An Overview of the Molecular Mechanisms Contributing to Musculoskeletal Disorders in Chronic Liver Disease: Osteoporosis, Sarcopenia, and Osteoporotic Sarcopenia.

The prevalence of osteoporosis and sarcopenia is significantly higher in patients with liver disease than in those without liver disease and osteoporosis and sarcopenia negatively influence morbidity and mortality in liver disease, yet these musculoskeletal disorders are frequently overlooked in clinical practice for patients with chronic liver disease. The objective of this review is to provide a comprehensive understanding of the molecular mechanisms of musculoskeletal disorders accompanying the pathogenesis of liver disease. The increased bone resorption through the receptor activator of nuclear factor kappa (RANK)-RANK ligand (RANKL)-osteoprotegerin (OPG) system and upregulation of inflammatory cytokines and decreased bone formation through increased bilirubin and sclerostin and lower insulin-like growth factor-1 are important mechanisms for osteoporosis in patients with liver disease. Sarcopenia is associated with insulin resistance and obesity in non-alcoholic fatty liver disease, whereas hyperammonemia, low amount of branched chain amino acids, and hypogonadism contributes to sarcopenia in liver cirrhosis. The bidirectional crosstalk between muscle and bone through myostatin, irisin, ß-aminoisobutyric acid (BAIBA), osteocalcin, as well as the activation of the RANK and the Wnt/ß-catenin pathways are associated with osteosarcopenia. The increased understandings for these musculoskeletal disorders would be contributes to the development of effective therapies targeting the pathophysiological mechanism involved.

Endoscopic Submucosal Dissection of Early Gastric Cancer with Mixed-Type Histology: A Systematic Review.

BACKGROUND: Endoscopic submucosal dissection (ESD) criteria are histologically categorized by early gastric cancer (EGC) with differentiated- and undifferentiated-type histology. However, EGC is histologically heterogenous and there have been no separate criteria for EGC with mixed-type histology [EGC-MH; differentiated-type predominant EGC mixed with an undifferentiated component (EGC-MD) or undifferentiated-type predominant EGC mixed with a differentiated component (EGC-MU)]. Moreover, therapeutic outcomes of ESD for EGC-MH have not been clearly described. AIM: This study aimed to evaluate the feasibility of ESD for EGC-MH. METHODS: We searched core databases for specific inclusion factors: patients with EGC-MH, intervention of ESD, and at least one of the following outcomes: rate of en bloc, complete, curative resection, recurrence, procedure-related adverse event, lymphovascular invasion (LVI), or lymph node metastasis (LNM) that enabled evaluation of feasibility of ESD. RESULTS: A total of eight (systematic review) and four studies (meta-analysis) were included. There was no robustness in age, location, or morphology of EGC-MH. Moderately differentiated adenocarcinoma was frequent in pre-ESD biopsy. EGC-MH showed larger size, deeper invasion, and higher rates of LVI/LNM than pure-type EGC. Total en bloc, complete resection, and curative resection rates were 94.6% (95% confidence interval 86.6-97.9%), 77.8% (57.9-89.9%), and 55.1% (50.4-59.6%), respectively. There was no LNM or extra-gastric recurrence after ESD if the EGC-MD met the curative resection criteria. However, the EGC-MD itself was a risk factor for non-curative resection. (Margin positivity was the most common reason.) CONCLUSIONS: Although ESD seems to be technically feasible, inaccurate prediction of lateral or vertical margin leads to lower curative resection rate. Application of more strict indication is needed for EGC-MH.

Ambient air pollution in gastrointestinal endoscopy unit.

