A real-world study on the influence of unplanned reoperations on hospitalized patients using the diagnosis-related group

OBJECTIVE

The issue of unplanned reoperations poses significant challenges within healthcare systems, with assessing their impact being particularly difficult. The current study aimed to assess the influence of unplanned reoperations on hospitalized patients by employing the diagnosis-related group (DRG) to comprehensively consider the intensity and complexity of different medical services.

METHODS

A retrospective cohort study of surgical patients was conducted at a large tertiary hospital with two hospital districts employing data sourced from a DRG database. Hospital length of stay (LOS) and hospitalization costs were measured as the primary outcomes. Discharge to home was measured as the secondary outcome. Frequency matching based on DRG, regression modeling, subgroup comparison and sensitivity analysis were applied to evaluate the influence of unplanned reoperations.

RESULTS

We identified 20820 surgical patients distributed across 79 DRGs, including 188 individuals who underwent unplanned reoperations and 20632 normal surgical patients in the same DRGs. After DRG-based frequency matching, 564 patients (188 with unplanned reoperations, 376 normal surgical patients) were included. Unplanned reoperations led to prolonged LOS (before matching: adjusted difference, 12.05 days, 95% confidence interval [CI] 10.36-13.90 days; after matching: adjusted difference, 14.22 days, 95% CI 11.36-17.39 days), and excess hospitalization costs (before matching: adjusted difference, $4354.29, 95% CI: $3,817.70-$4928.67; after matching: adjusted difference, $5810.07, 95% CI $4481.10-$7333.09). Furthermore, patients who underwent unplanned reoperations had a reduced likelihood of being discharged to home (before matching: hazard ratio [HR] 0.27, 95% CI 0.23-0.32; after matching: HR 0.31, 95% CI 0.25-0.39). Subgroup analyses indicated that the outcomes across the various subgroups were mostly uniform. In high-level surgery subgroups (levels 3-4) and in relation to complex diseases (relative weight ≥ 2), the increase in hospitalization costs and LOS was more pronounce after unplanned reoperations. Similar results were observed with sensitivity analysis by propensity score matching and excluding short LOS.

CONCLUSIONS

Incorporating the DRG allows for a more effective assessment of the influence of unplanned reoperations. In managing such reoperations, mitigating their influence, especially in the context of high-level surgeries and complex diseases, remains a significant challenge that requires special consideration.

Ischemic colitis with small-vessel occlusion, simultaneous total colectomy and liver transplantation: A case report

BACKGROUND

The colon is the hollow viscera that proportionally has the lowest vascular supply and is more predisposed to ischemic colitis. In the context of end-stage liver disease, various components may explain this group's greater predisposition to colonic ischemic events. Furthermore, portal hypertension generates a process of coagulopathy, impairing local vascularization. This case report describes a case of ischemic colitis with small-vessel occlusion found during liver transplantation in a patient with decompensated end-stage liver disease.

CASE SUMMARY

A 64-year-old man with liver cirrhosis due to non-alcoholic steatohepatitis and hepatocellular carcinoma. The patient underwent liver transplantation due to hepatic decompensation. The donor was a 53-year-old man who had died of a hemorrhagic stroke. Cavitary examination revealed diffuse ischemic colitis with significant distention and necrosis. Due to the condition of the colon, a subtotal colectomy was performed. Liver transplantation with warm ischemia time of 35 minutes, cold ischemia of 6 hours 30 minutes and total ischemia time of 7 hours 5 minutes. The patient improved clinically with oral tract function and physiotherapy, but unfortunately, he developed a bloodstream infection, a new septic shock and died six months after surgery.

CONCLUSION

Simultaneous total colectomy and orthotopic liver transplantation represent a rare situation. Ischemic events have a high mortality rate in the general population and are particularly important in cirrhotic patients.

A review of the genotoxic effects of antiparasitic drugs on parasites and their hosts

Antiparasitic medications are drugs used to treat infections caused by parasites like protozoa, helminths, and ectoparasites by either killing the parasite or inhibiting its growth and reproduction. These medications are crucial for treating parasitic diseases and can vary in dosage and administration depending on the type of infection with proper diagnosis being essential for effective treatment. Nevertheless, such drugs can also cause a range of side effects including genotoxicity, depending on the type of medication and the individual's response. Therefore, here we will summarize data on the genotoxic effects of some antiparasitic drugs since many parasites provoke DNA damage per se, and therapy can enhance such genotoxic effects. The DNA-damaging effects of antiparasitic drugs enable the use of some of them for cancer treatment. Since a parasitic disease comes with severe consequences, the cost-benefit should be considered when taking drugs against such a disease even in terms of their potential genotoxicity. While some antiparasitic drugs have shown genotoxic potential in laboratory studies, most are considered safe for human use at therapeutic doses. Long-term or high-dose exposure may carry more risk; moreover, the genotoxic effects of the drugs can interfere with the genotoxicity of the parasitic infection. More research is needed to fully understand the implications for human health. Nevertheless, the present study has confirmed the need for further cytogenetic research and regular patient monitoring to minimize the risk of an adverse event, especially among frequent travellers visiting parasite-affected areas.

