Helicobacter pylori and gastric cardia cancer: What do we know about their relationship?

The incidence of gastric cardia cancer is increasing around the world. Since the discovery of Helicobacter pylori (H. pylori), numerous studies have proved that it is a causative factor for many kinds of digestive system tumors. Although the literature on gastric cardia cancer and H. pylori is not scarce, there are still many controversies on the relationship between gastric cardia cancer and H. pylori. Many Western research results showed that there was a negative or no correlation between H. pylori infection and gastric cardia cancer, but in several studies in Asian countries, such as China, H. pylori was demonstrated to be a risk factor for gastric cardia cancer. Therefore, we intended to analyze the related studies to find out the relationship between H. pylori and gastric cardia cancer and find out the causes of the above controversies. We also conducted a meta-analysis of the relationship between cagA positive expression of H. pylori and gastric cardia cancer, to find out whether there is an effect between those two. The primary purpose of this paper was to explore the relationship between gastric cardia cancer and H. pylori. Through analysis, the study showed the reasons for the controversies mentioned above: (1) Geographical factors could affect the relationship between H. pylori and gastric cardia cancer; (2) The definition of gastric cardia cancer in various studies is inconsistent. The result of a meta-analysis about the relationship between H. pylori virulence factor cagA and gastric cardia cancer showed that there was no relationship between these two.

European Specialty Examination in Gastroenterology and Hepatology examination — improving education in gastroenterology and hepatology

The Federation of Royal Colleges, the British Society of Gastroenterology (BSG) and the European Section and Board of Gastroenterology and Hepatology developed the European Specialty Examination in Gastroenterology and Hepatology (ESEGH) from the United Kingdom Specialty Certificate Examination, which was the original examination. Since 2018 the Specialty Certificate Examination and the ESEGH were combined into a single exam, identical across Europe and the rest of the world. The ESEGH is mandated in 4 countries (United Kingdom, Switzerland, The Netherlands and Malta) and the number of entries increased from 50 in 2014 to 490 in 2019. Candidates from countries were the ESEGH is not mandated are sitting the Exam, showing us they realize the enormous interest of holding a certificate for knowledge in their Curriculum. We also have an increasing number of candidates from countries outside Europe.

Pathological characterization of occult hepatitis B virus infection in hepatitis C virus-associated or non-alcoholic steatohepatitis-related hepatocellular carcinoma

Occult hepatitis B virus (HBV) infection, by definition, is a state in which infection with this virus does not manifest with the conventional diagnostic laboratory criteria reserved for the obvious form of HBV infection. As a result, occult HBV infection is commonly a surprise finding discovered accidently during the evaluation of other apparent liver diseases, such as hepatitis C virus (HCV) infection or non-alcoholic fatty liver disease and, more importantly, their evolution into life-threatening hepatocellular carcinoma. As infection with HCV and occult HBV is rarely considered when assessing these more obvious conditions, and in an attempt to offer a better understanding of this phenomenon, this study attempted to shed some light onto the uniqueness of occult HBV infection by addressing the natural history of HBV and HCV infections, as well as non-alcoholic fatty liver disease. This was carried out by taking into account the exclusive integration process undertaken by the HBV genome into infected host hepatocytes, with consideration given to conditions which afford reactivation of the occult infection and stress on the molecular mechanisms that underlie occult HBV infection. Finally, the clinical outcome of occult HBV infection and its relation to hepatocellular carcinoma is analyzed.

Treatment strategies and preventive methods for drug-resistant Helicobacter pylori infection

The infection and drug resistance rates of Helicobacter pylori (H. pylori) are high and must be prevented and treated by better strategies. Based on recent research advances in this field as well as the results from our team and those on traditional Chinese medicine, we review the causes of drug resistance, and prevention and treatment strategies for drug-resistant H. pylori infection, with an aim to make suggestions for the development of new drugs, such as establishment of new target identification and screening systems, modification of existing drug structures, use of new technologies, application of natural products, and using a commercial compound library. This article may provide reference for eradication of drug-resistant H. pylori.

Probiotics in inflammatory bowel disease: Does it work?