BACKGROUND: The gastrointestinal endoscopy unit is frequently exposed to gastrointestinal gas expelled from patients and electrocoagulated tissue through carbonation. This can be potentially harmful to the health of not only the healthcare personnel but also patients who undergo endoscopy. This study aimed to measure the air quality in the endoscopy unit. METHODS: We measured indoor air quality indices (CO2, total volatile organic compounds (VOCs), PM2.5, NO2, CO, and ozone) using portable passive air quality monitoring sensors in the procedural area, recovery area, and cleansing-of-equipment area, at 1-min intervals for 1 week, and the type and number of endoscopic procedures were recorded. RESULTS: CO2, PM2.5, NO2, and ozone levels were the highest in the cleansing area, followed by the procedural and recovery areas, and VOC level was highest in the procedural area. The proportion of poor-quality level of CO2 and VOCs was highest in the procedural area and that of NO2 was highest in the cleansing area. The proportion of tolerable to poor-quality (exceeding acceptable level) level of CO2 and total VOCs in the procedural area was 26% and 19.2% in all measurement times, respectively. The proportion of tolerable to poor-quality level of NO2 in the cleansing area of the endoscopy unit was 32.1% in all measurement times. Multivariate analyses revealed that tolerable to poor-quality (exceeding acceptable level) level of VOCs was associated with the number of endoscopic procedures (odds ratio, 1.79; 95% confidence interval, 1.42-2.27) and PM2.5 level (1.27, 1.12-1.44). Moreover, tolerable to poor-quality level of CO2 was associated with the number of colonoscopy (5.35, 1.19-24.02), especially with electrocoagulation procedures (24.31, 1.31-452.44) in the procedural area. CONCLUSIONS: Healthcare personnel and patients who undergo endoscopy are frequently exposed to ambient air pollution. Health-related protective strategies for ambient air pollution in the endoscopy unit are warranted. CLINICALTRIALS. GOV REGISTRATION NUMBER: NCT03724565.

Automated classification of gastric neoplasms in endoscopic images using a convolutional neural network.

BACKGROUND: Visual inspection, lesion detection, and differentiation between malignant and benign features are key aspects of an endoscopist's role. The use of machine learning for the recognition and differentiation of images has been increasingly adopted in clinical practice. This study aimed to establish convolutional neural network (CNN) models to automatically classify gastric neoplasms based on endoscopic images. METHODS: Endoscopic white-light images of pathologically confirmed gastric lesions were collected and classified into five categories: advanced gastric cancer, early gastric cancer, high grade dysplasia, low grade dysplasia, and non-neoplasm. Three pretrained CNN models were fine-tuned using a training dataset. The classifying performance of the models was evaluated using a test dataset and a prospective validation dataset. RESULTS: A total of 5017 images were collected from 1269 patients, among which 812 images from 212 patients were used as the test dataset. An additional 200 images from 200 patients were collected and used for prospective validation. For the five-category classification, the weighted average accuracy of the Inception-Resnet-v2 model reached 84.6 %. The mean area under the curve (AUC) of the model for differentiating gastric cancer and neoplasm was 0.877 and 0.927, respectively. In prospective validation, the Inception-Resnet-v2 model showed lower performance compared with the endoscopist with the best performance (five-category accuracy 76.4 % vs. 87.6 %; cancer 76.0 % vs. 97.5 %; neoplasm 73.5 % vs. 96.5 %; P  < 0.001). However, there was no statistical difference between the Inception-Resnet-v2 model and the endoscopist with the worst performance in the differentiation of gastric cancer (accuracy 76.0 % vs. 82.0 %) and neoplasm (AUC 0.776 vs. 0.865). CONCLUSION: The evaluated deep-learning models have the potential for clinical application in classifying gastric cancer or neoplasm on endoscopic white-light images.

Effect of ilaprazole on the healing of endoscopic submucosal dissection-induced gastric ulcer: randomized-controlled, multicenter study.

BACKGROUND: The optimal treatment regimen or the duration of treatment for an endoscopic submucosal dissection (ESD)-induced gastric ulcer has not been established. The aim of this study was to assess the efficacy of novel proton-pump inhibitor, ilaprazole, for the treatment of ESD-induced gastric ulcer. METHODS: This was a prospective, open-label, randomized multicenter study. Between June 2015 and March 2018, a total of 176 patients (178 lesions) who underwent ESD for a gastric neoplasm were randomly allocated to receive the oral proton-pump inhibitor ilaprazole 20 mg or rabeprazole 20 mg daily for 8 weeks. The primary outcome was the ulcer healing rate at 4 and 8 weeks. RESULTS: A total of 155 (157 lesions) and 154 patients (156 lesions) were included in the modified intention-to-treat (mITT) and per-protocol analyses, respectively. There was no significant difference in the ulcer healing rate (ilaprazole vs. rabeprazole, 97.4% vs. 97.0 p = 0.78 at 4 weeks, 100% vs. 100%, p = 0.95 at 8 weeks in the mITT analysis) or stage of ulcer (scar stage, 25.6% vs. 17.7%, p = 0.25 at 4 weeks, 92.3% vs. 88.6%, p = 0.59 at 8 weeks in the mITT analysis) between the treatment groups. The quality of ulcer healing was not significantly different between the two groups. No independent predictive factor for higher-quality ulcer healing was found in the multivariate analysis. CONCLUSIONS: According to this trial, ilaprazole and rabeprazole showed no significant difference in the healing of artificial gastric ulcers. Most of the ulcers achieved complete healing within 4-8 weeks. TRIAL REGISTRATION: ClinicalTrial.gov NCT02638584.