Role of home-blended tube feedings in pediatric patients with gastrostomy tubes: A retrospective study

BACKGROUND

Both blended tube feed (BTF) and commercial tube feed (CTF) can be administered through a gastrostomy tube (GT). There is very little evidence about using home BTF (HBTF). Nevertheless, families increasingly request this type of nutrition because they attribute some benefits to it. Our objective was to evaluate the efficacy and safety of using HBTF via GT as an alternative to CTF.

METHODS

Single-center, retrospective, and observational study of patients under 18 years old who underwent GT between 2014 and 2020. We reviewed demographics, anthropometrics, clinical characteristics, and types of diet and gastrointestinal (GI) symptoms over 12 months after the placement of the GT.

RESULTS

Forty patients (40% boys) were included. The median age at GT placement was 15 months (interquartile range 5-57.5). The most common underlying diagnosis was a neurological disorder (45%). In 75% of patients, Nissen fundoplication was performed. At the 12-month follow-up, 18 patients (45%) were receiving 100% HBTF, 14 (35%) were receiving a mixed diet (HBTF + CTF), four (10%) were receiving 100% CTF, and four (10%) were no longer using the GT. Those with a 100% HBTF diet showed a statistically significant higher weight at the 12-month follow-up than those who had received any percentage of CTF. No other statistically significant differences in anthropometric indices or GI symptoms were found between the two groups. Only three cases of mechanical complications were reported.

CONCLUSION

In our experience, using HBTF via the GT provides an alternative to CTF in pediatric patients who require enteral nutrition.

Case series of small bowel adenocarcinoma associated with Crohn's disease

Long-standing Crohn's disease (CD) is well known to be associated with gastrointestinal malignancies. Patients with CD have a higher risk of developing small bowel adenocarcinoma (SBA) compared to healthy individuals. However, CD-associated SBA is not as common as colorectal cancer. While patients with CD often present with complicated stricture lesions in the small intestine, it is difficult to confirm all lesions by endoscopy. There is still no consensus on the surgical treatment of small bowel strictures with suspected CD-associated SBA. We report a case of small bowel high-grade dysplasia and two cases with advanced SBA. Case 1 involved a 53-year-old man whose high-grade dysplastic lesion of the small intestine was discovered incidentally postoperatively and successfully resected curatively. Case 2 was that of a 60-year-old man and Case 3 involved a 69-year-old man. Both patients had multiple small bowel stenotic lesions and were diagnosed with advanced small bowel cancer during follow-up. In conclusion, for patients with long-standing Crohn's disease who are refractory to treatment or have stenotic lesions, surgical resection should be considered as a treatment option with CD-associated SBA in consideration.

Impact of Artificial Intelligence on Gastroenterology Trainee Education

Artificial intelligence (AI) is transforming gastroenterology, particularly in endoscopy, which has a direct impact on trainees and their education. AI can serve as a valuable resource, providing real-time feedback and aiding in tasks like polyp detection and lesion differentiation, which are challenging for trainees. However, its implementation raises concerns about cognitive overload, overreliance, and even access disparities, which could affect training outcomes. Beyond endoscopy, AI shows promise in clinical management and interpreting diagnostic studies such as motility testing. Thoughtful adoption of AI can optimize training and prepare future trainees for the modern healthcare landscape.

The rapidly evolving landscape of HCC: Selecting the optimal systemic therapy

Over the past years, there has been a remarkable advance in the systemic treatment options for advanced HCC. The overall survival has gradually increased over time, with larger benefits for patients with sensitive tumors and preserved liver function, the latter being an essential condition for the delivery of sequential lines of treatment and optimization of clinical outcomes. With the approval of new first-line agents and the introduction of immune checkpoint inhibitor-based therapies, the treatment landscape of advanced HCC is becoming wider than ever. Atezolizumab plus bevacizumab and, more recently, durvalumab plus tremelimumab have entered the clinical practice and are the current standard of care for treatment-naïve patients, surpassing sorafenib and lenvatinib monopoly. As no head-to-head comparisons are available among all the first-line treatment options, the recommendation for the most appropriate choice and sequence is patient-driven and integrates efficacy data with clinical comorbidities, background liver disease, and the safety profile of available drugs. In addition, predictive biomarkers for successful patients' stratification are yet to be available and constitute the focus of ongoing research. The treatment algorithm is likely to become even more complex since systemic therapeutic approaches are now being translated into earlier stages of the disease, with an impact on the evolution of the sequential treatment of patients with HCC.

Improving 30-day mortality after radiologically inserted gastrostomy tube from 2007 to 2019: A population-based study of 15,605 patients

BACKGROUND AND AIMS

Radiologically inserted gastrostomy (RIG) allows long-term enteral nutrition when percutaneous endoscopic gastrostomy (PEG) tube insertion is not feasible either due to technical difficulty or a higher risk of complications. The aims of this study were to examine mortality associated with RIG insertion.