The number of patients with inflammatory bowel disease (IBD), a group of diseases mainly represented by Crohn’s disease (CD) and ulcerative colitis (UC), has increased in recent decades. As a consequence, the number of people undergoing any drug treatment against these diseases has expanded. However, IBD conventional therapies present several limitations, which lead researchers to look for better alternatives to improve the quality of life of patients. Moreover, microbiome imbalance seems to play a crucial role in the pathogenesis of IBD, since important alterations in bacterial, viral, protist and fungal populations are observed in the gut microbiota of affected individuals. Given the importance of such life forms in that context, the use of probiotics becomes a plausible alternative for treating affected patients. Trials have been developed aiming the evaluation of probiotics potential to induce and to maintain remission in CD and UC. Regarding the tested microorganisms, various non-pathogenic bacteria and fungi have been assessed. However, consistent results have been obtained only with some of them, including Escherichia coli Nissle 1917, VSL#3, Saccharomyces boulardii, Lactobacillus, and Bifidobacterium. Therefore, this minireview aims to explore the role of microbiota in the genesis of such a disorder and to compile the most concrete data on probiotic-related efficiency in IBD treatment.

Systematic review with meta-analysis of the epidemiological evidence relating smoking to type 2 diabetes

BACKGROUND

Evidence relating tobacco smoking to type 2 diabetes has accumulated rapidly in the last few years, rendering earlier reviews considerably incomplete.

AIM

To review and meta-analyse evidence from prospective studies of the relationship between smoking and the onset of type 2 diabetes.

METHODS

Prospective studies were selected if the population was free of type 2 diabetes at baseline and evidence was available relating smoking to onset of the disease. Papers were identified from previous reviews, searches on Medline and Embase and reference lists. Data were extracted on a range of study characteristics and relative risks (RRs) were extracted comparing current, ever or former smokers with never smokers, and current smokers with non-current smokers, as well as by amount currently smoked and duration of quitting. Fixed- and random-effects estimates summarized RRs for each index of smoking overall and by various subdivisions of the data: Sex; continent; publication year; method of diagnosis; nature of the baseline population (inclusion/exclusion of pre-diabetes); number of adjustment factors; cohort size; number of type 2 diabetes cases; age; length of follow-up; definition of smoking; and whether or not various factors were adjusted for. Tests of heterogeneity and publication bias were also conducted.

RESULTS

The literature searches identified 157 relevant publications providing results from 145 studies. Fifty-three studies were conducted in Asia and 53 in Europe, with 32 in North America, and seven elsewhere. Twenty-four were in males, 10 in females and the rest in both sexes. Fifteen diagnosed type 2 diabetes from self-report by the individuals, 79 on medical records, and 51 on both. Studies varied widely in size of the cohort, number of cases, length of follow-up, and age. Overall, random-effects estimates of the RR were 1.33 [95% confidence interval (CI): 1.28-1.38] for current vs never smoking, 1.28 (95%CI: 1.24-1.32) for current vs non-smoking, 1.13 (95%CI: 1.11-1.16) for former vs never smoking, and 1.25 (95%CI: 1.21-1.28) for ever vs never smoking based on, respectively, 99, 156, 100 and 100 individual risk estimates. Risk estimates were generally elevated in each subdivision of the data by the various factors considered (exceptions being where numbers of estimates in the subsets were very low), though there was significant (P < 0.05) evidence of variation by level for some factors. Dose-response analysis showed a clear trend of increasing risk with increasing amount smoked by current smokers and of decreasing risk with increasing time quit. There was limited evidence of publication bias.

CONCLUSION

The analyses confirmed earlier reports of a modest dose-related association of current smoking and a weaker dose-related association of former smoking with type 2 diabetes risk.

Single-balloon and spiral enteroscopy may have similar diagnostic and therapeutic yields to double-balloon enteroscopy: Results from a meta-analysis of randomized controlled trials and prospective studies

BACKGROUND

Double-balloon, single-balloon, and spiral enteroscopy (DBE, SBE, and SE) have revolutionized the management of intestinal diseases. However, evidence about efficacies of these methods is lacking. We aimed to conduct a meta-analysis comparing the clinical outcomes among DBE, SBE, and SE.

