Colon-Adhering Delivery System with Inflammation Responsiveness for Localized Therapy of Experimental Colitis

Ulcerative colitis (UC) is a chronic inflammation-related disease that severely affects the colon and rectum regions. A variety of therapy regimens are used for the treatment of UC. Clinically, therapeutic enema is the choice of therapy for UC patients. Irrespective of on-site administration, the major limitation of therapeutic enemas is the dispossession of the medicine followed by low drug availability for the therapeutic action. In our present work, we have developed an enzyme-responsive injectable hydrogel (ER-hydrogel) to overcome the limitations of therapeutic enema. The hydrogels possess two major advantages, which are being exploited for therapeutic drug delivery in UC: prolonged retention and enzyme responsiveness. The former is one of the prominent advantages of hydrogel compared to free drug enema and the latter controls the release of the drug or provides drug release on-demand. The ER-hydrogel was formulated by the heat-cool method and for therapeutic purposes, a corticosteroid drug, budesonide (Bud), was encapsulated into the ER-hydrogel and evaluated for its various physicochemical and therapeutic potentials in dextran sodium sulfate (DSS)-induced UC. In vitro and ex vivo adhesion studies confirm the retention or mucoadhesive nature of the ER-hydrogel, and the upsurge in Bud release from the Bud-loaded ER-hydrogel upon the addition of esterase enzyme confirms the enzyme-mediated drug release from the ER-hydrogel. Moreover, Bud-loaded ER-hydrogel exhibited promising results in alleviating the disease activity index of UC, and restored the length of the colon, which is the main hallmark of UC. In terms of the health of the colon tissue, the Bud-loaded ER-hydrogel restored the colonic tissue damage, as seen in the H&E-stained, AB-NR-stained, and HID-AB-stained colon sections. Finally, the Bud-loaded ER-hydrogel also markedly subsided the IL-1β, TNF-α, MPO, and nitrite levels in serum and colon tissues. Thus, the fabricated Bud-loaded ER-hydrogel possesses appreciable translational potential due to its ability to significantly ameliorate inflammatory changes compared to naive or water-based therapeutic enema in acute experimental colitis in mice.

Causes And Consequences Of The Shortage Of Physicians In Sindh, Pakistan: A Local Perspective

The narrative review was designed to investigate potential factors that contribute to the shortage of primary care and specialty care physician workforce in Sindh, Pakistan, and how the disparity contributes to the proliferation of medical quackery across the province. There are serious consequences for the patients, putting additional strain on Sindh's healthcare system. Pakistan is one of the many countries where the demand for doctors is outpacing the supply. The province of Sindh lacks the medical personnel necessary to address its healthcare needs. Since there is a greater need than supply of general practitioners and specialists, there may be a growing gap between the healthcare workforce and patient care which may reinforce mounting physician shortage in the future due to factors, such as an ageing physician population, an escalating general population, and the fact that many doctors are nearing retirement age.

Therapeutic Potential of Methotrexate-Loaded Superparamagnetic Iron Oxide Nanoparticles Coated with Poly(lactic-co-glycolic acid) and Polyethylene Glycol against Breast Cancer: Development, Characterization, and Comprehensive In Vitro Investigation

Novel superparamagnetic iron oxide nanoparticles (SPIONs) of Methotrexate (MTX) were developed using supercritical liquid technology and optimized with a Box-Behnken design in order to assess its potential as a candidate for the treatment of breast cancer. MTX-SPIONs coated with poly(lactic-co-glycolic acid)-polyethylene glycol 400 had an aggregate size of 500 nm and an encapsulation efficiency of 46.8 ± 3.9%. The Fourier-transformed infrared spectroscopy analysis revealed a shift in the main bands due to intermolecular hydrogen bonds, whereas the differential scanning calorimetry analysis revealed the absence of the MTX melting endotherm, indicating complete encapsulation with oxide nanoparticles. The zeta potential results indicated a value of 4.98 mV, whereas the in vitro release study revealed an initial burst release followed by a considerable release of 35.1 ± 2.78% after 12 h. Using flow cytometry, control, MTX, and MTX-SPIONs were evaluated for apoptosis, with MTX-SPIONs exhibiting greater apoptosis than the control group and MTX. In addition, MTX-SPIONs inhibited cell division and content organization while substantially increasing the proportion of cells in the G1 and G2 phases relative to the control group. MTX-SPIONs exhibited prolonged anticancer effects against MCF-7 cell lines compared to MTX alone, indicating that SPION-delivered chemotherapeutics may increase cytotoxicity. The medication was stable with low encapsulated drug loss, suggesting that the supercritical liquid technology-based method is a promising way for generating drug-polymer magnetic composite nanoparticles for cancer treatment.

