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Abstract Background To understand the evolutionary steps required for a virus to become virulent in a new host, a human influenza A virus (IAV), A/Hong Kong/1/68(H3N2) (HK-wt), was adapted to increased virulence in the mouse. Among eleven mutations selected in the NS1 gene, two mutations F103L and M106I had been previously detected in the highly virulent human H5N1 isolate, A/HK/156/97, suggesting a role for these mutations in virulence in mice and humans. Results To determine the selective advantage of these mutations, reverse genetics was used to rescue viruses containing each of the NS1 mouse adapted mutations into viruses possessing the HK-wt NS1 gene on the A/PR/8/34 genetic backbone. Both F103L and M106I NS1 mutations significantly enhanced growth in vitro (mouse and canine cells) and in vivo (BALB/c mouse lungs) as well as enhanced virulence in the mouse. Only the M106I NS1 mutation enhanced growth in human cells. Furthermore, these NS1 mutations enhanced early viral protein synthesis in MDCK cells and showed an increased ability to replicate in mouse interferon β (IFN-β) pre-treated mouse cells relative to rPR8-HK-NS-wt NS1. The double mutant, rPR8-HK-NS-F103L + M106I, demonstrated growth attenuation late in infection due to increased IFN-β induction in mouse cells. We then generated a rPR8 virus possessing the A/HK/156/97 NS gene that possesses 103L + 106I, and then rescued the L103F + I106M mutant. The 103L + 106I mutations increased virulence by >10 fold in BALB/c mice. We also inserted the avian A/Ck/Beijing/1/95 NS1 gene (the source lineage of the A/HK/156/97 NS1 gene) that possesses 103L + 106I, onto the A/WSN/33 backbone and then generated the L103F + I106M mutant. None of the H5N1 and H9N2 NS containing viruses resulted in increased IFN-β induction. The rWSN-A/Ck/Beijing/1/95-NS1 gene possessing 103L and 106I demonstrated 100 fold enhanced growth and >10 fold enhanced virulence that was associated with increased tropism for lung alveolar and bronchiolar tissues relative to the corresponding L103F and I106M mutant. Conclusions The F103L and M106I NS1 mutations were adaptive genetic determinants of growth and virulence in both human and avian NS1 genes in the mouse model.

Background and study aims Use of fluoroscopy in gastrointestinal endoscopy is an essential aid in advanced endoscopic interventions. However, it also raises concerns about radiation exposure. This study aimed to develop consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, prioritizing the safety and well-being of healthcare workers and patients. Methods A modified Delphi approach was employed to achieve consensus over three rounds of surveys. Proposed statements were generated in Round 1. In the second round, panelists rated potential statements on a 5-point scale, with consensus defined as ≥80% agreement. Statements were subsequently prioritized in Round 3, using a 1 (lowest priority) to 10 (highest priority) scale. Results Forty-six experts participated, consisting of 34 therapeutic endoscopists and 12 endoscopy nurses from six continents, with an overall 45.6% female representation (n = 21). Forty-three item statements were generated in the first round. Of these, 31 statements achieved consensus after the second round. These statements were categorized into General Considerations (n = 6), Education (n = 10), Pregnancy (n = 4), Family Planning (n = 2), Patient Safety (n = 4), and Staff Safety (n = 5). In the third round, accepted statements received mean priority scores ranging from 7.28 to 9.36, with 87.2% of statements rated as very high priority (mean score ≥ 9). Conclusions This study presents consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, addressing the well-being of healthcare workers and patients. These consensus-based statements aim to mitigate risks associated with radiation exposure while maintaining benefits of fluoroscopy, ultimately promoting a culture of safety in healthcare settings., Competing Interests: Conflict of Interest Tyler Berzin - Consultant for: Medtronic, Boston Scientific, Wision AI, Microtech. Alan N. Barkun - Consultant for Olympus Inc and Medtronic Inc. Cecilia Binda – Lecturer for Steris, Fujifilm, Boston Scientific, Q3 Medical. Alessandro Fugazza – Consultant for Boston Scientific. Rogier P. Voermans - Consultancy and research grant for Boston Scientific, Research grant Prion Medical; Consultancy fee form from Cook Medical. Lecturer Viatris and Zambon. Nauzer Forbes – Speaker for Boston Scientific, Pentax Medical. Consultant for Boston Scientific, Pentax Medical and AstraZeneca. Mariano Villarroel – Consultant for Boston Scientific. Yen-I Chen – Consultant for Boston Scientific. President of Chess Medical. Robert Bechara – Consultant for Olympus, Pentax, Vantage, Medtronic, Pendopharm. Payal Saxena – Consultant for Boston Scientific, Ambu, Erbe. Amrita Sethi – Consultant for Boston Scientific, Interscope, Medtronic, Olympus; Research Support for Boston Scientific, Fujifilm and ERBE. Cesare Hassan: Fujifilm Co. (consultancy); Medtronic Co. (consultancy). Alessandro Repici: Fujifilm Co. (consultancy); Olympus Corp (consultancy); Medtronic Co. (consultancy). Bret Peterson – Consultant for Olympus, Pentax. Investigator for Boston Scientific and Ambu. Silvia Carrara – Consultant for Olympus and Aboca. Jeffrey D. Mosko – Speaker for Boston Scientific, Pendopharm, SCOPE rounds, Vantage, Medtronic. Medical Advisory Board for Pendopharm, Boston Scientific, Janssen, Pentax, Fuji. Grants and Research support from CAG. Christopher W. Teshima – Speaker for Medtronic and Boston Scientific, Consultant for Boston Scientific. Gary R. May – Consultant for Olympus. Speaker for Pentax, Fuji and Medtronic. Samir C Grover –Research grants and personal fees from AbbVie and Ferring Pharmaceuticals, personal fees from Takeda, Sanofi, and BioJAMP, education grants from Janssen, and has equity in Volo Healthcare. All the authors have no relevant financial disclosures or conflicts of interest to declare., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Bleeding complications associated with oral anticoagulant (OAC) frequently lead to emergency department visits and hospitalization. Short-term all-cause mortality after severe bleeding is substantial ranging from about 10% for gastrointestinal bleeding (the most frequent single site) to about 50% for intracranial bleeding. A protocolized, multidisciplinary approach to bleeding ensures is needed to (i) rapidly identify of patients at risk of adverse outcomes, (ii) optimize delivery of supportive measures, (iii) treat the source of bleeding, and (iv) administer anticoagulant reversal or hemostatic therapies judiciously for patients most likely to benefit. We convened a multidisciplinary panel of experts (emergency medicine, gastroenterology, general internal medicine, hematology, neurology, pharmacy, thrombosis,) to review the literature and provide practical guidance including a corresponding algorithm for use at the point of care to assist clinicians in the management of patients with acute severe OAC-related bleeding., Competing Interests: All authors received an honorarium from Thrombosis Canada for participation in the development of this manuscript. In the last 36 months, Dr. Crowther has received Personal Funding, including but not limited to preparation of educational material, participation in Advisory Boards, or providing expert testimony for Bayer, Astra Zeneca, Pfizer, Hemostasis Reference Laboratories, Syneos Health, and Eversana. He has participated in various medicolegal activities relating to thrombosis, anticoagulant drugs, or other aspects of internal medicine and hematological practice. He