Should All Patients Trial Subcutaneous Methotrexate Prior to Commencing Biologic Therapy? A Real World Study.

Introduction: Methotrexate (MTX) is the bed rock of inflammatory arthritis management. However, intolerance is a limiting factor for drug optimisation and retention. There is data to suggest subcutaneous (SC) MTX is better tolerated. It is less clear whether this strategy is effective in those where the oral preparation is inefficacious and its potential to avoid escalation to biologic therapy. Objectives: To analyse the reasons for switching to SC MTX in a real-world setting, clinical outcomes achieved and proportion requiring biologic prescription. Materials and Methods: A retrospective survey of patients prescribed SC MTX in a university teaching hospital identified 352 patients. 298 switched from oral to SC MTX- 164 stopped oral MTX due to side effects, 134 stopped due to inefficacy, and 54 started SC MTX as first line therapy. 103 patients progressed to biologic therapy. Rheumatoid arthritis (RA): DAS-28 improved from a mean of 4.06 (0.63-8.06) to 2.83 (0.14-7.32) following the switch (p<0.0001). Psoriatic arthritis (PsA): total joint count improved from a mean of 7 (0-42) to 2 (0-25) (p<0.0001). Swollen joint count improved from a mean of 2 (0-26) to 1 (0-6) (p=0.09). Discussion: SC MTX is an effective solution for RA and PsA, irrespective of whether oral MTX is inefficacious or intolerable. Where oral MTX was ineffective, a switch to SC achieved low disease activity despite multi-morbidity, long disease course and protracted oral MTX exposure. This intervention prevented over two-thirds of patients requiring biologics. SC MTX is a durable strategy with excellent disease outcomes and substantial economic benefits.

The diagnosis and management of systemic autoimmune rheumatic disease-related interstitial lung disease: British Society for Rheumatology guideline scope.

Interstitial lung disease (ILD) is a significant complication of many systemic autoimmune rheumatic diseases (SARDs), although the clinical presentation, severity and outlook may vary widely between individuals. Despite the prevalence, there are no specific guidelines addressing the issue of screening, diagnosis and management of ILD across this diverse group. Guidelines from the ACR and EULAR are expected, but there is a need for UK-specific guidelines that consider the framework of the UK National Health Service, local licensing and funding strategies. This article outlines the intended scope for the British Society for Rheumatology guideline on the diagnosis and management of SARD-ILD developed by the guideline working group. It specifically identifies the SARDs for consideration, alongside the overarching principles for which systematic review will be conducted. Expert consensus will be produced based on the most up-to-date available evidence for inclusion within the final guideline. Key issues to be addressed include recommendations for screening of ILD, identifying the methodology and frequency of monitoring and pharmacological and non-pharmacological management. The guideline will be developed according to methods and processes outlined in Creating Clinical Guidelines: British Society for Rheumatology Protocol version 5.1.

The Safety of Cold Versus Hot Snare Polypectomy in Polyps 10-20 mm: A Systematic Review and Meta-Analysis.

Colonoscopy remains the primary method for preventing colorectal cancer. Traditionally, hot snare polypectomy (HSP) was the method of choice for removing polyps larger than 5 mm. Yet, for polyps smaller than 10 mm, cold snare polypectomy (CSP) has become the favored approach. Lately, the use of CSP has expanded to include the removal of sessile polyps that are between 10 and 20 mm in size. Our systematic review and meta-analysis aimed to evaluate the safety of cold snare polypectomy (CSP) compared to hot snare polypectomy (HSP) for resecting polyps measuring 10-20 mm. We searched the Medical Literature Analysis and Retrieval System Online (MEDLINE), Embase, and Cochrane databases up to April 2020 to find studies that directly compared CSP to HSP for polyps larger than 10 mm. Our main focus was on assessing the risk of delayed bleeding after polypectomy; a secondary focus was the incidence of any adverse events that required medical intervention post procedure. Our search yielded three comparative studies, two observational studies, and one randomized controlled trial (RCT), together encompassing 1,193 polypectomy procedures. Of these, 485 were performed using CSP and 708 with HSP. The pooled odds ratio (OR) for post-polypectomy bleeding (PPB) was 0.36 (95% confidence interval {CI}: 0.02, 7.13), with a Cochran Q test P-value of 0.11 and an I2 of 53%. For the risk of any adverse events necessitating medical care, the pooled OR was 0.15 (95% CI: 0.01, 2.29), with a Cochran Q test P-value of 0.21 and an I2 of 35%. The quality of the two observational studies was deemed moderate, and the RCT was only available in abstract form, preventing quality assessment. Our analysis suggests that there is no significant difference in the incidence of delayed post-polypectomy bleeding or other adverse events requiring medical attention between CSP and HSP for polyps measuring 10-20 mm.

