An examining the static and dynamic mechanical characteristics of milled ramie root reinforced polyester composites

This research works discuss about the effective utilization of waste Ramie Root, that has been in reinforced polyester composites, powdered fillers that have not been treated are used. Four different composites plate were formed with compression moulding technique process consisting of 20, 30 and 40% of Powdered Ramie Root with 80, 70 and 60% unsaturated polyester resin, respectively. The maximum mechanical properties were observed for the composite with 30:70 weight volume percentages of milled ramie root synthetic reinforced polyester. The findings show that the glass transition temperature, storage modulus, and loss factors all rise when the composition of composites changes. Additionally, the powder cohesion force (bonding strength) has a greater impact on dynamic mechanical properties. Thermo-gravimetric the inclusion of Ramie Root powder caused the thermal deterioration peak of the composite to move from 370 °C to 418 °C, according to analysis (TGA) conducted under flowing oxygen. According to the measurement of water absorption, the ideal weight ratio of Fiber: Unsaturated Polyester Resin is 30:70, which modifies the fibres' surfaces and ensures optimal adhesion between the fibre and matrix in composite materials. Scanning electron microscopic investigation is done to ascertain the fracture behaviour of the composite. As a result of their stability, high tensile strength, and bending stiffness, the produced composites can be used in light-load applications by material technologists.

Identification of Bioactive Compounds of Leaf Extracts of Sida cordata (Burm.f.) Borss.Waalk. by GC/MS Analysis

Sida cordata (Burm.f.) Borss.Waalk. is a perennial prostrate herb belonging to the family Malvaceae found in the tropical and subtropical plains of India, Sri Lanka and Pakistan. It is one of the most essential plants in Ayurveda and Siddha system of traditional medicine and is used to treat various diseases and ailments. The present study is carried out to investigate the preliminary phytochemicals and bioactive compounds of leaf extracts by GC-MS. GC-MS analysis of leaf extracts revealed the presence of 50 compounds in all four solvents. Petroleum ether extract showed the presence of 18 compounds, whereas ethanol extract showed 12 compounds; chloroform and acetone extracts showed the presence of 10 compounds each. Phytol is the most significant compound in petroleum ether (28.72%), ethanol (32.99%), and acetone (41.61%) extracts. Whereas in chloroform extract, 1,2-benzenedicarboxylic acid (49.07%) is the most significant bioactive compound having antioxidant, antifouling and antimicrobial properties.

GC-MS Analysis of Bioactive Compounds of Flower Extracts of Calycopteris floribunda Lam.: A Multi Potent Medicinal Plant

Calycopteris floribunda Lam. is a potent medicinal woody climber that belongs to Combretaceae. This plant is usually found in dry deciduous tropical forests and is used in various medicinal practices like Ayurveda, Unani and Sidda. Whole plant and its different parts like leaves, flowers and stem are used in the treatment of diarrhoea, dysentery, jaundice and malaria. It is also have anthelminthic, anti-inflammatory, antifungal, hepatoprotective and anticancerous activities. Knowing its medicinal properties, the present study is undertaken to investigate the preliminary phytochemical constituents and bioactive compounds of flower extracts by GC-MS. GC-MS analysis of flower extracts revealed the presence of over all 41 compounds, of which, acetone and ethanol extracts showed the presence of 13 compounds each, chloroform extract 8 and petroleum ether extract 7 compounds. Some compounds were common in two and three extracts only. The significant bioactive compounds identified are 1,2-benzenedicarboxylic acid (59.81%) in chloroform extract, triterpene lupeol (34.98%) in ethanol extract, tetratetracontane (26.99%) in petroleum ether extract and gamma sitosterol (22.04%) in acetone extract.

Endoscopic ultrasound-guided gastroenterostomy versus surgical gastrojejunostomy in treatment of malignant gastric outlet obstruction: Systematic review and meta-analysis

Background and study aims  Palliative treatment of malignant gastric outlet obstruction (GOO) has conventionally been with surgical gastrojejunostomy (SGJ). Advent of devices like lumen apposing metal stents has made endoscopic ultrasound-guided gastroenterostomy (EUS-GE) a potential alternative to SGJ for these patients. We performed a systematic review and meta-analysis of studies that compared outcomes of EUS-GE versus SGJ. Methods  We performed a comprehensive systematic search of multiple electronic databases and conference proceedings through January 2021 and identified six studies that compared outcomes of EUS-GE versus SGJ in the management of malignant GOO. The rates of technical success, clinical success, and AEs were analyzed, and pooled odds ratios were calculated using random effects model. Results  Six studies were included in our analysis with a total of 484 patients, of which 291 underwent EUS-GE and 193 underwent SGJ. The technical success rate of SGJ was superior to EUS-GE (OR = 0.195; 95 %CI:0.054-0.702; P  = 0.012; I ²  = 0). The clinical success of EUS-GE was statistically similar to SGJ (OR = 1.566; 95 %CI:0.585-4.197; P  = 0.372; I ²  = 46.68 %). EUS-GE had significantly fewer AEs compared to SGJ (OR = 0.295; 95 %CI:0.172-0.506; P  < 0.005; I ²  = 0). Among studies which reported reintervention rates, EUS-GE was statistically similar to SGJ (OR = 0.587; 95 %CI:0.174-1.979; P  = 0.390, I ²  = 54.91). Minimal to moderate heterogeneity was noted in the analyses. Conclusions  EUS-GE has equivalent clinical success and reintervention rates, but significantly lower adverse events compared to SGJ. When feasible, EUS-GE appears to be an effective and safe alternative to SGJ for palliative management of malignant GOO.

