A survey of practice patterns and adherence to national and international guidelines on the management of Helicobacter pylori infection among gastroenterologists and gastroenterology fellows in India.

BACKGROUND: Patients and primary care providers alike benefit greatly from the expertise of gastroenterologists when it comes to managing Helicobacter pylori (H. pylori) infection. However, information on gastroenterologists' practices in the management of H. pylori infection is scarce in this part of the world. This study aimed at evaluating the practice patterns of gastroenterologists and gastroenterology fellows in India. METHOD: This was a cross-sectional questionnaire-based survey of gastroenterologists and gastroenterology fellows working in India. RESULTS: Total 207 gastroenterologists and 53 fellows filled out the questionnaire. Responses were received from all around India. Approximately 70% of respondents perceive H. pylori to be a gastric pathogen, while 20% regard it as a commensal bacterium. While the proportion of respondents who chose a test and treat method (34.6%) for uninvestigated dyspepsia without alarm symptoms was comparable to empirical proton pump inhibitor (PPI) therapy (38.8%), about one-fifth chose a scope and treat strategy in this setting. Even in the absence of alarm signs, more than half of respondents (61.5%) preferred endoscopic biopsy to detect H. pylori. While rapid urease testing (RUT) was the preferred modality (80%) for detecting H. pylori, about one-third preferred single-site RUT (from the antrum). Only 40% followed the Updated Sydney protocol, while performing biopsies and a majority (78.8%) are unable to discontinue PPIs before testing for H. pylori. PPI-clarithromycin-based triple treatment was the preferred regimen (67%) for first-line eradication, while nearly a quarter of respondents did not utilize bismuth due to concerns about adverse effects. CONCLUSION: The survey reveals a lack of adherence to the current H. pylori guidelines for diagnosis, testing and treatment among gastroenterologists and gastroenterology fellows in India. It is vital that scientific societies simplify guidelines, investigate challenges to their effective implementation and execute targeted interventions to increase adherence.

Histological scores are poor predictors of short term outcomes in acute severe ulcerative colitis: An observational study.

BACKGROUND: The role of various histologic scores in predicting outcomes in acute severe ulcerative colitis (ASUC) is unexplored. METHODS: Consecutive patients of ASUC undergoing sigmoidoscopy and histological assessment by two independent pathologists for Simplified Geboes score (SGS), Robarts Histopathology Index (RHI) and Nancy histological index (NHI)] were included. Primary outcome was the role of histology in predicting need for second-line therapy or colectomy. RESULTS: Of 82 patients with ASUC (mean age: 36 years, males 47.5 %), non-response to steroids was observed in 27 (32.9 %) of cases. Sixteen patients required second-line drug therapy and 8 required colectomy. There was no significant association between the need for second-line therapy or colectomy and the baseline histological scores [NHI (p = 0.61), SGS (p = 0.116) and RHI (p = 0.109)]. All three scores performed poorly to predict the need for second-line treatment or colectomy within 28 days. There was no significant association between histological scores and steroid response (NHI (p = 0.796), SGS (p = 0.57) and RHI (p = 0.941)]. All three scores had a strong positive correlation observed between each other but not with endoscopic Mayo score. CONCLUSION: The three histologic scores (SGS, RHI and NHI) performed poorly in prediction of need for second-line treatment or colectomy in ASUC. Future studies should study the impact of histologic assessment on long term outcomes in ASUC.

Tracking Wall Characteristics of Necrotic Pancreatic Fluid Collections in Acute Pancreatitis on Serial Contrast-Enhanced Computed Tomography.

