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Condensed tannin content of seven varieties of sorghum (White, Sandalbar, YS-98, JS-88, JS-263, JS-2002 and Hegari) found in Pakistan were determined and their effect on nutrient digestibility and absorption of minerals was investigated in White Leghorn Layers. For digestibility trial, 20 individually caged White Leghorn layers (30 weeks of age) were divided randomly into four experimental groups (5 birds/group) where each bird served as a replicate. Four isocaloric and isonitrogenous experimental diets i.e. control (C), low tannin (LT), medium tannin (MT) and high tannin (HT) were prepared. Diet C was without tannin; whereas, diet LT, MT and HT contained 1, 2 and 3 percent sorghum tannin, respectively. Among the seven varieties of sorghum grains the highest amount of tannin (5.34%) was observed in the variety Sandalbar; whereas, the lowest concentration of tannin was observed in white sorghum (0.02%). All tannin containing diets reduced the digestibility of nitrogen and starch but the effect was more severe with 3% tannin. However, ether extract digestibility remained unaffected. The mineral contents (calcium, phosphorus, sodium, potassium, magnesium and iron) in the feces of layers using sorghum tannins were significantly (P<0.05) more than those using diets without tannin. The results revealed that the effect of tannins on mineral absorption was more severe in birds fed high tannin diet (3%) than that of low tannin diets. [ABSTRACT FROM AUTHOR]

Effect of feeding management on production performance of broilers during summer was investigated. Three hundred day-old broiler chicks were reared in a group for one week (adaptation period). At day 8, all the birds were weighed individually and 180 chicks of middleweight range (μ±1σ) were selected to be used as experimental birds. The chicks were randomly divided into 18 experimental units (replicates) having 10 chicks each. These replicates were further allotted to six treatment groups (A, B, C, D, E and F) each having three replicates. Three feeding methods i.e., continuous feeding (CF, 24 h feeding), intermittent feeding (IF, 1 h feed and 3 h off) and feed withdrawal (FW, no feed from 9:00 am. to 5:00 pm.) were used. Under each feeding system, birds were fed a ration either without supplemented fat or with 3% supplemented fat. Birds kept under IF system showed significantly (P<0.05) lower weight gain, feed consumption and water consumption but better feed utilization than those of continuous fed birds; whereas, the birds kept under FW system showed no difference regarding feed utilization than those kept under CF system. Addition of fat in ration significantly reduced weight gain, feed intake and water consumption of the experimental birds than those fed ration without fat supplementation. However, fat supplemented ration did not show any difference regarding water consumption of the birds than those provided ration without fat supplementation, when they were kept under IF system. IF and FW systems significantly (P<0.05) reduced the leg abnormalities (hock burn) of the birds. No mortality was observed in the birds kept under IF system; whereas, 1.66 and 8.30% mortality was found in the birds kept under FW and CF systems, respectively. Mortality was found to be 2.22% in the birds fed fat supplemented ration and 4.44% in the birds fed ration without supplementation of fat. Birds kept under IF system fetched more profit than those kept under FW and CF feeding systems. [ABSTRACT FROM AUTHOR]

This study was conducted to evaluate the role of peacock-peahen ratios on egg production, fertility and hatchability in Indian Peafowl (Pavo cristatus) in a Wildlife Park to explore most productive mating sex ratio for a period of 16 weeks. A total of 42 birds (12♂ & 30♀) was selected for the study and kept in 12 cages. The sex ratios maintained were 1♂: 1♀ (Group A), 1♂: 2♀ (Group B), 1♂: 3♀ (Group C) and 1♂: 4♀ (Group D). Each group had three replicates. The birds were randomly released into twelve cages with each cage contained one sex ratio. Before data collection, the birds were given an adaptation period of one week. Peacock-peahen ratio (1♂: 3♀) exhibited significant effect (P<.0.05) on mean egg production (1.78±0.14), egg weight (98.21g±7.02), egg fertility (81.25%±6.28), hatchability (61.95%±1.00) and mounting numbers (2.66+0.09). Whereas, the mean display duration, display number, mounting duration and total time taken for mating were not affected by any peacock-peahen mating ratio. Maximum number of eggs were produced having mating sex ratio 1:3 in terms of egg production, egg weight, egg fertility (%), hatchability (%) and number of mating. [ABSTRACT FROM AUTHOR]

