Nutritional ketosis has been found to improve metabolic and inflammatory markers, including lipids, HbA1c, high-sensitivity CRP, fasting insulin and glucose levels, and aid in weight management. We discuss these findings and elaborate on potential mechanisms of ketones for promoting weight loss, decreasing hunger, and increasing satiety. Humans have evolved with the capacity for metabolic flexibility and the ability to use ketones for fuel. During states of low dietary carbohydrate intake, insulin levels remain low and ketogenesis takes place. These conditions promote breakdown of excess fat stores, sparing of lean muscle, and improvement in insulin sensitivity.

By school age, some bilingual children can score equivalently to monolinguals in receptive vocabulary but still lag in expressive vocabulary. In this study, we test whether bilingual children have greater difficulty with lexical access, as has been reported for adult bilinguals. School-aged French–English bilingual children were given tests of receptive vocabulary and picture naming. The bilingual children's performance was compared to English monolinguals'. We found that bilingual children scored slightly lower on some measures of comprehension and lower on producing the target word. The bilinguals were more likely to correctly identify the target picture even if they had not produced the name. The differences in comprehension but not production could be statistically accounted for by the variation in receptive vocabulary. These results suggest that, school-aged bilinguals can be close to monolinguals in receptive vocabulary but have a harder time accessing the exact word for production. We discuss reasons for this difficulty with lexical access and strategies that children used when they did not produce the target word.

Objectives and study aim  Colonoscopy prevents colorectal cancer by removing adenomatous polyps, but missed adenomas lead to interval cancers. Different devices have been used to increase adenoma detection rates (ADR). Two such devices of interest are the transparent cap (Olympus) and Endocuff (ARC Medical). Our study aimed to compare differences in ADR between Endocuff-assisted colonoscopy (EAC), cap-assisted colonoscopy (CAC) and standard colonoscopy (SC). Patients and methods  A sample size of 126 subjects was calculated to determine an effect size of 30 %. Patients undergoing screening or surveillance colonoscopy between March 2016 and January 2017 were randomized to SC, CAC or EAC groups. Three experienced endoscopists performed all colonoscopies. Patient demographics, procedure indication, Boston Bowel Prep Score (BBPS), withdrawal time, polyp size, location, histopathology, were analyzed. Results  There was no difference in ADR (52 %, 40 % and 54 %) in the SC, CAC and EAC groups respectively ( P  = 0.4). Similar findings were also observed for proximal ADR (45 %, 35 %, and 50 %, P  = 0.4) and SSA detection rate (16 %, 14 %, and 23 %, P  = 0.5). EAC detected higher mean ADR per colonoscopy compared to CAC (1.70 vs 0.76, P  = 0.01). However, there was no significant difference in mean ADR per positive colonoscopy (2.08, 1.63, and 2.59, P  = 0.21). Conclusion  In a randomized controlled trial comparing AC to CAC and SC, neither device conferred additional benefits in ADR among high detectors. When comparing each device, EAC may be better than CAC at detecting more total adenomas.

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Aims: Endoscopic management of indeterminate strictures and complex stones remains a challenge, for which the latest generation single-operator digital cholangioscope (SpyGlass DS) has shown promising results. We aimed to study the clinical impact of single-operator digital cholangioscope at our tertiary academic center. Methods: We retrospectively reviewed all digital cholangioscopies performed from June 2015 to May 2018. Patient characteristics, procedure characteristics, and post-procedural patient outcomes were recorded. Results: A total of 50 patients (26 men, average age 61.4 years) underwent 67 procedures. Indications were biliary stones (21/50, 42%), strictures and primary sclerosing cholangitis surveillance (22/50, 46%), and miscellaneous (7/50, 14%). The average procedure time was 82 ± 29 min (99.5 min for stones and 74.2 min for strictures). Stone clearance was achieved in 19/21 (90.47%) cases, with electrohydraulic lithotripsy employed in 16/21 and repeat cholangioscopy necessary in 9/21. Malignant strictures (10) were differentiated from benign (12) in all cases both in patients with primary sclerosing cholangitis (9) and in those without (13), based on visual cholangioscopic features (sensitivity and specificity 100%), single-operator digital cholangioscope–directed biopsies (sensitivity 60% and specificity 100%), and brush cytology (sensitivity 37.5% and specificity 100%). Complications included one post-sphincterotomy bleeding and one post-procedural cholangitis despite antibiotic prophylaxis, but no procedure-related mortality. Conclusion: Single-operator digital cholangioscope had a high success rate and a low rate of complications for management of indeterminate strictures and difficult biliary stones. Visual cholangioscopic features of biliary strictures had excellent diagnostic accuracy, and targeted biopsies outperformed brush cytology. Early implementation of cholangioscopy for select indications leads to successful patient outcomes and reduces diagnostic delays, cost, and risks of repeat endoscopic retrograde cholangiopancreatographies.

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