When I say … burnout

In the world of wellness, 'burnout' might as well be a God term. But what do we really mean when we say, "I'm burned out." And is this one little word enough?

Propofol-induced myoclonus during maintenance of anaesthesia

Myoclonus is a known side effect of propofol and can interfere with surgery and possibly precipitate patient injury. Here, we report a 23-year-old patient undergoing an L5 osteoblastoma resection with a predominantly propofol-based anaesthetic who developed intra-operative myoclonus. Other adjuncts included ketamine, lidocaine and fentanyl infusions. The myoclonus did not improve after deepening the anaesthetic with propofol, opioid boluses or discontinuation of the lidocaine infusion. The myoclonus ceased after reducing the propofol infusion and increasing the ketamine and opioid infusions. The remainder of the intra-operative course was uneventful. This report details our intra-operative management of propofol-induced cortical reflex myoclonus and discusses our institution's experience with treating this phenomenon.

Biomaterial-based strategies for immunomodulation in IBD: current and future scenarios

Instinctive gastrointestinal inflammatory conditions with persistent intestinal inflammation are known as "inflammatory bowel diseases" (IBDs). IBDs are growing progressively common throughout the world although it is still unclear what causes them. IBDs that cause recurrent, intermittent, and disburse inflammatory responses, may also have systemic symptoms such as ulcerative colitis and Crohn's disease. It has been discovered that a number of medications, including antibiotics, corticosteroids, and immune-suppressants, can promote mucous and damaged epithelial restoration. The incidences of general and specific therapy failure in IBD continue to climb, even though the availability of advanced biologics including anti-interleukins, anti-integrins, anti-tumor necrosis factor (anti-TNF), and small molecules such as tofacitinib exist. Management therapies that are currently being researched include specifically JAK (janus kinase) inhibitors, anti-IL (anti-interleukin) (IL-12, IL23), and leukocyte inhibitors such as sphingosine-1-phosphate receptors. Clinical treatments can have various adverse effects. In order to give pharmacological drugs to the disease-specific sites with improved efficacy and fewer complications, innovative frameworks centered on biomaterials are needed. We provide an outlook on the current state of several biomaterials used to treat IBD. This article comprehensively addresses numerous microparticles, nanoparticles, and hydrogels that have recently been made from natural bio-polymers and lipids. To support colon-specific target delivery and steady release of medications during IBD therapies, these various biomaterial-based monotherapies could be employed as efficient drug delivery systems.

NLRP3 Inflammasome-Targeting Nanomicelles for Preventing Ischemia-Reperfusion-Induced Inflammatory Injury

Ischemia-reperfusion (I/R) injury is a disease process that affects several vital organs. There is widespread agreement that the NLRP3 inflammasome pathway plays a crucial role in the development of I/R injury. We have developed transferrin-conjugated, pH-responsive nanomicelles for the entrapment of MCC950 drug. These nanomicelles specifically bind to the transferrin receptor 1 (TFR1) expressed on the cells of the blood-brain barrier (BBB) and thus help the cargo to cross the BBB. Furthermore, the therapeutic potential of nanomicelles was assessed using in vitro, in ovo, and in vivo models of I/R injury. Nanomicelles were injected into the common carotid artery (CCA) of a middle cerebral artery occlusion (MCAO) rat model to achieve maximum accretion of nanomicelles into the brain as blood flows toward the brain in the CCA. The current study reveals that the treatment with nanomicelles significantly alleviates the levels of NLRP3 inflammasome biomarkers which were found to be increased in oxygen-glucose deprivation (OGD)-treated SH-SY5Y cells, the I/R-damaged right vitelline artery (RVA) of chick embryos, and the MCAO rat model. The supplementation with nanomicelles significantly enhanced the overall survival of MCAO rats. Overall, nanomicelles exerted therapeutic effects against I/R injury, which might be due to the suppression of the activation of the NLRP3 inflammasome.

Insight into the transcription factors regulating Ischemic Stroke and Glioma in Response to Shared Stimuli

Cerebral ischemic stroke and glioma are the two leading causes of patient mortality globally. Despite physiological variations, 1 in 10 people who have an ischemic stroke go on to develop brain cancer, most notably gliomas. In addition, glioma treatments have also been shown to increase the risk of ischemic strokes. Stroke occurs more frequently in cancer patients than in the general population, according to traditional literature. Unbelievably, these events share multiple pathways, but the precise mechanism underlying their co-occurrence remains unknown. Transcription factors (TFs), the main components of gene expression programmes, finally determine the fate of cells and homeostasis. Both ischemic stroke and glioma exhibit aberrant expression of a large number of TFs, which are strongly linked to the pathophysiology and progression of both diseases. The precise genomic binding locations of TFs and how TF binding ultimately relates to transcriptional regulation remain elusive despite a strong interest in understanding how TFs regulate gene expression in both stroke and glioma. As a result, the importance of continuing efforts to understand TF-mediated gene regulation is highlighted in this review, along with some of the primary shared events in stroke and glioma.