METHODS

We searched randomized controlled trials and prospective studies in MEDLINE, PubMed, EMBASE, Cochrane Library, and Chinese CQVIP database. Studies referencing the comparison of at least two of these three methods were included. Primary outcome was diagnostic yield. Other outcomes were therapeutic yield, total enteroscopy, examination time, time to maximum insertion, and depth of maximal insertion (DMI).

RESULTS

Eleven studies including 727 patients were identified: DBE vs SE (n = 6), DBE vs SBE (n = 4), and SBE vs SE (n = 1). The diagnostic and therapeutic yields did not differ significantly when comparing DBE with SE [odds ratio (OR) = 1.19, 95% confidence interval (CI): 0.68-2.08; OR = 1.17, 95%CI: 0.61-2.23] and DBE with SBE (OR = 0.85, 95%CI: 0.55-1.33; OR = 1.71, 95%CI: 0.64 - 4.60). Total enteroscopy, examination time, time to maximum insertion, and DMI were similar between SBE and DBE. DBE was superior to SE with regard to DMI [mean difference (MD) = 36.76, 95%CI: 5.09-68.43], with longer time to maximum insertion (MD = 15.14, 95%CI: 12-18.27) and examination time (MD = 12.98, 95%CI: 9.57-16.38).

CONCLUSION

DBE and SBE have similar clinical outcomes. Compared with DBE, SE seems to have similar diagnostic and therapeutic yields, but shorter procedural time in cost of less depth of insertion. SE needs further evaluation vs SBE. DBE is recommended for complete enteroscopy.

Chinese research into ulcerative colitis from 1978 to 2017: A bibliometric analysis

BACKGROUND

Over the last 40 years, with accumulating evidence demonstrating a significant increase in the incidence of ulcerative colitis (UC) in China, the number of studies on UC has been rapidly increasing. But it still lacks a comprehensive meta-analysis of publications regarding UC for the last four decades in China. Thus, a bibliometric analysis of UC is warranted to investigate the trend and distribution of the publications on UC in China in recent years. And it is supposed that the number of the papers related to UC increased by year.

AIM

To investigate the current status of research output from Chinese studies related to UC during the period of 1978 to 2017, with special attention paid to the distribution of publication dates, journals, regions, and research organizations.

METHODS

Publications on UC were searched in the Chinese periodical database SinoMed from January 1978 to December 2017. The search term used for retrieval was “ulcerative colitis”. The language of the publications was restricted to English or Chinese. The studies have to be performed in China. Then, a bibliometric analysis was performed on the distribution of publication dates, journals, regions, and research organizations with EndNote, Excel, MySQL, and GraphPad Prism.

RESULTS

A total of 16257 papers matched the search criteria, which included 7561 papers published in core journals, 4641 evidence-based articles, and 4177 publications of randomized controlled trials. These papers were mainly published in Chinese Journal of Coloproctology, World Chinese Journal of Digestology, Chinese Journal of Digestion, Chinese Journal of Integrated Traditional and Western Medicine on Digestion, and Modern Journal of Integrated Traditional Chinese and Western Medicine. In particular, the majority of these organizations were located in Jiangsu, Henan, Shandong, and Guangdong Provinces which are rich areas or have the largest population per province. Most of these studies were conducted by academic institutions.

CONCLUSION

Over the past four decades, the output of research into UC in China has increased significantly, with academic institutions playing a central role in the academic field, but the number and quality of these researches vary substantially among different regions.

Effectiveness and safety of sedation in gastrointestinal endoscopy: An opinion review

Although endoscopy is a less invasive procedure than surgery, patients can experience pain without sedation. Patients expect reduced pain during endoscopies from effective and safe sedatives. Midazolam and propofol are used for endoscopic sedation in many countries and regions. Midazolam is a widely available benzodiazepine, and many clinical trials have shown it to be an effective sedative. However, patients who are sedated with midazolam require rest in the recovery room due to its relatively long half-life, and an antagonist such as flumazenil may need to be administered in cases of deep or prolonged sedation. Propofol is a short-acting sedative with a short half-life and a quick recovery time. Therefore, the use of propofol has been increasing. However, propofol has a narrow margin of safety and often induces adverse effects such as respiratory depression. Also, propofol has no specific antagonist, and should be administered by an anesthesiologist or an endoscopist familiar with anesthesia. Remimazolam, which is a novel ultra-short-acting benzodiazepine, has recently gained attention. Remimazolam has a short half-life and an antagonist. Both effective and safe sedation is desired in accordance with the increasing need for sedative endoscopies. Therefore, in this review each sedative is summarized.