Background Encapsulated pancreatic fluid collection (PFC) is a requisite for endoscopic drainage procedures. The 4-week threshold for defining walled-off necrosis does not capture the dynamic process of encapsulation. We aim to investigate the changes in the wall characteristics of PFC in acute necrotizing pancreatitis (ANP) by comparing baseline contrast-enhanced computed tomography (CECT) with follow-up CT scans. Methods This retrospective study comprised consecutive patients with ANP who underwent a baseline CECT within first 2 weeks and follow-up CECT in the third to fifth weeks of illness. Presence, extent, and encapsulation thickness (defined as enhancing wall around the collection) on baseline CECT were compared with follow-up CT (done in the third-fifth weeks of illness). Results Thirty patients (19 males and 11 females; mean age 41.5 ± 13.5 years) were included in the study. The mean time to first CECT was 10 ± 3.6 days. There were 58 collections. The most common site was the lesser sac ( n = 29), followed by the left pararenal space ( n = 15). At baseline CT, 52 (89.7%) collections had varying degree of encapsulation (15.3%, complete encapsulation). Complete encapsulation was seen in 52 and 82.6% collections in third and fourth week, respectively. All collections in fifth week and beyond were encapsulated. The wall was thicker on follow-up CECT scans ( p < 0.01). The mean wall thickness was not significantly associated with the degree of encapsulation ( p = 0.417). There was no significant association between the site and degree of encapsulation ( p = 0.546). Conclusion Encapsulation is dynamic and collections may get "walled off" before 4 weeks. Walled-off collections should be defined based on imaging rather than a fixed 4-week revised Atlanta classification threshold.

Aflatoxin exposure is associated with an increased risk of gallbladder cancer.

Gall bladder cancer (GBC) is common among the socioeconomically deprived populations of certain geographical regions. Aflatoxin is a genotoxic hepatocarcinogen, which is recognized to have a role in the pathogenesis of hepatocellular carcinoma. However, the role of aflatoxin in the pathogenesis of GBC is largely unknown. We determined serum AFB1-Lys albumin adduct (AAA) levels as a marker of aflatoxin exposure in the patients with GBC and compared to those without GBC. The relationship of AAA levels to cytogenetic (TP53mutation&HER2/neu amplification) and radiological characteristics of the tumor was assessed. We included GBC cases (n = 51) and non-GBC controls (n = 100). Mean serum AAA levels were higher in the GBC group (n = 51) than those without GBC (n = 100) (26.1 ± 12.2 vs. 13.1 ± 11.9 ng/mL; p < .001). HER2/neu expression was associated with higher AAA levels compared to those with equivocal or negative expression (43.9 ± 3 vs. 28.6 ± 10 vs. 19.3 ± 7 ng/mL; p < .001). Older age (age >50 years) (odds ratio [OR] = 3.2 [CI: 1.3-8.2]; p = .013), positive Helicobacter pylori serology (OR = 5.1 [CI: 1.4-17.8]; p = .012), presence of GS (OR = 5 [CI: 1.5-16.9]; p = .009) and detectable AAA levels (OR = 6.8 [CI: 1.3-35.7]; p = .024) were independent risk factors for the presence of the GBC among all study subjects. Among patients harboring GS, older age (age >50 years) (OR = 4.5 [CI: 1.3-14.9]; p = .015), female gender (OR = 3.8 [CI: 1.2-12.5]; p = .027), presence of multiple GS (OR = 21.9 [CI: 4.8-100.4]; p < .001) and high serum AAA levels (OR = 5.3 [CI: 1.6-17.3]; p = .006) were independent risk factors for the presence of the GBC. Elderly age >50 years (OR = 2.6 [CI: 1.3-5.2]; p = .010) and frequent peanut consumption (OR = 2.3 [CI: 1.1-4.9]; p = .030) were independent risk factors for high serum AAA levels. The current study has implications for the prevention of GBC through the reduction of dietary aflatoxin exposure.

Hindi translation and validation of the English version of the gastrointestinal symptom rating scale questionnaire: An observational study.