Cortisone-loaded stearoyl ascorbic acid based nanostructured lipid carriers alleviate inflammatory changes in DSS-induced colitis

Ulcerative colitis is a chronic inflammatory disease which poorly affects the colon and spreads toward the rectum over time. Cortisone (CRT) is a corticosteroid clinically used for the management of inflammatory diseases like colitis and other inflammatory bowel diseases. Due to some physicochemical properties' cortisone has limited potency in clinics. To overcome drug-related problems, we successfully prepared lipid nanocarriers with generally regarded as safe (GRAS) materials approved by USFDA. The present study aimed to assess the therapeutic efficacy of CRT-loaded 6-o-stearoyl ascorbic acid (SAA) nanostructured lipid carriers (NLCs) against DSS-induced colitis mice. Formulation and characterizations of reported nanostructured lipid carrier were performed according to our previously optimized parameters. The average hydrodynamic diameter of NLCs was 182 nm as measured by DLS with 81.14 % encapsulation efficacy. TEM, AFM and SEM images analysis confirmed its spherical appearance. hTERT-BJ cells viability up to a dose of 500 μg/ml shows cytocompatible characteristics of blank NLCs. CRT-loaded NLCs treatment normalizes physically observed parameters such as disease activity index, weight variation etc. These NLCs were able to significantly reduce the severity of colitis in terms of colon histoarchitecture, regaining of the goblet cells, mucins secretions, inhibition of proinflammatory cytokines etc. Treatment with CRT-loaded NLCs effectively downregulated the overexpression of inflammatory enzymes like cyclooxygenase-2 (COX-2), Inducible nitric oxide synthase (iNOS) etc. The results of this study concluded that these CRT-encapsulated NLCs efficiently manage the disease severity induced by DSS.

A177 RISK OF VENOUS THROMBOEMBOLISM IN COVID-19 PATIENTS WITH INFLAMMATORY BOWEL DISEASE: A POPULATION-BASED MATCHED COHORT STUDY

Background

Venous thromboembolism (VTE), is associated with significant morbidity and mortality. Inflammation increases the risk of VTE, and it is a well-recognised complication of both inflammatory bowel disease (IBD) and COVID-19.

Purpose

To compare the risk of VTE among individuals with and without IBD following a positive COVID-19 test.

Method

Using health administrative data from Ontario, Canada we conducted a retrospective matched cohort study.All Ontario residents with a positive SARS-CoV-2 PCR test between January 1,2020 and December 30,2021 who had been diagnosed with IBD prior to their COVID-19 infection (identified using a validated algorithm) were matched to 5 individuals without IBD based on year of birth, sex, mean neighbourhood income quintile, date of positive COVID-19 test, and rural/urban residence. Individuals with a cancer diagnosis in the 5 years prior to their first COVID-19 positive test were excluded. Individuals were followed from positive COVID-19 PCR test until VTE event, death, migration out of Ontario or March 31, 2022.VTEs were identified from emergency department or hospitalization data using ICD-10 codes. Incidence rate of VTEs among individuals with IBD were assessed at 1, 6 and 12 months. Proportional cause-specific hazards models compared the risk of VTEs in people with and without IBD, treating death as a competing risk and controlling for vaccination status (2^nd dose ≥14 days prior to positive COVID-19 test) and a history of VTE (VTE in the 5 years prior to infection).

Result(s)

There were 4293 people with IBD (44% Crohn’s disease, mean age ±SD 46.1±17.2 y) matched to 20,207 with out IBD (mean age 45.3±16.8 y) with a positive SARS-CoV-2 PCR test. Within 1 month of a positive COVID-19 test, the crude incidence rate of VTE in individuals with IBD was 4.77(95%CI, 4.75-4.80) per 100,000 person-days compared to 8.25(95%CI, 8.20-8.30) per 100,000 among people without IBD.Within 6 months, these rates were 1.86(95%CI, 1.86-1.87) and 2.12(95%CI, 2.11-2.12) per 100,000 person-days among people with and without IBD, respectivley. Within 12 months, these rates were 1.59(95% CI, 1.58-1.59) and 1.42(95% CI, 1.42-1.42) per 100,000 person-days among people with and without IBD, respectively.After adjusting for vaccination status and history of VTE there was no difference in the risk of VTE for people with and without IBD (HR 1.08, 95%CI, 0.64 to 1.83).