Biliary Sphincterotomy Alone versus Biliary Stent with or without Biliary Sphincterotomy for the Management of Post-Cholecystectomy Bile Leak: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic therapy with endoscopic retrograde cholangiopancreatography is considered the first-line treatment in the management of post-cholecystectomy bile leak (PCBL). Currently, there is no consensus on the most effective endoscopic intervention for PCBL. Hence, we performed a systematic review and meta-analysis to compare the effectiveness and safety of the two interventional groups (biliary sphincterotomy [BS] alone vs. biliary stent ± BS) in management of PCBL.

METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through January 2021). The primary outcome was to compare the pooled rate of clinical success between the 2 groups. The secondary outcome was to estimate the pooled rate of adverse events.

RESULTS

The pooled rate of clinical success with BS alone (5 studies, 299 patients) was 88% (95% confidence interval (CI): 84-92%, I2: 0%) and for biliary stent ± BS (5 studies, 864 patients) was 97% (CI: 93-100%, I2: 79%). The rate of clinical success in biliary stent ± BS group was significantly higher than BS alone group (OR: 3.91 95% CI: 2.29-6.69, p < 0.001, I2: 13%). The rate of adverse events was numerically lower in biliary stent ± BS group compared to BS alone (3 studies; OR: 0.65 95% CI: 0.41-1.03, p = 0.07) without statistical significance. Low heterogeneity was noted in the analysis.

CONCLUSIONS

Biliary stent ± BS is more effective in endoscopic management of PCBL compared to BS alone. This may be related to inter-endoscopist variation in completeness of sphincterotomy and post-sphincterotomy edema, which can influence the preferential trans-papillary flow of bile.

Contamination Rates in Duodenoscopes Reprocessed Using Enhanced Surveillance and Reprocessing Techniques: A Systematic Review and Meta-Analysis

Background/Aims

Multiple outbreaks of multidrug-resistant organisms have been reported worldwide due to contaminated duodenoscopes. In 2015, the United States Food and Drug Administration recommended the following supplemental enhanced surveillance and reprocessing techniques (ESRT) to improve duodenoscope disinfection: (1) microbiological culture, (2) ethylene oxide sterilization, (3) liquid chemical sterilant processing system, and (4) double high-level disinfection. A systematic review and meta-analysis was performed to assess the impact of ESRT on the contamination rates.

Methods

A thorough and systematic search was performed across several databases and conference proceedings from inception until January 2021, and all studies reporting the effectiveness of various ESRTs were identified. The pooled contamination rates of post-ESRT duodenoscopes were estimated using the random effects model.

Results

A total of seven studies using various ESRTs were incorporated in the analysis, which included a total of 9,084 post-ESRT duodenoscope cultures. The pooled contamination rate of the post-ESRT duodenoscope was 5% (95% confidence interval [CI]: 2.3%–10.8%, inconsistency index [I²]=97.97%). Pooled contamination rates for high-risk organisms were 0.8% (95% CI: 0.2%–2.7%, I²=94.96).

Conclusions

While ESRT may improve the disinfection process, a post-ESRT contamination rate of 5% is not negligible. Ongoing efforts to mitigate the rate of contamination by improving disinfection techniques and innovations in duodenoscope design to improve safety are warranted.

Intraluminal Endovascular Coil Migration: A Rare Complication Post-Embolization of the Gastroduodenal Artery for a Previously Bleeding Duodenal Ulcer

Transarterial angiographic embolization is a highly effective, safe treatment for non-variceal upper gastrointestinal bleeding refractory to endoscopic intervention. However, intraluminal coil migration is a possible complication. Coil migration, while usually a self-limiting process, can lead to significant rebleeding. In our case, a patient presented with a life-threatening duodenal ulcer hemorrhage, likely precipitated by intraluminal endovascular coil migration after a recent gastro-duodenal artery embolization. He was successfully managed without endoscopic coil removal and had no additional gastrointestinal bleeding. It is important for endoscopists to be aware of this complication and weigh the risks and benefits of coil removal.

Outcomes of Radiofrequency Ablation versus Endoscopic Surveillance for Barrett's Esophagus with Low-Grade Dysplasia: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic therapy using radiofrequency ablation (RFA) is a recommended treatment for Barrett's esophagus with high-grade dysplasia (BE-HGD) without a visible lesion which is managed by resection. However, currently, there is no consensus on the management of BE with low-grade dysplasia (BE-LGD) - RFA versus endoscopic surveillance. Hence, we performed a systematic review and meta-analysis of these comparative studies to compare the risk of progression to HGD or esophageal adenocarcinoma (EAC) among patients with BE-LGD treated with RFA versus endoscopic surveillance.

METHODS

The primary outcome was to compare the risk of progression to HGD or EAC among patients with BE-LGD treated with RFA versus endoscopic surveillance.

RESULTS

Four comparative studies reporting a total of 543 patients with BE-LGD were included in the meta-analysis (234 in RFA and 309 in endoscopic surveillance). The progression of BE-LGD to either HGD or EAC was significantly lower in patients treated with RFA compared to endoscopic surveillance (OR: 0.17, 95% confidence interval [CI]: 0.04-0.65, p = 0.01). The progression to HGD alone was significantly lower in patients treated with RFA versus endoscopic surveillance (OR: 0.23, 95% CI: 0.08-0.61, p = 0.003). The progression to EAC alone was numerically lower in RFA than endoscopic surveillance without statistical significance (OR: 0.44, 95% CI: 0.17-1.16, p = 0.09). Moderate heterogeneity was noted in the analysis.