A Rare Case of Parotid Stone Adherence to the Facial Nerve.

This case report details a complex case of parotid gland sialolithiasis with stones adherent to the facial nerve, a scenario that presents a significant surgical challenge. Traditional sialendoscopy failed to address the condition in a 23-year-old female patient, leading to the adoption of a combined endoscopic transcutaneous approach. This method successfully resolved the condition without intraoperative complications, maintaining intact facial nerve function postoperatively. The case emphasizes the importance of individualized surgical strategy and expert technique in advanced parotid surgery, advocating this approach for similarly complex sialolithiasis cases.

Genome-wide association studies identifies genetic loci related to fatty acid and branched-chain amino acid metabolism and histone modifications under varying nitrogen treatments in safflower (Carthamus tinctorius).

Effective identification and usage of genetic variation are prerequisites for developing nutrient-efficient cultivars. A collection of 94 safflower (Carthamus tinctorius ) genotypes (G) was investigated for important morphological and photosynthetic traits at four nitrogen (N) treatments. We found significant variation for all the studied traits except chlorophyll b (chl b ) among safflower genotypes, nitrogen treatments and G×N interaction. The examined traits showed a 2.82-50.00% increase in response to N application. Biological yield (BY) reflected a significantly positive correlation with fresh shoot weight (FSW), root length (RL), fresh root weight (FRW) and number of leaves (NOL), while a significantly positive correlation was also observed among carotenoids (C), chlorophyll a (chl a ), chl b and total chlorophyll content (CT) under all treatments. Superior genotypes with respect to plant height (PH), FSW, NOL, RL, FRW and BY were clustered into Group 3, while genotypes with better mean performance regarding chl a , chl b C and CT were clustered into Group 2 as observed in principal component analysis. The identified eight best-performing genotypes could be useful to develop improved nitrogen efficient cultivars. Genome-wide association analysis resulted in 32 marker-trait associations (MTAs) under four treatments. Markers namely DArT-45481731 , DArT-17812864 , DArT-15670279 and DArT-45482737 were found consistent. Protein-protein interaction networks of loci associated with MTAs were related to fatty acid and branched-chain amino acid metabolism and histone modifications.

Clinical and laboratory profile of Expanded Dengue Syndrome: experience of 2019 outbreak from Dhaka, Bangladesh.

BACKGROUND OBJECTIVES: Bangladesh is afflicted with periodic dengue outbreak every few years and one of the worst upsurges was recorded in 2019 during which there was an increasing trend of dengue with unusual symptoms which were not so common before. This study aims to describe the experience of three tertiary care centres of Dhaka regarding the clinical and laboratory, hospital outcome and management profile of the Expanded Dengue Syndrome (EDS) cases admitted from the 2019 outbreak. METHODS: The current work was a cross-sectional observational study which took place from August 1 to December 31 2019 at three major tertiary care centres in Dhaka, Bangladesh. Out of total 2017 screened dengue cases, 49 met the inclusion criteria and 39 were enrolled after taking informed written consent. Data was analysed using Microsoft Excel and Graph pad prism 9.3.1. A probability value of p<0.05 was considered statistically significant. RESULTS: Out of the 39 cases, majority were male (79.49%) with median (±IQR) age of 33(±9) years. Hypertension (4; 10.26%) was the most commonly associated co-morbidity. Among the systemic manifestations, most prevalent was hepatitis (38.49%) followed by encephalopathy (12.82%). Majority of the patients were suffering from primary infection (85%). Case fatality rate was 15.38%. Hepatitis and meningoencephalitis were the predominant cause of death. This study records the only known case report of Acute respiratory dress syndrome (ARDS) complicating dengue from Bangladesh. None of the patients from our cohort were managed by steroids. Only two (5.13%) out of 39 cases received antibiotics. INTERPRETATION CONCLUSION: In the year 2019, an unusual rise in EDS cases with about 15.4% fatalities were observed in this study. Hepatitis was the most common presentation and cause of death. Here, we report the first ARDS case encountered in Bangladesh. Despite the multifaceted presentation of EDS, indiscriminate use of antibiotics and steroid was minimal. Early recognition of multifarious features of EDS is important for choosing the targeted treatment option which can avert many deaths. The results of this study underline the necessity for more in-depth research into the risk factors that are contributing to mortality in EDS cases.