Biologics such as antitumor necrosis factor (anti-TNF) drugs have emerged as important agents in the treatment of many chronic inflammatory diseases, especially in cases refractory to conventional treatment modalities. However, opportunistic infections have become a major safety concern in patients on anti-TNF therapy, and physicians who utilize these agents must understand the increased risks of infection. A literature review of the published data on the risk of bacterial, viral, fungal, and parasitic infections associated with anti-TNF therapy was performed and the clinical presentation, diagnostic tests, management, and prevention of opportunistic infections in patients receiving anti-TNF therapy were reviewed. Awareness of the therapeutic potential and associated adverse events is necessary for maximizing therapeutic benefits while minimizing adverse effects from anti-TNF treatments. Patients should be adequately vaccinated when possible and closely monitored for early signs of infection. When serious infections occur, withdrawal of anti-TNF therapy may be necessary until the infection has been identified and properly treated. [ABSTRACT FROM AUTHOR]

Non-obstructive dysphagia (NOD) is defined as symptomatic dysphagia in patients with negative endoscopic and radiographic workup. The management of NOD remains controversial as there is a discrepancy between different guidelines and clinical practice. Despite the lack of high-quality studies, empiric dilation for NOD is a common clinical practice among endoscopists and the approach varies between different clinical centers. In this review, we summarize the published literature on empiric dilation for NOD and propose a management algorithm for offering empiric dilation to patients presenting with dysphagia. [ABSTRACT FROM AUTHOR]

Objectives: Adenomatous polyps are common, occurring in up to 25% of the population older than 50 years of age in the United States. Conflicting data are present in the literature about the impact of specific adenoma locations and the prediction on the number and advanced histology of adenomas elsewhere. With this study we aimed to review the association between cecal adenoma and the risk of discovering more and advanced adenomas in the remainder of the colon.Methods: We performed a retrospective study of 1880 patients who received outpatient colonoscopies between June 2012 and December 2014 at the Veterans Affairs Medical Center in Oklahoma City. The data collected included patient demographics, indications for colonoscopy, smoking history, alcohol use, family history of colon cancer, quality of bowel preparation, number of adenomas, location, size of adenomas, and the histology of adenomas and colon cancer.Results: The mean age of the study population was 61.6 ± 9.4 year, with 95% of the population being men. Cecal adenomas were found in 243 (12.9%) of patients. Patients with cecal adenoma tended to be older (65 ± 7 vs 61 ± 10, P < 0.0001), more likely to be men (97% vs 94%, P = 0.06) and less likely to have a colonoscopy done for screening indication (11% vs. 13%., P = 0.03). After adjusting for age, sex, indication, and quality of bowel preparation, patients with cecal adenoma were found to have a sixfold increase in finding ≥10 other adenomas elsewhere (4.5% vs 0.8% P = 0.0009) and a threefold increase in finding advanced adenomas (17.7% vs 9.9% P = 0.002) in the remainder of the colon. Stratifying by location, the increased risk was more pronounced in the right side (24.7% vs 8.9% P ≤ 0.0001) compared with the left side.Conclusions: Cecal adenoma is associated with an increased risk of finding more and advanced adenomas in the remainder of the colon, especially on the right side; therefore, the discovery of a cecal adenoma should prompt a more thorough evaluation of the entire colon, particularly the right colon. [ABSTRACT FROM AUTHOR]

