Abstract:1: Before commencing hands-on upper gastrointestinal bleeding (UGIB) training, trainees should have thorough knowledge of: pathology, vascular anatomy, technical use of devices, clinical care pathways, and all relevant components of pre-, intra-, and postprocedural patient care. Abstract:2: Preadoption technical skills required for training in the management of UGIB include adequate scope handling, intubation technique, washing and suctioning of residue, mucosal examination, and handling of accessories. Abstract:3: Preadoption technical skills required for training in the management of UGIB should be assessed individually based on a competency framework and not solely on numerical thresholds. Abstract:4: The integrative skills required for the management of UGIB do not essentially differ from those needed in other endoscopic procedures and should include adequate situational awareness, collaboration, team leadership, and patient communication in order to ensure short- and long-term goals are achieved. Abstract:5: The trainee should reach minimum recommended standards for key performance indicators in upper GI endoscopy before starting training in the management of UGIB. Abstract:6: Attendance of at least one half-day training session on a dedicated simulator that provides GI bleeding training at the beginning of training for management of UGIB is advised. Abstract:7: Trainees should be supervised directly and carefully during UGIB training for a minimum of 20 procedures with endoscopic stigmata of recent hemorrhage in order to prevent failure of hemostasis and ensure adequate trainee skill acquisition. Abstract:8: Trainers should take into account pre-endoscopic and intraprocedural factors predicting outcome, technical complexity, and risk of hemostatic failure when deciding appropriateness and degree of trainee involvement in case management. Abstract:9: During their training, trainees should be exposed to all hemostatic modalities, as per ESGE guideline recommendations, and the opportunities for teaching arising from the specifics of each UGIB case. Abstract:10: Trainers should use "successful hemostasis," defined as the absence of any further bleeding (persistent or recurrent bleeding), as the ultimate goal of training in the endoscopic management of UGIB. Abstract:11: Patients with recurrent bleeding should be treated by experienced endoscopists or by a trainee under their direct supervision owing to the higher risk of failure of conventional endoscopic treatment. Abstract:12: Trainers who are teaching management of UGIB should fulfil the same standards as any trainer of basic endoscopy procedures. Abstract:13: Trainees should be exposed to multidisciplinary team discussions and care pathways for failed endoscopic treatment of UGIB. Abstract:14: Training centers with limited UGIB case volumes are encouraged to offer short-term immersive training in centers with high volume caseloads of UGIB in order to ensure sufficient exposure for trainees. Abstract:15: Competency in managing UGIB is defined as the ability to assess the need for endoscopy, and plan and carry out successful hemostasis. Abstract:16: Trainees should manage an indicative number of 30 cases in which successful hemostasis is achieved before evaluation of competence in management of UGIB. Abstract:17: UGIB-CAT is advised as a formative assessment tool during training to track acquisition of competence and provide trainee feedback. Abstract:18: Trainees should undergo a formal summative assessment of competence in managing UGIB during their training. Abstract:19: Endoscopists should continue a period of tracking results and mentored practice with an experienced colleague for at least 6 months after achieving competence in managing UGIB. Abstract:20: As trainees move to independent practice, they should have established access to or referral pathways for key supporting specialties involved in the nonendoscopic management of acute UGIB (including emergency medicine, surgery, and interventional radiology).

Background: Acute GI bleeding (AGIB) can be associated with significant mortality. Topical endoscopic hemostatic powders (TEHPs) have become established as one of the endoscopic treatment modalities for AGIBs. There is no dedicated consensus on the role of TEHPs in the GIB algorithm. Objective: We aimed to develop expert-led consensus statements to provide guidance on the use of TEHPs in AGIBs. Design: A team of 15 experts in the field of acute AGIB from 8 countries was recruited to construct consensus statements on the use of TEHPs. A first meeting was held to define statements. Using the RAND/UCLA appropriateness method, they voted on statements by combining expert collective judgment and best available evidence in a 2-round voting process. Statements were rated on a 9-point interval scale (1 to 9). Four statistical methods were used to delineate statements that satisfied all criteria of appropriateness. For a statement to be considered appropriate, it had to meet all statistical definitions of appropriateness showing consensus agreement. Results: Following round 2, 11 final statements were scored as appropriate, reaching overall consensus. Key recommendations include that TEHPs are effective in achieving hemostasis in malignancy-related GIBs, can be used as “salvage” therapy for nonvariceal GIBs and can be used as a bridge to definitive nonendoscopic therapy. Conclusion: We present a dedicated international consensus statement aimed at providing guidance to clinicians on best practice use of TEHPs in patients with AGIBs. There was consensus among the panel on the need for future trials to compare the use of different hemostatic powders in patients presenting with GIB.