Conclusion(s)

IBD patients with COVID-19 were not more likely to experience a VTE infection compared with the general popluation. The risk of VTE was highest soon after COVID-19 and declined thereafter.

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None

Disclosure of Interest

None Declared

A114 UNIFIED MAGNIFYING ENDOSCOPIC CLASSIFICATION (UMEC) FOR GASTROINTESTINAL LESIONS: A NORTH AMERICAN EDUCATION STUDY

Background

Magnification endoscopy and magnification narrow-band imaging are image enhanced endoscopy technologies that may allow for the diagnosis of advanced neoplasia in the GI tract on the basis of imaging characteristics. Recently, the Unified Magnifying Endoscopic Classification (UMEC) has been developed, which unified the criteria for the esophagus, stomach, and colon. UMEC divides optical diagnosis into one of the three categories: non-neoplastic, intramucosal neoplasia, and deep submucosal invasive cancer.

Purpose

The objective of this study is to educate North American endoscopists on the use of the UMEC schema, and to ascertain performance of the UMEC framework among North American endoscopists.

Method

Using UMEC, five North American endoscopists (>1000 procedures) without prior training in magnifying endoscopy independently diagnosed previously collected endoscopic image set of the esophagus, stomach, and colon. The endoscopists were trained on the use of UMEC via an eleven-minute training video with exemplars of each element of UMEC from esophagus, stomach, and colon. All endoscopists were blinded to white-light and non-magnifying NBI findings as well as histopathological diagnosis. The diagnostic performance of UMEC was assessed while using the gold standard histopathology as a reference.

Result(s)

A total of 299 gastrointestinal lesions (77 esophagus, 92 stomach, and 130 colon) were assessed using UMEC. For esophageal squamous cell carcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 65.2% (95% CI: 50.9–77.9) to 87.0% (95% CI: 75.3–94.6), 77.4% (95% CI: 60.9–89.6) to 96.8% (95% CI: 86.8–99.8), and 75.3% to 87.0%, respectively. For gastric adenocarcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 94.9% (95% CI: 85.0–99.1) to 100%, 52.9% (95% CI: 39.4–66.2) to 92.2% (95% CI: 82.7–97.5), and 73.3% to 93.3%, respectively. For colorectal adenocarcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 76.2% (95% CI: 62.0–87.3) to 83.3% (95% CI: 70.3–92.5), 89.7% (95% CI: 82.1–94.9) to 97.7% (95% CI: 93.1–99.6), and 86.8% to 90.7%, respectively.

Image

Conclusion(s)

UMEC is a simple and practical classification that can be used to introduce and educate endoscopists to magnification narrow-band imaging and optical diagnosis.

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CAG

Disclosure of Interest

M. R. A. Fujiyoshi Grant / Research support from: 2022 CAG/AbbVie Education Research Grant, Y. Fujiyoshi: None Declared, N. Gimpaya: None Declared, R. Bechara: None Declared, T. Jeyalingam: None Declared, N. Calo: None Declared, N. Forbes: None Declared, R. Khan: None Declared, M. Atalla: None Declared, A. Toshimori: None Declared, Y. Shimamura: None Declared, M. Tanabe: None Declared, J. Mosko: None Declared, H. Inoue: None Declared, S. Grover: None Declared

A128 GLOBAL TRENDS IN TRAINING AND CREDENTIALING GUIDELINES FOR GASTROINTESTINAL (GI) ENDOSCOPY: A SYSTEMATIC REVIEW

Background

Credentialing in GI endoscopy is not a universally standardized process. National guidelines may provide a framework for local training, however in certain settings, training committees set minimal competency requirements that must be met before a clinician can be accredited to practice independently. There is a paucity of literature assessing the inter-societal and geographic variability in guidelines and training requirements in endoscopy.

Purpose

To systematically review the available credentialing guidelines proposed by different GI endoscopy societies and affiliated training committees internationally.

Method

We conducted a systematic review according to the PRISMA guidelines. A comprehensive literature search was performed for credentialing guidelines for GI endoscopy from inception until January 2022. Two reviewers screened and one reviewer abstracted data using a pre-defined data collection form.