Introduction: Some observational studies have demonstrated the benefit of famotidine in COVID-19-infected individuals. The preference of using an H2 receptor antagonist (H2RA) over proton pump inhibitors (PPI) during the COVID-19 pandemic has been questioned by clinicians. Aim: To compare the outcomes of hospitalized patients who were taking H2RA vs. PPI. Material and methods: We conducted a retrospective review of patients admitted for COVID-19 infection from 1 March until 31 July 2020. We included 396 patients admitted during the study period. Of the total, 39 (9.8%) received H2RA and 86 (21.7%) were taking PPI as home medications; 6 patients were taking both H2RA and PPI. Results: The baseline characteristics and comorbid conditions were similar in both groups. The mean age was 57.79 ±17.36 years, 43.2% were female, and 48.7% were Caucasian. The common comorbid conditions included HTN (56.8%), obesity (44.4%), diabetes mellitus (38.6%), and coronary artery disease (30.1%). Smoking was more prevalent in the PPI group (42.5% vs. 18.2%, p = 0.03). Gastrointestinal symptoms were seen on initial presentation in 31.1%, and 43.9% had elevated liver enzymes. The H2RA group had similar mortality (HR = 0.84, 95% CI: 0.35-2.05) to the non-H2B group. It remained non-significant as compared to PPI (HR = 0.34-3.19, 95% CI: 0.34-3.19). The secondary outcomes including readmission, ICU admission, and severe COVID infections (including ARDS and thromboembolism) were similar in these groups. Conclusions: The H2 receptor antagonist used as a home medication did not show benefit over the PPI in patients admitted for COVID-19 infections. [ABSTRACT FROM AUTHOR]

Background: The most common immunosuppressant, Anti-thymocyte Globulin (ATGs) has been widely used by clinicians for the treatment and prevention of rejection at the time of organ transplant. Transplantation is the best option for the people with renal failure at end stage, requiring replacement of renal therapy. This is a promising treatment option with significant benefits in terms of mortality and morbidity. ATG prevents organ rejection by inhibition of activated T-cells and other immune and non-immune cells. The aim of the study was to compare different induction regimens with ATG for the survival of smooth kidney transplantation. Methodology: Studies of the last 20 years, focusing on kidney transplantation and the efficacy of anti-thymocyte use for kidney transplantation were reviewed for the study literature. The keywords used were Kidney Transplantation, Induction agents, ATG, Allograft, Immunosuppressant Agents. Results: Literature suggested that the most important problem with transplantation is the protection of the allograft from activated immunological forces, which begin to react early in the period after transplantation and cause significant damage with serious short-term and long-term consequences. This process is called rejection, which is usually classified as cell-mediated and antibody-mediated rejection. The phenomenon mediated by cells causes concern, as it is the cause of future failures and damage to the allograft. To combat these phenomena with different results, various strategies were adopted. Among these therapies, ATG has recognized the exceptional importance of preventing cellular mediated rejection, allowing allotransplants to function smoothly with the greatest possible long-term benefits. Conclusion: It can be concluded on the basis of previous studies that ATG as an induction agent, is more efficient in reducing the rejection rate in the renal transplantation as compared with other agents.