CLU (clusterin) and PPARGC1A/PGC1α coordinately control mitophagy and mitochondrial biogenesis for oral cancer cell survival.

Mitophagy involves the selective elimination of defective mitochondria during chemotherapeutic stress to maintain mitochondrial homeostasis and sustain cancer growth. Here, we showed that CLU (clusterin) is localized to mitochondria to induce mitophagy controlling mitochondrial damage in oral cancer cells. Moreover, overexpression and knockdown of CLU establish its mitophagy-specific role, where CLU acts as an adaptor protein that coordinately interacts with BAX and LC3 recruiting autophagic machinery around damaged mitochondria in response to cisplatin treatment. Interestingly, CLU triggers class III phosphatidylinositol 3-kinase (PtdIns3K) activity around damaged mitochondria, and inhibition of mitophagic flux causes the accumulation of excessive mitophagosomes resulting in reactive oxygen species (ROS)-dependent apoptosis during cisplatin treatment in oral cancer cells. In parallel, we determined that PPARGC1A/PGC1α (PPARG coactivator 1 alpha) activates mitochondrial biogenesis during CLU-induced mitophagy to maintain the mitochondrial pool. Intriguingly, PPARGC1A inhibition through small interfering RNA (siPPARGC1A) and pharmacological inhibitor (SR-18292) treatment counteracts CLU-dependent cytoprotection leading to mitophagy-associated cell death. Furthermore, co-treatment of SR-18292 with cisplatin synergistically suppresses tumor growth in oral cancer xenograft models. In conclusion, CLU and PPARGC1A are essential for sustained cancer cell growth by activating mitophagy and mitochondrial biogenesis, respectively, and their inhibition could provide better therapeutic benefits against oral cancer.

The Use of a Self-Assembling Peptide Gel for Stricture Prevention in the Esophagus after Endoscopic Submucosal Dissection: A U.S. Multicenter Prospective Study.

BACKGROUND AND AIMS: Post-operative stricture is serious common adverse event following extensive endoscopic submucosal dissection (ESD) in the esophagus. The self-assembling peptide (SA) gel has been shown to promote tissue healing and re-epithelialization. We aimed to evaluate the effect of the SAP gel for esophageal stricture prevention after ESD. METHODS: Multicenter prospective study of patients who underwent esophageal ESD followed by SAP gel application between March 2022 to December 2023. Patients were included if ESD mucosal defect involved ≥ 50% of the circumference of the esophagus. High-risk cases were defined as mucosal defects ≥75% of the circumference. Stricture was defined as the inability to pass an endoscope ≥8.9 mm in diameter or a narrow-caliber lumen in a patient with symptoms. RESULTS: A total of 43 patients (median age 71 years; 81.4% men) underwent ESD (median resected specimen size 50 mm) during the study period. SAP gel (median 3 mL) was successfully applied in all cases (median time 4 minutes). In aggregate, stricture occurred in 20.9% (9/43) of the cases. Stricture developed in 30.8% of the high-risk cases: 80% (4/5) after circumferential ESD and 19% (4/21) in those with defects ≥75% but <100% of the circumference. All cases of stricture resolved with endoscopic treatment. Three cases (6.9%) of postoperative bleeding occurred and were adequately managed endoscopically. CONCLUSION: We demonstrate that SAP gel application was easy, quick, and associated with a relatively low stricture rate comparable to other prophylactic methods. Additional comparative studies are needed to corroborate these preliminary findings.