CONCLUSIONS

Based on our meta-analysis, there was a significant reduction in the risk of progression to HGD or EAC among patients with BE-LGD treated with RFA compared with those undergoing endoscopic surveillance. Endoscopic eradication therapy with RFA should be the preferred management approach for BE-LGD.

ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events.

METHODS

We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone.

RESULTS

10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 - 83.6) and 64.8 % (95 %CI 53.1 - 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 - 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 - 92.2) and 72.5 % (95 %CI 52.3 - 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 - 14.5). Substantial heterogeneity was noted.

CONCLUSIONS

OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed.

Proton pump inhibitor in upper gastrointestinal fecal microbiota transplant: A systematic review and analysis

BACKGROUND AND AIMS

Fecal microbiota transplantation (FMT) is used in recurrent Clostridioides difficile infections. However, protocols are facility dependent, and one variable is whether pre-procedural proton pump inhibitors (PPIs) are given. In theory, PPIs reduce acidity and protect the transplanted microbiome for the most potent dose. We conducted a systematic review to study the effect of PPIs on FMT delivered by upper gastrointestinal (GI) routes.

METHODS

We searched Pubmed/Medline, Cochrane Library, Embase, Scopus, and Web of Science through December 16, 2018 using variations of keywords "fecal microbiota transplant" and "Clostridium difficile infection." Two authors independently reviewed 4210 results and found 11 qualifying studies with data on upper GI FMT, use of PPIs, and the rate of treatment failure at follow-up.

RESULTS

Of 233 included patients, treatment failure occurred in 20.6% of those with use of PPIs versus 22.6% in the group without (relative risk 0.91; confidence interval 0.56-1.50). Limitations include the lack of studies directly comparing outcomes based on use of PPIs and inability to control for possible confounders such as chronic PPI use, amount of stool transplanted, and pre-FMT antibiotics.

CONCLUSIONS

We did not find evidence supporting a clinically significant benefit from routine use of PPIs in FMT protocol. It is possible that the theoretical benefit from improved survival of transplanted microbiota is offset by negative effects on the microbiome. We suggest that routine use of PPIs in upper GI FMT be reconsidered. Further investigation is needed to optimize protocols for safety and efficacy.

Outcomes of endoscopic sleeve gastroplasty; how does it compare to laparoscopic sleeve gastrectomy? A systematic review and meta-analysis

Background and study aims Endoscopic sleeve gastroplasty (ESG) is a novel moderately invasive technique in endo-bariatrics as compared to laparoscopic sleeve gastrectomy (LSG). Data is limited as to its efficacy and safety.

Methods We searched multiple databases from inception through August 2019 to identify studies that reported on ESG in the treatment of obesity. Our goals were to calculate the pooled rates of total weight loss (%TWL), excess weight loss (%EWL), and body mass index (BMI) at 1 month, 6 months, and 12 months with ESG. We included studies that reported on LSG, in a similar time frame as ESG, and compared the 12-month outcomes.

Results From eight studies on ESG (1815 patients), the pooled rates of %TWL at 1 month, 6 months, and 12 months were 8.7 (7.2–10.2), 15.3 (14.1–16.6) and 17.1 (15.1–19.1), respectively. The pooled rates of %EWL at 1 month, 6 months, and 12 months were 31.7 (29.3–34.1), 59.4 (57–61.8) and 63 (51.3–74.6), respectively. The pooled rates of BMI at 1 m, 6 m, and 12 m were 32.6 (31–34.3), 30.4 (29–31.8) and 30 (27.7–32.3, I2 = 97), respectively. At 12 months, the pooled %TWL, %EWL and BMI with LSG (7 studies, 2179 patients) were 30.5 (27.4–33.5), 69.3 (60.1–78.4) and 29.3 (27.1–31.4) respectively. On comparison analysis, %TWL with LSG was superior to ESG (P = 0.001). %EWL and BMI were comparable. All adverse events, bleeding and gastro-esophageal reflux disease were significantly lower with ESG when compared to LSG.

Conclusion ESG demonstrates acceptable weight loss parameters and seems to have a better safety profile when compared to LSG.

Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high risk acute cholecystitis patients: a systematic review and comparative meta-analysis

BACKGROUND

Endoscopic transpapillary gallbladder drainage (ETGBD) and endoscopic ultrasound-guided gallbladder drainage (EUSGBD) are alternatives to percutaneous gallbladder drainage (PCGBD) for patients with acute cholecystitis who are unfit for surgery. Data comparing these modalities are limited and have reported conflicting results.

METHODS

We searched multiple databases from inception to May 2019 to identify studies that reported on ETGBD, EUSGBD, and PCGBD in the management of acute cholecystitis in patients with a high surgical risk. Aims were to compare the pooled rates of technical success, clinical success, adverse events, and disease recurrence.