Background: Spontaneous pancreatic portal vein fistula (PPVF) - a rare complication of pancreatic inflammation - varies widely in presentation and means of diagnosis but has been previously associated with bleeding complications and mortality. A systematic review of published literature was performed to assess the frequency of outcomes., Methods: A search of electronic databases (PubMed, Ovid MEDLINE, Scopus, EMBASE, gray literature) resulted in 1667 relevant unique manuscripts; 52 met inclusion criteria., Results: A total of 74 unique (male n = 47, 63.5 %) patients were included. Mean age was 53.5 (±11.9) years. History of alcohol use was reported in 55 (74.3 %). Underlying chronic pancreatitis (CP) was present in 49 (66.2 %). In cases where presenting symptoms were reported (n = 57, 77.4 %), the most frequent were abdominal pain (63.5 %), weight loss (14.9 %), rash (12.2 %), nausea/vomiting (12.2 %), and polyarthritis (9.5 %). Computed tomography was the most common imaging modality used to confirm the diagnosis (n = 20, 27.0 %), followed by magnetic resonance cholangiopancreatography (n = 14, 18.9 %). Portal vein thrombosis was reported in 57 (77.0 %), and bleeding events (luminal, variceal, or intra-pseudocyst) were reported in 13(17.6 %) patients. Younger age was associated with higher risk of bleeding events. Mortality was reported in 12 (16.2 %) patients at any time during follow up. Older age and polyarthritis at presentation were associated with mortality., Conclusions: PPVF is a rare and potentially fatal condition, though rates of bleeding complication and death were relatively low in this population. High-quality observational studies are needed to better understand the pathophysiology and natural history of this diagnosis., Competing Interests: Declaration of competing interest AEP: Board Member, National Pancreas Foundation. All other authors declare no relevant conflicts of interest., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Aims: A synthetic lifting agent, ORISE, used for endoscopic mucosal resections, has been recalled from the market since November 2022 due to clinical complications. Despite this, the impact of ORISE-associated complications is expected to persist in the foreseeable future. We present a large single institutional series of therapeutic resections from patients for whom ORISE was used for initial endoscopic procedures, highlighting the pitfalls and complications associated with its use., Methods: All specimens showing lifting agent granulomata (LAGs) associated with the use of ORISE were identified. The H&E slides were reviewed to define the morphological characteristics and extent of LAG in the intestinal wall and other organs. The clinical impression and gross findings were compared with the final pathological diagnosis., Results: 34 cases (28 resections and 6 repeat endoscopic mucosal resection specimens) showed LAG. On microscopy, 20.5% showed no residual disease, 64.7% also showed residual precursor lesion and 14.7% also showed malignancy. In 64.2% of cases, a mass lesion was seen grossly but no malignancy was identified microscopically. ORISE was present in vascular spaces (n=9), lymph nodes (n=2), other organs such as appendix (n=1) and omentum/peritoneum (n=1). The major discordance between clinical impression (mass/neoplasm) and final pathology (no residual malignancy) was seen in 4/34 (11.8%) cases. LAGs were seen up to 10 months after the use of ORISE in the prior endoscopic procedure., Conclusion: ORISE deposits may mimic residual/disseminated neoplasm and prompt inadvertent changes in surgical decisions. Awareness of this pitfall is essential to prevent unwarranted surgical resections in patients undergoing follow-up for endoscopically resected lesions., Competing Interests: Competing interests: One of the coauthors is an editor (VD) and one coauthor is an editorial board member (MV)., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: This retrospective study, conducted using the U.S. National Inpatient Sample (NIS), examines the outcomes and management of nonvariceal upper gastrointestinal bleeding (NVUGIB) in COVID-19 patients and identifies predictive factors to enhance patient prognosis., Methods: We analyzed the 2020 U.S. NIS data involving adult patients (≥18 years) admitted with NVUGIB and categorized them based on the presence of COVID-19. Primary and secondary outcomes, NVUGIB-related procedures, and predictive factors were evaluated., Results: Of 184,885 adult patients admitted with NVUGIB, 1.6% (2990) had COVID-19. Patients with NVUGIB and COVID-19 showed higher inpatient mortality, acute kidney injury, need for intensive care, and resource utilization metrics. Notably, there was a lower rate of early esophagogastroduodenoscopy (EGD). Multivariate logistic regression revealed conditions like peptic ulcer disease, mechanical ventilation, and alcohol abuse as significant positive predictors for NVUGIB in COVID-19 patients, whereas female gender and smoking were negative predictors., Conclusion: Our findings suggest that COVID-19 significantly increases the risk of mortality and complications in NVUGIB patients. The observed decrease in early EGD interventions, potentially contributing to higher mortality rates, calls for a review of treatment strategies. Further multicenter, prospective studies are needed to validate these results and improve patient care strategies.