Nutritional status and its associated factors among the geriatric population in outpatient clinics of a tertiary care hospital in Karachi, Pakistan.

Context: Elderly malnourishment remains a largely unexplored area, despite having a significant effect on the level of mortality and morbidity. This study aims to explore the level of malnourishment and identify those at risk of malnourishment among the elderly population presenting to a teaching hospital in Karachi. Aims: To assess nutritional status and its associated factors among the elderly population. Settings and Design: This study was conducted in outpatient clinics of family medicine at a teaching hospital and its outreach primary care centres from December 2020 to December 2021. The study design was cross-sectional. Materials and Methods: The prevalence of malnourishment and at risk of malnourishment with its associated factors were assessed using the Mini-Nutritional Assessment (MNA) scale as a screening tool among the elderly population (65 years and above) presenting to the family medicine OPDs of a teaching hospital. Statistical Analysis: Data were analysed using the Statistical Package for the Social Sciences (SPSS) version 21. Results: A total of 191 patients were recruited into the study, and the majority of them were males (66.5%). Median age and body mass index (BMI) of participants were 70 (IQR = 74-65) years and 24 (IQR = 27-21) kg/m2, respectively. The median MNA scores were 23.5 (IQR = 20.5-26). A total of 92 (48.2%) participants were found to have a normal nutritional status, 81 (42.4%) were found to be at a risk of malnourishment, and 18 (9.4%) were malnourished. On the multivariable regression model, BMI and ability to manage finances were significantly associated with malnourishment. Conclusion: This study shows an alarmingly high rate of the elderly population at risk of developing malnourishment, and financial independence and increasing BMI were associated with a decreased risk of malnourishment.

Use of telemedicine to tackle health problems in South Asia during the COVID-19 era and beyond: a systematic review.

Introduction: Telemedicine (TM) and teleconsultation services flourished during coronavirus disease 2019 (COVID-19) transmission to avoid COVID-19 infection and physical contact. Many physicians switched to the virtual treatment mode and nearly all types of health disciplines were covered. Through this systematic review, the authors tried to explore the strengths and weaknesses of TM, identify the barriers to adopting TM by population, and explain the limitations of this healthcare delivery model. Methods and results: In this systematic review, 28 studies were included (>53% high-quality studies) as eligible, where nearly 75% (n=21) of the studies were from India, and the remaining 25% (n=7) were from Pakistan, Bangladesh, Sri Lanka, and Nepal. Advice related to cancer, autoimmune diseases, and neurological diseases were the most common among the health disciplines in which TM was used. A peak in teleconsultation was observed during the high transmission phase of COVID-19, although major queries were associated with existing health complications and comorbidities. Conclusion: Other than a few concerns regarding connectivity, privacy, and diagnosis, TM was in fact affordable, timesaving, feasible, and accurate, which ensured a highly satisfying experience among the participants (>80%).

Advancing Antibiotic Residue Analysis: LC-MS/MS Methodology for Ticarcillin Degradation Products in Tomato Leaves.