RESULTS

1223 patients (22 studies), 557 patients (14 studies), and 13 351 patients (46 studies) were treated by ETGBD, EUSGBD, and PCGBD, respectively. The pooled technical and clinical successes were: ETGBD 83 % (95 % confidence interval [CI] 80.1 - 85.5, I ² = 29) and 88.1 % (95 %CI 83.6 - 91.4, I ² = 50), respectively; EUSGBD 95.3 % (95 %CI 92.8 - 96.9, I ² = 0) and 96.7 % (95 %CI 94.0 - 98.2, I ² = 0), respectively; and PCGBD 98.7 % (95 %CI 98.0 - 99.1, I ² = 0) and 89.3 % (95 %CI 86.6 - 91.5, I ² = 84), respectively. Clinical success with EUSGBD was significantly superior to the other approaches. All complications were comparable between the groups. Pancreatitis occurred with ETGBD in 5.1 % (95 %CI 3.5 - 7.3), whereas bleeding and perforation occurred with EUSGBD in 4.3 % (95 %CI 2.7 - 6.8) and 3.7 % (95 %CI 2.3 - 6.0), respectively. Stent migration occurred with PCGBD in 7.4 % (95 %CI 5.5 - 10.0).

CONCLUSION

EUSGBD demonstrated better clinical success than ETGBD and PCGBD in the management of acute cholecystitis patients at high surgical risk.

EUS-guided biliary drainage: A systematic review and meta-analysis

ERCP is the current procedure of choice for patients with jaundice caused by biliary obstruction. EUS-guided biliary drainage (EUS-BD) has emerged as an alternative to ERCP in patients requiring biliary drainage. The aim of the study was to conduct a systematic review and meta-analysis to report the overall efficacy and safety of EUS-BD. We conducted a comprehensive search of several databases including PubMed, EMBASE, Web of Science, Google Scholar, and LILACS databases (earliest inception to June 2018) to identify studies that reported EUS-BD in patients. The primary outcome was to look at the technical and clinical success of the procedure. The secondary analysis focused on calculating the pooled rate of re-interventions and all adverse-events, along with the commonly reported adverse-event subtypes. Twenty-three studies reporting on 1437 patients were identified undergoing 1444 procedures. Majority of the patient population were male (53.86%), with an average age of 67.22 years. The pooled technical success rates and clinical success rates were 91.5% (95% confidence interval [CI]: 87.7-94.2, I^[2] = 76.5) and 87% (95% CI: 82.3-90.6, I^[2] = 72.4), respectively. The total adverse event rates were 17.9% (95% CI: 14.3-22.2, I^[2] = 69.1). Subgroup analysis of three major individual adverse events was bile leak: 4.1% (2.7-6.2, I^[2] = 46.7), stent migration: 3.9% (2.5-6.2, I^[2] = 43.5), and infection: 3.8% (2.8-5.1, I^[2] = 0) Substantial heterogeneity was noted in the analysis. EUS-BD has high technical and clinical success rate and hence a very effective procedure. Concerns about publication bias exist. Careful consideration should be given to the adverse events and weighing the risks and benefits of the alternative nonsurgical/surgical approaches.

Risk of progression in Barrett's esophagus indefinite for dysplasia: a systematic review and meta-analysis

BACKGROUND AND AIMS

Risk of progression in Barrett's esophagus (BE) with low-grade dysplasia (LGD) and high-grade dysplasia (HGD) has been established. However, the natural history of BE with indefinite dysplasia (BE-IND) remains unclear. We performed a systematic review and meta-analysis to estimate the pooled risk of progression to HGD and/or esophageal adenocarcinoma (EAC) in BE-IND.

METHODS

We performed a systematic search of multiple databases to June 2018 to identify studies reporting the incidence of HGD, EAC, or HGD/EAC as an outcome in patients with BE-IND undergoing endoscopic surveillance. The pooled incidence rate of HGD and/or EAC and EAC alone was estimated.

RESULTS

We identified 8 studies reporting the incidence of HGD and/or EAC and 5 studies reporting the incidence of EAC in BE-IND. The pooled incidence of HGD and/or EAC (89 cases in 1441 patients over 5306.2 person-years) was 1.5 per 100 person-years (95% confidence interval [CI], 1.0-2.0). The pooled incidence of EAC (40 cases in 1266 patients over 4520.2 person-years) was 0.6 per 100 person-years (95% CI, 0.1-1.1). Substantial heterogeneity was noted in the analyses. On subgroup analysis, the incidence of EAC was higher in studies from Europe compared with North America (0.9% vs 0.1%, P = .01). The pooled incidence of LGD was 11.4 per 100 person-years (95% CI, 0.06-0.2).

CONCLUSION

The estimated incidence of HGD and/or EAC and EAC alone in BE-IND is similar to the previously reported progression risk in BE-LGD. Based on these risk estimates, patients with BE-IND should be placed on active endoscopic surveillance.

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy: A systematic review and meta-analysis

BACKGROUND/AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging procedure rarely associated with severe postprocedure complications. Hormonal changes during pregnancy promote cholelithiasis, but there are limited clinical data available on the outcomes of ERCP in pregnant women. ERCP techniques without irradiation were recently introduced as potential alternative. We performed a systematic review and meta-analysis to assess the safety of ERCP in pregnancy and to compare outcomes of radiation versus nonradiation ERCP.

MATERIALS AND METHODS

A systematic search of PubMed, Medline/Ovid, Web of Science, and Google Scholar through April 18^th, 2018 using PRISMA and MOOSE guidelines identified 27 studies reporting the outcomes of ERCP in pregnancy. Random effects pooled event rate and 95% confidence intervals (CIs) were estimated. Heterogeneity was measured by I², and meta-regression analysis was conducted. Adverse outcomes were divided into fetal, maternal pregnancy-related, and maternal nonpregnancy-related.