Recent guidelines on biliary cannulation are lacking. This guideline is an initiative of the World Endoscopy Organization (WEO) with the involvement of a panel of experts from Asia, Europe, and America. Relevant clinical questions on four areas (post-endoscopic retrograde cholangiopancreatography [ERCP] pancreatitis [PEP] prophylaxis, biliary cannulation techniques, sphincterotomy/papillary balloon dilation, and biliary cannulation in special circumstances) were developed and answered after systematic reviews of the literature and using the Grading of Recommendations Assessment, Development, and Evaluation methodology. Successful biliary cannulation and sphincterotomy are cornerstones of ERCP and are indispensable for almost all therapeutic and advanced diagnostic procedures. However, adverse events, particularly PEP, may commonly occur and impair patients' outcomes. A high cannulation rate and a low rate of PEP are quality indicators for ERCP and should be the goal of all endoscopists. With this guideline we aimed to provide clinical practice advice applicable worldwide, regardless of resources and expertise availability. The main recommendations focus on specific aspects of ERCP, including pre-, intra-, and postprocedural measures to reduce the risk of PEP, the technique for an initial biliary cannulation attempt, options for cannulation in cases of difficult biliary access, alternatives to ERCP in case of failure (percutaneous- and endoscopic ultrasound-guided), and biliary access in altered anatomy (periampullary diverticulum and postsurgical anatomy) and in the presence of duodenal stenosis.

To date, the combined shear and torsional behavior of reinforced concrete (RC) beams reinforced with continuous glass-fiber reinforced polymer (GFRP) spiral stirrups has not been thoroughly investigated. Accordingly, this paper investigates the behavior of RC beams reinforced with GFRP bars and rectangular continuous spirals under combined shear and torsion. The experimental program involved testing six RC beams, each measuring 3000 mm in length, 200 mm in width, and 400 mm in depth. The test parameters focused on the configuration of transverse reinforcement (GFRP spirals versus GFRP tie stirrups) and varying transverse reinforcement ratios. Four specimens were reinforced with GFRP spirals at different reinforcement ratios to assess the effect of transverse reinforcement on shear and torsional capacities. One specimen was reinforced with GFRP tie stirrups to investigate the influence of stirrup configuration, and one specimen was without web reinforcement (control) to evaluate the impact of concrete strength on the capacities. Experimental results showed that beams with GFRP spirals or tie stirrups failed due to the progressive widening of diagonal tension cracks and subsequent rupture of the GFRP reinforcement at bent portions, while the control beam failed due to concrete splitting. The results demonstrated that reducing the spacing of GFRP spirals significantly enhanced shear and torsional capacities. The experimental findings were compared with existing design codes and a newly proposed model based on the space truss analogy.

Although estimating the post -cracking torsional stiffness is vital for distributing the torsional moment in analyzing statically indeterminate reinforced concrete (RC) structures, none of the North American codes provide an analytical approach for determining the torsional stiffness after cracking. Moreover, the scarcity of experimental work has resulted in the lack of torsion design provisions for concrete box girders reinforced with glass fiber -reinforced polymer (GFRP). Therefore, the purpose of this research was to study the stiffness characteristics of RC box girders reinforced with GFRP reinforcement and to provide a simple analysis technique that can be used to predict post -cracking torsional stiffness. Fourteen concrete box girders were fabricated and tested under a pure torsional moment. In addition, data on 10 solid rectangular RC beams with GFRP reinforcement was collected from the literature. The test results indicate that the concrete strength, as well as the ratio, type, and configuration of the web reinforcement, substantially affected the post -cracking torsional stiffness of the tested specimens. An analytical model was developed for estimating the torsional stiffness after cracking. This model was based on a thin -walled tube and space truss analogy using a concept of postcracking shear modulus. The proposed model considers the effect of concrete strength, the configuration and ratio of the GFRP web reinforcement, and the ratio of the GFRP longitudinal bars. In addition, an equation to calculate the ultimate twist of the GFRP-RC members was developed. The validity of the proposed model was investigated by analytically regenerating the torque -twist curves of the tested box girders and the other specimens available in the literature. require ered. be Elfagren 2004). torque stiffness leads member in specifies calculated a cracking accurate considered the cracking applied stiffness hand, RC bars (Karlsson Lampert

