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The registry reports 3-year safety and clinical performance of the ultrathin strut (60 μm) biodegradable polymer-coated Tetrilimus, an everolimus-eluting stent (EES) (Sahajanand Medical Technologies Limited, India), in ‘real-world’ patients with coronary artery disease. A total of 815 Tetrilimus EES were implanted in 735 lesions in 594 patients. At 3-year follow-up, primary endpoint (target lesion failure, TLF) was reported in 8.6 % patients, including 2.6 % cardiac deaths, 3.5 % myocardial infarction and 2.6 % target lesion revascularization. At three-year, no cases of definite stent thrombosis were reported. The final three-year results of PERFORM-EVER registry endorse the continuous safety and effectiveness Tetrilimus EES.

Agriculture is key cornerstone for a country's economic stability. This is true especially for an overpopulated agricultural country like India. Three agricultural revolutions in the past changed the traditional farming system into a higher yielding and more efficient one than in the past. The agriculture sector is currently facing many issues including declining soil fertility, inaccurate soil analysis, irrigation, disease infestation etc. Artificial intelligence (AI) can play a crucial role in managing such issues. By incorporating AI technologies in agriculture, the load and impact on ecosystems and resources can be reduced. Also, suitable herbicides, pesticides and fertilisers in appropriate quantities can be used more effectively and efficiently, resulting in enhanced food production in order to keep pace with global population growth. This paper reviews the use of artificial intelligence, particularly machine learning and deep learning techniques, in various agricultural tasks such as seed sowing, irrigation management, soil management, crop management, weed control and crop disease detection. The AIfor crop disease detection is provided special attention. Further, the advantages, challenges and opportunities of the use of AIin agriculture are also brought forth.

ABSTRACTThe textile industry has emerged as a major pollution source owing to a rise in carbon footprint, the spike in greenhouse gas emission, and increasing landfill waste. Sustainable fashion has become a new style statement and industries are shifting their orientation towards environment-friendly manufacturing. The theory of planned behavior (TPB) model was employed with environmental concern, personal moral norms, and perceived consumer effectiveness to better predict the eco-friendly apparel purchase intention of educated Indian youths. Variance-based partial least square-structural equation modeling (PLS-SEM) was applied to evaluate the hypothesized model. Findings indicated that perceived behavioral control has a strong significant positive influence on purchase intention followed by personal moral norms, attitude, and perceived consumer effectiveness. Environmental concern was found to have an indirect effect on purchase intention through three primary TPB variables and personal moral norms. Multi-group analysis (MGA) was performed to examine the moderating effect of perceived consumer effectiveness on an attitude–intention relationship. The highly perceived consumer effectiveness group was shown to have a more consistent attitude-purchase intention relationship as compared to the low-perceived consumer effectiveness group. The study promulgates insights to professionals and policymakers to formulate sustainable marketing strategies and policies to cope with the indigenous market conditions.

This article reviews the pathophysiology, risk factors, clinical presentation/diagnosis, and management of SCC.

AbstractThis study develops a two-period model in which the manufacturer determines a price floor and sets production output before demand becomes certain. The model defines the distance between price floor and high-demand-state price in concern to the degree of price flexibility. While conflicting empirical results underscore the importance of theoretical underpinnings, this study shows that economies of scale determine the relation between market competition and price rigidity. A decline in output leads to higher average costs in the industry characterised by economies of scale, a hike in average costs adds pressure on the inventory liquidation that drives price cutting in the low-demand state. Prices tend to more fluctuate as the product becomes more homogeneous or more players enter into the industry. The knowledge of the relationship between market competition, product homogeneity, and price rigidity is critical in formulating antitrust and monetary policies.

Submucosal tunnel endoscopic resection (STER) is an emerging therapeutic tool that allows direct visualization and resection of submucosal tunneling endoscopic resection (SETs) from the upper GI tract while maintaining the integrity of the mucosa. Our aim was to conduct a systematic review and meta-analysis to evaluate the efficacy and safety of STER in treating all types of SETs found in the upper GI tract.