RESULTS

In all, 27 studies reporting on 1,307 pregnant patients who underwent ERCP were identified. Median age was 27.1 years. All results were statistically significant (P < 0.01). The pooled event rate for overall adverse outcomes was 15.9% (95% CI = 0.132-0.191) in all studies combined, 17.6% (95% CI = 0.109-0.272) in nonradiation ERCP (NR-ERCP) subgroup and 21.6% (95% CI = 0.154-0.294) in radiation ERCP subgroup. There was no significant difference in the pooled event rate for fetal adverse outcomes in NR-ERCP 6.2% (95% CI = 0.027-0.137) versus 5.2% (95% CI = 0.026-0.101) in radiation ERCP group. There was no significant difference in maternal pregnancy-related adverse outcome event rate between NR-ERCP (8.4%) (95% CI = 0.038-0.173) and radiation ERCP (7.1%) (95% CI = 0.039-0.125). Maternal nonpregnancy-related adverse outcome event rate in NR-ERCP was 7.6% (95% CI = 0.038-0.145), which was half the event rate in radiation ERCP group of 14.9% (95% CI = 0.102-0.211).

CONCLUSIONS

ERCP done by experienced endoscopists is a safe procedure during pregnancy. Radiation-free techniques appear to reduce the rates of nonpregnancy-related complications, but not of fetal and pregnancy-related complications.

2434. Proton Pump Inhibitor Use on Efficacy of Fecal Microbiota Transplant Administered by Trans-Oral Routes for Clostridioides Difficile Infection: A Systematic Review and Analysis

Background

Current guidelines include fecal microbiota transplantation (FMT) in the management of recurrent Clostridioides difficile infections (CDI). However, FMT protocols are often facility dependent, and one variable is whether proton pump inhibitors (PPI) are given during preparation. Theoretically, PPIs reduce acidity and protects the transplanted microbiome for the most potent dose. On the other hand, PPIs have also been shown to negatively alter the microbiome and increase the risk of CDI. We conducted a systematic review of the literature to study PPI use on the efficacy of FMT delivered by the trans-oral route.

Methods

We searched PubMed/Medline, Cochrane Library, Embase, Scopus, and Web of Science through December 16th, 2018 using variations of keywords “fecal microbiota transplant” and “Clostridium difficile infection” with 4210 results. Two independent authors reviewed and excluded studies with unrelated topics, abstracts, case reports, or a low level of evidence. Studies with data on trans-oral FMT, PPI use, and the success rate were included. Final review yielded 11 studies including randomized controlled, case–control, cohort, retrospective and prospective trials. The primary outcome was the rate of FMT failure, defined as recurrence of symptoms with positive CDI testing at follow-up.

Results

Out of 233 included patients, 131 received a PPI per FMT protocol resulting in 27 cases of treatment failure. There were 23 cases of recurrence out of 102 patients who did not receive pre-FMT PPI. The primary outcome occurred in 20.6% in the group with PPI use vs. 22.6% in the group without (RR 0.91; CI 0.56 - 1.50). Limitations include the lack of studies directly comparing outcomes with respect to PPI use, and inability to control possible confounders such as chronic PPI use, amount of stool transplanted, and pre-FMT antibiotics.

Conclusion

We did not find a significant difference in efficacy between FMT protocols with regard to PPI use. It is possible that the theoretical benefit from increased survival of transplanted microbiota is offset by negative effects associated with PPIs. We suggest that routine use of PPIs in FMT be reconsidered in the absence of clear benefit. Further investigation is needed to optimize protocols for safety and efficacy.

Disclosures

All authors: No reported disclosures.

Autoimmune hepatitis in patients with human immunodeficiency virus infection: A systematic review of the published literature

BACKGROUND

Liver disease in patients with HIV is common and typically has complex and multifactorial presentations that represent a major cause of morbidity and mortality. Autoimmune hepatitis (AIH) is rarely reported in patient with HIV and the disease course and clinical outcomes for treatment have not been well characterized. We are aiming to determine the patient characteristics, disease prevalence, and treatment outcomes from published articles of patients with HIV and AIH.

METHOD

A systematic search of PubMed, Web of Science, and Google Scholar through February 20, 2019 identified 15 studies that reported the outcomes of AIH in patients with HIV. Because of the small sample sizes and skewed distributions, resampling tests of mean differences using permutation distributions (MAXn = 10,000 permutations) were utilized; analyses were performed using R (v. 3.5.1). Categorical differences were calculated using Fisher exact test for odds ratio = 1 (equal odds), and Cramer V was calculated for effect size; analyses were completed in SPSS (v. 25).

RESULTS

By reviewing 15 studies reporting a total of 35 patients with AIH and HIV, male patients were found to have significantly higher aspartate transaminase and alanine transaminase levels at time of diagnosis. No other significant findings identified. The CD4 count and viral load did not show significant correlation with AIH diagnosis or its prognosis. All patients but one who presented with severe immune deficiency and responded to highly active anti-retroviral therapy received immunosuppressive treatment without side effects and achieved remission except 2 lost to follow-up and 3 expired.

CONCLUSION

Although rare, but AIH can develop in patients with HIV and physicians should consider it in the differential diagnosis for HIV patients presented with abnormal liver function tests, especially after excluding hepatitis C virus and drug-induced liver injury.Patients with immune deficiency disorders who present with AIH can be treated safely with steroid either as monotherapy or in combination with another immune suppressant therapy.