BACKGROUND: The gastrointestinal symptom rating scale (GSRS) is a questionnaire in English language which is designed to assess the clinical symptoms in patients with irritable bowel syndrome (IBS) and peptic ulcer disease. This validated scale has questions on around 15 items and has been validated in patients with dyspepsia and IBS. AIM: To translate and validate the English version of the GSRS questionnaire to the Hindi version. METHODS: The purpose of the present work was to create a Hindi version of this questionnaire for use in the Indian population. The process involved various steps as per the World Health Organization methodology including initial forward translation, backward translation, and assessment by an expert committee. Initial pilot testing was followed by testing in healthy and diseased individuals. RESULTS: The Hindi translation was pilot tested in 20 individuals and further validated in healthy controls (n = 30, 15 females) and diseased individuals (n = 72, 27 females). The diseased group included patients with functional dyspepsia and IBS. Cronbach's alpha for internal consistency on the final translated GSRS questionnaire was 0.715 which is considered adequate. Twelve questions significantly differentiated the diseased population from the healthy population (P value < 0.05) in the translated Hindi version of the GSRS. CONCLUSION: The translated Hindi GSRS can be used to evaluate gastrointestinal function in clinical trials and community surveys in Hindi speaking populations.

Dietary behaviour, attitude and food perceptions of patients with ulcerative colitis - An observational study.

BACKGROUND: Dietary knowledge, perception and practices may have a role in determining the nutritional status of patients with inflammatory bowel disease (IBD). However, the assessment of these patterns has infrequently been done in developing countries. We aimed to evaluate patients with ulcerative colitis (UC) about their dietary beliefs, practices and changes after the diagnosis. METHODS: We conducted a cross-sectional survey among patients with UC at a tertiary care centre in North India. Apart from clinical details, we collected information about dietary beliefs, sources of information, dietary practices and changes after the diagnosis of UC. The information was collected using a designed and pretested survey questionnaire. RESULTS: We included 93 patients with a mean age of 40.6 ± 13.3 years and 49 (52.7%) were men. A majority of patients felt that diet had an important role in the causation of IBD (86%, n = 80) and triggering relapses (86%, n = 80). A total of 94.6% of patients (n = 88) felt that certain foods (especially spicy and fatty food and milk) items increased the symptoms of IBD. Patients felt that some food items (yogurt and buttermilk) improved the symptoms. A total of 96.8% of patients (n = 90) changed their diet in some form (commonly, restriction of milk products and outside food), 64% of patients (n = 60) deprived themselves of their favourite food after diagnosis, 80.6% of patients (n = 75) felt a need for additional dietary advice. Regular milk intake was seen more often by patients in remission than those with active disease in IBD (36/47 (76.6%) vs 7/15(46.6%), p = 0.03). CONCLUSION: Most patients believe that diet has an important role in the causation, relapses and treatment of UC. Patients also felt the need for more information regarding diet in IBD.

Recurrent Skin Ulcers with Facial Dysmorphism and Sinopulmonary Infections: Thinking Beyond Hyper-IgE Syndrome.

Prolidase deficiency (PD) is a rare inborn error of metabolism causing ulcers and other skin disorders, splenomegaly, developmental delay, and recurrent infections. Most of the literature is constituted of isolated case reports. It occurs due to the mutations in the prolidase gene ( PEPD ) that result in loss of prolidase activity. We reported here a child who had presented with features compatible with hyper-immunoglobulin E syndrome (HIES) like recurrent skin ulcers, recurrent infections, facial dysmorphism, retained primary teeth, and elevated levels of immunoglobulin E levels but with normal flow cytometric assays, which was later diagnosed as PD.

Enhancement Patterns of Malignant Gallbladder Masses at Multiphasic Contrast-enhanced CT: Associations With Clinicoradiopathological Features.

Purpose: To assess the enhancement patterns of malignant gallbladder masses at multiphasic contrast-enhanced computed tomography (CECT) and their association with the clinicoradiopathological features. Material and methods: In this retrospective study, consecutive patients with mass-forming gallbladder cancer (GBC) who underwent biphasic [hepatic arterial phase (HAP) and portal venous phase (PVP)] CECT between January 2019 and January 2023 were included. The enhancement patterns at CT scans were assessed independently by two radiologists blinded to the clinicopathological data. The masses were categorized into the typical group (hypoattenuation relative to normal liver in HAP) and the atypical group (isoenhancement or hyperenhancement in HAP). Enhancement patterns in PVP were also evaluated. The association between enhancement characteristics and the pathological grade and type, radiological aggressiveness (biliary/vascular involvement, lymph node, liver, and omental metastases), resectability, and overall survival was assessed. Results: Sixty-five patients (41 females, mean age was 52.5 ± 17.6 years) were included in the study. On HAP images, eight lesions (12.3%) were hyperattenuating, nine (13.8%) were isoattenuating, and 48 (73.8%) were hypoattenuating. Of the 17 masses in the atypical group, 8 (47.1%) lesions showed washout, and 9 showed persistent enhancement (52.9%) in the PVP. Heterogeneous peripheral and central enhancement in HAP were significantly associated with lymph node metastases (P = 0.019). Enhancement pattern was not significantly associated with pathological grade/type, other radiological features, resectability, and overall survival. Conclusion: Mass-forming GBC has variable enhancement. Heterogeneous HAP enhancement is associated with lymph node metastases.