Gas embolism is a rare but potentially devastating complication of endoscopic procedures. We describe 3 cases of gas embolism which were associated with endoscopic procedures (esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography). We treated these at our hyperbaric medicine center with 3 different outcomes: complete resolution, death, and disability. We review the literature regarding this unusual complication of endoscopy and discuss the need for prompt identification and referral for hyperbaric oxygen therapy. Additional adjunctive therapies are also discussed.

OBJECTIVES:Pancreatic cancer (PC) is a lethal malignancy that lacks specific diagnostic markers. The present study explores the diagnostic potential of the most differentially overexpressed secretory mucin MUC5AC alone and in combination with CA19-9 using multi-center training and validation sets.METHODS:The expression of MUC5AC in benign pancreatic pathologies, PC precursor lesions, primary PC tissues and metastatic lesions was evaluated by immunohistochemistry. Circulating MUC5AC levels were measured using sandwich ELISA assay developed in-house, and CA19-9 was measured using radioimmunoassay. A combined training set (n=346) was used to evaluate the diagnostic (n=241) and predictive (n=105, total samples 201 from pre- and post-surgical and chemotherapy set) significance of MUC5AC. Results were further validated with a pre-defined cut-off value using independent sets from the Mayo Clinic (n=94) and the University of Pittsburgh Medical Center (n=321).RESULTS:Tissue expression analyses indicated the de novo expression of MUC5AC in pancreatic intraepithelial precursor lesions 1A (PanIN1A); the expression was maintained through all stages of progression to invasive adenocarcinoma. The median circulating MUC5AC levels in patients with resectable early-stage PC (EPC) (stage 1/2; 67.2 ng/ml, IQR: 23.9–382.1) and unresectable late-stage PC (LPC) (stage 3/4; 389.7 ng/ml, IQR: 87.7–948.6) were significantly higher compared with (P-value ≤0.0001) benign controls (BC) (7.2 ng/ml, IQR: 0.4–26.5) and (P-value ≤0.0001) chronic pancreatitis (CP) controls (8.4 ng/ml, IQR: 1.5–19.2). In the diagnostic training set (n=241), MUC5AC efficiently differentiated EPC from healthy controls (HC) (83%/80% sensitive (SN)/specific (SP)), BC (67%/87% SN/SP), and CP (83%/77% SN/SP). Independent validation sets from the Mayo Clinic and UPMC confirmed the diagnostic potential of MUC5AC to differentiate EPC from BC (68%/73%; 65%/83%) and CP (68%/79%; 65%/72%). Furthermore, MUC5AC and CA19-9 combination significantly improved (p-value < 0.001) the diagnostic accuracy for differentiating resectable cases from controls.CONCLUSIONS:MUC5AC is a valuable diagnostic biomarker, either alone or in combination with CA19-9, to differentiate PC from CP and benign controls.

Pancreatic diseases pose significant diagnostic challenge as signs and symptoms often overlap. We investigated the potential of pancreatic juice neutrophil gelatinase-associated lipocalin, macrophage inhibitory cytokine 1 (MIC-1), and carbohydrate antigen 19-9 (CA19-9) to aid in the diagnosis of patients with symptoms suggestive of pancreatic diseases.