Forward-viewing endoscope for ERCP in patients with Billroth II gastrectomy: a systematic review and meta-analysis.

BACKGROUND: The forward-viewing endoscope has been increasingly used to perform endoscopic retrograde cholangiopancreatography (ERCP) in patients who underwent Billroth II gastrectomy. This study intended to assess efficacy and safety of the forward-viewing endoscope for ERCP in Billroth II gastrectomy patients compared with conventional side-viewing endoscope using a systematic review and meta-analysis. METHODS: A systematic review was conducted for studies that evaluated the outcomes of ERCP for patients with Billroth II gastrectomy. Random-effect model meta-analyses with subgroup analyses were conducted. The methodological quality of the included publications was evaluated using the risk of bias assessment tool for non-randomized studies. The publication bias was assessed. RESULTS: In total, 25 studies (1 randomized, 18 retrospective, 1 prospective, and 5 case series studies) with 2446 patients (499 forward-viewing and 1947 side-viewing endoscopes) were analyzed. The pooled afferent loop intubation rate was higher with the forward-viewing endoscope (90.3%, 95% confidence interval (CI) 85.6-93.6 vs. 86.8%, 95% CI 82.8-89.9%). The pooled selective cannulation rate was higher with the side-viewing endoscope (92.3%, 95% CI 88.0-95.2 vs. 91.1%, 95% CI 87.2-93.9%). The pooled bowel perforation rate was higher with the side-viewing endoscope (3.6%, 95% CI 2.3-5.7 vs. 3.0%, 95% CI 1.7-5.3%). The pooled pancreatitis rate was higher with the forward-viewing endoscope (5.4%, 95% CI 3.6-8.0 vs. 2.5%, 95% CI 2.3-5.7%). The pooled bleeding rate was higher with the forward-viewing endoscope (3.0%, 95% CI 1.6-5.5 vs. 2.0%, 95% CI 1.4-3.0%). The heterogeneity among the studies was not significant. The publication bias was minimal. CONCLUSION: This meta-analysis indicates that the forward-viewing endoscope is as safe and effective as conventional side-viewing endoscope for ERCP in patients with Billroth II gastrectomy.

Prokinetics for the treatment of functional dyspepsia: Bayesian network meta-analysis.

BACKGROUND: Controversies persist regarding the effect of prokinetics for the treatment of functional dyspepsia (FD). This study aimed to assess the comparative efficacy of prokinetic agents for the treatment of FD. METHODS: Randomized controlled trials (RCTs) of prokinetics for the treatment of FD were identified from core databases. Symptom response rates were extracted and analyzed using odds ratios (ORs). A Bayesian network meta-analysis was performed using the Markov chain Monte Carlo method in WinBUGS and NetMetaXL. RESULTS: In total, 25 RCTs, which included 4473 patients with FD who were treated with 6 different prokinetics or placebo, were identified and analyzed. Metoclopramide showed the best surface under the cumulative ranking curve (SUCRA) probability (92.5%), followed by trimebutine (74.5%) and mosapride (63.3%). However, the therapeutic efficacy of metoclopramide was not significantly different from that of trimebutine (OR:1.32, 95% credible interval: 0.27-6.06), mosapride (OR: 1.99, 95% credible interval: 0.87-4.72), or domperidone (OR: 2.04, 95% credible interval: 0.92-4.60). Metoclopramide showed better efficacy than itopride (OR: 2.79, 95% credible interval: 1.29-6.21) and acotiamide (OR: 3.07, 95% credible interval: 1.43-6.75). Domperidone (SUCRA probability 62.9%) showed better efficacy than itopride (OR: 1.37, 95% credible interval: 1.07-1.77) and acotiamide (OR: 1.51, 95% credible interval: 1.04-2.18). CONCLUSIONS: Metoclopramide, trimebutine, mosapride, and domperidone showed better efficacy for the treatment of FD than itopride or acotiamide. Considering the adverse events related to metoclopramide or domperidone, the short-term use of these agents or the alternative use of trimebutine or mosapride could be recommended for the symptomatic relief of FD.