Background and study aims Noninvasive ampullary neoplasms may be removed by surgery or endoscopy. However, given the morbidity and mortality associated with surgery, endoscopic papillectomy (EP) is the preferred approach. Radiofrequency ablation (RFA) after EP has emerged as a promising alternative therapy to avoid surgery after incomplete EP. Our goal was to evaluate the efficacy and safety of RFA for residual or recurrent lesions with intraductal extension after endoscopic papillectomy. Patients and methods The inclusion criteria include clinical trials, cohort studies, and case series evaluating patients with residual or recurrent lesions with intraductal extension after EP treated with RFA. Case reports, duplicated data, and studies with follow-up periods < 10 months were excluded. The metanalysis evaluated adverse events, surgical conversion rate, clinical success and recurrence. Results Seven studies were selected, totaling 124 patients. RFA was associated with a clinical success rate of 75.7% (95% confidence interval [CI] 65.0-88.0%; I 2 = 23.484) in a mean follow-up period < 10 months. However, the biliary stricture rate was 22.2% (95% CI 12.1-28.4%; I 2 = 61.030), 14.3% of pancreatitis (95% CI 8.8-22.3%; I 2 < 0.001), 7.0% of cholangitis (95% CI 3.3-14.5%; I 2 < 0.001), 4.0% of bleeding (95% CI 1.7-9.3%; I 2 < 0.001), and recurrence of 24.3% (95% CI 16.0-35.0%; I 2 = 23.484). Conclusions RFA is feasible and appears to be effective for managing residual or recurrent lesions with intraductal extension after EP. However, long-term follow-up and high-quality studies are required to confirm our findings., Competing Interests: Conflict of Interest Dr. Diogo Turiani Hourneaux De Moura: BariaTek Medical - Advisory Board Member (Consulting fees). This was not relevant to this study. Dr. Eduardo Guimaraes Hourneaux De Moura: Olympus - Consultant (Consulting fees) and Boston Scientific - Consultant (Consulting fees). These were not relevant to this study. The other authors declare no potential conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Competing Interests: Dr Holzwanger is a consultant for Virgo. Dr Gabr is a consultant for Medtronic, ConMed, Olympus, Boston Scientific, Fuji, and AdaptivEndo. Dr Berzin is a consultant for Boston Scientific, Medtronic, and Fuji. Dr Pleskow is a consultant for Boston Scientific, Medtronic, Olympus, and Fuji. All other authors disclosed no financial relationships relevant to this publication.

Competing Interests: The authors disclosed no financial relationships relevant to this publication.

We aimed to calculate the sex-specific prevalence of psychological distress and unhealthy eating habits among adolescents across countries and regions, and to explore their potential associations. We used data from the Global School-Based Health Survey (GSHS) for 61 countries. Psychological distress was defined based on the existence of ≥ 2 factors from the following: loneliness, anxiety, suicide ideation, suicide planning, and suicide attempt. Four unhealthy dietary behaviours were examined: inadequate fruit intake, inadequate vegetable intake, daily consumption of soft drinks, and weekly fast-food consumption. We used random-effects meta-analysis to estimate the overall and regional pooled prevalence. Mixed-effect multilevel logistic regressions were used to estimate adjusted odds ratios (aORs) of unhealthy dietary behaviours in relation to psychological distress. Among 222,401 school-going adolescents (53.3% girls), the prevalence of psychological distress was 17.9%, with girls reporting higher than boys (20.8% vs. 14.9%). Adolescents in the African region reported the highest prevalence (22.5%), while those in the South-East Asia region reported the lowest (11.3%). The prevalence of inadequate fruit intake, inadequate vegetable intake, daily soft drink consumption, and weekly fast-food consumption was 37.0%, 28.5%, 50.0%, and 57.4% respectively. Psychological distress was associated with inadequate fruit intake (pooled aOR = 1.19, 95% CI 1.17-1.23), inadequate vegetable intake (pooled OR = 1.19, 1.16-1.22), daily consumption of soft drinks (pooled aOR = 1.14, 1.12-1.17), and weekly consumption of fast food (pooled aOR = 1.12, 1.09-1.15). Our findings indicate a substantial variance in the burden of psychological distress and unhealthy dietary behaviours across different regions. Adolescents experiencing psychological distress were more likely to have unhealthy dietary habits., (© 2023. The Author(s).)