METHODS

Adult patients with RIG insertion from 2007 to 2019 were identified in the Hospital Episode Statistics database. Indications and adverse events were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes. Provider nutrition support data were available from the Getting It Right First Time in Gastroenterology Report 2021. Multivariable logistic regression analysis examined factors associated with 30-day mortality following a RIG.

RESULTS

15,605 patients were studied (68.0 % male; age 64(Interquartile range (IQR) 56-73)). There was a steady increase in the number of RIGs inserted from 510 per year in 2007 to 1787 per year in 2019. 59.9 % of RIGs were inserted as an outpatient. 63.3 % of RIGs were inserted in head and neck cancer patients. Of the patients who had a RIG insertion, 4.7 % had pneumonia within 7 days and 6.9 % died within 30 days of RIG insertion. Thirty-day mortality fell from 12.2 % in 2007 to 5.8 % in 2019. Higher 30-day mortality rates were observed in patients with Dementia (16.4 %) and in NHS providers without a nutrition support nurse (11.5 %). Factors associated with 30 day mortality included: increasing age (>81 years odds ratio (OR) 13.67 (95 % confidence interval (CI) 4.99-37.48), p < 0.001); increasing NHS provider volume of RIG insertion >12 per year (OR 0.69 (95 % CI (0.55-0.88), p = 0.003); RIG insertion during an emergency admission (OR 2.53 (95 % CI 2.19-2.93), p < 0.001); increasing comorbidity Charlson score >5 (OR 1.38 (95 % CI 1.10-1.75), p = 0.006); NHS provider without a nutrition support nurse (OR 1.38 (95%CI 1.09-1.75), p = 0.007) and other neurological conditions than stroke as indication for RIG (OR 1.55 (95%CI 1.24-1.95), p < 0.001).

CONCLUSIONS

Despite an increase in RIG insertion over the study period, 30-day mortality has fallen by 52 %. Providers without a nutrition support nurse and providers with a lower volume of RIG insertions were associated with higher mortality.

Upper gastrointestinal triple stenosis in a patient with trisomy 17p syndrome: Case report and literature review

Upper gastrointestinal stenosis, which can be congenital or acquired, can lead to dysphagia. The association between trisomy 17p syndrome, a rare chromosomal abnormality, and upper gastrointestinal stenosis is unclear. A 20-year-old man diagnosed with trisomy 17p syndrome was referred to our department due to recurrent vomiting. Esophagogastroduodenoscopy revealed stenotic areas in the esophagus, stomach, and duodenum. The congenital gastrointestinal stenosis present in both the duodenum and esophagus suggested that the stasis and reflux of digestive fluids exacerbated stenosis in the stomach and esophagus. Gastric acid suppression therapy and endoscopic dilation of the esophagus and duodenum effectively resolved the patient's vomiting symptoms.

Proteinuria is associated with worse outcomes in babies born to mothers with preeclampsia: A retrospective cohort study at a tertiary referral hospital in Brazil

To evaluate whether the presence of proteinuria, although no longer mandatory in the revised diagnostic criteria, results in worse maternal and fetal outcomes in preeclampsia (PE). A retrospective cohort study was conducted, analyzing data from pregnant patients diagnosed with PE between January 2015 and December 2019 at a tertiary care center in Brazil. Ethical approval was obtained, and the patient records were reviewed to assess maternal and perinatal outcomes based on the revised diagnostic criteria by the College of Obstetricians and Gynecologists, focusing on the presence or absence of proteinuria. The study included 816 pregnant patients with PE, of whom 685 (83.9%) were diagnosed based on proteinuria. The revised criteria, which include indicators of organ damage, identified an additional 131 cases (16.4%). Analysis showed no significant differences in maternal outcomes between proteinuria and non-proteinuria groups, including intensive care unit (ICU) admission, acute pulmonary edema (APE), HELLP syndrome, eclampsia, or C-section rates. However, babies born to mothers with proteinuria PE experienced worse outcomes, including fetal growth restriction, low birth weight, ICU admission, and higher rates of preterm birth. Relative risk analysis demonstrated a high risk of babies being born with low birth weight, ICU admission, and being born preterm and very preterm in cases where proteinuria was present in mothers with PE. The presence of proteinuria is associated with significantly worse outcomes in babies born to mothers with preeclampsia, while no significant differences were observed in maternal outcomes.

Knowledge, experience, and willingness to vaccinate against intestinal parasitic infections: A multi-country study in Asia

BACKGROUND

Intestinal parasitic infections (IPIs) remain a significant public health challenge and a neglected disease in many parts of Asia, contributing to morbidity and mortality, particularly in vulnerable populations. Despite the potential of vaccines to reduce the burden of these neglected IPIs, little is known about the public's willingness to be vaccinated against these infections.

OBJECTIVE

This study aimed to assess the general population's knowledge, symptom experiences, and willingness to vaccinate against IPIs across six countries: Malaysia, Vietnam, India, Pakistan, and China.