Transverse versus longitudinal mucosal incision during POEM for esophageal motility disorders: a randomized trial.

BACKGROUND: Longitudinal incision is the commonly used incision for entry into the submucosal space during peroral endoscopic myotomy (POEM) for esophageal motility disorders. Transverse incision is another alternative for entry and retrospective data suggest it has less operative time and chance of gas-related events. METHODS: This was a single-center, randomized trial conducted at a tertiary care hospital. Patients undergoing POEM for esophageal motility disorders were randomized into group A (longitudinal incision) and group B (transverse incision). The primary objective was to compare the time needed for entry into the submucosal space. The secondary objectives were to compare the time needed to close the incision, number of clips required to close the incision, and development of gas-related events. The sample size was calculated as for a non-inferiority design using Kelsey method. RESULTS: Sixty patients were randomized (30 in each group). On comparing the 2 types of incisions, there was no difference in entry time [3 (2, 5) vs 2 (1.75, 5) min, p = 0.399], closure time [7 (4, 13.5) vs 9 (6.75, 19) min, p = 0.155], and number of clips needed for closure [4 (4, 6) vs 5 (4, 7), p = 0.156]. Additionally, the gas-related events were comparable between the 2 groups (capnoperitoneum needing aspiration-5 vs 2, p = 0.228, and development of subcutaneous emphysema-3 vs 1, p = 0.301). CONCLUSION: This randomized trial shows comparable entry time, closure time, number of clips needed to close the incision, and gas-related events between longitudinal and transverse incisions. REGISTRATION NUMBER: CTRI/2021/08/035829.

Dual-energy CT in differentiating benign gallbladder wall thickening from wall thickening type of gallbladder cancer.

OBJECTIVE: To evaluate the performance of dual-energy computed tomography (DECT) in differentiating non-acute benign from malignant gallbladder wall thickening (GBWT). METHODS: This prospective study comprised consecutive adults with GBWT who underwent late arterial phase (LAP) and portal venous phase (PVP) DECT between January 2022 and May 2023. The final diagnosis was based on histopathology or 3-6 months follow-up imaging. DECT images in LAP and PVP were assessed independently by two radiologists. The demographic, qualitative, and quantitative parameters were compared between two groups Multivariate logistic regression was performed to determine the association between the aforementioned factors and malignant GBWT. RESULTS: Seventy-five patients (mean age 56 ± 12.8 years, 46 females) were included. Forty-two patients had benign, and 33 had malignant GBWT. In the overall group, female gender (p = 0.018), lymphadenopathy (p = 0.011), and omental nodules (p = 0.044) were significantly associated with malignant GBWT. None of the DECT features differed significantly between benign and malignant GBWT in overall group. In the xanthogranulomatous cholecystitis (XGC, n = 9) vs. gallbladder cancer (GBC) (n = 33) subgroup, mean attenuation value at 140 keV LAP VMI was significantly associated with malignant GBWT [p = 0.023, area under curve 0.759 (95%CI 0.599-0.919)]. CONCLUSION: DECT-generated quantitative parameters do not add value in differentiating non-acute benign from malignant GBWT. However, DECT may have a role in differentiating XGC from GBC in a selected subgroup of patients. Further, larger studies may be necessary to confirm these findings. CLINICAL RELEVANCE STATEMENT: In patients with non-acute gallbladder wall thickening in whom there is suspicion of xanthogranulomatous cholecystitis (XGC), DECT findings may allow differentiation of XGC from wall thickening type of gallbladder cancer. KEY POINTS: Differentiation of benign and malignant gallbladder wall thickening (GBWT) at CT is challenging. Quantitative dual energy CT (DECT) features do not provide additional value in differentiating benign and malignant GBWT. DECT may be helpful in a subgroup of patients to differentiate xanthogranulomatous cholecystitis from gallbladder cancer.