The indiscriminate use of antibiotics in agriculture has raised concerns about antibiotic residues in food products, necessitating robust analytical methods for detection and quantification. In this study, our primary aim was to develop a robust and advanced liquid chromatography-tandem mass spectrometry (LC-MS/MS) methodology specifically designed for the accurate quantification of ticarcillin degradation products in tomato leaves. The choice of ticarcillin as the target analyte stems from its frequent use in agriculture and the potential formation of degradation products, which can pose a threat to food safety. The use of tomatoes as the target sample matrix in this study is justified by their significance in human diets, their widespread cultivation, and their suitability as a model for assessing antibiotic residue dynamics in diverse agricultural environments. By optimizing the MS/MS parameters, the study successfully demonstrates the practicality and reliability of the employed LC-MS/MS method in accurately assessing ticarcillin degradation product (Thiophene-2-Acetic acid and Thiophene-3-Acetic acid) levels. The chromatographic separation was achieved using a specialized column, ensuring high resolution and sensitivity in detecting analytes. Multiple reaction monitoring (MRM) data acquisition was employed to enhance the selectivity and accuracy of the analysis. The developed method exhibited excellent linearity and precision, meeting the stringent requirements for antibiotic residue analysis in complex matrices. Key outcomes of this study include the successful identification and quantification of ticarcillin and its degradation products in tomato leaves, providing crucial insights into the fate of this antibiotic in agricultural settings. The methodology's applicability was further demonstrated by analyzing real-world samples, highlighting its potential for routine monitoring and ensuring food safety compliance. In summary, our study constitutes a noteworthy advancement in the domain of antibiotic residue analysis, offering a reliable method for quantifying ticarcillin degradation products in tomato leaves. The optimized parameters and MRM-based LC-MS/MS approach enhance the precision and sensitivity of the analysis, opening up opportunities for further studies in the assessment of antibiotic residues in agricultural ecosystems.

Relations of Parental Acceptance-Rejection and Psychological (Mal)Adjustment with Forgiveness and Vengeance among Bangladeshi Young Adults.

The study investigated whether adults' memories of parental acceptance-rejection in childhood predict their current levels of forgiveness and vengeance as mediated by psychological (mal)adjustment. The data were collected from 252 young adults (Women = 137, Men = 115, Age range = 18 - 22 years; Mage = 19.42; SD = 0.99). Measures used were the Adult Parental Acceptance-Rejection Questionnaire (PARQ) short form for fathers and mothers, the Adult Personality Assessment Questionnaire (PAQ) short form for adults, the Heartland Forgiveness Scale (HFS), the Vengeance Scale (VS-10), and the Personal Information Form. Mediation analysis indicated that memories of maternal and paternal rejection predicted vengeance as mediated by psychological maladjustment among both men and women. Further, women's and men's memories of parental (both maternal and paternal) acceptance predicted forgiveness as mediated by psychological adjustment.

Peroral endoscopic myotomy for spastic esophageal dysmotility among opioid users: a multicenter propensity score matching study.

BACKGROUND AND AIMS: Opioid-induced esophageal dysfunction (OIED) often presents as spastic esophageal disorders (SEDs) and esophagogastric junction outflow obstruction (EGJOO). The aim of this study was to evaluate and compare clinical outcomes of peroral endoscopic myotomy (POEM) for SEDs and EGJOO among opioid users and nonusers. METHODS: This propensity score (PS) matching study included consecutive opioid users and nonusers who underwent POEM for SEDs and EGJOO between January 2018 and September 2022. The following covariates were used for the PS calculation: age, sex, duration of symptoms, Eckardt score, type of motility disorder, and length of myotomy during POEM. Clinical response was defined as a post-POEM Eckardt score ≤3. RESULTS: A total of 277 consecutive patients underwent POEM during the study period. PS matching resulted in the selection of 64 pairs of patients strictly matched 1:1 (n = 128) with no statistically significant differences in demographic, baseline, or procedural characteristics or in the parameters considered for the PS between the 2 groups. Clinical response to POEM was significantly lower among opioid users (51 of 64 [79.7%]) versus nonusers (60 of 64 [93.8%]) (P = .03) at a median follow-up of 18 months. Among opioid users, higher opioid dose (>60 morphine milligram equivalents per day) was associated with a higher likelihood of failure to respond to POEM (odds ratio, 4.59; 95% confidence interval, 1.31-3.98; P = .02). CONCLUSIONS: Clinical response to POEM for SEDs and EGJOO is significantly lower among opioid users versus nonusers. There was a dose-relationship between opioids and response to POEM, with higher daily opioid usage associated with a higher likelihood of treatment failure.