MATERIALS AND METHODS

A cross-sectional online survey was conducted between June and December 2023 across six countries in Asia region. Participants completed a self-administered online questionnaire that assessed demographic information, knowledge of IPIs, symptom experiences, and willingness to receive a vaccine against IPIs for themselves and their children. Univariate and multivariable logistic analyses were performed to determine the factors related to vaccination the willingness.

RESULTS

A total of 5470 complete responses were received. The highest proportion of individuals willing to receive the vaccine was in India (86.1 %), followed by China (80.8 %) and Pakistan (75 %), with Vietnam having the lowest proportion at 50.1 %. For child vaccination, China had the highest willingness (83.3 %). A higher knowledge score was significantly associated with increased willingness to be vaccinated [adjusted odds ratio (aOR)= 1.91, 95 % CI: 1.70-2.15]. Additionally, a higher symptom experience score was significantly associated with greater vaccination willingness (aOR=1.71, 95 % CI: 1.50-1.94). Females residing in urban-suburban areas showed significantly higher vaccination intentions. The willingness to vaccinate children against IPIs closely mirrored the trends observed in self-vaccination willingness, with knowledge being the only factor significantly associated with the willingness to vaccinate children.

CONCLUSION

The study underscores the importance of enhancing educational efforts regarding neglected IPIs and vaccination, particularly when vaccines are available and recommended.

Incidence and management of hepatic immune‑related adverse events in advanced urologic cancers treated with immune checkpoint inhibitors: A multicenter retrospective study

The present study aimed to evaluate the incidence, characteristics and management of hepatic immune-related adverse events (irAEs) in patients with advanced or metastatic urothelial carcinoma (UC) and renal cell carcinoma (RCC) receiving immune checkpoint inhibitors (ICIs). Data regarding the demographics, ICI regimens and hepatic irAEs from 213 patients with metastatic UC or metastatic RCC receiving ICIs between February 2018 and September 2023 at three tertiary medical centers (Inje University Busan Paik Hospital, Busan, South Korea; Dongnam Institute of Radiological and Medical Sciences Cancer Center, Busan, South Korea; Pusan National University Hospital, Busan, South Korea) in South Korea were collected and retrospectively analyzed. Hepatic irAEs were graded using the Common Terminology Criteria for Adverse Events version 5.0 and classified based on R value patterns. Among the 213 patients evaluated, 76 (35.6%) experienced at least one irAE, whereas 48 (22.5%) developed hepatic irAEs. The median onset time for hepatic irAEs was 6.5 weeks, with incidence rates being higher with combination therapies than with monotherapies (31.8 vs. 18.3%; P=0.014). Furthermore, 72.9 and 27.1% of the patients had grade 1-2 and 3-4 hepatic irAEs, respectively. The patterns of liver toxicity included cholestatic (35.4%), mixed (35.4%) and hepatocellular (29.2%). All patients with grade 1-2 hepatic irAE recovered with supportive treatment without ICI discontinuation or corticosteroids use. Among the 13 patients with grade ≥3 hepatic irAEs, 12 recovered with high-dose corticosteroids, while 1 died due to fulminant hepatitis. Hepatic irAEs are common in patients with advanced and metastatic urologic cancers who are treated with ICIs, particularly with combination therapies. Most cases have low-grade irAE that are manageable without ICI discontinuation; however, severe cases require prompt recognition and treatment with corticosteroids. These findings emphasize the importance of regular liver function monitoring and appropriate management strategies for hepatic irAEs in patients with urologic cancer receiving ICI therapy.

Advancements in Nano-Mandoor Bhasma: Unravelling the Particle Size-Ascorbic Acid Synergy for Enhanced Iron Bioavailability for Anemia Treatment

Mandoor Bhasma (MB) medicine, based on classical Indian Ayurveda, was size- and surface-modified to improve its therapeutic efficiency for treating iron-deficient anemia. Physical grinding reduced the size of MB to the nanoparticle (nano-MB) range without changing its chemical composition, as measured by particle size distribution. The surface of nano-MB was modified with ascorbic acid (nano-AA-MB) and confirmed using scanning electron microscopy and Fourier transformed infrared spectroscopy. Enhanced iron dissolution from the surface-modified nano-AA-MB under neutral-to-alkaline pH conditions, and in the intestinal region of the simulated gastrointestinal tract (GIT) digestion model was determined using inductively coupled plasma mass spectroscopy. GIT digestae of MB microparticles and nano-AA-MB were found to be biocompatible in human colon epithelial (Caco-2) cells, with the latter showing threefold higher iron uptake. Subsequently, a dose-dependent increase in cellular ferritin protein was observed in the nano-AA-MB digestae-treated Caco-2 cells, indicating the enhanced bioavailability and storage of dissolved iron. Overall, the study showed that reducing the size of centuries-old traditional Mandoor Bhasma medicine to nanoscale, and its surface-modification with ascorbic acid would help in enhancing its therapeutic abilities for treating iron-deficient anemia.