has also worked with multiple for-profit and not-for-profit entities such as Up To Date and medical communication companies. He holds the Leo Pharma Chair in Thromboembolism, endowed at McMaster University. Dr. Siegal has received honoraria paid indirectly to her institution from Astra Zeneca, BMS-Pfizer, Roche and Servier. She is supported by a Tier 2 Canada Research Chair in Anticoagulant Management of Cardiovascular Disease and is the secretary of Thrombosis Canada. Dr Mithoowani receives authorship royalties from UpToDate. Dr Castellucci has received honoraria for speaking engagement from Bayer, Insara and Medscape, is the vice president of Thrombosis Canada and the chair of World Thrombosis Day. Dr Dowlatshahi has received a consulting fee from AstraZeneca and has a patent pending for CARL (Contrast leakage detection on CT). Dr de Wit is the Research Committee chair for Canadian Association of Emergency Physicians Research Committee, the vice-chair for Thrombosis Canada’s Patient and Family Committee, and a committee chair of the Predictive and Diagnostic Variables in Thrombotic Disease Scientific Standardization committee for the International Society of Thrombosis and Haemostasis. Dr Lin has nothing to disclose. Dr Forbes has received consulting fees and honoraria for speaker engagements for Boston Science and Pentax Medical, is a member Standards of Practice Committee for the American Society for Gastrointestinal Endoscopy and the Clinical Guidelines Committee for the Canadian Association of Gastroenterologists. Dr Bungard has received an honorarium for attending an advisory board meeting for Pfizer, and is chair of Thrombosis Canada’s Patient and Family Committee for Thrombosis Canada., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for strategies to manage endoscopically placed gastrostomy tubes. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses the utility of percutaneous endoscopic gastrostomy (PEG) versus interventional radiology-guided gastrostomy (IR-G), need for withholding antiplatelet and anticoagulant medications before PEG tube placement, appropriate timing to initiate tube feeding after PEG, and selection of the appropriate technique of gastrostomy in patients with malignant dysphagia. In patients needing enteral access, the ASGE suggests PEG as the preferred technique for initial gastrotomy over IR-G. The ASGE recommends that tube feeding can be safely started within 4 hours of gastrostomy. The ASGE suggests that PEG can be performed without withholding antiplatelet medications. The ASGE suggests that the periprocedural management of anticoagulants should be based on a multidisciplinary discussion regarding the risk of bleeding versus cardiovascular events. In patients with malignant dysphagia, either transoral "pull" PEG or direct PEG can be performed for initial enteral access., Competing Interests: Disclosure The following authors disclosed financial relationships: D. R. Kohli: Consultant for and research support from Olympus Corporation of the Americas. W. M. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and Conmed Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, Conmed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. S. G. Sheth: Consultant for Janssen Research & Development, LLC. S. A. McClave: Consultant for Nestle; speaker for Nestle and Abbott; advisory board for Avanos. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Endoscopic retrograde cholangiopancreatography (ERCP)-related adverse events (AEs) are associated with morbidity, mortality, and healthcare expenditure. We aimed to assess incidences and comparisons of ERCP AEs., Methods: We included studies performed after 2000 reporting on ERCP AEs from database inception through March 12, 2024. Outcomes included pancreatitis, bleeding, cholangitis, cholecystitis, perforation, and death. DerSimonian and Laird random effects meta-analyses were performed to calculate incidences of AEs. Subgroup and pairwise meta-analyses were performed. Meta-regression was performed on median recruitment year to assess temporal trends in pancreatitis incidence., Results: A total of 380 studies were included. The incidence of death attributable to ERCP was 0.2% (95% confidence intervals, CI, 0.1-0.3%, I 2 44%, n=47,258) in all-comers. The overall incidence of pancreatitis was 4.6% (95% CI 4.0-5.1%, I 2 96%, n=293,378) among all-comers and 6.5% (95% CI 5.9-7.1%, I 2 89%, n=88,809) among first-time patients. Pancreatitis incidence remained stable between 2000-2023 (average annual percent change 0.06, 95%CI -0.27 to 0.39). The overall incidences of the following AEs for all-comers were: bleeding (1.5%, 95% CI 1.2-1.7%, I 2 93%, n=229,655), cholangitis (2.5%, 95%CI 1.9-3.3%, I 2 96%, n=121,619), cholecystitis (0.8%, 95%CI 0.5-1.2%, I 2 39%, n=7,799), and perforation (0.5%, 95%CI 0.4-0.6%, I 2 90%, n=306,378)., Conclusions: ERCP-associated AEs remain common. Incidence of post-ERCP pancreatitis remained static despite improvements in techniques, prevention, and recognition. These results are important to patients, endoscopists, and policy makers to inform consent and to encourage implementation of available risk mitigation strategies., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background: Stent misdeployment (SMD) is a feared technical challenge of EUS-guided choledochoduodenostomy using a lumen apposing stent (EUS-CDS) that has been poorly characterized. We aim to ascertain the rate of SMD in EUS-CDS for malignant distal biliary obstruction (MDBO) and describe its outcomes while identifying variables associated with its occurrence. In addition, we aim to propose a de novo SMD classification., Method: A post hoc analysis of two RCTs comparing EUS-CDS vs. endoscopic retrograde cholangiopancreatography in MDBO. The main endpoint was the rate of SMD classified as misdeployment of the distal flange (type I), proximal flange (type II), contralateral bile duct wall injury (type III), or double mucosal puncture (type IV). A multivariable analysis was performed to identify variables associated with the odds of SMD and/or technical failure and clinical failure or stent dysfunction., Results: 152 patients were included with a technical success of 93.4%. SMDs occurred in 11 (7.2%) patients (95% CI, 3.1%-11.4%): 8 type I, 1 type II, and 2 type III. Endoscopic salvage was successful in 81.8%. SMDs led to an adverse event (AE) in 4 cases (2 mild and 2 moderate) with an overall AE rate of 2.6% (95% CI, 0.7%-6.6%). On multivariable analysis, an extrahepatic bile duct diameter of ≤ 15 mm was associated with increase odds of SMD and/or technical failure., Conclusion: SMD is relatively common in EUS-CDS and is associated with an extra-hepatic bile duct diameter measuring ≤ 15 mm. The majority of SMDs can be rescued endoscopically with low risk for AE., Competing Interests: Yen-I Chen is a consultant for Boston Scientific, has received research funding from Boston Scientific and is the co-founder of Chess Medical Inc. Anand Sahai is a consultant Boston Scientific and Pentax. Bertrand Napoleon has received honorarium for proctoring endoscopy training from Maunea Kea, Boston Scientific, Olympus, and Taewoong Medical. Rastislav Kunda is a consultant for Boston Scientific, Olympus, M.I.Tech, Omega Medical Imaging, Q3 Medical-AMG International and EndoGastricSolutions. Nauzer Forbes is a consultant and speaker for Boston Scientific and Pentax Medical, a speaker for AstraZeneca, and has received research funding from Pentax Medical. Anthony Yuen Bun Teoh is a consultant for Boston Scientific, Cook, Taewoong, Microtech, and MI Tech Medical Corporations. All other authors have no relevant conflict of interest., (Thieme. All rights reserved.)