Liquid Nitrogen Spray Cryotherapy in Treatment of Barrett's Esophagus, where do we stand? A Systematic Review and Meta-Analysis

Radiofrequency ablation (RFA) is the preferred treatment option for Barrett's esophagus (BE) to achieve complete eradication (CE) of dysplasia (D), and intestinal metaplasia (IM). Cryotherapy, using liquid nitrogen (LNC), is a cold-induced tissue-injury technique option for the ablation of BE. We conducted a systematic review and meta-analysis to assess the overall efficacy and safety of LNC in the treatment of BE. We conducted a search of multiple electronic databases and conference proceedings from inception through June 2018. The primary outcome was to estimate the pooled rates of CE-IM, CE-D, and CE-HGD. The secondary outcome was to estimate the risk of adverse events and recurrence of disease after LNC. Nine studies reported 386 patients who were treated with LNC. The pooled rate of CE-IM was 56.5% (95% CI 48.5-64.2, I2 = 47), pooled rate of CE-D was 83.5% (95% CI 78.3-87.7, I2 = 22.8), and pooled rate of CE-HGD was 86.5% (95% CI 64.4-95.8, I2 = 88.1). Rate of adverse events was 4.7%, and the risk of BE recurrence was 12.7%. On subgroup analysis, the pooled rate of CE-IM with LNC in patients who failed RFA was 58.4% (95% CI 47.2-68.8, I2 = 32.5), and the pooled rate of CE-D in the same population was 81.9% (95% CI 72.5-88.6, I2 = 5.9). CE-D rates with LNC are comparable to RFA while CE-IM rates appear to be lower than the rates achievable with RFA. CE-IM rate in RFA failed patients is 58.4% and thus LNC is a rescue option to consider in this population.

Safety and efficacy of combined antegrade and retrograde endoscopic dilation for complete esophageal obstruction: a systematic review and meta-analysis

Background

Complete esophageal obstruction (CEO) due to occlusive proximal stricture occurs after chemoradiation for head and neck cancers. A combined antegrade and retrograde endoscopic technique with controlled recanalization and dilation (CARD) has been shown to be an effective and safe method for regaining and maintaining esophageal luminal patency in the short term.

Methods

We conducted a comprehensive search of multiple electronic databases and conference proceedings, including PubMed, EMBASE, and Web of Science databases (from inception through November 2018), to identify studies that reported the outcomes of CARD. The primary outcomes were the pooled rates of technical and clinical success, specifically improvement in dysphagia and independence from percutaneous endoscopic gastrostomy (PEG)-tube feeds. The secondary outcomes were the need for repeat dilations and the risks of complications, such as pneumomediastinum, perforation, and death.

Results

From a total of 19 studies (229 cases and 251 procedures) the calculated technical success rate was 88.9% (95% confidence interval [CI] 83.9-92.5, I²=0). The rates of improvement in dysphagia and being PEG-tube free were 58.4% (95%CI 50-66.3, I²=12.6) and 43.5% (95%CI 34.1-53.4, I²=30.6), respectively. The pooled rate of repeat dilatations was 78.9% (95%CI 69.7-85.8, I²=15.2). The risks of pneumomediastinum, perforation and death were 9.9% (95%CI 6.2-15.6, I²=0), 8% (95%CI 4.8-13, I²=0), and 6.8% (95%CI 3.4-13.1, I²=0), respectively. Minimal heterogeneity was noted in the analysis.

Conclusions

The CARD procedure for CEO has a high technical success rate, but also a high rate of repeat dilations. Given its complexity and associated adverse events, this procedure should be restricted to centers with a high level of expertise.

Hot snare vs. cold snare polypectomy for endoscopic removal of 4 - 10 mm colorectal polyps during colonoscopy: a systematic review and meta-analysis of randomized controlled studies

Introduction  In recent years, cold snare polypectomy (CSP) has increasingly been used over hot snare polypectomy (HSP) for the removal of colorectal polyps (4 - 10 mm in size). However, the optimal technique (CSP vs. HSP), in terms of complete polyp resection and complications, is uncertain. Our aim was to compare incomplete resection rate (IRR) of polyps and complications using CSP vs. HSP. Methods  Randomized controlled studies (RCTs) comparing CSP and HSP for removal of 4 - 10 mm colorectal polyps were considered. Studies were included in the analysis if they obtained biopsy specimens from the resection margin to confirm the absence of residual tissue and reported complications. IRR and complication rate were the outcome measures. Pooled rates were reported as Odds Ratios (OR) or risk difference with 95 % Confidence Interval (CI). Results  In total, three RCTs were included in the final analysis. A total of 1051 patients with 1485 polyps were randomized to either HSP group (n = 741 polyps) or CSP group (n = 744 polyps). The overall IRR did not differ between the two groups (HSP vs. CSP: 2.4 % vs. 4.7 %; OR 0.51, 95 %CI 0.13 - 1.99, P  = 0.33, I ²  = 73 %). The HSP group had a lower rate of overall complications compared to the CSP group (3.7 % vs. 6.6 %; OR 0.53, 95 % CI 0.3 - 0.94, P  = 0.03, I ²  = 0 %). Polyp retrieval rates were not different between the two groups (99 % vs. 98.1 %). Conclusion  Our results suggest that HSP and CSP techniques can be effectively used for the complete removal of 4 - 10 mm colorectal polyps; however, HSP has a lower incidence of overall complications.