Assessment of current criteria for primary nonresponse in chronic hepatitis B patients receiving entecavir therapy.

UNLABELLED: A primary nonresponse to oral drugs against hepatitis B virus (HBV) is a generally accepted criterion for interrupting treatment. We investigated whether the concept of primary nonresponse suggested by current American (AASLD) and European (EASL) guidelines is appropriate for treatment with entecavir (ETV). The study included 1,254 treatment-naïve patients who had pretreatment HBV DNA levels of >2,000 IU/mL and received ETV 0.5 mg/day for over 6 months. "Primary nonresponse" was defined as a <2 log drop in HBV DNA after 6 months of therapy by AASLD and as a <1 log drop after 3 months by EASL. The cumulative probability of virological response (VR; HBV DNA of <15 IU/mL) was compared in patients with and without primary nonresponse. Median time to achieve VR was significantly shorter in primary responders by AASLD than nonresponders (12 versus 24 months; P = 0.004), but the cumulative probability of achieving a VR at 54 months was similar in the two groups (95.8% versus 100%). Time to achieve a VR and cumulative probability of VR over time did not differ between primary responders and nonresponders by EASL. On-treatment virological breakthrough occurred in 18 patients with a cumulative rate of 5.6% at 72 months. ETV resistance was detected in 13 of these 18 patients (72.2%), who were all classified as primary responder according to both guidelines. CONCLUSION: Long-term ETV therapy generally leads to a VR in treatment-naïve patients, although the time to achieve it is delayed in primary nonresponders. The current recommendation to change therapy in primary nonresponders needs to be modified to reflect drug differences in antiviral potency and resistance risk.

Characteristics of microbiome-derived metabolomics according to the progression of alcoholic liver disease.

BACKGROUND AND AIM: The prevalence and severity of alcoholic liver disease (ALD) are increasing. The incidence of alcohol-related cirrhosis has risen up to 2.5%. This study aimed to identify novel metabolite mechanisms involved in the development of ALD in patients. The use of gut microbiome-derived metabolites is increasing in targeted therapies. Identifying metabolic compounds is challenging due to the complex patterns that have long-term effects on ALD. We investigated the specific metabolite signatures in ALD patients. METHODS: This study included 247 patients (heathy control, HC: n = 62, alcoholic fatty liver, AFL; n = 25, alcoholic hepatitis, AH; n = 80, and alcoholic cirrhosis, AC, n = 80) identified, and stool samples were collected. 16S rRNA sequencing and metabolomics were performed with MiSeq sequencer and liquid chromatography coupled to time-of-flight-mass spectrometry (LC-TOF-MS), respectively. The untargeted metabolites in AFL, AH, and AC samples were evaluated by multivariate statistical analysis and metabolic pathotypic expression. Metabolic network classifiers were used to predict the pathway expression of the AFL, AH, and AC stages. RESULTS: The relative abundance of Proteobacteria was increased and the abundance of Bacteroides was decreased in ALD samples (p = 0.001) compared with that in HC samples. Fusobacteria levels were higher in AH samples (p = 0.0001) than in HC samples. Untargeted metabolomics was applied to quantitatively screen 103 metabolites from each stool sample. Indole-3-propionic acid levels are significantly lower in AH and AC (vs. HC, p = 0.001). Indole-3-lactic acid (ILA: p = 0.04) levels were increased in AC samples. AC group showed an increase in indole-3-lactic acid (vs. HC, p = 0.040) level. Compared with that in HC samples, the levels of short-chain fatty acids (SCFAs: acetic acid, butyric acid, propionic acid, iso-butyric acid, and iso-valeric acid) and bile acids (lithocholic acids) were significantly decreased in AC. The pathways of linoleic acid metabolism, indole compounds, histidine metabolism, fatty acid degradation, and glutamate metabolism were closely associated with ALD metabolism. CONCLUSIONS: This study identified that microbial metabolic dysbiosis is associated with ALD-related metabolic dysfunction. The SCFAs, bile acids, and indole compounds were depleted during ALD progression. CLINICAL TRIAL: Clinicaltrials.gov, number NCT04339725.