Background:  Post-endoscopic retrograde cholangiopancreatography (ERCP) adverse events (AEs) are common, as is unplanned healthcare utilization (UHU). We aimed to assess potential etiologic associations between intra-/post-procedural patient-reported experience measures (PREMs) and post-ERCP AEs and UHU. METHODS : Prospective data from a multicenter collaborative were used. A 0-10 Likert-based PREM assessing intra- and post-procedural symptoms was applied to patients following ERCP, and follow-up was performed at 30 days to identify AEs and UHU for reasons not meeting the definitions of any AE. Multivariable logistic regression was conducted using PREM domains as exposures and AEs and UHU as outcomes, with a priori selected covariates. Odds ratios (ORs) and 95 %CIs for each PREM domain were reported., Results:  From 2018 to 2023, 3434 patients were included. A post-procedural abdominal pain score > 3 was associated with pancreatitis (OR 3.71 [95 %CI 2.37-5.73]), while a score > 6 was associated with perforation (OR 9.54 [95 %CI 1.10-59.37]). Post-procedural pain was also associated with UHU within 30 days when used as a continuous exposure (OR 1.08 per point [95 %CI 1.01-1.16]), and when partitioned at a score > 3 (OR 1.79 [95 %CI 1.13-2.74]) and a score > 6 (OR 1.93 [95 %CI 1.02-3.46]). No other intra- or post-procedural PREMs were associated with any AEs or UHU., Conclusions:  Patient-reported abdominal pain from a Likert-based PREM at the time of discharge from ERCP was associated with pancreatitis, perforation, and UHU within 30 days. Applying PREMs could potentially prevent UHU and/or facilitate earlier management and improved outcomes for patients with post-ERCP AEs., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Introduction: Clinically significant post-endoscopic retrograde cholangiopancreatography (ERCP) bleeding (CSPEB) is common. Contemporary estimates of risk are lacking. We aimed to identify risk factors of and outcomes after CSPEB., Methods: We analyzed multicenter prospective ERCP data between 2018 and 2024 with 30-day follow-up. The primary outcome was CSPEB, defined as hematemesis, melena, or hematochezia resulting in (i) hemoglobin drop ≥ 20 g/L or transfusion and/or (ii) endoscopy to evaluate suspected bleeding and/or (iii) unplanned healthcare visitation and/or prolongation of existing admission. Firth logistic regression was used. P values <0.05 were significant, with odds ratios (ORs) and 95% confidence intervals reported., Results: CSPEB occurred after 129 (1.5%) of 8,517 ERCPs (mean onset 3.2 days), with 110 of 4,849 events (2.3%) occurring after higher risk interventions (sphincterotomy, sphincteroplasty, precut sphincterotomy, and/or needle-knife access). Patients with CSPEB required endoscopy and transfusion in 86.0% and 53.5% of cases, respectively, with 3 cases (2.3%) being fatal. P2Y 12 inhibitors were held for a median of 4 days (interquartile range 4) before higher risk ERCP. After higher risk interventions, P2Y 12 inhibitors (OR 3.33, 1.26-7.74), warfarin (OR 8.54, 3.32-19.81), dabigatran (OR 13.40, 2.06-59.96), rivaroxaban (OR 7.42, 3.43-15.24), and apixaban (OR 4.16, 1.99-8.20) were associated with CSPEB. Significant intraprocedural bleeding after sphincterotomy (OR 2.32, 1.06-4.60), but not after sphincteroplasty, was also associated. Concomitant cardiorespiratory events occurred more frequently within 30 days after CSPEB (OR 12.71, 4.75-32.54)., Discussion: Risks of antiplatelet-related CSPEB may be underestimated by endoscopists based on observations of suboptimal holding before higher risk ERCP. Appropriate periprocedural antithrombotic management is essential and could represent novel quality initiative targets., (Copyright © 2024 by The American College of Gastroenterology.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the diagnosis and management of pancreatic masses. This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses needle selection (fine-needle biopsy [FNB] needle vs FNA needle), needle caliber (22-gauge vs 25-gauge needles), FNB needle type (novel or contemporary [fork-tip and Franseen] vs alternative FNB needle designs), and sample processing (rapid on-site evaluation [ROSE] vs no ROSE). In addition, this guideline addresses stent selection (self-expandable metal stents [SEMS] vs plastic stents), SEMS type (covered [cSEMS] vs uncovered [uSEMS]), and pain management (celiac plexus neurolysis [CPN] vs medical analgesic therapy). In patients with solid pancreatic masses undergoing EUS-guided tissue acquisition (EUS-TA), the ASGE recommends FNB needles over FNA needles. With regard to needle caliber, the ASGE suggests 22-gauge over 25-gauge needles. When an FNB needle is used, the ASGE recommends using either a fork-tip or a Franseen needle over alternative FNB needle designs. After a sample has been obtained, the ASGE suggests against the routine use of ROSE in patients undergoing an initial EUS-TA of a solid pancreatic mass. In patients with distal malignant biliary obstruction undergoing drainage with ERCP, the ASGE suggests using SEMS over plastic stents. In patients with proven malignancy undergoing SEMS placement, the ASGE suggests using cSEMS over uSEMS. If malignancy has not been histopathologically confirmed, the ASGE recommends against the use of uSEMS. Finally, in patients with unresectable pancreatic cancer and abdominal pain, the ASGE suggests the use of CPN as an adjunct for the treatment of abdominal pain. This document outlines the process, analyses, and decision approaches used to reach the final recommendations and represents the official ASGE recommendations on the above topics., Competing Interests: Disclosure The following authors disclosed financial relationships: J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. G. I. Papachristou: Research support from AbbVie Inc. V. Sahai: Consultant and advisor for AstraZeneca, Autem, Cornerstone, Delcath Systems, GlaxoSmithKline, Helsinn, Histosonics, Ipsen, Incyte, Kinnate, Lynx Group, Servier, and Taiho; research support from Actuate, Agios, Bristol-Myers Squibb, Celgene, Clovis, Cornerstone, Exelixis, Fibrogen, Incyte, Ipsen, Medimmune, NCI, Relay, Repare, Syros, and Beigene; travel compensation from ASCO, Cholangiocarcinoma Foundation, and Lynx Group. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and Fujifilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc and AbbVie Inc. D. R. Kohli: Research grant from Olympus Corporation of the Americas. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. S. Pawa: Consultant for Boston Scientific Corporation. N. R. Thiruvengadam: Received support from Boston Scientific Corporation. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Disclosure The following authors disclosed financial relationships: J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies and Boston Scientific Corporation. S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. G. I. Papachristou: Research support from AbbVie Inc. V. Sahai: Consultant and advisor for AstraZeneca, Autem, Cornerstone, Delcath Systems, GlaxoSmithKline, Helsinn, Histosonics, Ipsen, Incyte, Kinnate, Lynx Group, Servier, and Taiho; research support from Actuate, Agios, Bristol-Myers Squibb, Celgene, Clovis, Cornerstone, Exelixis, Fibrogen, Incyte, Ipsen, Medimmune, NCI, Relay, Repare, Syros, and Beigene; travel compensation from ASCO, Cholangiocarcinoma Foundation, and Lynx Group. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals; research support from GI Dynamics. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Cook Medical LLC, and Olympus Corporation of the Americas; advisory board for Merit Medical. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and Fujifilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc. and AbbVie Inc. D. R. Kohli: Research support from Olympus Corporation of the Americas. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. S. Pawa: Consultant for Boston Scientific Corporation. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. N. C. Thosani: Consultant for Pentax of America, Inc, Ambu Inc, and Boston Scientific Corporation; travel compensation and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships.

Background:  Computer-aided detection (CADe) has been developed to improve detection during colonoscopy. After initial reports of high efficacy, there has been an increasing recognition of variability in the effectiveness of CADe systems. The aim of this study was to evaluate a CADe system in a varied colonoscopy population., Methods:  A multicenter, randomized trial was conducted at seven hospitals (both university and non-university) in Europe and Canada. Participants referred for diagnostic, non-immunochemical fecal occult blood test (iFOBT) screening, or surveillance colonoscopy were randomized (1:1) to undergo CADe-assisted or conventional colonoscopy by experienced endoscopists. Participants with insufficient bowel preparation were excluded from the analysis. The primary outcome was adenoma detection rate (ADR). Secondary outcomes included adenomas per colonoscopy (APC) and sessile serrated lesions (SSLs) per colonoscopy., Results:  581 participants were enrolled, of whom 497 were included in the final analysis: 250 in the CADe arm and 247 in the conventional colonoscopy arm. The indication was surveillance in 202/497 colonoscopies (40.6 %), diagnostic in 199/497 (40.0 %), and non-iFOBT screening in 96/497 (19.3 %). Overall, ADR (38.4 % vs. 37.7 %; P  = 0.43) and APC (0.66 vs. 0.66; P  = 0.97) were similar between CADe and conventional colonoscopy. SSLs per colonoscopy was increased (0.30 vs. 0.19; P  = 0.049) in the CADe arm vs. the conventional colonoscopy arm., Conclusions:  In this study conducted by experienced endoscopists, CADe did not result in a statistically significant increase in ADR. However, the ADR of our control group substantially surpassed our sample size assumptions, increasing the risk of an underpowered trial., Competing Interests: T. Rath has received speaker fees from Olympus Medical, PENTAX Medical, Mauna Kea Technologies, Medtronic, Takeda, Galapagos, Falk, Janssen, AbbVie, Repha, Medical Tribune, and Lilly. C. Spada has received consultancy fees from Medtronic and AnX Robotics, and speaker fees from Olympus, PENTAX Medical, and Norgine. N. Forbes is a consultant for Boston Scientific Corp. and PENTAX Medical, and has received speaker fees and research funding from PENTAX Medical. G. Vanbiervliet has received consultancy fees from Boston Scientific Corp. and Ambu A/S, and lecture and conference fees from Fujifilm Medical, Norgine, Tillots, and PENTAX Medical. P.J. Belletrutti has received speaker fees from Pendopharm and consultancy fees from Vantage Endoscopy. P. Siersema has received research support from The E-Nose company, Lucid Diagnostics, Micro Tech, Magentiq Eye Ltd., Norgine, and Endo Tools Therapeutics, and consultancy fees from Magentiq Eye Ltd. M. Maas, E. Soons, S. Kashin, P. Cesaro, A. Eickhoff and D. Salvi declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Competing Interests: Disclosure All authors disclosed no financial relationships.