Chinese Guidelines on the Management of Hepatic Encephalopathy in Cirrhosis (2024)

With progress in basic and clinical research on hepatic encephalopathy in cirrhosis worldwide, the Chinese Society of Hepatology of the Chinese Medical Association has invited experts in relevant fields to revise the 2018 "Chinese Guidelines on the Management of Hepatic Encephalopathy in Cirrhosis." The updated guidelines provide recommendations for the clinical diagnosis, treatment, and both primary and secondary prevention of hepatic encephalopathy in cirrhosis.

Gastrointestinal disease in end-stage renal disease

When kidney function declines to a point where it can no longer maintain life and requires renal replacement therapy (i.e. renal transplant or dialysis), it is called end-stage renal disease (ESRD). Patients with ESRD often experience a range of gastrointestinal (GI) symptoms, with prevalence rates reported as high as 77%-79%. These symptoms and pathologies arise from various factors, including electrolyte imbalance, fluid imbalance, toxin buildup, uremia, medications, dietary and lifestyle restrictions, and the effects of dialysis. GI diseases in patients with renal failure can be further categorized into upper GI, small bowel, and lower GI issues. Common conditions include gastroesophageal reflux disease, nausea and vomiting, dysmotility within the esophagus and stomach, upper GI bleeding, peptic ulcer bleeding, angioectasia, irritable bowel syndrome, mesenteric ischemia, angiodysplasia, diverticular disease, constipation, pancreatitis, and diseases associated with peritoneal dialysis peritonitis and peritoneal stenosis. This review assesses the existing literature on the different GI diseases among individuals with ESRD, shedding light on their pathophysiology and prevalence.

Intronic region polymorphisms of autophagy gene ATG16L1 predispose individuals to Hepatitis B virus infection

Intronic region polymorphisms, rs2241879 G/A, rs13005285 G/T, and rs7587633 C/T of ATG16L1 were analyzed in this case-control study in HBV-infected patients to find their role in HBV infection. The mutant alleles rs2241879A (OR = 1.57) and rs13005285T (OR = 1.39) were the risk factors for HBV infection. These alleles were associated with different stages of infection: asymptomatic rs13005285T (OR = 1.91), acute rs13005285T (OR = 1.58), chronic rs2241879A (OR = 1.62), and cirrhosis rs2241879A (OR = 3.02). Moreover, on applying various genetic models, rs2241879A predisposed individuals to HBV infection (homozygous model; AA vs. GG; OR = 2.58). Patients with CHB infection, the homozygous model showed an OR of 2.79, while the dominant model had an OR of 1.96. Among cirrhosis patients, the homozygous model resulted in an OR of 9.43, and the dominant model showed an OR of 4.92. The rs13005285 variant significantly increased the risk of acute HBV infection in the co-dominant model (OR = 1.78) and dominant model (OR = 1.84). Individuals with the rs7587633 variant at the asymptomatic stage of infection showed a reduced risk under the co-dominant model (OR = 0.41) and the dominant model (OR = 0.54). We identified GCG, GTG and GCT haplotypes corresponding to rs2241879, rs7587633, and rs13005285 SNPs, which play a protective role in HBV infection. Furthermore, we also developed a PCR-ARFLP assay for genotyping rs13005285G/T which would help to analyze this polymorphism in low-income settings where high-end instrumentation is not accessible.

The efficacy, safety, and persistence of vedolizumab versus adalimumab in patients with inflammatory bowel disease: a systematic review and meta-analysis

PURPOSE

This systematic review and meta-analysis compared the efficacy, safety, and treatment persistence of vedolizumab and adalimumab in patients with inflammatory bowel disease (IBD).

METHODS

Through a comprehensive search of three databases up to September 2024, we calculated pooled effect estimates for binary outcomes using risk ratios (RR) with 95% confidence intervals (CIs). Heterogeneity was evaluated using Cochran's I2 and Q statistics, with a random-effects model applied when I2 exceeded 50%, and a fixed-effects model used otherwise. For randomized trials, the Cochrane Risk of Bias Tool was applied; the Newcastle-Ottawa Scale assessed nonrandomized trials.

RESULTS

We analyzed 12 studies involving 4095 patients. The findings showed that vedolizumab had higher clinical remission and response rates compared to adalimumab (RR: 1.24, 95% CI 1.14-1.34, P < 0.01; RR: 1.11, 95% CI 1.01-1.22, P = 0.03). However, no significant differences were observed in endoscopic remission between the two treatments (RR: 0.74, 95% CI 0.47-1.18, P = 0.21). Safety outcomes, based on adverse and serious adverse event rates, have no significant differences (RR: 0.67, 95% CI 0.41-1.12, P = 0.13; RR: 0.78, 95% CI 0.36-1.68, P = 0.53). Treatment persistence also showed no significant difference between vedolizumab and adalimumab (RR: 0.78, 95% CI 0.55-1.12, P = 0.19).

CONCLUSIONS

Our study suggests that vedolizumab may be more effective than adalimumab in alleviating symptoms and achieving clinical response. Importantly, this effectiveness is achieved without an increase in adverse events. No significant difference was found in treatment persistence. However, high heterogeneity may weaken the evidence, requiring further randomized trials for confirmation.