Utility of gastrointestinal ultrasound in functional gastrointestinal disorders: A narrative review

Gastrointestinal (GI) ultrasound (GIUS) is valuable in the evaluation of GI diseases such as inflammatory bowel disease, but its use in functional GI disorders (FGIDs) is largely unknown although promising. In order to review the current knowledge on current and potential uses of GIUS in FGIDs, information was obtained via a structured literature search through PubMed, EMBASE and Google Scholar databases with a combination of MESH and keyword search terms: “ultrasound”, “functional GI disorders”, “irritable bowel syndrome”, “functional dyspepsia”, “intestinal ultrasound”, “point of care ultrasonography”, “transabdominal sonography”, “motility”, “faecal loading”, “constipation”. GIUS is currently used for various settings involving upper and lower GI tracts, including excluding organic diseases, evaluating physiology, guiding treatment options and building rapport with patients. GIUS can be potentially used to correlate mechanisms with symptoms, evaluate mechanisms behind treatment efficacy, and investigate further the origin of symptoms in real-time. In conclusion, GIUS is unique in its real-time, interactive and non-invasive nature, with the ability of evaluating several physiological mechanisms with one test, thus making it attractive in the evaluation and management of FGIDs. However, there are still limitations and concerns of operator dependence and lack of validation data for widespread implementation of GIUS in FGIDs.

Hypoxia and oxidative stress: The role of the anaerobic gut, the hepatic arterial buffer response and other defence mechanisms of the liver

The liver is considered a vital organ and is the hub for multiple chemical functions, such as intermediary metabolism and the detoxification of ingested toxins, which are essential for the preservation of life, hence, the origin or the word “liver”. The liver has enormous, highly diversified catalytic potential. This enormous catalytic potential generates massive oxidative stress, which is important for the functions of the liver but is detrimental to the viability of the liver. The liver receives approximately 80% of its blood supply from the portal vein, which brings less saturated blood from the gastrointestinal tract. Hepatocytes operate in a relatively hypoxic microenvironment due to this portal inflow. The development of this hypoxic microenvironment of the liver is an important evolutionary adaptation for its detoxification function that is not recognized in the literature as a defence mechanism against the oxidative stress generated during the detoxification process. This review describes liver function in relation to its oxidative catalytic potential and the oxidative stress generated by it as well as the evolutionary defence mechanisms present in the liver against this oxidative stress to provide new insights into liver function.

L-carnitine supplementation in non-alcoholic fatty liver disease: A systematic review and meta-analysis

BACKGROUND

Non-alcoholic fatty liver disease (NAFLD) dominates the landscape of modern hepatology. Affecting 25% of the general population, there is critical unmet need to identify broadly available, safe and cost-effective treatments. Cumulative evidence in animal and human models suggests that intrahepatic and skeletal muscle fatty acid oxidation is impaired in NAFLD, such that lipid accretion is not matched by efficient utilisation. L-carnitine is a crucial mediator of fatty acid metabolism in vivo, promoting mitochondrial lipid β-oxidation and enhancing tissue metabolic flexibility. These physiological properties have generated research interest in L-carnitine as a potentially effective adjunctive therapy in NAFLD.

AIM

To systematically review randomised trials reporting effects of dietary L-carnitine supplementation on liver biochemistry, liver fat and insulin sensitivity in NAFLD.

METHODS

Search strategies, eligibility criteria and analytic methods were specified a priori (PROSPERO reference: CRD42018107063). Ovid MEDLINE, Ovid EMBASE, PubMed, Web of Science and the Cochrane Library were searched from their inception until April 2019. Outcome measures included serum concentrations of alanine and aspartate aminotransferase (ALT and AST), liver fat and insulin sensitivity assessed by the homeostasis model of insulin resistance (HOMA-IR). A random effects meta-analysis was performed for, ALT, AST and HOMA-IR measures separately. Between-study heterogeneity was measured using I² statistics.