Background: The COVID-19 pandemic resulted in a rapid accumulation of novel vaccine research evidence. As a means to monitor this evidence, the Public Health Agency of Canada (PHAC) created the E vidence e X traction T eam for R esearch A nalysis ( EXTRA ), which contributed to situational awareness in Canada through a bibliographic repository used to support decision-making by the National Advisory Committee on Immunization. We describe the process by which this literature was identified and catalogued, and provide an overview of characteristics in the identified literature., Methods: To expedite the process, PHAC leveraged an artificial intelligence (AI) tool to assist in the screening and selection of relevant articles. Literature search results were initially screened by AI, then manually reviewed for relevance. Relevant articles were tagged using controlled vocabulary and stored in a bibliographic repository. This repository was analyzed to identify trends in vaccine research over time according to several key characteristics., Results: As of December 31, 2023, EXTRA's repository contained 19,050 articles relevant to PHAC's immunization mandate. The majority of these articles (63.9 %) were identified between August 2021 and January 2023, with an average of 20 relevant articles added daily during this period. Nearly 14,000 articles reported on mRNA vaccines. Safety outcomes were most frequently reported (n = 8,289), followed by immunogenicity (n = 7,269) and efficacy/effectiveness (n = 3,246). COVID-19 vaccine literature output started to decrease in mid-2023, two years after the initial dramatic increase in mid-2021., Conclusions: This hybrid (AI and human) approach was critical for PHAC situational awareness and the development of timely vaccine guidance in Canada during the COVID-19 pandemic. Given the volume of data and analyses required, the AI-augmented processes made this massive undertaking manageable. Analysis of COVID-19 vaccine research patterns supports projections of research volume, type, and rate that will help predict resourcing and information needs to plan future emergency vaccine guidance activities., Competing Interests: The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Matthew Tunis reports financial support was provided by Public Health Agency of Canada. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Crown Copyright © 2024 Published by Elsevier Ltd.)

Competing Interests: Disclosure The following authors disclosed financial relationships: N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. S. Pawa: Consultant for Boston Scientific Corporation. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation, Olympus, and Neptune Medical. T. H. Baron: Consultant for Boston Scientific Corporation, Olympus Corporation, Medtronic, Inc, WL Gore & Associates, Inc, Cook Endoscopy, and CONMED Corporation; speaker for Boston Scientific Corporation, Olympus Corporation, Medtronic, Inc, and WL Gore & Associates; travel compensation from CONMED Corporation; food and beverage compensation from Olympus Corporation of the Americas, Ambu, Inc, Boston Scientific Corporation, and Cook Medical LLC. A. Y. B. Teoh: Consultant for Boston Scientific Corporation, Cook Medical LLC, Taewoong and Microtech, MI Tech, and CMR Medical Corporations. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and CONMED Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, CONMED Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and FujiFilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc and AbbVie Inc; consultant for Boston Scientific. D. R. Kohli: Research support from Olympus Corporation of the Americas. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. U. Navaneethan: Consultant for ER Squibb & Sons, LLC; travel compensation from ER Squibb & Sons, LLC, Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, and AbbVie Inc; food and beverage compensation from ER Squibb & Sons, LLC, Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, AbbVie Inc, Pfizer Inc, Apollo Endosurgery US Inc, Celgene Corporation, and Olympus America Inc; speaker for Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, AbbVie Inc, and Pfizer Inc. S. G. Sheth: Consulted for Janssen Research & Development, LLC. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships.

Background and Aims: Audit and feedback (A&F) for endoscopic retrograde cholangiopancreatography (ERCP) is relatively understudied despite the demonstrated effectiveness of A&F for endoscopic procedures such as colonoscopy. Endoscopist 'report cards' are one A&F tool. We aimed to develop an ERCP report card and assess its appropriateness, acceptability and feasibility through usability testing., Methods: A prototype report card was designed using a combination of published quality indicators and established predictors of adverse events (AE). Exploratory analyses from a prospective multi-center registry were performed to further identify novel and/or understudied parameters for possible inclusion. Semi-structured interviews with ERCP endoscopists were conducted and framework analysis performed. Validated post-interview usability instruments were administered. Feedback was incorporated to create a final report card., Results: The report card included domains of technical parameters, AE rates/prevention, and patient-reported experience measures (PREMs). Qualitative feedback was positive, with respondents agreeing with inclusion of relevant content in most domains. Post-interview instruments revealed adequate appropriateness and acceptability. PREMs were felt by respondents to be poorly actionable and were replaced with appropriateness of indication and fluoroscopy usage parameters in the final report card. Concerns were raised regarding the feasibility of implementation due to reliance on difficult-to-obtain granular intraprocedural data., Conclusions: We designed and tested an ERCP report card that has potential to be an effective A&F intervention for endoscopists in clinical practice. Though feasibility of data capture and implementation are currently limitations, advances in video recording and artificial intelligence technologies could accelerate widespread adoption of such a tool., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Background and Aims: Difficult biliary cannulation (DBC) is a known risk factor for developing post-ERCP pancreatitis (PEP). To better understand how DBC increases PEP risk, we examined the interplay between technical aspects of DBC and known PEP risk factors., Methods: This was a secondary analysis of a multicenter, randomized controlled trial comparing rectal indomethacin alone with the combination of rectal indomethacin and prophylactic pancreatic duct (PD) stent placement for PEP prophylaxis in high-risk patients. Participants were categorized into 3 groups: DBC with high preprocedure risk for PEP, DBC without high preprocedure risk for PEP, and non-DBC at high preprocedure risk for PEP., Results: In all, 1601 participants (84.1%) experienced DBC, which required a mean of 12 cannulation attempts (standard deviation, 10) and mean duration of 14.7 minutes (standard deviation, 14.9). PEP rate was highest (20.7%) in DBC with a high preprocedure risk, followed by non-DBC with a high preprocedure risk (13.5%), and then DBC without a high preprocedure risk (8.8%). Increasing number of PD wire passages (adjusted odds ratio [aOR], 1.97; 95% confidence interval [CI], 1.25-3.1) was associated with PEP in DBC, but PD injection, pancreatic sphincterotomy, and number of cannulation attempts were not associated with PEP. Combining indomethacin with PD stent placement lowered the risk of PEP (aOR, .61; 95% CI, .44-.84) in DBCs. This protective effect was evident in up to at least 4 PD wire passages., Conclusions: DBC confers