Periampullary Diverticula and ERCP Outcomes: A Systematic Review and Meta-Analysis

INTRODUCTION

Periampullary diverticulum (PAD) is most often asymptomatically found in elderly population. ERCP in the presence of PAD is technically challenging since the location and orientation of the ampulla could be altered. Various studies have reported differing results on the technical success and safety outcomes of ERCP in the presence of PAD. We aimed at a meta-analysis of such studies to assess the technical success and the occurrence of complications during ERCP in patients with PAD.

METHODS

We conducted a comprehensive search of several databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception to October 2017). The search was done in accordance with PRISMA guidelines to identify studies. Studies that reported on the ERCP outcomes based on the presence of PAD were included. Both prospective and retrospective studies, manuscripts and abstracts were included. Only articles in English literature were included. The primary analysis focused on the overall technical success of ERCP in the presence of PAD, and the secondary analysis was to estimate the risk of occurrence of complications.

RESULTS

Our search resulted in 16 studies that were included for final analysis. These 16 studies reported on 2794 patients, who had PAD, and the control group included 13,032 patients, who did not have a PAD during ERCP. Our meta-analysis of this data showed an Odd's ratio estimate of having a successful ERCP procedure in patients with PAD to be 0.51 [95% C.I. (0.35-0.72)] when compared to patients without it. This was statistically significant, with a p value 0.00. Considerable heterogeneity was noted among the studies. The heterogeneity proportion was quantified at 74.6% based on I² statistic. The secondary outcomes measured were complications. We analyzed the pooled Post-ERCP Pancreatitis (PEP), cholangitis, perforation, and bleeding. Only those studies that had the data for these complications in both the study and the control groups were selected. PEP: The pooled Odd's estimate of having PEP was 1.28, [95% C.I (0.88-1.87)] from 12 studies reporting on 1863 patients with PAD in comparison with 7803 patients without it. The risk of PEP occurrence tended to be more in the group without PAD, though it was not statistically significant, with a p value 0.20. There was some heterogeneity observed between the studies, with the quantification I² statistic being 28.6%. Our analysis shows that having PAD does not put a patient at increased risk for PEP. Bleeding: The pooled Odds estimate was 1.69, 95% C.I. 0.88-3.25 from nine studies reporting on 1816 patients with PAD in comparison with 5327 patients without it. This was not statistically significant, p value 0.11. Considerable heterogeneity was noted, with I² being 55.7%. The risk of having a bleed was noted to be more in control group, and having PAD did not put patients at increased risk for bleeding during an ERCP procedure. Perforation: Patients with PAD undergoing ERCP were not at increased risk for perforation. Seven studies reported on this complication. This was noted in seven patients out of 1245 in study group, and 19 patients out of 4912 in control group. The pooled Odd's estimate was 1.24, 95% C.I. 0.54-2.87. There was no statistical significance, p value 0.61. No heterogeneity was noted among the studies included in this analysis. Cholangitis: Only four studies reported on this complication. In a total of 778 patients in study group, four had cholangitis and eight had this complication out of 3886 patients in the control group. The pooled Odd's was 2.12, 95% C.I. 0.61-7.33. There was no statistical significance, p value 0.24. No heterogeneity was noted.

CONCLUSION

ERCP is technically feasible and increasingly successful when performed by experts in the presence of PAD. The risk of complications such as PEP, bleeding, perforation and cholangitis does not differ between ERCP done in patients with and without PAD.

Comparison of Franseen and fork-tip needles for EUS-guided fine-needle biopsy of solid mass lesions: A systematic review and meta-analysis

Franseen-tip and Fork-tip needles have been widely used in EUS guided fine-needle biopsy (FNB) of solid organs. There is conflicting data on the performance of these needles and unanswered questions on the ideal number of needle-passes and the requirement of an onsite cytopathologist (ROSE). We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through July 2018) to identify studies that reported on the use of Forktip and Franseen-tip needles in EUS-FNB of solid organs. The primary outcome was to estimate and compare the pooled rates of diagnostic-yield. A subgroup analysis compared the outcomes based on the number of needle-passes and the availability of ROSE. A total of 23 study-arms were available for analysis. The pooled rate of diagnostic yield with Fork-tip needle was 92.8% (95% CI 85.3 - 96.6, I² = 73.1) and the pooled rate of diagnostic yield with Franseen-tip needle was 92.7% (95% CI 86.4 - 96.2, I² = 88.4).

Lumen apposing metal stents in drainage of pancreatic walled-off necrosis, are they any better than plastic stents? A systematic review and meta-analysis of studies published since the revised Atlanta classification of pancreatic fluid collections

Lumen-apposing metal stents (LAMS) are increasingly being used in the drainage of pancreatic walled-off necrosis (WON). Best choice of stent is subject to argument, and studies are varied in the reported outcomes between LAMS and plastic stents (PS) to this end. We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (earliest inception through July 2018) to identify studies that reported on the use of LAMS and PS in WON drainage. Studies published since the release of the revised Atlanta classification for pancreatic fluid collections (2014 to current) were included in the analysis. The outcomes were to estimate and compare the pooled rates of clinical success, and adverse-events. A total of 9 studies (737 patients) for LAMS and 6 studies (527 patients) for PS were included in the analysis. The pooled rate of clinical-success with LAMS was 88.5% (95% CI 82.5-92.6, I² = 71.7) and with PS was 88.1% (95% CI 80.5-93.0, I² = 78.1) and the difference was not statistically significant, P = 0.93. No difference was noted in the pooled rates of all adverse-events, LAMS: 11.2% (6.8-17.9, I² = 82.0); vs PS: 15.9% (8.4-27.8, I² = 78.8); P = 0.38. Based on our meta-analysis, LAMS and PS demonstrate equal clinical outcomes and equal adverse-events in the drainage of pancreatic WON.