Longitudinal dynamics and clinically available predictors of poor response to COVID-19 vaccination in multiple myeloma.

Not available.

An analysis of lncRNAs related to fiber quality and the discovery of their target genes in a Gossypium hirsutum line with Gossypium mustelinum introgression.

KEY MESSAGE: Analysis of fiber quality lncRNAs and their target genes from a pair of Gossypium mustelinum near-isogenic lines provide new prospects for improving the fiber quality of Upland cotton. Long noncoding RNAs (lncRNAs) are an important part of genome transcription and play roles in a wide range of biological processes in plants. In this research, a pair of near-isogenic cotton lines, namely, a Gossypium mustelinum introgression line (IL9) with outstanding fiber quality and its recurrent Upland cotton parent (PD94042), were used as the experimental materials. Cotton fibers were selected for lncRNA sequencing at 17 and 21 days post-anthesis. A total of 2693 differentially expressed genes were identified. In total, 5841 lncRNAs were ultimately screened, from which 163 differentially expressed lncRNAs were identified. Target genes of the lncRNAs were predicted by two different methods: cis and trans. Some of the target genes were related to cell components, membrane components, plant hormone signal transduction and catalytic metabolism, and the results indicated that there might also be important effects on the development of fiber. Four differentially expressed target genes related to fiber quality (Gomus.D05G015100, Gomus.A05G281300, Gomus.A12G023400 and Gomus.A10G226800) were screened through gene function annotation, and the functions of these four genes were verified through virus-induced gene silencing (VIGS). Compared to the negative controls, plants in which any of these four genes were silenced showed significant reductions in fiber strength. In addition, the plants in which the Gomus.A12G023400 gene was silenced showed a significant reduction in fiber uniformity, whereas the plants in which Gomus.A05G281300 was silenced showed a significant increase in fiber fineness as measured via micronaire. Our results showed that these genes play different roles during fiber development, impacting fiber quality.

Outcomes with HLA-matched unrelated donor versus haploidentical hematopoietic cell transplantation.

We investigated the outcomes after adult haploidentical (haplo) and matched unrelated donor (MUD) hematopoietic cell transplantation (HCT) in a single-center study (n = 452) including 276 MUD and 176 haplo transplants. Myeloablative (37%) and reduced-intensity conditioning (63%) were performed. Graft sources included peripheral blood (50%) and bone marrow (50%). GVHD prophylaxis included tacrolimus/methotrexate (53%) and post-transplant cyclophosphamide-based (47%). In MUD versus haplo HCT recipients, a similar incidence of neutrophil engraftment (18 vs 17 days, p = 0.895), grade II-IV acute GVHD (51% vs 50%, p = 0.773), relapse (26% vs 23%, p = 0.578), non-relapse mortality (22% vs 23%, p = 0.817), 1-year disease-free survival (62% vs 63%. p = 0.921), and 1-year overall survival (73% vs 74%, p = 0.744) were observed. Earlier platelet engraftment (22 vs 27 days, p < 0.001) and higher chronic GVHD (45% vs 35%, p = 0.040) were noted in MUD as compared to haplo HCT. Allogeneic transplantation should be done promptly whenever indicated, utilizing either matched unrelated or haploidentical donors.

Development and initial validation of a video-based peroral endoscopic myotomy assessment tool.

BACKGROUND AND AIMS: Video analysis has emerged as a potential strategy for performance assessment and improvement. We aimed to develop a video-based skill assessment tool for peroral endoscopic myotomy (POEM). METHODS: POEM was deconstructed into basic procedural components through video analysis by an expert panel. A modified Delphi approach and 2 validation exercises were conducted to refine the POEM assessment tool (POEMAT). Twelve assessors used the final POEMAT version to grade 10 videos. Fully crossed generalizability (G) studies investigated the contributions of assessors, endoscopists' performance, and technical elements to reliability. G coefficients below .5 were considered unreliable, between .5 and .7 as modestly reliable, and above .7 as indicative of satisfactory reliability. RESULTS: After task deconstruction, discussions, and the modified Delphi process, the final POEMAT comprised 9 technical elements. G analysis showed low variance for endoscopist performance (.8%-24.9%) and high interrater variability (range, 63.2%-90.1%). The G score was moderately reliable (≥.60) for "submucosal tunneling" and "myotomy" and satisfactorily reliable (≥.70) for "active hemostasis" and "mucosal closure." CONCLUSIONS: We developed and established initial content and response process validity evidence for the POEMAT. Future steps include appraisal of the tool using a wider range of POEM videos to establish and improve the discriminative validity of this tool.