Current status of image-enhanced endoscopy in inflammatory bowel disease.

In inflammatory bowel disease (IBD), chronic inflammation leads to unfavorable clinical outcomes and increases the risk of developing colorectal neoplasm (CRN); thereby highlighting the importance of endoscopically evaluating disease activity as well as detecting and characterizing CRN in patients with IBD. With recent advances in image-enhanced endoscopic (IEE) technologies, especially virtual chromoendoscopy (VCE) platforms, this review discusses state-of-the-art IEE techniques and their applicability in assessing disease activity and surveillance colonoscopy in patients with IBD. Among various IEE, VCE demonstrated the capacity to identify quiescent disease activity. And endoscopic remission defined by the new scoring system using VCE platform better predicted clinical outcomes, which may benefit the tailoring of therapeutic strategies in patients with IBD. High-definition dye-chromoendoscopy (HD-DCE) is numerically superior to high-definition white light endoscopy (HD-WLE) in detecting CRN in IBD; however, discrepancy is observed in the statistical significance. VCE showed comparable performance in detecting dysplasia to HD-WLE or DCE and potential for optical diagnosis to differentiate neoplastic from nonneoplastic lesions during surveillance colonoscopy. Applying these novel advanced IEE technologies would provide opportunities for personalized medicine in IBD and optimal treatment of CRN in patients with IBD.

Diagnosis and management of acute colonic diverticulitis: results of a survey among Korean gastroenterologists.

BACKGROUND/AIMS: Some management strategies for acute colonic diverticulitis remain controversial in Korean real-world practice because their clinical features differ from those in the West. This study aimed to investigate the opinions of Korean physicians regarding the diagnosis and treatment of acute diverticulitis. METHODS: A web-based survey was conducted among gastroenterologists specializing on treating lower gastrointestinal disorders. The questionnaires concerned overall management strategies for colonic diverticulitis, including diagnosis, treatment, and follow-up. RESULTS: In total, 209 gastroenterologists responded to the survey. Less than one-fourth of the respondents (23.6%) answered that left-sided colonic diverticulitis is more likely to be complicated than right-sided colonic diverticulitis. Most respondents agreed that immunocompromised patients with diverticulitis have worse clinical outcomes than immunocompetent patients (71.3%). Computed tomography was the most preferred tool for diagnosing diverticulitis (93.9%). Approximately 89% of the respondents answered that they believed antibiotic treatment is necessary to treat acute uncomplicated diverticulitis. Most respondents (92.6%) agreed that emergency surgery is not required for diverticulitis with an abscess or microperforation without panperitonitis. Further, 94.7% of the respondents agreed that colon cancer screening is necessary in patients aged ≥ 50 years with diverticulitis after they have recovered from acute illness. Many respondents (71.4%) agreed that surgery for recurrent diverticulitis should be individualized. CONCLUSION: Opinions regarding management strategies for colonic diverticulitis among Korean gastroenterologists were well agreed upon in some areas but did not agree well in other areas. Evidence-based guidelines that meet the practical needs of the Korean population should be developed.

Comparative outcomes of acute colonic diverticulitis in immunocompromised versus immunocompetent patients: a systematic review and meta-analysis.

BACKGROUND/AIMS: Immunocompromised patients with acute colonic diverticulitis are at high risk for complications and failure of non-surgical treatment. However, evidence on the comparative outcomes of immunocompromised and immunocompetent patients with diverticulitis is lacking. This systematic review and meta-analysis investigated the outcomes of medical treatment in immunocompromised and immunocompetent patients with diverticulitis. METHODS: A comprehensive literature search was conducted in PubMed, Embase, and the Cochrane Library. Studies comparing the clinical outcomes of immunocompromised and immunocompetent patients with diverticulitis were included. RESULTS: A total of 10 studies with 1,946,461 subjects were included in the quantitative synthesis. The risk of emergency surgery and postoperative mortality after emergency surgery was significantly higher in immunocompromised patients than in immunocompetent patients with diverticulitis (risk ratio [RR], 1.76; 95% confidence interval [CI], 1.31-2.38 and RR, 3.05; 95% CI, 1.70-5.45, respectively). Overall risk of complications associated with diverticulitis was non-significantly higher in immunocompromised than in immunocompetent patients (RR, 1.24; 95% CI, 0.95-1.63). Overall mortality irrespective of surgery was significantly higher in immunocompromised than in immunocompetent patients with diverticulitis (RR, 3.65; 95% CI, 1.73-7.69). By contrast, postoperative mortality after elective surgery was not significantly different between immunocompromised and immunocompetent patients with diverticulitis. In subgroup analysis, the risk of emergency surgery and recurrence was significantly higher in immunocompromised patients with complicated diverticulitis, whereas no significant difference was shown in mild disease. CONCLUSIONS: Immunocompromised patients with diverticulitis should be given the best medical treatment with multidisciplinary approach because they had increased risks of surgery, postoperative morbidity, and mortality than immunocompetent patients.