Comparison of outcomes for supine vs. prone position ERCP: a systematic review and meta-analysis

Background  While endoscopic retrograde cholangiopancreatography (ERCP) is usually performed in the prone position, some studies have advocated for ERCP in the supine position. Studies comparing the technical success and safety outcomes have shown variable results. We performed a systematic review and meta-analysis of studies reporting the comparison between the two positions for ERCP outcomes. Methods  We conducted a search of electronic databases and conference proceedings including PubMed, EMBASE, and Web of Science databases (from inception through October 2016) to identify studies that reported the comparison of technical success and safety outcomes between supine and prone ERCP. The primary outcome was to estimate the pooled rates of technical success. The secondary outcome was to estimate the risks of complications, such as cardiopulmonary and post-ERCP pancreatitis (PEP). Results  Six studies reporting on 309 supine and 1415 prone ERCPs were identified. The pooled technical success rates for completion of ERCP in supine and prone positions were 89.1 % (95 %CI = 80.9 - 94.0) and 95.6 % (95 %CI = 91.5 - 97.7), respectively. The pooled rates for complications (cardiopulmonary and PEP) in the supine position were 37.5 % (95 %CI = 19.1 - 60.3) and 3.5 % (95 %CI = 1.6 - 7.3), respectively. The pooled rates for complications (cardiopulmonary and PEP) in the prone position were 41.0 % (95 %CI = 20.9 - 64.8) and 3.9 % (95 %CI = 2.4 - 6.4), respectively. The mean time required for the procedure was 30 minutes and 29.8 minutes for supine and prone positions, respectively. Substantial heterogeneity was noted in the analysis. Conclusion  Prone ERCPs have a higher technical success rate with a slightly lower mean duration but a higher number of adverse events. The decision with regard to patient position should be made after evaluating the overall clinical scenario.

Drugs in Development for Hepatitis B

With high morbidity and mortality worldwide, there is great interest in effective therapies for chronic hepatitis B (CHB) virus. There are currently several dozen investigational agents being developed for treatment of CHB. They can be broadly divided into two categories: (1) direct-acting antivirals (DAAs) that interfere with a specific step in viral replication; and (2) host-targeting agents that inhibit viral replication by modifying host cell function, with the latter group further divided into the subcategories of immune modulators and agents that target other host functions. Included among the DAAs being developed are RNA interference therapies, covalently closed circular DNA (cccDNA) formation and transcription inhibitors, core/capsid inhibitors, reverse transcriptase inhibitors, hepatitis B surface antigen (HBsAg) release inhibitors, antisense oligonucleotides, and helioxanthin analogues. Included among the host-targeting agents are entry inhibitors, cyclophilin inhibitors, and multiple immunomodulatory agents, including Toll-like receptor agonists, immune checkpoint inhibitors, therapeutic vaccines, engineered T cells, and several cytokine agents, including recombinant human interleukin-7 (CYT107) and SB 9200, a novel therapy that is believed to both have direct antiviral properties and to induce endogenous interferon. In this review we discuss agents that are currently in the clinical stage of development for CHB treatment as well as strategies and agents currently at the evaluation and discovery phase and potential future targets. Effective approaches to CHB may require suppression of viral replication combined with one or more host-targeting agents. Some of the recent research advances have led to the hope that with such a combined approach we may have a functional cure for CHB in the not distant future.

Zinc oxide nanoparticles (ZnONPs) alleviate heavy metal-induced toxicity in Leucaena leucocephala seedlings: A physiochemical analysis

The present study describes the role of zinc oxide nanoparticles (ZnONPs) in reversing oxidative stress symptoms induced by heavy metal (Cd and Pb) exposure in Leucaena leucocephala (Lam.) de Wit. Seedling growth was significantly enhanced with the augmentation of ZnONPs following Cd and Pb exposure. Heavy metal accumulations were recorded as 1253.1 mg Cd per kg DW and 1026.8 mg Pb per kg DW for the respective treatments. Results demonstrated that ZnONPs augmentation caused an increase in photosynthetic pigment and total soluble protein contents while a significant decrease in malondialdehyde (MDA-lipid peroxidation) content in leaves. Antioxidative enzymes such as superoxide dismutase (SOD), catalase (CAT) and peroxidase (POX) were, in turn, elevated in heavy metal-exposed leaves amended with ZnONPs. The ameliorating effect of ZnO nanoparticles on oxidative stress induced toxicity was also confirmed by the reduced MDA content and the elevated level of antioxidative enzyme activities in leaf tissues of L. leucocephala seedlings. Further, addition of ZnONPs in combination with Cd and Pb metals induced distinct genomic alterations such as presence of new DNA bands and/or absence of normal bands in the RAPD pattern of the exposed plants. This study uniquely suggests a potential role of zinc oxide nanoparticles in the remediation of heavy metal contaminated media.

Role of strain imaging in right heart disease: a comprehensive review

Advances in the imaging techniques of the heart have fueled the interest in understanding of right heart pathology. Recently, speckle tracking echocardiography has shown to aid in understanding various right heart diseases and better management. Its role is well established in diagnosing right heart failure, pulmonary artery hypertension, arrhythmogenic right ventricular dysplasia and congenital heart disease. We review the basic mechanics of speckle tracking and analyze its role in various right heart conditions.