Snare Tip Soft Coagulation vs Argon Plasma Coagulation vs No Margin Treatment After Large Nonpedunculated Colorectal Polyp Resection: a Randomized Trial.

BACKGROUND & AIMS: Thermal treatment of the defect margin after endoscopic mucosal resection (EMR) of large nonpedunculated colorectal lesions reduces the recurrence rate. Both snare tip soft coagulation (STSC) and argon plasma coagulation (APC) have been used for thermal margin treatment, but there are few data directly comparing STSC with APC for this indication. METHODS: We performed a randomized 3-arm trial in 9 US centers comparing STSC with APC with no margin treatment (control) of defects after EMR of colorectal nonpedunculated lesions ≥15 mm. The primary end point was the presence of residual lesion at first follow-up. RESULTS: There were 384 patients and 414 lesions randomized, and 308 patients (80.2%) with 328 lesions completed ≥1 follow-up. The proportion of lesions with residual polyp at first follow-up was 4.6% with STSC, 9.3% with APC, and 21.4% with control subjects (no margin treatment). The odds of residual polyp at first follow-up were lower for STSC and APC when compared with control subjects (P = .001 and P = .01, respectively). The difference in odds was not significant between STSC and APC. STSC took less time to apply than APC (median, 3.35 vs 4.08 minutes; P = .019). Adverse event rates were low, with no difference between arms. CONCLUSIONS: In a randomized trial STSC and APC were each superior to no thermal margin treatment after EMR. STSC was faster to apply than APC. Because STSC also results in lower cost and plastic waste than APC (APC requires an additional device), our study supports STSC as the preferred thermal margin treatment after colorectal EMR. (Clinicaltrials.gov, Number NCT03654209.).

Low delayed bleeding and high complete closure rate of mucosal defects with the novel through-the-scope dual-action tissue clip after endoscopic resection of large nonpedunculated colorectal lesions (with video).

BACKGROUND AND AIMS: Complete closure after endoscopic resection of large nonpedunculated colorectal lesions (LNPCLs) can reduce delayed bleeding but is challenging with conventional through-the-scope (TTS) clips alone. The novel dual-action tissue (DAT) clip has clip arms that open and close independently of each other, facilitating tissue approximation. We aimed to evaluate the rate of complete closure and delayed bleeding with the DAT clip after endoscopic resection of LNPCLs. METHODS: This was a multicenter prospective cohort study of all patients who underwent defect closure with the DAT clip after EMR or endoscopic submucosal dissection (ESD) of LNPCLs ≥20 mm from July 2022 to May 2023. Delayed bleeding was defined as a bleeding event requiring hospitalization, blood transfusion, or any intervention within 30 days after the procedure. Complete closure was defined as apposition of mucosal defect margins without visible submucosal areas <3 mm along the closure line. RESULTS: One hundred seven patients (median age, 64 years; 42.5% women) underwent EMR (n = 63) or ESD (n = 44) of LNPCLs (median size, 40 mm; 74.8% right-sided colon) followed by defect closure. Complete closure was achieved in 96.3% (n = 103) with a mean of 1.4 ± .6 DAT clips and 2.9 ± 1.8 TTS clips. Delayed bleeding occurred in 1 patient (.9%) without requiring additional interventions. CONCLUSIONS: The use of the DAT clip in conjunction with TTS clips achieved high complete defect closure after endoscopic resection of large LNPCLs and was associated with a .9% delayed bleeding rate. Future comparative trials and formal cost-analyses are needed to validate these findings. (Clinical trial registration number: NCT05852457.).