RESULTS

Five eligible randomised trials were included in the qualitative and quantitative synthesis (n = 338). All of the 5 included trials assessed the effect of L-carnitine on serum ALT, identified from Italy, South Korea and Iran. Weighted mean difference (WMD) for ALT between L-carnitine and control groups after intervention was -25.34 IU/L [95%CI: -41.74-(-8.94); P = 0.002]. WMD for AST between L-carnitine and control groups was -13.68 IU/L (95%CI: -28.26-0.89; P = 0.066). In three studies (n = 204), HOMA-IR was evaluated. WMD for HOMA-IR between L-carnitine and control groups was -0.74 units [95%CI: -1.02-(-0.46); P < 0.001]. Two studies using validated outcome measures reported a significant reduction in liver fat in L-carnitine vs control groups post-intervention (P < 0.001).

CONCLUSION

Pooled results indicate that L-carnitine supplementation attenuates ALT, liver fat and insulin resistance in NAFLD cohorts, confirming a beneficial effect of L-carnitine for a highly prevalent condition with a growing economic burden.

Long-term efficacy of capecitabine plus oxaliplatin chemotherapy on stage III colon cancer: A meta-analysis

BACKGROUND

Many clinical studies for the long-term survival or efficacy of capecitabine plus oxaliplatin (XELOX) in colon cancer have already been studied, but its clinical benefit is controversial.

AIM

To evaluate the long-term efficacy of XELOX regimen in comparison with other adjuvant chemotherapy protocols in colon cancer.

METHODS

By searching the PubMed, EMBASE and Cochrane databases, a total of 12 randomized controlled trials involving 6698 stage III colon cancer cases (XELOX protocol: n = 3298 cases; other adjuvant chemotherapy protocol: n = 3268 cases) were included. The parameter outcomes included the overall survival and the disease-free survival. The quality control of selected literature was based on the Jadad scale and the GRADE system.

RESULTS

In comparison to other adjuvant chemotherapy regimen, XELOX regimen showed a better overall survival (odds ratio = 1.29, 95% confidence interval: 1.15-1.44, P < 0.0001) and a better disease-free survival (odds ratio = 1.32, 95% confidence interval: 1.18-1.46, P < 0.0001) for colon cancer patients, suggesting the XELOX regimen can be a good option for postoperative treatment of stage III colon cancer.

CONCLUSION

The XELOX regimen can be a preferred option for adjuvant treatment of stage III colon cancer after surgery.

Is there still a role for sucralfate in the treatment of gastritis?

The endoscopic diagnosis of gastritis is usually made when a patient develops symptoms and undergoes an upper gastrointestinal endoscopy. There are often obvious aetiological causes such as smoking, alcohol Helicobacter pylori infection or drug treatment. Lifestyle changes can sometimes improve symptoms but often patients will be treated with a proton pump inhibitor. The stomach mucosa produces a protective mucous to prevent damage cause by gastric acid and exogenous agents can disrupt this layer. Repair of this protective layer can be enhanced by reduction in gastric acid secretion using H2 receptor antagonist or proton pump inhibitors or by cytoprotective drugs such as misoprostol, sucralfate, aluminium ions or bismuth subsalts. Sucralfate is a complex polymer which at a low pH changes its chemical configuration and binds to serum protein to form a protective layer protecting the mucosa against further injury. Cytoprotective drugs were the first line treatment for peptic disease including gastritis for many years but since the launch of cimetidine in 1976 and the subsequent launch of omeprazole in 1988, their use has slowly declined. First line treatment for patients with symptomatic gastritis after removal of potential causative factors is likely to be a proton pump inhibitor in 2019. This is despite the fact that there is some evidence that sucralfate is superior than a H2 receptor antagonist in the endoscopic healing rates in patients with gastritis. The logical treatment choice in patients with resistance symptoms is a combination of a proton pump inhibitor and sucralfate but evidence is lacking. Until such evidence is available In the meantime, we would suggest that there is a role for sucralfate in the treatment of intransigent gastritis and that mucosal protection should be considered even ahead of acid suppression given its favourable safety and toxicity profile.