Use of device-assisted enteroscopy in small bowel disease: an expert consensus statement by the Korean Association for the Study of Intestinal Diseases.

The introduction of device-assisted enteroscopy (DAE) in the beginning of 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of the small bowel diseases, DAE has the unique advantages of observing the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how to perform it and what technical factors should be considered. In response to these needs, the Korean Association for the Study of Intestinal Diseases developed an expert consensus statement on the performance of DAE by reviewing the current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

[Use of Device-Assisted Enteroscopy in Small Bowel Disease: An Expert Consensus Statement by the Korean Association for the Study of Intestinal Diseases].

The introduction of device-assisted enteroscopy (DAE) in the beginning of the 21st century has revolutionized the diagnosis and treatment of diseases of the small intestine. In contrast to capsule endoscopy, the other main diagnostic modality of small bowel diseases, DAE has the unique advantages of allowing the observation of the region of interest in detail and enabling tissue acquisition and therapeutic intervention. As DAE becomes an essential procedure in daily clinical practice, there is an increasing need for correct guidelines on when and how it is to be performed and what technical factors should be taken into consideration. In response to these needs, the Korean Association for the Study of Intestinal Diseases has developed an expert consensus statement on the performance of DAE by reviewing current evidence. This expert consensus statement particularly focuses on the indications, choice of insertion route, therapeutic intervention, complications, and relevant technical points.

Impact of the Volume and Distribution of Training Datasets in the Development of Deep-Learning Models for the Diagnosis of Colorectal Polyps in Endoscopy Images.

BACKGROUND: Establishment of an artificial intelligence model in gastrointestinal endoscopy has no standardized dataset. The optimal volume or class distribution of training datasets has not been evaluated. An artificial intelligence model was previously created by the authors to classify endoscopic images of colorectal polyps into four categories, including advanced colorectal cancer, early cancers/high-grade dysplasia, tubular adenoma, and nonneoplasm. The aim of this study was to evaluate the impact of the volume and distribution of training dataset classes in the development of deep-learning models for colorectal polyp histopathology prediction from endoscopic images. METHODS: The same 3828 endoscopic images that were used to create earlier models were used. An additional 6838 images were used to find the optimal volume and class distribution for a deep-learning model. Various amounts of data volume and class distributions were tried to establish deep-learning models. The training of deep-learning models uniformly used no-code platform Neuro-T. Accuracy was the primary outcome on four-class prediction. RESULTS: The highest internal-test classification accuracy in the original dataset, doubled dataset, and tripled dataset was commonly shown by doubling the proportion of data for fewer categories (2:2:1:1 for advanced colorectal cancer: early cancers/high-grade dysplasia: tubular adenoma: non-neoplasm). Doubling the proportion of data for fewer categories in the original dataset showed the highest accuracy (86.4%, 95% confidence interval: 85.0-97.8%) compared to that of the doubled or tripled dataset. The total required number of images in this performance was only 2418 images. Gradient-weighted class activation mapping confirmed that the part that the deep-learning model pays attention to coincides with the part that the endoscopist pays attention to. CONCLUSION: As a result of a data-volume-dependent performance plateau in the classification model of colonoscopy, a dataset that has been doubled or tripled is not always beneficial to training. Deep-learning models would be more accurate if the proportion of fewer category lesions was increased.

No-Code Platform-Based Deep-Learning Models for Prediction of Colorectal Polyp Histology from White-Light Endoscopy Images: Development and Performance Verification.