This study investigates the experimental and analytical torsional behavior of reinforced concrete (RC) bridge box girders reinforced with glass fiber-reinforced polymer (GFRP) bars and continuous spiral stirrups, representing a first in literature. Reinforced concrete box girders were constructed and examined until failure to assess the influence of the spiral pitch and web reinforcement configuration on torsional behavior and strength. The test specimens had continuous GFRP spirals and tie stirrups; the control specimen did not have web reinforcement. The specimens were 4,000 mm long, 380 mm wide, and 380 mm high, and had a wall thickness of 100 mm. The test results demonstrate that the box girder with spiral GFRP reinforcement achieved higher torsional strength and lower twist than its counterpart specimen reinforced with individual GFRP tie stirrups by approximately 6% and 11%, respectively. The specimen with a narrow spiral pitch performed better than the specimens with a wide spiral pitch. An analytical iterative softened membrane model for torsion (SMMT) was used to estimate the entire torsional behavior of box girders with spiral GFRP reinforcement. The analytical results were compared with the experimental results of four bridge box girders with spiral GFRP reinforcement to validate the model's accuracy. The comparison indicates that the model could reasonably predict the cracking and ultimate torsional strength as well as the associated twists.

The behavior of high-strength concrete (HSC) box girders reinforced with glass-fiber-reinforced polymers (GFRP) under pure torsional loading has not been addressed, so far. Three large-scale concrete box girders reinforced with GFRP bars and stirrups were cast and examined under pure torsional loading over a clear span of 2000 mm. The box girders measured 4000 mm long, 380 mm wide, 380 mm deep, and 100-mm wall thickness. The test parameters include the web reinforcement configuration (spirals vs. ties) and concrete strength (NSC vs. HSC). The test specimens included two girders constructed with NSC-one reinforced with GFRP continuous spirals and one with GFRP individual ties-and the last one with HSC and GFRP continuous spirals. The test results indicated that the specimen with HSC and spiral stirrups exhibited the highest pre-and-post-cracking torsional strength and stiffness compared to counterpart specimens with NSC and ties or spirals.

Background: Chronic obstructive pulmonary disease is a multisystem disease with multiple comorbidities. Hearing is dependent on the cochlear functions that may be affected by oxygenation. Affection of hearing is problematic and represents a major concern that should be seriously investigated as an important comorbidity in chronic obstructive pulmonary disease patients. Objective: To assess auditory status among chronic obstructive pulmonary disease patients. Methodology: The current study was carried out at Al-Azhar University Hospitals, Cairo, from 1 August 2021 to 2022, including 120 participants. In addition to the control group (60 healthy participants), there were two study groups: chronic obstructive pulmonary disease patients with respiratory failure group (30 patients) and non-respiratory failure group (30 patients). Hearing functions were studied using pure tone audiometry, and auditory brain stem response. Results: There was statistically significant hearing impairment in chronic obstructive pulmonary disease patients in comparison to control group. The hearing impairment was more significant in chronic obstructive pulmonary disease with respiratory failure group in comparison to chronic obstructive pulmonary disease without respiratory failure group. The auditory impairment shows a negative interrelationship with oxygen tension (PaO2) and a positive interrelationship with the smoking index. Conclusion: Hearing affection was meaningfully higher among chronic obstructive pulmonary disease patients and more prominent in patients with respiratory failure. Hypoxia results in deterioration of pure tone audiometry and increased absolute and interpeak latencies in auditory brain stem response. At every frequency, the mean pure tone audiometry thresholds were higher for chronic obstructive pulmonary disease groups than control group albeit remaining in the mild to moderate area of hearing loss. Retro-cochlear affection was suggested among patients with chronic obstructive pulmonary disease as evidenced with the prolongation of auditory brain stem response waves latencies.

Background & Aims: Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. Methods: Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. Results: Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. Conclusions: Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. Impact and implications: Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion.