Gender prevalence of cardiovascular diseases in the geriatric population of India: A meta-analysis using R

BACKGROUND

Population ageing is an important challenge for developed as well as developing countries due to the downward trends in mortality rates. The elderly population is increasing worldwide. Cardiovascular diseases (CVDs) are one of the most common diseases in the geriatric population. These diseases involve the heart or blood vessels and include hypertension, rheumatic heart disease, heart failure, and heart attack. An estimated 17.7 million people in India will die from CVDs representing 31% of all global deaths.

AIM

To perform a systematic review and meta-analysis of the gender prevalence of CVDs in the geriatric population of India.

METHODS

In the present study, we searched databases such as Google Scholar, PubMed and MEDLINE from the year 2003 to 2019 to identify the prevalence of CVDs in the Indian geriatric population. A meta-analysis was conducted using the statistical software R version 3.4.3 and the random effect model was used to determine the pooled estimate of the prevalence of CVDs in the geriatric population of India along with the 95% confidence interval rather than using the fixed effect model. The random effect model takes into consideration the heterogeneity across the various studies.

RESULTS

The prevalence of CVDs in the Indian geriatric population was determined in 6586 male subjects from 32 studies and 8164 female subjects from 32 studies, respectively. The overall prevalence of CVDs in the Indian geriatric population was 36.6% (95%CI: 31.9%-41.3%). In addition, calculation of the various heterogeneity statistics (Cochran’s Q = 3836.85, I² = 98.6%, P < 0.0001) indicated heterogeneity in the prevalence of CVDs in the elderly Indian population in these studies. The prevalence of CVDs in elderly males was 38.0% (95%CI: 33.0%-43.0%) and the prevalence of CVDs in elderly females was 40.9% (95%CI: 35.5%-46.2%).

CONCLUSION

The results indicate that the prevalence of CVDs in the female geriatric population was relatively higher than that in the male geriatric population. Policy makers must take immediate steps to prevent CVDs and improve geriatric health care services in India.

Use of music during colonoscopy: An updated meta-analysis of randomized controlled trials

BACKGROUND

Music seems to be beneficial in multiple clinical areas. Colonoscopy is a stressful event for patients, especially with conscious sedation. Music during colonoscopy has been evaluated in multiple randomized controlled trials (RCTs) with varied results. Even meta-analyses on the subject over the years have yielded inconsistent conclusions. Therefore, we conducted an up-to-date meta-analysis regarding music during colonoscopy.

AIM

To assess the effects of music played during colonoscopy on patients’ perspectives and sedation requirements.

METHODS

Multiple large databases were aggressively searched (November 2018). RCTs comparing music to without music during colonoscopy on adult patients were included. Pooled estimates were calculated for sedative medication doses, total procedure time, and patients’ experience, willingness to repeat procedure, and pain scores using odds ratio (OR) and mean difference (MD) with random effects model.

RESULTS

Eleven studies (n = 988) were included. Music during colonoscopy showed a statistically significant reduction in procedure times (MD: -2.3 min; 95%CI: -4.13 to -0.47; P = 0.01) and patients’ pain (MD: -1.26; 95%CI: -2.28 to -0.24; P = 0.02) while improving patients’ experience (MD: -1.11; 95%CI: -1.7 to -0.53; P < 0.01) as compared to no music. No statistically significant differences were observed between music and no music during colonoscopy for midazolam (MD: -0.4 mg; 95%CI: -0.9 to 0.09; P = 0.11), meperidine (MD: -3.06 mg; 95%CI: -10.79 to 4.67; P = 0.44), or patients’ willingness to repeat the colonoscopy (OR: 3.89; 95%CI: 0.76 to 19.97; P = 0.1).

CONCLUSION

Music appears to improve overall patient experience while reducing procedure times and patient pain. Therefore, music, being a non-invasive intervention, should be strongly considered during colonoscopy.