Result(s)

From the 653 records obtained from our search, 20 credentialing guidelines from 12 different GI societies were ultimately included in the review. These guidelines encompassed the following procedures and outlined the following key-performance indicators; a) Colonoscopy: the recommended minimum number of procedures performed ranged from 150-275 with a minimum cecal intubation and adenoma detection rate of 85-90% and 20-30% respectively; b) EGD: the minimum number of procedures prior to credentialing ranged from 130-1000, the minimum duodenal intubation rate ranged from 95-100%, and the range for minimum number of upper GI bleeds managed was 20-45 (in addition to other procedural KPIs); c) ERCP: the recommended minimum number of procedures prior to credentialing ranged from 100-300 cases with a minimum selective duct cannulation rate of 80-90%. Guidelines for flexible sigmoidoscopy, EUS and capsule endoscopy were also obtained.

Image

Conclusion(s)

There is a general concordance amongst the various international GI societies with regards to minimum procedural volume and performance in key procedural tasks prior to credentialing, however the use of validated education assessment tools was lacking in the majority of guidelines. Additional KPI’s need to be explored for less routinely performed procedures such as EUS and capsule endoscopy.

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None

Disclosure of Interest

None Declared

A119 DEVELOPMENT AND EVALUATION OF LOW-COST GEL POLYPS FOR POLYPECTOMY SKILLS TRAINING IN NOVICE ENDOSCOPISTS

Background

Polypectomy is an essential skill for endoscopists to acquire. As polyps are encountered ad hoc during colonoscopies, exposure to polypectomy in clinical training may vary. There is a need to deliver a curriculum that standardizes exposure to polypectomy while remaining cost-effective for endoscopy programs worldwide.

Purpose

To develop low-cost simulated polyps that can be incorporated into endoscopic training programs, and to evaluate their perceived realism and useability for polypectomy training.

Method

We designed 3D molds based on the Paris classification, a validated rubric for polyp morphology. The polyps are depicted in Figure 1. Using low-cost materials, we created gel-based polyps compatible with physical colonic simulators. Current versions of the polyps were finalized based on visual realism and durability. Expert (performed >1000 procedures) and novice (<25 procedures) endoscopists were invited to perform simulated polypectomies and evaluate the realism of the polyps. Using a 7-point Likert scale (“strongly disagree” to “strongly agree”), we administered a survey adapted from the Direct Observed Polypectomy Skills (DOPyS) checklist to evaluate the polyps on practicality of design and useability for training. Additionally, the simulator’s resemblance to human polypectomy was assessed through a scale with 1 indicating “low resemblance” and 7 indicating “high resemblance”. The ease of identifying morphology was also evaluated, with 1 indicating “difficult” and 7 indicating “easy”.

Result(s)

The survey was completed by 11 expert endoscopists and 10 novices. The median score submitted by experts on the polyps’ useability in training the technique for mobilization of the polyp was 7 (IQR 6-7). Experts rated the simulator’s practicality in teaching cold snare or electrocautery techniques with a median score of 6 (IQR 6-7). Lastly, the ability of the simulator to develop skills in identifying and treating the residual polyp was assessed by expert endoscopists, giving it a median score of 6 (IQR 6-7). The simulators were tested on similarity to human polypectomy, with the median score of expert groups being 5 (IQR 5-6), and novice groups being 6 (IQR 6-6). Both groups were asked to rate if morphology could be identified using the simulator; the median score of expert groups being 6 (IQR 6-7), and 6.5 for novice endoscopists (IQR 5-7).

Image

Conclusion(s)

The development of simulated polyps with differing morphologies using low-cost and common materials with high realism is feasible. These polyps may potentially be integrated into different endoscopic training programs.

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None

Disclosure of Interest

A. Zhao: None Declared, N. Gimpaya: None Declared, J. Lisondra: None Declared, R. Fujiyoshi: None Declared, Y. Fujiyoshi: None Declared, R. Khan Grant / Research support from: Rishad Khan has received research grants from AbbVie (2018) and Ferring Pharmaceuticals (2019) and research funding from Pendopharm (2019). , D. Tham: None Declared, M. Scaffidi: None Declared, R. Bansal: None Declared, C. Walsh: None Declared, S. Grover Shareholder of: Samir C. Grover has equity in Volo Healthcare., Grant / Research support from: Samir C. Grover has received research grants and personal fees from AbbVie and Ferring Pharmaceuticals, personal fees from Takeda, education grants from Janssen.

A115 THE PERFORMANCE OF NATURAL LANGUAGE PROCESSING IN INTERPRETING COLONOSCOPY REPORTS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Background

Screening colonoscopy is integral in the effort to identify and remove potentially cancerous lesions. Important quality indicators include the adenoma detection rate and more recently, the sessile/serrated adenoma detection rate. Natural language processing (NLP) is a computer-based linguistic technique that leverages artificial intelligence to abstract meaningful information from text. This tool carries the potential to automate the task of analyzing large volumes of colonoscopy and pathology reports to generate data on key performance metrics.