higher PEP risk in an additive fashion to preprocedural risk factors. PD wire passages appear to add the greatest PEP risk in DBCs, but combining indomethacin with PD stent placement reduces this risk, even with increasing PD wire passages., Competing Interests: Disclosure Dr. Andrew Y. Wang discloses owning publicly traded stock in Pfizer and GE HealthCare Technologies. Dr. Mouen Khashab is a consultant for Boston Scientific and Olympus and he receives royalties from Elsevier and UpToDate. Dr. Andy Ross is a consultant for Boston Scientific and Olympus. Dr. Samuel Han is a consultant for Boston Scientific. Dr. Ji Young Bang is a consultant for Boston Scientific and Olympus. Dr. Shyam Varadarajulu is a consultant for Boston Scientific and Olympus. Dr. Field F. Willingham is a consultant for Boston Scientific and Cook Medical. Dr. Somashekar G. Krishna receives honoraria and grant support from Taewoong. Dr. Rajesh Keswani is a consultant for Boston Scientific. Dr. Steven A. Edmundowivcz is a consultant for Olympus and receives honoraria from Boston Scientific. Dr. Raj J. Shah is a consultant for Boston Scientific and Cook Medical. Dr. Nauzer Forbes is a consultant for Boston Scientific and Pentax. Dr. Yen-I Chen is a consultant for Boston Scientific. Dr. Alan Barkun is a Research support, consultation, Advisory board in Medtronic; Research support in Cook; Consultant, Payment or honoraria for lectures and trave in Takeda Canada Inc.; Consultant, Payment or honoraria for lectures and travel fees in Olympus Inc.; Payment or honoraria for lectures and travel fees in AstraZeneca Inc.; Advisory board in Pendopharm Canada Inc. The other authors disclosed no financial relationships. Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) under award number: U01DK104833. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the role of endoscopy in the management of chronic pancreatitis (CP). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework. The guideline addresses effectiveness of endoscopic therapies for the management of pain in CP, including celiac plexus block, endoscopic management of pancreatic duct (PD) stones and strictures, and adverse events such as benign biliary strictures (BBSs) and pseudocysts. In patients with painful CP and an obstructed PD, the ASGE suggests surgical evaluation in patients without contraindication to surgery before initiation of endoscopic management. In patients who have contraindications to surgery or who prefer a less-invasive approach, the ASGE suggests an endoscopic approach as the initial treatment over surgery, if complete ductal clearance is likely. When a decision is made to proceed with a celiac plexus block, the ASGE suggests an EUS-guided approach over a percutaneous approach. The ASGE suggests indications for when to consider ERCP alone or with pancreatoscopy and extracorporeal shock wave lithotripsy alone or followed by ERCP for treating obstructing PD stones based on size, location, and radiopacity. For the initial management of PD strictures, the ASGE suggests using a single plastic stent of the largest caliber that is feasible. For symptomatic BBSs caused by CP, the ASGE suggests the use of covered metal stents over multiple plastic stents. For symptomatic pseudocysts, the ASGE suggests endoscopic therapy over surgery. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics., Competing Interests: Disclosure The following authors disclosed financial relationships: S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas;food and beverage compensation from Boston Scientific Corporation. C. Forsmark: Consultant for Nestle Healthcare Nutrition, Inc. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, AbbVie Inc, and Ambu Inc; travel and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Pawa: Consultant for Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. D. R. Kohli: Research support from Olympus Corporation of the Americas. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc. and AbbVie Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and FujiFilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals; research support from GI Dynamics. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Information on how school-based programs is implemented and sustained during crises is limited. In this study, we assessed the impact of the COVID-19 pandemic on the implementation of a HIV prevention intervention in The Bahamas. Data were collected from 139 Grade 6 teachers in 2021-2022. Teachers attended virtual training and received implementation monitoring from coordinators. On average, teachers taught 26.4 (SD = 9.2) of the 35 core activities, and 7.4 (SD = 2.4) out of 9 sessions. More than half (58.3%) of teachers completed 28 or more core activities; 69.1% covered eight or all nine sessions, which is equivalent to 80% of the HIV intervention curriculum. Almost half of the teachers (43%) reported that the pandemic negatively impacted their ability to teach the program; 72% of teachers maintained that the program remained "very important" during times of crisis. Greater self-efficacy and supports increased implementation fidelity., (© 2024. The Author(s).)

Competing Interests: Disclosure The following authors disclosed financial relationships: S. G. Sheth: Consultant for Janssen Research & Development, LLC. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. C. Forsmark: Consultant for Nestle Healthcare Nutrition, Inc. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Pawa: Consultant for Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation; food and beverage compensation from Medtronic, Inc, Boston Scientific Corporation, Pentax of America, Inc, and Ambu Inc. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. D. R. Kohli: Research grant from Olympus Corporation of the Americas. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc and AbbVie Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and Fujifilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and ConMed Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, ConMed Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships.

Aim : To understand mean (WCS mean ) and peak (WCS peak ) worst case scenarios within training and game play in male professional soccer. Methods : Thirty-one ( n  = 31) first team players were monitored across 37 matches and 14 MD-3 sessions. Playing status was distinguished, football drills analyzed, and performance explored in long-period: >6 days, moderate-period: 5-6 days, and congested-period: ≤4 days. Relative total distance (TD), high-speed running distance (HSRD, >19.8 km·h -1 ), sprint distance (SD, >25.2 km·h -1 ), accelerations/decelerations (A+D, >3 m·s -2 ), accelerations (Acc, >3 m·s -2 ), and decelerations (Dec, >-3 m·s -2 ) were measured as well as Maximum acceleration (Max Acc; m·s -2 ) and deceleration (Max Dec; m·s -2 ). Results : Analysis of variance found differences between matches and training in WCS mean for TD, HSRD, SD, and Max Dec in all positions ( p  < .001; partial η 2  > .275). Fullbacks displayed differences between match and training in Max Acc (moderate ESs; p  < .001), while center backs and central midfielders in Max Dec (large ESs; p  > .05). Main effects of playing status were discovered for all metrics except Max Dec ( p  < .001; partial η 2  > .124). Analysis showed differences between long- and congested-period for A+D and Dec (large ESs; p  ≤ .05). Conclusions : Findings provide more insights into short peak intensity demands of soccer showing that the maximum high velocity action of acceleration and deceleration is not being replicated in training. Nonstarters lack maximum intensity exposure in matches (WCS peak ) increasing the gap between training and competition even higher during congested fixture periods.