Impact of the Timing of Percutaneous Catheter Drainage following Endoscopic Drainage on Outcomes in Acute Necrotizing Pancreatitis.

Background The role of dual-modality drainage of walled-off necrosis (WON) in patients with acute pancreatitis (AP) is established. However, there are no data on the association of clinical outcomes with the timing of percutaneous catheter drainage (PCD). We investigated the impact of the timing of PCD following endoscopic drainage of WON on clinical outcomes in AP. Materials and Methods This retrospective study comprised consecutive patients with necrotizing AP who underwent endoscopic cystogastrostomy (CG) of WON followed by PCD between September 2018 and March 2023. Based on endoscopic CG to PCD interval, patients were divided into groups (≤ and >3 days, ≤ and >1 week, ≤ and >10 days, and ≤ and >2 weeks). Baseline characteristics and indications of CG and PCD were recorded. Clinical outcomes were compared between the groups, including length of hospitalization, length of intensive care unit stay, need for surgical necrosectomy, and death during hospitalization. Results Thirty patients (mean age ± standard deviation, 35.5 ± 12.7 years) were evaluated. The mean CG to PCD interval was 11.2 ± 7.5 days. There were no significant differences in baseline characteristics and indications of CG and PCD between the groups. The mean pain to CG interval was not significantly different between the groups. Endoscopic necrosectomy was performed in a significantly greater proportion of patients undergoing CG after 10 days ( p = 0.003) and after 2 weeks ( p = 0.032). There were no significant differences in the complications and clinical outcomes between the groups. Conclusion The timing of PCD following endoscopic CG does not affect clinical outcomes.

Strategies to Improve Colonoscopy Preparation in Inflammatory Bowel Disease. A Systematic Review and Network Meta-analysis of Randomized Trials.

BACKGROUND AND AIMS: Colonoscopy has a vital role in the diagnosis of inflammatory bowel disease (IBD), as well as in the estimation of disease severity, monitoring response to therapy, and surveillance for neoplasia. We performed a systematic review of randomised trials of various bowel preparations for colonoscopy in IBD. METHODS: We searched various electronic databases (PubMed, Embase, and CENTRAL) for studies reporting about the use of various strategies to improve colonoscopy preparation in IBD. We included only randomized clinical trials (RCTs). A network meta-analysis was done using a frequentist approach to compare the effectiveness of various bowel preparations. The risk of bias was assessed using Cochrane risk of bias tool 2.0. Other outcome parameters like compliance, tolerance, acceptance, and adverse effects were assessed qualitatively. RESULTS: Seven RCTs reporting about 960 patients were included. On comparison with 4 liter (L) of poliethylen glycol (PEG), oral sulfate solution (OR=1.1, 95%CI: 0.65-1.86); PEG2L/Ascorbate (OR=0.98, 95%CI: 0.65-1.48); PEG1L (OR=1, 95%CI: 0.55-1.81); PEG2L plus bisacodyl (OR=1.08, 95%CI: 0.71-1.65); PEG4L plus simethicone (OR=1, 95%CI: 0.67-1.50); PEG/ sodium picosulfate and magnesium citrate (SPMC) 1.5L (OR=0.99, 95%CI: 0.55-1.78); SPMC 2L (OR=1.09, 95%CI: 0.61-1.97) had similar effectiveness. Three RCTs reported compliance, five RCTs reported tolerance, two studies reported patient acceptance and five RCTs reported data on the willingness of patients to repeat the procedure in the future. Low-volume preparations had better compliance, tolerance, acceptance, and willingness to repeat. No difference in additional outcomes like change in disease activity after colonoscopy, procedure-related outcomes after colonoscopy like cecal intubation rate, and change in electrolyte levels were found. CONCLUSION: Various bowel preparations had similar effectiveness in respect to colonoscopy preparation in IBD patients. Low-volume preparations have better compliance, tolerance, and acceptance. The systematic review was limited by a small number of included RCTs.

