenum in all but two procedures (95%), in which the stent was inserted through the gastric antrum. Fluoroscopic guidance was used in two-thi

Upper gastrointestinal bleeding from oesophageal or gastric varices is an important medical condition in patients with portal hypertension. Despite the emergence of a number of novel endoscopic and radiologic therapies for oesophagogastric varices, controversy exists regarding the indication, timing and modality of therapy. The aim of this review is to provide a concise and practical evidence-based overview of these issues.

BACKGROUND: The Australian Pancreatic Cancer Screening Program (APCSP) offers endoscopic ultrasound surveillance for individuals at increased risk of pancreatic ductal adenocarcinoma (PDAC) with all participants requiring assessment by a Familial Cancer Service before or after study enrolment. METHODS: Individuals aged 40-80 years (or 10 years younger than the earliest PDAC diagnosis) were eligible for APCSP study entry if they had 1) ≥ two blood relatives with PDAC (at least one of first-degree association); 2) a clinical or genetic diagnosis of Hereditary Pancreatitis or Peutz-Jeghers syndrome irrespective of PDAC family history; or 3) a known PDAC predisposition germline pathogenic variant (BRCA2, PALB2, CDKN2A, or Lynch syndrome) with ≥one PDAC-affected first- or second-degree relative. Retrospective medical record review was conducted for APCSP participants enrolled at the participating Australian hospitals from January 2011 to December 2019. We audited the genetic investigations offered by multiple Familial Cancer Services who assessed APCSP participants according to national guidelines, local clinical protocol and/or the availability of external research-funded testing, and the subsequent findings. Descriptive statistical analysis was performed using Microsoft Excel. RESULTS: Of 189 kindreds (285 participants), 50 kindreds (71 participants) had a known germline pathogenic variant at enrolment (BRCA2 n = 35, PALB2 n = 6, CDKN2A n = 3, STK11 n = 3, PRSS1 n = 2, MLH1 n = 1). Forty-eight of 136 (35%) kindreds with no known germline pathogenic variant were offered mutation analysis; 89% was clinic-funded, with increasing self-funded testing since 2016. The relatively low rates of genetic testing performed reflects initial strict criteria for clinic-funded genetic testing. New germline pathogenic variants were detected in five kindreds (10.4%) after study enrolment (BRCA2 n = 3 kindreds, PALB2 n = 1, CDKN2A n = 1). Of note, only eight kindreds were reassessed by a

In this research, I investigate the reasons for women’s underrepresentation in the political sphere of Cyprus as it is interpreted from the experiences of eight women politicians from a wide political spectrum. The interviewees were asked to assess the lack of women in politics, the gender equality policies from the UN and EU and mostly the gender quotas strategy. The thesis starts by introducing the participants in details indicating their diversity. From the very start the participants made clear the main factors of women’s underrepresentation in politics. The impact of culture and stereotypes, the ineffective ways in which policies are being implemented by the government and the lack of state infrastructures regarding childcare can prevent women from getting involved with politics. To unravel and examine each factor separately, I started the analysis by examining the Cypriot culture from a historic perspective and the social roles of Cypriot women since the 20th century. That lead me to dive more into what prompted the shifting of social roles throughout history. Women altered their roles during conflicts from solely mother/wives to agents of peacebuilders and then strikers. By taking the role of strikers, they functioned in a peaceful manner to state intensively their demands. Demands emerging from the frustration towards the government of Cyprus and its failure to implement ratified policies from the UN and EU aiming for gender equality. The interviewees in this research interpreted gender equality policies created by the UN and EU, making explicit that it’s debatable if and how gender quotas will succeed, since the strategy can stigmatize women and portray them as the vulnerable group in need of assistance. Lastly, the interviewees provided insight into the political life as a woman and a mother, pointing out the various barriers they had to overcome. The thesis indicates a set of various causes for women’s absence in the decision-making process which are hard