Purpose

The aim of this study is to systematically review the available literature on the performance of NLP in identifying the presence of an adenoma or a sessile/serrated adenoma in colonoscopy reports.

Method

We performed a systematic review and meta-analysis according to PRISMA recommendations. A comprehensive literature query was conducted on MEDLINE, EMBASE, CINAHL, and CDSR, through July 2022. Studies were included if they evaluated the performance of NLP in extracting data from colonoscopy reports. Our primary outcome was the performance of NLP models in correctly identifying an adenoma reported in a colonoscopy report. Two authors independently screened studies and abstracted data using an a priori designed data collection form. We pooled the sensitivity and specificity of our primary outcome using a univariate analysis first, followed by a bivariate analysis. Using the open-source package ‘mada’ which is written in R, we generated a summary estimate and a summary receiver operating characteristic curve.

Result(s)

From the 1030 unique studies obtained from our literature search, 13 studies met the inclusion criteria. Eligible studies were used for our meta-analysis. In the univariate analysis, the pooled sensitivity and specificity for detecting an adenoma by the NLP systems was 0.978 (95% CI 0.938-0.992) and 0.997 (95% CI 0.984-0.999), respectively. Similarly, in univariate analysis, the pooled sensitivity and specificity for detecting a sessile/serrated adenoma by the NLP systems was 0.984 (95% CI 0.929-0.996) and 1.0 (95% CI 0.998-1.000), respectively. In the bivariate analysis, the summary estimates for the sensitivity and specificity of the NLP system in detecting an adenoma were 0.973 (95% CI 0.929-0.990) and 0.992 (95%CI 0.978-0.997) respectively. For detecting a sessile/serrated adenoma, the summary estimates for sensitivity and specificity were 0.964 (95% CI 0.895-0.988) and 0.998 (95% CI 0.995-0.999) respectively.

Conclusion(s)

NLP models have excellent performance in extracting quality metric data from colonoscopy reports. Based on the available literature, we suggest integration of NLP in quality improvement efforts in colonoscopy.

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None

Disclosure of Interest

None Declared

A117 VALIDITY EVIDENCE FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY COMPETENCY ASSESSMENT TOOLS: A SYSTEMATIC REVIEW

Background

Assessment of competence in endoscopic retrograde cholangiopancreatography (ERCP) is essential to ensure trainees possess the skills needed for independent practice. Traditionally, ERCP training has used the apprenticeship model, whereby novices learn skills under the supervision of an expert. A growing focus on procedural quality, however, has supported the implementation of competency-based medical education models which require documentation of a trainee’s competence for independent practice. Observational assessment tools with strong evidence of validity are critical to this process. Validity evidence supporting ERCP observational assessment tools has not been systematically evaluated.

Purpose

To conduct a systematic review of ERCP assessment tools and identify tools with strong evidence of validity using a unified validity evidence framework

Method

We conducted a systematic search using electronic databases and hand-searching from inception until August 2021 for studies evaluating observational assessment tools of ERCP performance. We used a unified validity framework to characterize validity evidence from five sources: content, response process, internal structure, relations to other variables, and consequences. Each domain was assigned a score of 0-3 (maximum score 15). We assessed educational utility and methodological quality using the Accreditation Council for Graduate Medical Education framework and the Medical Education Research Quality Instrument, respectively.

Result(s)

From 2769 records, we included 17 studies evaluating 7 assessment tools. Five tools were studied for clinical ERCP, one on simulated ERCP, and one on simulated and clinical ERCP. Validity evidence scores ranged from 2-12. The Bethesda ERCP Skills Assessment Tool (BESAT), ERCP Direct Observation of Procedural Skills Tool (ERCP DOPS), and The Endoscopic Ultrasound (EUS) and ERCP Skills Assessment Tool (TEESAT) had the strongest validity evidence with scores of 10, 12, and 11, respectively. Regarding educational utility, most tools were easy to use and interpret, and required minimal additional resources. Overall methodological quality was strong, with scores ranging from 10-12.5 (maximum 13.5).

Conclusion(s)

The BESAT, ERCP DOPS, and TEESAT have strong validity evidence compared to other assessments. Integrating tools into training may help drive learners’ development and support competency decision-making.