Deep-learning enabled ultrasound based detection of gallbladder cancer in northern India: a prospective diagnostic study.

Background: Gallbladder cancer (GBC) is highly aggressive. Diagnosis of GBC is challenging as benign gallbladder lesions can have similar imaging features. We aim to develop and validate a deep learning (DL) model for the automatic detection of GBC at abdominal ultrasound (US) and compare its diagnostic performance with that of radiologists. Methods: In this prospective study, a multiscale, second-order pooling-based DL classifier model was trained (training and validation cohorts) using the US data of patients with gallbladder lesions acquired between August 2019 and June 2021 at the Postgraduate Institute of Medical Education and research, a tertiary care hospital in North India. The performance of the DL model to detect GBC was evaluated in a temporally independent test cohort (July 2021-September 2022) and was compared with that of two radiologists. Findings: The study included 233 patients in the training set (mean age, 48 ± (2SD) 23 years; 142 women), 59 patients in the validation set (mean age, 51.4 ± 19.2 years; 38 women), and 273 patients in the test set (mean age, 50.4 ± 22.1 years; 177 women). In the test set, the DL model had sensitivity, specificity, and area under the receiver operating characteristic curve (AUC) of 92.3% (95% CI, 88.1-95.6), 74.4% (95% CI, 65.3-79.9), and 0.887 (95% CI, 0.844-0.930), respectively for detecting GBC which was comparable to both the radiologists. The DL-based approach showed high sensitivity (89.8-93%) and AUC (0.810-0.890) for detecting GBC in the presence of stones, contracted gallbladders, lesion size <10 mm, and neck lesions, which was comparable to both the radiologists (p = 0.052-0.738 for sensitivity and p = 0.061-0.745 for AUC). The sensitivity for DL-based detection of mural thickening type of GBC was significantly greater than one of the radiologists (87.8% vs. 72.8%, p = 0.012), despite a reduced specificity. Interpretation: The DL-based approach demonstrated diagnostic performance comparable to experienced radiologists in detecting GBC using US. However, multicentre studies are warranted to explore the potential of DL-based diagnosis of GBC fully. Funding: None.

Role of imaging in evaluating the complications of endoscopic management of pancreatic fluid collections in acute pancreatitis.

Acute pancreatitis is associated with local and systemic complications. Pancreatic fluid collection (PFC) is the most common local complication. Infected or symptomatic PFCs need drainage. Endoscopic drainage (ED) is the first-line procedure for accessible PFCs adjacent to the stomach and duodenum. ED is performed under endoscopic ultrasound (EUS) guidance. The technical and clinical success rates of EUS-guided ED in well-encapsulated PFCs are high. ED of poorly encapsulated PFCs is associated with complications. Bleeding and perforation are the most common complications. Contrast-enhanced computed tomography is critical in planning ED and early detection and management of complications. With the increasing utilization of ED for PFC, the radiologist must be familiar with the ED techniques, types of stents, and the complications related to ED. In this review, we discuss the technical aspects of the ED as well as the imaging findings of ED-related complications.

EnsembleSeq: a workflow towards real-time, rapid, and simultaneous multi-kingdom-amplicon sequencing for holistic and resource-effective microbiome research at scale.