Background and Aim Pancreatic cancer (PC) carries a poor prognosis and is often detected at later stages. Screening programs for moderate‐ and high‐risk people are still under debate. We present the results from a prospective study on endoscopic ultrasound (EUS) as a one‐off screening tool for pancreatic cancer screening. Methods Asymptomatic patients with moderate‐ or high‐risk of PC were invited to participate. Moderate risk consisted of one first‐degree and at least one second‐degree relative with PC and no PC‐associated genetic mutations. High risk consisted of >1 first‐degree relatives with PC or PC‐associated mutations (i.e. BRCA2, Lynch Syndrome, Familial Atypical Multiple Mole Melanoma Syndrome, STK11, or PALB2). All included patients had genetic counseling and a screening EUS done. Primary outcome was the detection of PC on EUS. Secondary outcomes assessed the evolution of psychological symptoms based on the Impact of Events Scale (IES) and Personal Consequences Questionnaire (PCQ) before and after the screening took place. Results A total of 122 patients had a screening EUS performed between 2013 and 2019; 60 were male, 55.8 years was the mean age, 78 were at high risk for PC, and 25 had PC‐associated mutations. No pancreatic cancers were identified at the one‐off EUS screening. Overall, patients' IES/PCQ scores did not change after screening and feedback of no malignancy, with the exception of females (less concerned about PC after screening EUS). Conclusions EUS did not detect any PCs in either a moderate‐ or high‐risk population as a one‐off screening method. The EUS procedure and genetic counseling improved psychological symptoms for the female subset of this population.

BACKGROUND AND AIM: During COVID-19 outbreak, restrictions to in-person consultations were introduced with a rise in telehealth. An indirect benefit of telehealth could be better attendance. This study aimed to assess "failure-to-attend" (FTA) rate and satisfaction for two endoscopy-related compulsory telehealth clinics during the COVID-19 outbreak. METHODS: Consecutive patients booked for endoscopy-related telehealth clinics at a tertiary hospital were prospectively assessed. In-person clinic control data were assessed retrospectively. Sample size was calculated to detect an anticipated increase in attendance of 8%. Secondary outcomes included FTA differences between clinics and evaluation of patients and doctors satisfaction. Satisfaction was assessed based on six Likert scale questions used in previous telehealth research and asked to both patients and doctors (6Q_score). This study was exempt from IRB review after institutional IRB review. RESULTS: There were 691 patients booked for appointments in our endoscopy clinics during the study periods (373 in 2020). FTA rates were lowered by half during the compulsory telehealth clinics (12.6% to 6.4%, P < 0.01). The patient 6Q_score was higher for the advanced endoscopy clinic (84.6% vs 73.8%, P < 0.01), while the doctor 6Q_score was similar between both advanced clinics and post endoscopy clinics (91.1% vs 92.5% respectively, P = 0.80). An in-person follow-up consultation was suggested for 3.5% of the appointments, while the necessity of physical examination was flagged in 5.1%. CONCLUSIONS: The use of phone consultations in endoscopy-related clinics during the COVID-19 outbreak has improved FTA rates while demonstrating high satisfaction rates. The need for in-person follow-up consultations and physical examination were low.

In this research, I investigate the reasons for women’s underrepresentation in the political sphere of Cyprus as it is interpreted from the experiences of eight women politicians from a wide political spectrum. The interviewees were asked to assess the lack of women in politics, the gender equality policies from the UN and EU and mostly the gender quotas strategy. The thesis starts by introducing the participants in details indicating their diversity. From the very start the participants made clear the main factors of women’s underrepresentation in politics. The impact of culture and stereotypes, the ineffective ways in which policies are being implemented by the government and the lack of state infrastructures regarding childcare can prevent women from getting involved with politics. To unravel and examine each factor separately, I started the analysis by examining the Cypriot culture from a historic perspective and the social roles of Cypriot women since the 20th century. That lead me to dive more into what prompted the shifting of social roles throughout history. Women altered their roles during conflicts from solely mother/wives to agents of peacebuilders and then strikers. By taking the role of strikers, they functioned in a peaceful manner to state intensively their demands. Demands emerging from the frustration towards the government of Cyprus and its failure to implement ratified policies from the UN and EU aiming for gender equality. The interviewees in this research interpreted gender equality policies created by the UN and EU, making explicit that it’s debatable if and how gender quotas will succeed, since the strategy can stigmatize women and portray them as the vulnerable group in need of assistance. Lastly, the interviewees provided insight into the political life as a woman and a mother, pointing out the various barriers they had to overcome. The thesis indicates a set of various causes for women’s absence in the decision-making process which are hard