BACKGROUND: The authors previously developed deep-learning models for the prediction of colorectal polyp histology (advanced colorectal cancer, early cancer/high-grade dysplasia, tubular adenoma with or without low-grade dysplasia, or non-neoplasm) from endoscopic images. While the model achieved 67.3% internal-test accuracy and 79.2% external-test accuracy, model development was labour-intensive and required specialised programming expertise. Moreover, the 240-image external-test dataset included only three advanced and eight early cancers, so it was difficult to generalise model performance. These limitations may be mitigated by deep-learning models developed using no-code platforms. OBJECTIVE: To establish no-code platform-based deep-learning models for the prediction of colorectal polyp histology from white-light endoscopy images and compare their diagnostic performance with traditional models. METHODS: The same 3828 endoscopic images used to establish previous models were used to establish new models based on no-code platforms Neuro-T, VLAD, and Create ML-Image Classifier. A prospective multicentre validation study was then conducted using 3818 novel images. The primary outcome was the accuracy of four-category prediction. RESULTS: The model established using Neuro-T achieved the highest internal-test accuracy (75.3%, 95% confidence interval: 71.0-79.6%) and external-test accuracy (80.2%, 76.9-83.5%) but required the longest training time. In contrast, the model established using Create ML-Image Classifier required only 3 min for training and still achieved 72.7% (70.8-74.6%) external-test accuracy. Attention map analysis revealed that the imaging features used by the no-code deep-learning models were similar to those used by endoscopists during visual inspection. CONCLUSION: No-code deep-learning tools allow for the rapid development of models with high accuracy for predicting colorectal polyp histology.

Bismuth-Based Quadruple Therapy versus Metronidazole-Intensified Triple Therapy as a First-Line Treatment for Clarithromycin-Resistant Helicobacter pylori Infection: A Multicenter Randomized Controlled Trial.

Background/Aims: Clarithromycin resistance is a main factor for treatment failure in the context of Helicobacter pylori infection. However, the treatment regimen for clarithromycin-resistant H. pylori infection has not yet been determined. We aimed to compare the efficacy and cost-effectiveness of 14-day bismuth-based quadruple therapy versus 14-day metronidazole-intensified triple therapy for clarithromycin-resistant H. pylori infection with genotypic resistance. Methods: This was a multicenter, randomized, controlled trial. A total of 782 patients with H. pylori infection examined using sequencing-based clarithromycin resistance point mutation tests were recruited between December 2018 and October 2020 in four institutions in Korea. Patients with significant point mutations (A2142G, A2142C, A2143G, A2143C, and A2144G) were randomly assigned to receive either 14-day bismuth-based quadruple therapy (n=102) or 14-day metronidazole-intensified triple therapy (n=99). Results: The overall genotypic clarithromycin resistance rate was 25.7% according to the sequencing method. The eradication rate of 14-day bismuth-based quadruple therapy was not significantly different in the intention-to-treat analysis (80.4% vs 69.7%, p=0.079), but was significantly higher than that of 14-day metronidazole-intensified triple therapy in the per-protocol analysis (95.1% vs 76.4%, p=0.001). There were no significant differences in the incidence of side effects. In addition, the 14-day bismuth-based quadruple therapy was more cost-effective than the 14-day metronidazole-intensified triple therapy. Conclusions: Fourteen-day bismuth-based quadruple therapy showed comparable efficacy with 14-day metronidazole-intensified triple therapy, and it was more cost-effective in the context of clarithromycin-resistant H. pylori infection.

Korean Association for the Study of Intestinal Diseases guidance for clinical practice of adult inflammatory bowel disease during the coronavirus disease 2019 pandemic: expert consensus statements.

Many unexpected problems have resulted from the unprecedented coronavirus disease 2019 (COVID-19) pandemic. The optimal management of patients with inflammatory bowel disease (IBD) during the COVID-19 pandemic has also been a challenge. Therefore, the Korean Association for the Study of Intestinal Diseases (KASID) developed a consensus statement of experts regarding the management of IBD during the COVID-19 pandemic. This consensus statement made recommendations regarding the risk and treatment of COVID-19 in IBD patients. This statement emphasizes that IBD is not a risk factor for COVID-19, and care should be taken not to exacerbate IBD in patients in remission state by maintaining their medications, except for corticosteroids.