DIVERT-Ca: unveiling the hidden link between acute diverticulitis and colorectal cancer risk-multicentre retrospective study

INTRODUCTION

Colorectal cancer (CRC) is the third most common cancer worldwide, accounting for approximately 10% of all malignancies. Emerging trends of association with risk factors such as diverticulitis highlight the need for updated screening and follow-up protocols. We aimed to examine risk factors associated with the development of CRC within 12 months following an episode of acute diverticulitis, and identify areas to streamline follow-up.

METHODS

We performed a retrospective multicentre study of adult patients admitted in 2022 with computed tomography (CT) confirmed acute diverticulitis across four large NHS Trusts in the UK. Patient demographics, comorbidities, clinical presentation, vital signs, laboratory results, details of in-patient stay, and follow-up investigations were collected and analysed. Our primary outcome was the incidence of CRC within 12 months of index presentation with acute diverticulitis. Analysed secondary outcomes were potential patient risk factors associated with a diagnosis of CRC and follow-up protocols. All statistical analysis was performed using R (version 4.4) and P-values of < 0.05 were considered statistically significant.

RESULTS

A total of 542 patients with acute diverticulitis over the study period were included. The median age of our cohort was 62 (51-73) years, and 204 (37.6%) were male. Ten (1.8%) patients were diagnosed with CRC within the 12-month period. Hinchey grade Ib was significantly associated with CRC (OR 4.51, P = 0.028). Colonoscopic follow-up requests were associated with age between 40 and 60 years, mild white cell count (WCC) elevation, and a hospital stay of 3-7 days. Male gender, age between 18 and 40 years, and elevated C-reactive protein (CRP) were all strongly associated with CRC but not statistically significant. Follow-up was inconsistent with 53.7% of the cohort having luminal investigations.

CONCLUSION

The incidence of CRC was in-keeping with published literature. Hinchey grade 1b was significantly associated with a subsequent CRC diagnosis. These findings emphasise the need for specialised radiological review of CT scans to detect underlying malignancy. Moreover, standardised follow-up protocols following an episode of acute diverticulitis are needed to avoid missing malignant lesions.

Diagnosis and management of invasive fungal infections due to non-Aspergillus moulds

Invasive fungal infection (IFI) due to moulds other than Aspergillus are a significant cause of morbidity and mortality. Non-Aspergillus mould (NAM) infections appear to be on the increase due to an ever-expanding population of immunocompromised hosts. In this review, Mucorales, Scedosporium species, Lomentospora prolificans and Fusarium species are examined in detail, and the microbiology, risk factors, diagnosis and treatment of emerging NAMs such as Paecilomyces variotti, Purpureocillium lilacinum and Rasamsonia are summarized. The challenges in diagnosis are emphasized and the emerging importance of molecular methods is discussed. Treatment of IFI due to NAMs is a multi-pronged and multi-disciplinary approach. Surgery, correction of underlying risk factors, and augmentation of the host immune response are as important as antifungal therapy. Many of these NAMs are intrinsically resistant to the currently licensed antifungal agents, so selection of therapy needs to be guided by susceptibility testing. There are new antifungal agents in development, and these have the potential to improve the efficacy and safety of antifungal treatment in the future. Ongoing research is required to fully delineate the epidemiology of NAM infections, and to develop better diagnostic tools and treatments so that outcomes from these infections can continue to improve.

Identifying hazardous alcohol use in primary care using phosphatidylethanol: Timing of screening matters

BACKGROUND AND AIMS

Alcohol is a well-established risk factor for numerous health conditions, making screening for hazardous alcohol use in healthcare a critical task. While self-reported data suggest that alcohol consumption varies across seasons, this seasonal fluctuation has not yet been confirmed using objective biological markers. This study aimed to measure whether phosphatidylethanol (PEth) captures variations in hazardous alcohol use across two temporal resolutions: month of the year and day of the week.

DESIGN

Observational cross-sectional study based on data from medical records.

SETTING

Healthcare services, Region Dalarna, Sweden, between 2017 and 2023.

PARTICIPANTS/CASES

Adult patients (n = 62 431, 50% females) screened for hazardous alcohol use with PEth within primary care.

MEASUREMENTS

This study utilizes test results from PEth, with results >0.30 μmol/l defined as hazardous alcohol use. We compared the prevalence of hazardous alcohol use across months and weekdays using logistic regression while adjusting for sex, age, smoking status, the Charlson Comorbidity Index and psychiatric diagnoses.

FINDINGS

The prevalence of hazardous alcohol use increased between May and August, ranging from 13.2% to 15.9%, compared with 10.7% in November. This corresponds to a 48% relative increase in the peak month of July [prevalence ratio (PR) = 1.48, 95% confidence interval (CI) = 1.33-1.64]. Hazardous alcohol use was also more prevalent among patients tested on Mondays (13.0%) compared with Thursdays, with the lowest prevalence (12.0%). The difference was particularly pronounced among female patients, with a 14.0% higher relative prevalence on Mondays (PR = 1.14, 95% CI = 1.02-1.27).