Bacterial communities are often concomitantly present with numerous microorganisms in the human body and other natural environments. Amplicon-based microbiome studies have generally paid skewed attention, that too at a rather shallow genus level resolution, to the highly abundant bacteriome, with interest now forking toward the other microorganisms, particularly fungi. Given the generally sparse abundance of other microbes in the total microbiome, simultaneous sequencing of amplicons targeting multiple microbial kingdoms could be possible even with full multiplexing. Guiding studies are currently needed for performing and monitoring multi-kingdom-amplicon sequencing and data capture at scale. Aiming to address these gaps, amplification of full-length bacterial 16S rRNA gene and entire fungal internal-transcribed spacer (ITS) region was performed for human saliva samples (n = 96, including negative and positive controls). Combined amplicon DNA libraries were prepared for nanopore sequencing using a major fraction of 16S molecules and a minor fraction of ITS amplicons. Sequencing was performed in a single run of an R10.4.1 flow cell employing the latest V14 chemistry. An approach for real-time monitoring of the species saturation using dynamic rarefaction was designed as a guiding determinant of optimal run time. Real-time saturation monitoring for both bacterial and fungal species enabled the completion of sequencing within 30 hours, utilizing less than 60% of the total nanopores. Approximately 5 million high quality (HQ) taxonomically assigned reads were generated (~4.2 million bacterial and 0.7 million fungal), providing a wider (beyond bacteriome) snapshot of human oral microbiota at species-level resolution. Among the more than 400 bacterial and 240 fungal species identified in the studied samples, the species of Streptococcus (e.g., Streptococcus mitis and Streptococcus oralis) and Candida (e.g., Candida albicans and Candida tropicalis) were observed to be the dominating microbes in the oral cavity, respectively. This conformed well with the previous reports of the human oral microbiota. EnsembleSeq provides a proof-of-concept toward the identification of both fungal and bacterial species simultaneously in a single fully multiplexed nanopore sequencing run in a time- and resource-effective manner. Details of this workflow, along with the associated codebase, are provided to enable large-scale application for a holistic species-level microbiome study. IMPORTANCE: Human microbiome is a sum total of a variety of microbial genomes (including bacteria, fungi, protists, viruses, etc.) present in and on the human body. Yet, a majority of amplicon-based microbiome studies have largely remained skewed toward bacteriome as an assumed proxy of the total microbiome, primarily at a shallow genus level. Cost, time, effort, data quality/management, and importantly lack of guiding studies often limit progress in the direction of moving beyond bacteriome. Here, EnsembleSeq presents a proof-of-concept toward concomitantly capturing multiple-kingdoms of microorganisms (bacteriome and mycobiome) in a fully multiplexed (96-sample) single run of long-read amplicon sequencing. In addition, the workflow captures dynamic tracking of species-level saturation in a time- and resource-effective manner.

Contrast Enhanced CT Versus MRI for Accurate Diagnosis of Wall-thickening Type Gallbladder Cancer.

Introduction: Diagnosis of wall-thickening type gallbladder cancer (GBC) is challenging. Computed tomography (CT) and magnetic resonance imaging (MRI) are commonly utilized to evaluate gallbladder wall thickening. However, there is a lack of data comparing the performance of CT and MRI for the detection of wall-thickening type GBC. Aim: We aim to compare the diagnostic accuracy of CT and MRI in diagnosis of wall-thickening type GBC. Materials and methods: This prospective study comprised consecutive patients suspected of wall-thickening type GBC who underwent preoperative contrast-enhanced CT and MRI. The final diagnosis was based on the histopathology of the resected gallbladder lesion. Two radiologists independently reviewed the characteristics of gallbladder wall thickening at CT and MRI. The association of CT and MRI findings with histological diagnosis and the interobserver agreement of CT and MRI findings were assessed. Results: Thirty-three patients (malignancy, 13 and benign, 20) were included. None of the CT findings were significantly associated with GBC. However, at MRI, heterogeneous enhancement, indistinct interface with the liver, and diffusion restriction were significantly associated with malignancy (P = 0.006, <0.001, and 0.005, respectively), and intramural cysts were significantly associated with benign lesions (P = 0.012). For all MRI findings, the interobserver agreement was substantial to perfect (kappa = 0.697-1.000). At CT, the interobserver agreement was substantial to perfect (k = 0.631-1.000). Conclusion: These findings suggest that MRI may be preferred over CT in patients with suspected wall thickening type GBC. However, larger multicenter studies must confirm our findings.