Video 1The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion., Competing Interests: Dr Holzwanger is a consultant for Virgo. Dr Gabr is a consultant for Medtronic, ConMed, Olympus, Boston Scientific, Fuji, and Adaptiv Endo. Dr Berzin is a consultant for Boston Scientific, Medtronic, and Fuji. Dr Pleskow is a consultant for Boston Scientific, Medtronic, Olympus, and Fuji. All other authors disclosed no financial relationships relevant to this publication., (© 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Non-alcoholic fatty liver disease (NAFLD) is the most common cause of liver disease worldwide. Endoscopic sleeve gastroplasty (ESG) has proven to be feasible, safe, and effective in the management of obesity. We performed the first systematic review and meta-analysis evaluating NAFLD and other metabolic parameters 12 months post-ESG. Four observational studies with a total of 175 patients were included. The results showed a significant (p < 0.05) reduction of 4.85 in hepatic steatosis index (95% CI - 6.02, - 3.67), 0.5 in NAFLD fibrosis score (95% CI - 0.80, - 0.19), 6.32 U/l in ALT (95% CI - 9.52, - 3.11), 17.28% in TWL (95% CI - 18.24, - 16.31), 6.31 kg/m 2 in BMI (95% CI - 8.11, - 4.52), 47.97% in EWL (95% CI - 49.10, - 46.84), and 0.51% in HbA1c (95% CI - 0.90, - 0.12). ESG improves liver parameters, provides weight loss, and reduces HbA1c levels in patients suffering from NAFLD., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Zenker's diverticulum treatment options range from endoscopic rigid or flexible procedures to surgery. There are limited studies available comparing these techniques. Frequently, the choice of treatment depends on the physician's preference or experience, as well as the institution's resources and capacity. Therefore, this study aims to define the best approach based on the highest efficacy and the lowest severe adverse events. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was performed. Only comparative studies were included, analyzing flexible endoscopy versus rigid endoscopy or surgery. The outcomes analyzed were clinical and technical success, severe adverse events, length of stay, and duration of the procedure. Analysis was performed using Review Manager 5.4.1 (RevMan 5.4, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Eight retrospective cohort studies met the inclusion criteria. A total of 1281 patients were identified, 492 underwent flexible endoscopy, 453 underwent rigid endoscopy, and 336 underwent surgery. There was no difference in clinical success [risk difference (RD), 0.07 (95% CI -0.05 to 0.19%); P = 0.26], technical success [RD, 0.07 (95% CI -0.03 to 0.16); P = 0.18], severe adverse events [RD, -0.03 (95% CI -0.13 to 0.07; P = 0.052), perforation [RD, 0.07 (95% CI -0.04 to 0.19); P = 0.22] or procedure time [mean difference (MD), - 10.03 (95% CI -26.93 to 6.88); P = 0.24). There was lower length of stay with flexible endoscopy compared to the other approaches [MD, -1.98 (95% CI -3.56 to -0.40); P = 0.001]. Based on the current evidence, the three main techniques are effective for the treatment of Zenker's diverticulum. Although there was no significant difference in the safety of each technique in this meta-analysis, this result should be interpreted cautiously due to the limited data and the risk of vies between the techniques, considering that the results tend to favor flexible endoscopy, mainly explained by the newer and safer devices. Length of stay is lower with flexible endoscopy versus the other techniques, which can be beneficial considering the geriatric populations where Zenker's diverticulum mainly occurs., Competing Interests: The authors have declared financial relationships, which are detailed in the next section., (Copyright © 2023, Cadena Aguirre et al.)