The torsional behavior of solid reinforced concrete (RC) members reinforced with fiber-reinforced polymer (FRP) bars has been the subject of several experimental studies. No experimental research, however, seems to have focused on RC box girders reinforced with FRP bars under a pure torsional moment. This paper reports the results of an experimental investigation on the torsional strength and behavior of full-scale RC box girders reinforced with longitudinal glass FRP (GFRP) bars. All specimens measured 380 mm (15 in.) in height, 380 mm (15 in.) in width, 100 mm (4 in.) wall thickness, and 4000 mm (157.48 in.) in length. They were tested under pure torsional loading over a clear span of 2000 mm (78.74 in.). The test specimens consisted of four RC box girders with longitudinal GFRP bars and one RC box girder with longitudinal steel bars as a reference. All the specimens were constructed without web reinforcement to study the contribution of the longitudinal reinforcement to torsional strength. The test variables included the longitudinal reinforcement ratio (ranging between 1.10 and 2.74%) and the type of longitudinal reinforcement (GFRP or steel). The test results indicate that increasing the GFRP longitudinal reinforcement ratio increased the torsional strength after the initiation of the first diagonal crack, especially for specimens with a high reinforcement ratio. In addition, theoretical torsional moment-twist curves were developed and gave predictions consistent with the experimental test results. Lastly, the ultimate torsional strength of the GFRP-RC box girders without web reinforcement was estimated with the CSA S806-12 (R2017) design equation with a modification related to the GFRP tensile strain limit.

To date, the torsional behavior of high-strength concrete (HSC) box girders reinforced with glass fiber-reinforced polymer (GFRP) reinforcement has not been investigated. This study reports on the experimental results of HSC box girders reinforced with GFRP bars, ties, and spirals under pure torsion. Seven full-scale reinforced concrete (RC) box girders with a total length of 4,000 mm, width of 380 mm, height of 380 mm, and wall thickness of 100 mm were examined over a clear span of 2,000 mm. The test parameters included the type, configuration, and amount of the web reinforcement and the concrete type. All specimens have the same longitudinal reinforcement ratio. The test specimens comprised three box girders reinforced with GFRP bars and individual ties, three specimens reinforced with GFRP bars and continuous spirals, and one box girder entirely reinforced with steel reinforcement as a reference specimen. Two girders were fabricated with normal-strength concrete (NSC)-one reinforced transversally with GFRP spirals; the other reinforced with ties-to investigate the influence of concrete type on torsional behavior. The test findings indicate that, at the same web reinforcement ratio and reinforcement configuration, the HSC specimens achieved higher pre- and post-cracking torsional strength and stiffness than their counterpart NSC specimens. The continuous spiral configuration instead of individual ties improved the overall torsional performance of the tested box girders. Moreover, the stirrup's capacity strongly influenced the torsional strength of the GFRP- and steel-reinforced concrete box girders, but the stirrup stiffness did not affect the ultimate torque.

Concrete box girders are significant structural elements in various engineering applications due to higher torsional stiffness and low self-weight. The use of glass fiber-reinforced polymers (GFRPs) as internal bars has been adopted for many structural applications. So far, the torsional behavior of reinforced concrete (RC) box girders reinforced with GFRP bars has not been addressed. Therefore, this paper presents experimental data on the torsional behavior of RC box girders reinforced with GFRP bars and stirrups. Six box girders measuring 4,000 mm in length, 380 mm in height, and 380 mm in width, with a wall thickness of 100 mm, were tested under pure torsional moment over a clear span of 2,000 mm. The test parameters included the type and amount of torsional reinforcement. The test specimens comprised four box girders entirely reinforced with GFRP reinforcement, one box girder with only longitudinal GFRP bars, and one box girder reinforced with steel reinforcement as a reference specimen. The test results indicate that the torsional strength of the steel and GFRP box girders was significantly affected by stirrup capacity; stirrup stiffness did not affect the torsional strength. Increasing the web's GFRP reinforcement ratio increased the torsional strength and stiffness. An analytical iterative softened membrane model for torsion (SMMT) was modified to predict the entire torsional behavior of the GFRP-reinforced concrete box girders. The model was validated by comparing the analytical results to the experimental results of the four GFRP-reinforced concrete box girders. The comparison indicates that the model was able to predict the cracking and ultimate torsional strength and the corresponding twist with reasonable agreement. In addition, a noniterative Rahal model was modified to predict the ultimate torsional strength of FRP-reinforced concrete members. At last, the experimental ultimate torsional strength was assessed with the corresponding value calculated according to available fiber-reinforced polymer design codes and guides.