CONCLUSIONS

In Sweden, the prevalence of hazardous alcohol use appears to fluctuate seasonally and, to a lesser extent, across weekdays, as measured by blood tests for phosphatidylethanol, a biomarker for hazardous alcohol use. November showed the lowest prevalence and July the highest, consistent across age, sex and the year of the observational period. Hazardous alcohol use showed a slight elevation of prevalence during Mondays compared with Tuesday to Friday.

Readmission of patients with hypertriglyceridemia-induced acute pancreatitis: a prospective cohort study

BACKGROUND

Acute pancreatitis (AP) is a common cause of acute hospital admissions in digestive system diseases. In East Asia, hypertriglyceridemia is gradually emerged as the second most common cause of pancreatitis. Vigilance for recurrence and unplanned readmissions due to other causes is still necessary after discharge. studies on hypertriglyceridemia-induced acute pancreatitis (HTG-AP) are scarce and mainly consists of retrospective studies.

METHODS

This was a prospective cohort study of adult patients with first episode of HTG-AP from December 2019 to February 2021 who were followed up for two years. Unscheduled readmission after the index discharge was the primary outcome. The Cox proportional-hazards model, and the Fine and Gray's competing-risk model were applied to the analyses.

RESULTS

Totally, 293 survival patients were followed-up after discharge. The overall unplanned readmission rate was 30.0% in two years. Among them, 60 (20.5%) patients were readmitted to hospital once, 16 (5.5%) were readmitted twice, and 13 (4.4%) were readmitted three times or more. In summary, a total of 143 cases of readmission information were collected during the follow-up period. The recurrence accounts for a significant 77.3% proportion and stands as the primary cause for readmission. Cox regression model favors infection (Hazard ratio [HR], 3.066; 95% confidence interval [CI], 1.192-7.888; P = 0.02) and age lower than 41.5 years old (HR, 3.157; 95% CI 1.883-5.292; P < 0.01) as independent risk factors for patient readmission by multivariate analysis. The competing-risk model support the similar results compared with the former.

CONCLUSION

Unplanned readmission of patients with hypertriglyceridemia-induced acute pancreatitis is common, especially for young patients with occurrence of any infection during hospitalization, and warrant further investigation.

Identification and validation of a CD4+ T cell-related prognostic model to predict immune responses in stage III-IV colorectal cancer

BACKGROUND

CD4+ T cells play an indispensable role in anti-tumor immunity and shaping tumor development. We sought to explore the characteristics of CD4+ T cell marker genes and construct a CD4+ T cell-related prognostic signature for stage III-IV colorectal cancer (CRC) patients.

METHOD

We combined scRNA and bulk-RNA sequencing to analyze stage III-IV CRC patients and identified the CD4+ T cell marker genes. Unsupervised cluster analysis was performed to divide patients into two clusters. The LASSO and multivariate Cox regression were performed to establish a prognostic-related signature. RT-qpcr and immunofluorescence staining were performed to examine the expression of ANXA2 in CRC tissue.

RESULT

We found a higher infiltration abundance of activated memory CD4+ T cells was associated with improved prognosis in stage III-IV CRC patients. Patients were divided into two subgroups with distinct clinical and immunological behaviors based on CD4+ T cell marker genes. And then a prognostic signature consisting of six CD4+ T cell marker genes was established, which stratified patients into high- and low-risk groups. Immune spectrum showed that the low-risk group had higher immune cell infiltration than the high-risk group. Furthermore, the risk score of this signature could predict the susceptibility of stage III-IV CRC patients to immune checkpoint inhibitors and chemotherapy drugs. Finally, we validated that ANXA2 was enriched in Tregs and was associated with infiltration of Tregs in CRC tumor microenvironment.

CONCLUSION

The CD4+ T cell-related prognostic signature established in the study can predict the prognosis and the response to immunotherapy in stage III-IV CRC patients. Our findings provide new insights for tumor immunotherapy of advanced CRC patients.

Psycho-gastroenterological profile of an Italian population of children with disorders of gut-brain interaction: A case-control study

BACKGROUND

Disorders of gut-brain interaction (DGBI) are common, but knowledge about their physiopathology is still poor, nor valid tools have been used to evaluate them in childhood.

AIM

To develop a psycho-gastroenterological questionnaire (PGQ) to assess the psycho-gastroenterological profile and social characteristics of a pediatric population with and without DGBI.

METHODS

One hundred and nineteen Italian children (age 11-18) were included: 28 outpatient patients with DGBI (Rome IV criteria) and 91 healthy controls. They filled the PGQ, faces pain scale revised (FPS-R), Bristol stool chart, gastrointestinal symptoms rating scale, state-trait anxiety inventory, Toronto alexithymia scale 20, perceived self-efficacy in the management of negative emotions and expression of positive emotions (APEN-G, APEP-G), irritable bowel syndrome-quality of life questionnaire, school performances, tobacco use, early life events, degree of digitalization.