Sclerosing mesenteritis is associated with a spectrum of diseases which include mesenteric lipodystrophy and mesenteric panniculitis. This inflammatory and fibrosing disorder can affect the small and large bowel wall and mesenteric vessels by exerting a mass effect. The following case highlights the difficulties with diagnosing and managing this unusual disease. A 64-year-old man presented with acute central abdominal pain, radiating to his back, and profuse vomiting. He was diagnosed clinically with small bowel obstruction. He had had an episode of small bowel obstruction 6 years earlier. At this time, he underwent an exploratory laparotomy, and a mass was identified in the small bowel mesentery. The features were thought to be in keeping with sclerosing mesenteritis. He had a dramatically favourable response to the initiation of prednisolone. He continued to be well and asymptomatic for a further 5 years on long-term maintenance low-dose steroids and 6-mercaptopurine. He re-presented in 2009 (six years after initial presentation) with very severe acute abdominal pain and vomiting. He had no recent change in weight or appetite, and had not had time off work. He underwent a second laparotomy and the tissue diagnosis was of metastatic carcinoid tumour involving the small bowel mesentery. This is the first case to our knowledge where sclerosing mesenteritis has been confirmed histologically on biopsy and then subsequently diagnosed with histologically proven carcinoid tumour. For this particular reason it must be always remembered that sclerosing mesenteritis is a 'pathological' and not a radiological diagnosis and that a large proportion of cases are associated with neoplasia.

A series of laboratory column leach tests for polymer agglomeration at Nifty, in Western Australia, culminated in a 6 m tall, 7.3 tonne column test which achieved over 90% recovery of contained Cu. Further laboratory optimisation tests identified several promising binding agents. A 35 000 t agglomerated ore heap leach production trial was commissioned at Nifty in 1996. Feed consisted of a blend of 35% shale ore and 65% silicified carbonate ore. Around 30 000 t of ore were agglomerated with Nalco's Extract-Ore 9560 polymer binder; the remaining 5 000 t were agglomerated with a Nalco experimental derivative polymer binder. The ore was leached for 303 days to an overall recovery of 73.5% total Cu. Although this did not meet expectations based on smaller column testing, the ultimate recovery was significantly higher than any previous ore treatment schemes at the site. Production heap leach operations were converted to the polymer agglomeration process in February 1997., A series of laboratory column leach tests for polymer agglomeration at Nifty, in Western Australia, culminated in a 6 m tall, 7.3 tonne column test which achieved over 90% recovery of contained Cu. Further laboratory optimisation tests identified several promising binding agents. A 35 000 t agglomerated ore heap leach production trial was commissioned at Nifty in 1996. Feed consisted of a blend of 35% shale ore and 65% silicified carbonate ore. Around 30 000 t of ore were agglomerated with Nalco's Extract-Ore 9560 polymer binder; the remaining 5 000 t were agglomerated with a Nalco experimental derivative polymer binder. The ore was leached for 303 days to an overall recovery of 73.5% total Cu. Although this did not meet expectations based on smaller column testing, the ultimate recovery was significantly higher than any previous ore treatment schemes at the site. Production heap leach operations were converted to the polymer agglomeration process in February 1997.