Abstract: Background: Long ampullary stenoses and fibrotic distal biliary strictures are not infrequently encountered during endoscopic retrograde cholangiopancreatography (ERCP). Instead of balloon dilation and stenting, we propose that these strictures can be managed with sphincterotome stricturoplasty (SS) during the initial ERCP. Objective: To report our clinical experience with SS for benign distal biliary strictures.Design: Review on prospectively collected data.Patients: All (consecutive) patients who underwent ERCP and SS performed by the authors in a 12-month period. Long ampullary stenosis and/or distal biliary stricture is defined as significant narrowing of CBD from the level of duodenal wall into the common bile duct (CBD) after initial sphincterotomy. The upstream CBD is dilated. Despite adequate ES, contrast drainage is poor due to the downstream stricture. SS was performed using the same sphincterotome in slightly bowed position under endoscopic and fluoroscopic guidance. The cutting wire was placed parallel to the superior border within the stricture and incising the stenosis. In cases of relatively long strictures, during initial SS the majority of the cutting wire was inside the biliary opening. This differs from ES, where about one-third to one-half of the length of cutting wire is outside the ampulla. Measurements: Clinical data, hospital course, procedure-related complication rates, and outcomes were prospectively collected in a database.Results: During the study period, 308 ERCPs were performed. Benign and short (≤15 mm in length) distal biliary strictures were observed in 25 patients. Mean ± SD stricture length was 7.4 ± 3.0 mm. The presumed etiologies for these strictures were choledocholithiasis (n = 22) and postsphincterotomy stenosis (n = 3). There was no perforation, post-ERCP pancreatitis, postsphincterotomy bleeding, or cholangitis. To date, none of these patients who had SS have needed follow-up ERCP. Limitations: Single-operator experience, limited follow-up period.Conclusions: Compared with balloon stricturoplasty ± biliary stenting, SS is a simple and cost-effective alternative option in managing long ampullary stenosis and/or distal fibrotic biliary stricture during the initial ERCP.

Overtube-assisted enteroscopy has expanded therapeutic options for the small bowel, but the effectiveness of spiral tip overtube-assisted endoscopy for retrograde small bowel evaluation is not known. This retrospective study reviewed the results of retrograde enteroscopy procedures among six consecutive patients. In these patients, cecal retroflexion was necessary to enter the terminal ileum when using an enteroscope, and 40 to 130 cm of the distal small bowel was intubated. The average procedure time was 52 minutes. The procedure was diagnostic in four patients, and successful endoscopic therapy was performed in three patients, including completion of a polypectomy at the ileocecal valve, resolution of a distal intestinal obstruction in a patient with cystic fibrosis, and a small bowel anastomotic stricture release. There were no procedure-related complications. Overtube-assisted enteroscopy with the spiral tip overtube allows for antegrade or retrograde evaluation of the small bowel. Panenteroscopy may become possible as the technique and equipment improve. The advantages of the different forms of overtube-assisted enteroscopy (spiral, single, and double balloon) need to be determined.

Abstract: Background: Pharyngo-esophageal stenosis (PES) and upper esophageal stricture are common in patients who receive radiation therapy for laryngeal and hypopharyngeal cancers. In severe or complete stenosis, the patients generally have complete dysphagia with inability to swallow their saliva. Diagnostic and therapeutic esophagogastroduodenoscopy (EGD) plays an important role in investigating the dysphagia and in managing the underlying stenosis. Methods and Results: We translate endoscopic retrograde cholangiopancreatography (ERCP) techniques and skills in approaching pancreaticobiliary obstruction in the management of severe and complete PES. We select and report three cases of severe or complete PES in which flexible endoscopic therapy was successfully provided by using fluoroscopy, ERCP wire guides, endoscopic balloons, and by performing pharyngo-esophageal puncture (PEP). Conclusions: We propose the term PEP in managing complete PES. We believe this approach can offer safety and efficiency with very high success rate.

Abstract: Background: Esophageal perforation, whether spontaneous or more commonly as a result of instrumentation, is a life-threatening condition and carries high mortality despite recent advances. Outcome is dependent on etiology, location of injury, and interval between perforation and initiation of therapy. Successful management of esophageal perforation entails combination of: (1) control of the leakage site either surgically or endoscopically to prevent further contamination, (2) drainage of contamination, and (3) appropriate antibiotics along with nutritional support. Methods: We report one case with a 5-cm-long iatrogenic mid-esophageal perforation. The perforation was successfully managed with esophageal tandem stenting above the lower esophageal sphincter (LES). Results: The radial expansile force of the inner stent and its anchorage by LES holds the outer stent in place and prevents the tandem stents migrating distally. Conclusions: Successful management of esophageal perforation depends on early diagnosis, control of site of leak, drainage of accompanying collections, and antibiotic and nutritional support.