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CAG

Disclosure of Interest

None Declared

MCC950 Regulates Stem Cells Destiny Through Modulating SIRT3-NLRP3 Inflammasome Dynamics During Oxygen Glucose Deprivation

Ischemic stroke is the major cause of death and morbidity worldwide. Stem cell treatment is at the forefront of ischemic therapeutic interventions. However, the fate of these cells following transplantation is mostly unknown. The current study examines the influence of oxidative and inflammatory pathological events associated with experimental ischemic stroke (oxygen glucose deprivation (OGD)) on the stem cell population (human Dental Pulp Stem Cells, and human Mesenchymal Stem Cells) through the involvement of the NLRP3 inflammasome. We explored the destiny of the above-mentioned stem cells in the stressed micro (-environment) and the ability of MCC950 to reverse the magnitudes. An enhanced expression of NLRP3, ASC, cleaved caspase1, active IL-1β and active IL-18 in OGD-treated DPSC and MSC was observed. The MCC950 significantly reduced NLRP3 inflammasome activation in the aforementioned cells. Further, in OGD groups, oxidative stress markers were shown to be alleviated in the stem cells under stress, which was effectively relieved by MCC950 supplementation. Interestingly, whereas OGD increased NLRP3 expression, it decreased SIRT3 levels, implying that these two processes are intertwined. In brief, we discovered that MCC950 inhibits NLRP3-mediated inflammation by inhibiting the NLRP3 inflammasome and increasing SIRT3. To conclude, according to our findings, inhibiting NLRP3 activation while enhancing SIRT3 levels with MCC950 reduces oxidative and inflammatory stress in stem cells under OGD-induced stress. These findings shed light on the causes of hDPSC and hMSC demise following transplantation and point to strategies to lessen therapeutic cell loss under ischemic-reperfusion stress.

Modified cereal bran (MCB) from finger millet, kodo millet, and rice bran prevents high-fat diet-induced metabolic derangements

Cereal bran consumption improves gastrointestinal and metabolic health. Unprocessed cereal brans have a limited shelf-life and contain anti-nutrient phytochemicals. In the present study, lipids and antinutrients (flavonoids, tannin, and polyphenol) were removed from finger millet, kodo millet and rice bran using chemo-enzymatic processing. The thus-obtained modified cereal brans (MCBs) were evaluated for their potential in preventing high fat diet (HFD)-induced obesity. C57BL/6 mice were fed a HFD or a HFD supplemented with 10% w/w modified finger millet bran (mFMB), modified kodo millet bran (mKMB), modified rice bran (mRB), or a combination of the modified brans (1 : 1 : 1) for twelve weeks. The MCBs reduced HFD-induced body weight gain, improved glucose homeostasis, decreased the Firmicutes/Bacteroidetes ratio, and increased the short chain fatty acid (SCFA) levels in the cecum. Liver dyslipidemia, oxidative stress, inflammation, visceral white adipose tissue (vWAT) hypertrophy, and lipolysis were also prevented by the MCBs. Among the individual MCBs, mRB showed a greater effect in preventing HFD-induced increase in the inflammatory cytokines (IL-6, TNF-α, and LPS) than mFMB and mKMB. mFMB and mKMB supplementation more significantly restored the relative abundance of Akkermansia muciniphila and butyrate-producing genera such as Lachnospiraceae, Eubacterium, and Ruminococcus than mRB. Ex vivo gut permeability assay, immunohistochemistry of tight junction proteins, and gene expression analysis in the colon revealed that the combination of three brans was better in preventing HFD-induced leaky gut in comparison to the individual brans. Hierarchical clustering analysis showed that the combination group was clustered closest to the NPD group, suggesting an additive effect. Our study implies that a combination of mFMB, mKMB, and mRB could be used as a nutraceutical or functional food ingredient for preventing HFD-induced gut derangements and associated metabolic complications.

Light activated simultaneous release and recognition of biological signaling molecule carbon monoxide (CO)

The therapeutic action of carbon monoxide (CO) is very well known and has been studied on various types of tissues and animals. However, real-time spatial and temporal tracking and release of CO is still a challenging task. This paper reported an amphiphilic CO sensing probe NP and phospholipid 1,2-Dipalmitoyl-sn-glycero-3-phosphocholine (DPPC) based nanoscale vesicular sensing system Ves-NP consisting of NP. The liposomal sensing system (Ves-NP) showed good selectivity and sensitivity for CO without any interference from other relevant biological analytes. Detection of CO is monitored by fluorescence OFF-ON signal. Ves-NP displayed LOD of 5.94 µM for CO detection with a response time of 5 min. Further, in a novel attempt, Ves-NP is co-embedded with the amphiphilic CO-releasing molecule 1-Mn(CO)₃ to make an analyte replacement probe Ves-NP-CO. Having a both CO releasing and sensing moiety at the surface of the same liposomal system Ves-NP-CO play a dual role. Ves-NP-CO is used for the simultaneous release and recognition of CO that can be controlled by light. Thus, in this novel approach, for the first time we have attached both the release and recognition units of CO in the vesicular surface, both release and recognition simultaneously monitored by the change in fluorescent OFF-ON signal.