Background: The incidence of major gastrointestinal bleeding (GIB) in patients on low-dose direct-acting oral anticoagulants (DOACs) is relatively unknown. Estimates from randomised controlled trials (RCTs) are lacking., Aims: To assess GIB incidence and predictors from RCT data of patients on aspirin, low-dose rivaroxaban, or both., Methods: This was a secondary analysis of RCT data wherein patients received aspirin 100 mg daily and rivaroxaban 2.5 mg b.d., aspirin alone, or rivaroxaban 5 mg b.d. Patients were followed from 2013 to 2016 at 602 centres. Outcomes included overall, upper, and lower GIB. We employed multivariable logistic regression to yield odds ratios (ORs) and 95% confidence intervals for potential exposures., Results: Among 27,395 patients, the annual incidence of GIB on rivaroxaban 2.5 mg b.d. with aspirin was 801.7 per 100,000 compared with 372.3 in 100,000 for aspirin. Age (OR 4.16, 2.53-6.82 for ≥75 vs. 55-64), peptic ulcer disease (PUD, OR 1.57, 1.01-2.44), liver disease (OR 2.09, 1.01-4.33), hypertension (OR 1.42, 1.04-1.94), and smoking (OR 1.85, 1.26-2.73) were associated with overall GIB. Kidney disease (OR 1.68, 1.12-2.51) was significantly associated with upper GIB, whereas diverticular disease (OR 3.75, 1.88-7.49) was associated with lower GIB. Addition of rivaroxaban to aspirin was associated more with lower GIB (OR 2.82, 1.64-4.84) than upper GIB (OR 1.86, 1.18-2.92)., Conclusions: We established incidences and identified risk factors for GIB in users of low-dose DOACs. Novel risk factors included current or former smoking and diverticulosis. Future studies should aim to validate these risk factors., (© 2024 The Author(s). Alimentary Pharmacology & Therapeutics published by John Wiley & Sons Ltd.)

Background: At the beginning of the COVID-19 pandemic, social distancing effects halted in-person clinical placements in nursing programs at all Canadian universities. To mitigate educational disruption, clinical practicums were pivoted to online delivery, despite knowledge gaps on the perspectives of nursing students and community liaisons on using virtual technology to facilitate clinical placements., Objective: Accordingly, we explored the impact of using innovative virtual technology to combat the social distancing effects of the COVID-19 pandemic on students' and community liaisons' experiences in a clinical community health nursing course., Methods: Using a descriptive qualitative research approach, we evaluated an innovative online clinical placement approach which we implemented to combat the disruptions of social distancing guidelines. Forty-five nursing students were grouped and paired with five community health organizations to create community-led health promotion projects using online videoconferencing. Upon completion of their practicum, six nursing students and four community liaisons participated in virtual individual interviews. Data was analyzed using a thematic analysis approach., Results: Three themes were developed: 1) Openness to change, 2) Effective virtual communication, and 3) Creation of learning spaces that foster nurturing relationships. On the theme of 'Openness to Change,' participants voiced the need to shift focus from common learning approaches to new, untested options. On the theme of 'Effective virtual communication,' participants valued the critical role of thorough virtual communication in online learning. On the theme of 'Creation of learning spaces that foster nurturing relationships,' participants appreciated the role of relationships, careful planning, and organization of virtual learning spaces for program success., Conclusion: The success and viability of virtual technology in clinical education are strongly related to individual and systems approach and adaptations to support students' access to learning opportunities. Our findings could be used to enhance access to virtual clinical education for students from disadvantaged and vulnerable populations., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Prophylactic pancreatic stent placement (PSP) is effective for preventing pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP) in high-risk cases, but the optimal technical approach to this intervention remains uncertain., Methods: In this secondary analysis of 787 clinical trial patients who underwent successful stent placement, we studied the impact of (i) whether pancreatic wire access was achieved for the sole purpose of PSP or naturally during the conduct of the case, (ii) the amount of effort expended on PSP, (iii) stent length, (iv) stent diameter, and (v) guidewire caliber. We used logistic regression models to examine the adjusted association between each technical factor and post-ERCP pancreatitis (PEP)., Results: Ninety-one of the 787 patients experienced PEP. There was no clear association between PEP and whether pancreatic wire access was achieved for the sole purpose of PSP (vs occurring naturally; odds ratio [OR] 0.82, 95% confidence interval [CI] 0.37-1.84), whether substantial effort expended on stent placement (vs nonsubstantial effort; OR 1.58, 95% CI 0.73-3.45), stent length (>5 vs ≤5 cm; OR 1.01, 95% CI 0.63-1.61), stent diameter (≥5 vs <5 Fr; OR 1.13, 95% CI 0.65-1.96), or guidewire caliber (0.035 vs 0.025 in; 0.83, 95% CI 0.49-1.41)., Discussion: The 5 modifiable technical factors studied in this secondary analysis of large-scale randomized trial data did not appear to have a strong impact on the benefit of prophylactic PSP in preventing PEP after high-risk ERCP. Within the limitations of post hoc subgroup analysis, these findings may have important implications in procedural decision making and suggest that the benefit of PSP is robust to variations in technical approach., (Copyright © 2024 by The American College of Gastroenterology.)

Background & Aims: Significant variability exists in colonoscopy quality indicators, including adenoma detection rate (ADR). We synthesized evidence from randomized trials in a network meta-analysis on interventions to improve colonoscopy quality., Methods: We included trials from database inceptions to September 25, 2023, of patients undergoing screening-related colonoscopy and presented efficacies of interventions within domains (periprocedural parameters, endoscopist-directed interventions, intraprocedural techniques, endoscopic technologies, distal attachment devices, and additive substances) compared to standard colonoscopy. The primary outcome was ADR. We used a Bayesian random-effects model using Markov-chain Monte Carlo simulation, with 10,000 burn-ins and 100,000 iterations. We calculated odds ratios with 95% credible intervals and present surface under the cumulative ranking (SUCRA) curves., Results: We included 124 trials evaluating 37 interventions for the primary outcome. Nine interventions resulted in statistically significant improvements in ADR compared to standard colonoscopy (9-minute withdrawal time, dual observation, water exchange, i-SCAN [Pentax Ltd], linked color imaging, computer-aided detection, Endocuff [Olympus Corp], Endocuff Vision [Olympus Corp], and oral methylene blue). Dual observation (SUCRA, 0.84) and water exchange (SUCRA, 0.78) ranked highest among intraprocedural techniques; i-SCAN (SUCRA, 0.95), linked color imaging (SUCRA, 0.85), and computer-aided detection (SUCRA, 0.78) among endoscopic technologies; WingCap (A&A Medical Supply LLC) (SUCRA, 0.87) and Endocuff (SUCRA, 0.85) among distal attachment devices and oral methylene blue (SUCRA, 0.94) among additive substances. No interventions improved detection of advanced adenomas, and only narrow-band imaging improved detection of serrated lesions (odds ratio, 2.94; 95% credible interval, 1.46-6.25)., Conclusions: Several interventions are effective in improving adenoma detection and overall colonoscopy quality, many of which are cost-free. These results can inform endoscopists, unit managers, and endoscopy societies on relative efficacies., (Copyright © 2024 AGA Institute. Published by Elsevier Inc. All rights reserved.)