Video 1Endoscopic treatment of a Bouveret syndrome showing and describing the techniques and procedures involved., (© 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Video 1Enhanced suction for removal of esophageal food impaction., (© 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Video 1Natural orifice transendoscopic surgery as a rescue for a dislodged lumen-apposing metal stent after EUS-directed transgastric ERCP., (© 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.)

Background: The 2018 Tokyo Guidelines (TG18) recommend urgent endoscopic biliary drainage based on acute cholangitis (AC) severity. Therefore, we evaluated the safety and mortality benefits of urgent endoscopic retrograde cholangiopancreatography (ERCP) in different age groups., Methods: Using International Classification of Diseases-10 (ICD-10) codes, we sampled adult AC patients from National Inpatient Sample. TG18 definition of cholangitis severity was used to identify patients with severe and nonsevere (mild or moderate) AC. Age categories were 18-64, 65-79, and 80 and above. Multivariate linear or logistic regression was used as appropriate. We used Stata, version 14.2, to perform analyses considering two-sided p < .05 as statistically significant., Results: Among 137 100 patients, there were 93 365 (68.09%) patients with nonsevere cholangitis and 43 735 (31.91%) patients with severe cholangitis. Urgent ERCP (within 24 h) resulted in decreased mortality in all age groups for both severe and nonsevere AC. Post-sphincterotomy bleeding was more common in patients ≥80 years of age, whereas post-ERCP acute cholecystitis was more common in patients 65-79 years. The rates of post-ERCP pancreatitis, bile duct perforation, and duodenal perforation did not differ among the age groups. In addition, there were no differences in the rate of sedation-related complications between different age groups who underwent urgent ERCP., Conclusion: This study demonstrates the mortality benefit from urgent ERCP for AC in different age groups and describes the safety of performing urgent ERCP in patients of various ages. Therefore, we recommend that urgent ERCP be performed according to the TG18 guidelines regardless of age., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Video 1., (Copyright © 2023 American Society for Gastrointestinal Endoscopy.)

The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Although the incidence rates are generally low (<1%), these can be avoided by recognizing pertinent risk factors, which can be patient, polyp, and technique/device related. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques to achieve hemostasis and manage colon perforations are reviewed., (Copyright © 2021 Elsevier Inc. All rights reserved.)

The coronavirus disease (COVID-19) pandemic has revealed many areas of public health preparedness that are lacking, especially in lower- and middle-income countries. Digital interventions provide many opportunities for strengthening health systems and could be vital resources in the current public health emergency. We provide several use cases for infection control, home-based diagnosis and screening, empowerment through information, public health surveillance and epidemiology, and leveraging crowd-sourced data. A thoughtful, concerted effort-leveraging existing experience and robust enterprise-grade technologies-can have a substantive impact on the immediate and distal consequences of COVID-19., (©Sultan Mahmood, Khaled Hasan, Michelle Colder Carras, Alain Labrique. Originally published in JMIR Public Health and Surveillance (http://publichealth.jmir.org), 16.04.2020.)

Background: Bangladesh, one of the most densely populated countries in the world has been ranked 9th on the Climate Risk Index for 2017: the 10 most affected countries & 7th on the Long-Term Climate Risk Index: the 10 countries most affected from 1998 to 2017. Every year it is afflicted with various climatic disasters including floods, hurricanes and cyclones. Apart from the obvious devastation of lives and property, there is a huge increase in clinical diseases when these disasters occur. Mental health of affected persons after these disasters is a topic that is often neglected by local and national level., Methods: A qualitative case study was conducted on perceived need on mental health support & availability of such services in a cyclone affected area in rural Bangladesh. Ten (10) key informant interviews (KIIs) with different stakeholders and ten (10) in-depth interviews (IDIs) with affected people were taken., Findings: We found that cyclones had numerous psychosocial impacts on the population including acute stress disorder, sleep disorder, post-traumatic stress disorders (PTSDs), generalized anxiety disorders, suicidal ideation and depression. The survivors had specific needs for receiving support. Children, elderly and women were perceived to be more vulnerable. The government and NGOs had no specific action plans and initiatives to address these issues and support the mental health of affected population. There was a visible gap in finding effective ways to provide affected people with the required mental health & psycho-social services (MHPSS)., Conclusion: Resilient, responsive and self-sustaining health systems for this vulnerable population are required. Implementation of effective mental health programs and strong mental health policies remain a challenge in Bangladesh where there is a cultural fatalistic acceptance of mental health issues., Competing Interests: Competing interestsThe authors declare that they have no competing interests., (© The Author(s) 2020.)