Nanomedicine as potential cancer therapy via targeting dysregulated transcription factors

Cancer as a disease possess quite complicated pathophysiological implications and is among the prominent causes of morbidity and mortality on global scales. Anti-cancer chemotherapy, surgery, and radiation therapy are some of the present-day conventional treatment options. However, these therapeutic paradigms own several retreats, including lack of specificity, non-targeted toxicological implications, inefficient drug delivery to targeted cells, and emergence of cancer resistance, ultimately causing ineffective cancer management. Owing to the advanced and better biophysical characteristic features and potentiality for the tailoring and customizations and in several fashions, nanotechnology can entirely transubstantiate the cancer identification and its managements. Additionally, nanotechnology also renders several answers to present-day mainstream limitations springing-up in anti-cancer therapeutics. Nanocarriers, owing to their outstanding physicochemical features including but not limited to their particle size, surface morphological features viz. shape etc., have been employed in nanomedicinal platforms for targeting various transcription factors leading to worthy pharmacological outcomes. This transcription targeting activates the wide array of cellular and molecular events like antioxidant enzyme-induction, apoptotic cell death, cell-cycle arrest etc. These outcomes are obtained after the activation or inactivation of several transcription factors and cellular pathways. Further, nanoformulations have been precisely calibrated and functionalized with peculiar targeting groups for improving their efficiency to deliver the drug-payload to specified and targeted cancerous cells and tissues. This review undertakes an extensive, across-the-board and all-inclusive approach consisting of various studies encompassing different types of tailored and customized nanoformulations and nanomaterials designed for targeting the transcription factors implicated in the process of carcinogenesis, tumor-maturation, growth and metastasis. Various transcription factors viz. nuclear factor kappa (NF-κB), signal transducer and activators of transcription (STAT), Cmyc and Twist-related protein 1 (TWIST1) along with several types of nanoparticles targeting these transcription factors have been summarized here. A section has also been dedicated to the different types of nanoparticles targeting the hypoxia inducing factors. Efforts have been made to summarize several other transcription factors implicated in various stages of cancer development, growth, progression and invasion, and their targeting with different kinds of nanomedicinal agents.

A derivation of factors influencing homeopaths to promote quackery in Sindh

This article provides multifaceted information as well as an assessment of how and why homoeopaths engage in quackery, which is neither safe, effective, or legal. The purpose of this study was to investigate the factors that influence the majority of homeopaths in Sindh to promote quackery through allopathic medical system, which is outside the boundaries of a homeopath's practice license and competency. The study also explains why homeopathy has remained popular in Sindh, Pakistan, despite its limitations and waning popularity in the United States (USA), the United Kingdom (UK), Russia, Australia, Canada, France, Germany, Switzerland, and Spain over the last decade, based on major national clinical research studies claiming that homeopathic medicines are no more effective than a placebo.

Biologically inspired stealth - Camouflaged strategies in nanotechnology for the improved therapies in various diseases

Nanotechnology has received increasing attention in the past decade and it's being used as a model for developing better treatments for a variety of diseases. Despite the fact that nanotechnology-based therapy has greatly improved treatment regimens, it still faces challenges such as inadequate circulation, insufficient accumulation at the target region, and undesired toxicity. In this regard, scientists are working on producing cell-membrane camouflaged nanoparticles as a biomimetic technique for modifying the surface of existing nanoparticles to produce significant therapeutic benefits following imparting myriad of desired functionalities. Membranes originating from erythrocytes, white blood cells, cancer cells, stem cells, platelets, or bacterial cells have been used to coat nanoparticle surfaces and create biologically inspired camouflaged nanoparticles. These biomemitic delivery systems have been proven to have potential applications in diagnosing and treating vaiorus diseases, including drug administration, immunisation, immunological regulation, and detoxification. From its inception to the present, we provide a complete description of this advanced technique for functionalizing nanoparticle surfaces. The method of making these membrane coated nanoparticles as well as their characterisation have been thoroughly discussed. Following that, we focused on the diversity of cell membranes derived from distinct cells in the evolution of nanoparticles, emphasising how these biologically inspired stealth - camouflaged techniques have led to increased therapeutic efficacy in a variety of disease states.