This clinical practice guideline from the American Society for Gastrointestinal Endoscopy provides an evidence-based approach for the role of therapeutic EUS in the management of biliary tract disorders. This guideline was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses the following: 1: The role of EUS-guided biliary drainage (EUS-BD) versus percutaneous transhepatic biliary drainage (PTBD) in resolving biliary obstruction in patients after failed ERCP. 2: The role of EUS-guided hepaticogastrostomy versus EUS-guided choledochoduodenostomy in resolving distal malignant biliary obstruction after failed ERCP. 3: The role of EUS-directed transgastric ERCP (EDGE) versus laparoscopic-assisted ERCP and enteroscopy-assisted ERCP (E-ERCP) in resolving biliary obstruction in patients with Roux-en-Y gastric bypass (RYGB) anatomy. 4: The role of EUS-BD versus E-ERCP and PTBD in resolving biliary obstruction in patients with surgically altered anatomy other than RYGB. 5: The role of EUS-guided gallbladder drainage (EUS-GBD) versus percutaneous gallbladder drainage and endoscopic transpapillary transcystic gallbladder drainage in resolving acute cholecystitis in patients who are not candidates for cholecystectomy., Competing Interests: Disclosure The following authors disclosed financial relationships: S. Pawa: Consultant for Boston Scientific Corporation. N. B. Marya: Consultant for Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Apollo Endosurgery US Inc. N. R. Thiruvengadam: Research support from Boston Scientific Corporation. S. Ngamruengphong: Consultant for Boston Scientific Corporation, Olympus, and Neptune Medical. T. H. Baron: Consultant for Boston Scientific Corporation, Olympus Corporation, Medtronic, Inc, WL Gore & Associates, Inc, Cook Endoscopy, and CONMED Corporation; speaker for Boston Scientific Corporation, Olympus Corporation, Medtronic, Inc, and WL Gore & Associates; travel compensation from CONMED Corporation; food and beverage compensation from Olympus Corporation of the Americas, Ambu, Inc, Boston Scientific Corporation, and Cook Medical LLC. A. Y. B. Teoh: Consultant for Boston Scientific Corporation, Cook Medical LLC, Taewoong and Microtech, MI Tech, and CMR Medical Corporations. W. Abidi: Consultant for Ambu Inc, Apollo Endosurgery US Inc, and CONMED Corporation; research support from GI Dynamics; food and beverage compensation from Ambu Inc, Apollo Endosurgery US Inc, CONMED Corporation, Olympus America Inc, AbbVie Inc, Boston Scientific Corporation, RedHill Biopharma Inc, and Salix Pharmaceuticals. S. K. Amateau: Consultant for Boston Scientific Corporation, Merit Medical, Olympus Corporation of the Americas, MTEndoscopy, US Endoscopy, Heraeus Medical Components, LLC, and Cook Medical LLC; travel compensation from Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation, Olympus Corporation of the Americas, and Cook Medical LLC; advisory board for Merit Medical. J. M. Chalhoub: Travel compensation from Olympus Corporation of the Americas; food and beverage compensation from Boston Scientific Corporation. N. Coelho-Prabhu: Consultant for Boston Scientific Corporation and Alexion Pharma; research support from Cook Endoscopy and FujiFilm; food and beverage compensation from Olympus America Inc and Boston Scientific Corporation. N. Cosgrove: Consultant for Olympus Corporation of the Americas and Boston Scientific Corporation; food and beverage compensation from Boston Scientific Corporation and Ambu Inc. S. E. Elhanafi: Food and beverage compensation from Medtronic, Inc, Nestle HealthCare Nutrition Inc, Ambu Inc, Salix Pharmaceuticals, Takeda Pharmaceuticals USA, Inc, and Merit Medical Systems Inc. N. Forbes: Consultant for Boston Scientific Corporation, Pentax of America, Inc, AstraZeneca, and Pendopharm Inc; speaker for Pentax of America, Inc and Boston Scientific Corporation; research support from Pentax of America, Inc. L. L. Fujii-Lau: Food and beverage compensation from Pfizer Inc and AbbVie Inc; consultant for Boston Scientific. D. R. Kohli: Research support from Olympus Corporation of the Americas. J. D. Machicado: Consultant for Mauna Kea Technologies, Inc; food and beverage compensation from Mauna Kea Technologies, Inc and Boston Scientific Corporation. U. Navaneethan: Consultant for ER Squibb & Sons, LLC; travel compensation from ER Squibb & Sons, LLC, Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, and AbbVie Inc; food and beverage compensation from ER Squibb & Sons, LLC, Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, AbbVie Inc, Pfizer Inc, Apollo Endosurgery US Inc, Celgene Corporation, and Olympus America Inc; speaker for Janssen Scientific Affairs, LLC, Takeda Pharmaceuticals USA, Inc, AbbVie Inc, and Pfizer Inc. S. G. Sheth: Consulted for Janssen Research & Development, LLC. N. C. Thosani: Consultant for Pentax of America, Inc, Boston Scientific Corporation, and Ambu Inc; travel compensation and food and beverage compensation from Pentax of America, Inc, Boston Scientific Corporation, and AbbVie Inc; speaker for AbbVie Inc. B. J. Qumseya: Consultant for Medtronic, Inc and Assertio Management, LLC; food and beverage compensation from Medtronic, Inc, Fujifilm Healthcare Americas Corporation, and Boston Scientific Corporation; speaker for Castle Biosciences. All other authors disclosed no financial relationships., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)