The aim of this study was to investigate factors contributing to poor bowel preparation in patients undergoing colonoscopy procedures. We used a reproducible search strategy to identify studies, searching 10 medical databases, including PubMed, Ovid, Medline, and Cochrane Library Database for reports published between 2000 and 2016. Fully published studies, evaluating risk factors for inadequate bowel preparation, were included. Two reviewers independently scored the identified studies for methodology and abstracted pertinent data. Pooling was conducted with both fixed-effects and random-effects models; results were presented from the random effects model when heterogeneity was significant. Odds ratios (OR) estimates with 95% confidence interval were calculated. Heterogeneity was assessed by I statistics. Twenty-four studies with a total of 49 868 patients met the inclusion criteria. Age (OR: -1.20), male sex (OR: 0.85), inpatient status (OR: 0.57), diabetes mellitus (OR: 0.58), hypertension (OR: 0.58), cirrhosis (OR: 0.49), narcotic use (OR: 0.59), constipation (OR: 0.61), stroke (OR; 0.51), and tricyclic antidepressant (TCA) use (0.51), were associated with inadequate bowel preparation. In our sensitivity analysis comparing Western and Asian countries, we found that diabetes, cirrhosis, male sex, history of stroke and TCA use were stronger risk factors for inadequate bowel preparation in Western countries than in Asian countries. We also found that history of stroke, TCA use, and race were risk factors for inadequate bowel preparation in patients receiving conventional bowel preparation compared with those receiving split-dose bowel preparation. Multiple risk factors affect the quality of bowel preparation and specific risk factors can be intervened upon, in different populations, to optimize preparation.

Background: Endoscopic procedures are frequently performed on patients chronically on opioids, raising concerns about the safety and efficacy of conventional sedation., Aims: We hypothesized that chronic opioid use is associated with longer procedure times, higher dosages of sedation medications, and an increase in adverse effects., Methods: This is a retrospective review from June 2012 to June 2013. Patients on chronic opioids (opioids use ≥ 12 weeks) were compared to randomly selected patients matched for age, race, and sex. Multivariate regression analysis was performed to identify factors that were independently predictive of longer procedure times., Results: Patients on chronic opioids required higher doses of fentanyl (122.0 ± 45.3 vs. 105.8 ± 47.2 µg; P < 0.0001) and midazolam (5.3 ± 5.3 vs. 4.4 ± 2 mg; P = 0.0037) and were more likely to receive diphenhydramine (42.8 vs. 22.6 %; P < 0.001). The induction period (11.3 ± 8.8 vs. 7.5 ± 4.0 min), duration of procedure (39.1 ± 17.5 vs. 33.4 ± 14.1 min), and recovery times (38.7 ± 15.3 vs. 33.8 ± 12.1 min) were significantly longer for patients on chronic opioids. In the multivariate regression analysis, opioid use was an independent predictor of longer procedure duration (P < 0.05). Hypotensive episodes did not differ between groups (2.8 vs. 2.7 %; P = 0.8). However, patients on chronic opioids experienced more pain (13.4 vs. 5.9 %; P 0.001) and hypertensive episodes (8.1 vs. 2.8 %; P 0.002)., Conclusion: Patients on chronic opioids represent a high-risk population with longer procedural times and more discomfort, despite higher dosages of sedative agents. Prospective studies are required to define the risks and benefits of more costly alternative sedation strategies for patients on chronic opioids.