Mechanisms of action of aqueous extract from the Hunteria umbellata seed and metformin in diabetes

The plant kingdom is an important potential source of effective treatment for various diseases. Most herbs have long been used for medicinal purposes, and plant metabolites with their derivatives had been used in ethnomedicine. However, concerns exist about the quality and safety of herbal medicine products, particularly relating to safety, dosage, and mechanism of action. This mini review reveals some insights about the Hunteria umbellate seed, which is similar to that of insulin secretagogue metformin. Studies have validated its beneficial role in hyperglycemic, insulin resistance and obesity conditions, which are components of metabolic syndrome. However, none of these studies evaluated the mechanisms by which this plant extract performs its anti-hyperglycemic, insulin resistance and anti-obesity actions in metabolic syndrome. This understanding would provide considerable progress toward drug design using this plant material. Hence the need for this awareness to sensitize the researchers in this field who are passionate about drug design to consider the pathways discussed below for Hunteria umbellata seeds. Hunteria umbellata seed extract may represent a new therapeutic strategy for type-2 diabetes in place of metformin if it is well-studied.

Fecal microbiota transplantation: Historical review and current perspective

There is a growing interest in the use of fecal transplantation for chronic intestinal conditions. We aim to review the methodology and safety of fecal microbiota transplantation and the evidence to support its use in treating a variety of diseases. We reviewed the history of fecal transplantation in China and found that there were varieties of fecal material used in ancient China. The first written record on fecal treatment was found in an ancient tomb in Middle China. This paper explores the historical and current perspectives of fecal microbiota transplantation. The ancient fecal transplantations did not have any background support from life science. In those ancient days, short of knowledge about bacteria, clinicians were aiming at a change of intestinal environment. Today, we aim at a change of the intestinal microbiome.

Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice

Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.

Preventive strategies for anastomotic leakage after colorectal resections: A review

Anastomosis is a crucial step in radical cancer surgery. Despite being a daily practice in gastrointestinal surgery, anastomotic leakage (AL) stands as a frequent postoperative complication. Because of increased morbidity, mortality, combined with longer hospital stay, the rate of re-intervention, and poor oncological outcomes, AL is considered the most feared and life-threatening complication after colorectal resections. Furthermore, poor functional outcomes with a higher rate of a permeant stoma in 56% of patients this could negatively affect the patient’s quality of life. This a narrative review which will cover intraoperative anastomotic integrity assessment and preventive measures in order to reduce AL. Although the most important prerequisites for the creation of anastomosis is well-perfused and tension-free anastomosis, surgeons have proposed several preventive measures, which were assumed to reduce the incidence of AL, including antibiotic prophylaxis, intraoperative air leak test, omental pedicle flap, defunctioning stoma, pelvic drain insertion, stapled anastomosis, and general surgical technique. However, lack of clear evidence of which preventive measures is superior over the other combined with the fact that the decision remains based on the surgeon’s choice. Despite the advances in surgical techniques, AL remains a serious health problem associated with increased morbidity, mortality with additional cost. Many preventative measures were employed with no clear evidence supporting the superiority of stapled anastomosis over hand-Sewn anastomosis, coating of the anastomosis, or pelvic drain. Defunctioning stoma, when justified it could decrease the leakage-related complications and the incidence of reoperation. MBP combined with oral antibiotics still recommended.

Antidiabetic agents in patients with hepatic impairment

Chronic liver disease (CLD) often coexists with type 2 diabetes mellitus, making diabetes management a challenge to the clinician. It is well known that liver is the major site of drug metabolism, and, therefore, its impairment affects hepatic metabolism of many antidiabetic agents. Furthermore, patients with CLD have serious comorbidities such as impaired renal function, hypoalbuminemia, lactic acidosis, hypoglycemia and malnutrition, making their treatment even more difficult. On the other hand, most of the antidiabetic agents, with the exception of insulin, need dosage titration due to alterations to their pharmacokinetics in patients with CLD. For well-established antidiabetic treatments, like metformin and sulfonylureas there are studies regarding their dosage chance in these patients. However, despite the growing problem of management of diabetes in patients with CLD the existing literature data, especially on newer antidiabetic agents, are limited and, furthermore, no direct guidelines exist. Therefore, in the present review article we try to summarize the existing literature data regarding management of diabetes in patients with CLD.

Tofacitinib for the treatment of ulcerative colitis: A review of the literature

Ulcerative colitis (UC) is a chronic immune-mediated inflammatory condition affecting the colon. Recently, tofacitinib, an oral small molecule that is an inhibitor of the Janus kinase signal transduction pathway, was proven efficacious for inducing and maintaining remission in adult patients with moderate to severe UC in three global Phase III studies. The purpose of this review is to summarize existing data on the efficacy, safety, and quality of life issues related to use tofacitinib as well as highlight recent real-world experience with this drug among patients with UC.