The importance of infrastructure for sustained economic development is well recognized. High transaction costs arising from inadequate and inefficient infrastructure can prevent the economy from realising its full growth potential regardless of the progress on other fronts. Physical infrastructure covering transportation, power and communication through its backward and forward linkages facilitates growth, social infrastructure including water supply, sanitation, sewage disposal, education and health, which are in the nature of primary services and has a direct impact on the quality of life. The performance of infrastructure is largely a reflection of the performance of the economy. Infrastructure industries are measured by six key infrastructure and core industries (i.e., electricity, crude oil, petroleum refinery products, coal, steel and cement). In this paper, the overall growth and performance of infrastructure services has been examined in depth on the basis of the different parameters such as trends in growth of physical output in infrastructure sectors, telecommunications, power, ports, railways, civil aviation, and post so as to examine whether there is a negative or positive association between infrastructure development and India's economic growth.

A 55-year-old woman presented with persistent nausea, vomiting, and weight loss previously attributed to Ménétrier’s disease. On further workup, she was found to have metastatic lobular breast carcinoma causing gastric outlet obstruction, diagnosed by endoscopic ultrasound with fine needle aspiration after previous gastric mucosal biopsies were unremarkable. In most reported cases of gastric metastasis from breast cancer, a diagnosis was established by mucosal biopsy. This case is an important reminder that mucosal biopsies can be negative in about 20% of patients with gastric metastasis, which may lead to a delay in diagnosis and treatment. Gastroenterologists should be diligent in taking deeper biopsies if there is a suspicion for gastric metastasis.

A 71-year-old male presented to our institution with cholestatic hepatitis after having recently undergone upper endoscopy for treatment of gastrointestinal bleeding. Further investigation with endoscopic retrograde cholangiopancreatography revealed a hemostatic clip on the ampulla of Vater. After initial attempts at cannulation of the common bile duct were unsuccessful, biliary decompression was achieved by use of needle-knife fistulotomy. A common bile duct stent was placed and the liver function tests improved prior to discharge.

Endoscopic therapy is increasingly used to treat high-grade dysplasia and/or early mucosal adenocarcinoma in patients with Barrett's esophagus. However, no randomized controlled trials have directly compared the efficacy of endoscopic therapy and traditional surgical approaches. This commentary discusses the findings of a retrospective, population-based study by Das et al. that demonstrates the effectiveness of endoscopic resection and/or endoscopic ablation in the treatment of early esophageal cancer. This study used data from the Surveillance Epidemiology and End Results database of the National Cancer Institute to compare cancer-free survival in patients with early esophageal cancer who were either treated with endoscopic therapy (n = 99) or surgical resection (n = 643). Analysis using a Cox proportional hazards model did not reveal a difference in esophageal cancer-specific mortality between the two groups. These results, therefore, support the use of endoscopic therapy in the treatment of early-stage esophageal cancer.

Elastofibroma is a benign tumor of the musculoskeletal system characterized by the abnormal accumulation of elastinophilic fibers. It has been classically described for subscapular region but has been reported in several musculoskeletal sites over the years and rarely even in the GI tract but never in pancreas. We therefore present the case of a 45-year-old female who presented with intermittent abdominal pain. CT of abdomen revealed 1.4 cm pancreatic neck lesion without peripancreatic lymphadenopathy. Endoscopic ultrasound (EUS) guided FNA was nondiagnostic. Surgical resection was performed with central pancreatectomy. Histopathology revealed well demarcated nodules of hypocellular collagen with abundant elastic fibers, characteristic of pancreatic elastofibroma. Treatment is not needed unless symptomatic and surgical resection is the preferred therapeutic option when indicated. This case adds another entity to the differential diagnosis of pancreatic mass lesions.