Blood glucose control in the intensive care unit: Where is the data?

Blood glucose control, including hyperglycemia correction, maintaining glucose at optimal level and avoiding hypoglycemia, is a challenge clinicians face every day in intensive care units (ICUs). If managed inadequately, its related mortality can increase. Prior to 2001, no relevant data from randomized, controlled studies assessing glucose control in the ICU were available. In the past 18 years, however, many clinical trials have defined criteria for managing abnormal blood glucose levels, as well as provided suggestions for glycemic monitoring. Point-of-care blood glucose monitors have become the preferred bedside technology to aid in glycemic management. In addition, in some institutions, continuous glucose monitoring is now available. Cost-effectiveness of adequate glycemic control in the ICU must be taken into consideration when addressing this complex issue. Newer types of glycemic monitoring may reduce nursing staff fatigue and shorten times for the treatment of hyperglycemia or hypoglycemia. There are a variety of glycemic care protocols available. However, not all ICU clinicians are aware of them. The following minireview describes some of these concepts.

Effect of dl-3-n-butylphthalide on infarction volume in animal models of ischemic stroke: A meta-analysis

BACKGROUND

Ischemic stroke is a frequently-occurring disease in the elderly and characterized by high morbidity and mortality. Dl-3-n-butylphthalide (NBP), a synthetic compound based on natural celery seeds, has potential therapeutic effects on cerebral ischemia, brain trauma, memory impairment, and epilepsy.

AIM

To evaluated the effect of NBP on infarct volume in experimental ischemic stroke.

METHODS

Twenty one relevant literatures were included from the PubMed, EMBASE, Web of Science, Chinese National Knowledge Infrastructure, VIP information database, and Wanfang database, and data on the effect of dl-3-n-butylphthalide on infarction volume in the middle cerebral artery occlusion model were extracted. Statistical analysis was performed using standard mean difference with random effects model of Revman 5.3.

RESULTS

The data of meta-analysis of the 21 studies had suggested that NBP reduced the cerebral infarction volume of middle cerebral artery occlusion model animals compared to the control group significantly [SMD: -3.97, 95%CI: -4.71 to -3.23, P < 0.01; heterogeneity: χ² = 59.09, df = 20 (P < 0.01); I² = 66 %].

CONCLUSION

NBP was effective in experimental ischemic stroke.

Pediatric recurrent Clostridium difficile infections in immunocompetent children: Lessons learned from case reports of the first twelve consecutive patients

BACKGROUND

Recurrent Clostridium difficile infection (CDI) in children can be difficult to manage and may represent an unidentified underlying pathology. Recurrence can be frequently encountered in immunodeficiency disorders and inflammatory bowel disease (IBD).

AIM

To report cases of a select population of children with recurrent CDI who are immunocompetent and do not have an identified IBD and examine the potential for any underlying risk factors, disease course and disease outcome.

METHODS

Review of charts for children aged 1-21 years with recurrent CDI referred to see pediatric gastroenterology service was performed. All subjects with known immunosuppression or IBD were excluded. Subjects were followed for at least 24 mo.

RESULTS

Twelve children seen consecutively were identified. All patients were treated with antibiotic courses for CDI prior to their referral. Five out of 12 patients had an underlying pathology that was not previously identified, including eosinophilic colitis and IBD. CDI symptoms resolved after treatment of underlying colitis without the need to target therapy for CDI. There were 9 patients that failed antibiotic treatment of CDI and required fecal microbiome transplant, which was safe and highly effective in preventing recurrence (100% efficacy). The gut microbial changes after fecal transplant were characterized by a remarkable and durable increase in diversity and in abundance of Bacteroides.

CONCLUSION

Pediatric patients with frequent recurrence of CDI may have an unidentified underlying gastrointestinal pathology that may warrant further investigation by a specialist who can identify these diseases and help optimize management. Many of these children may benefit from fecal microbial transplant which appears to be a safe, highly effective therapy that results in long term changes in the gut microbiome.