RESULTS

Compared to controls, patients had more medical examinations (35% of them went to the doctor more than five times), a higher school performance (23% vs 13%, P < 0.05), didn’t use tobacco (never vs 16%, P < 0.05), had early life events (28% vs 1% P < 0.05) and a higher percentage of pain classified as 4 in the FPS-R during the examination (14% vs 7%, P < 0.05).

CONCLUSION

Pediatric outpatients with DGBI had a higher prevalence of early life events, a lower quality of life, more medical examinations rising health care costs, lower anxiety levels.

Anaesthesia in chronic dialysis patients: A narrative review

The provision of anaesthesia for individuals receiving chronic dialysis can be challenging. Sedation and anaesthesia are frequently managed by critical care clinicians in the intensive care unit or operating room. This narrative review summarizes the important principles of sedation and anaesthesia for individuals on long-term dialysis, with reference to the best available evidence. Topics covered include the pharmacology of anaesthetic agents, the impacts of patient characteristics upon the pre-anaesthetic assessment and critical illness, and the fundamentals of dialysis access procedures.

Examining the Outcomes of Palliative Oophorectomy of Ovarian Metastases in de-Novo Metastatic Colorectal Cancer and Its Association with RAS Mutation Status: Insights from a Single-Institution Perspective

Background and Aim

Ovarian metastasis occurs in 3-5% of patients with CRC. Ovaries are considered sanctuary sites and typically do not respond effectively to chemotherapy. Patients with KRAS mutation generally have a worse prognosis compared to those with KRAS wild type. This study will discuss the effect of palliative oophorectomy on survival rates for those patients compared to chemotherapy alone.

Methods

This is a retrospective study; we reviewed the charts of patients diagnosed with metastatic colorectal cancer at KHCC between January 2015 and December 2022. Out of 862 patients, 50 patients were eligible for the study; Patients were divided into two groups based on their treatment type, the palliative oophorectomy group and the chemotherapy alone group. The primary endpoint was a three-year median overall survival rate between the two groups. The secondary endpoints included three-year median progression-free survival and the difference in survival rate between the groups based on KRAS and BRAF mutation status.

Results

In the oophorectomy group, the median overall survival (OS) was 19.3 months compared to 10.3 months in the chemotherapy alone group, with a P value of 0.05. Median progression-free survival (PFS) was also better in the oophorectomy group at 14.6 months compared to 9.4 months, with a P value of 0.59. For patients with KRAS mutation who underwent oophorectomy, the median OS was significantly better at 29.1 months compared to 10.3 months in the chemotherapy alone group, P value of 0.03.

Conclusion

Our study indicates that palliative oophorectomy in metastatic CRC is associated with better survival. Even patients who harbor mutated KRAS, which typically have more aggressive disease behavior, showed better survival outcomes with oophorectomy compared to systemic chemotherapy alone.

Study on the metastatic mechanism of LINC00115 in adenocarcinoma of the Esophagogastric junction

Adenocarcinoma of the esophagogastric junction (AEG) is a common and deadly cancer, and an in-depth investigation of its molecular mechanisms of metastasis is crucial for discovering new therapeutic targets. This study explores the role of the long non-coding RNA (lncRNA) LINC00115 in AEG metastasis and its underlying mechanisms. Through the analysis of 108 pairs of AEG cancer tissues and matched adjacent tissues, we found a significant upregulation of LINC00115 in AEG tissues, closely associated with TNM staging and lymph node metastasis. Utilizing cell counting kit-8 (CCK-8) assays, colony formation experiments, wound healing assays, flow cytometry for apoptosis and cell cycle analysis, and Transwell assays, we have confirmed that LINC00115 significantly promotes proliferation, migration, and invasion of AEG cells in vitro. Animal experiments further validate the role of LINC00115 in promoting tumor growth and metastasis in vivo. Additionally, our nuclear-cytoplasmic fractionation experiments and RNA fluorescence in situ hybridization (FISH) reveal that LINC00115, along with its interacting protein KH-Type splicing regulatory protein (KHSRP), predominantly localizes to the cell nucleus. By conducting RNA pull-down assays and mass spectrometry (MS) analysis, we have identified a direct interaction between LINC00115 and KHSRP protein and further determined their binding sites through catRAPID and ENCORI databases. This study provides evidence of LINC00115 as a novel biomarker and potential therapeutic target for AEG and offers a fresh perspective on understanding the molecular mechanisms of AEG metastasis.

Molecular characterization of colorectal cancer (CRC) using next generation sequencing (NGS) in bridging the gap between research and clinical practice: from biomarker discovery to clinical implementation

BACKGROUND

Colorectal cancer (CRC) is the second most common cancer in men and third in females, a heterogeneous disease involving multistep mechanisms that represents 10% of all cancers globally. This study investigates gene mutation profiling in CRC using Next-Generation sequencing machine.

METHOD

Formalin-fixed paraffin-embedded tissues of 30 CRC patients were retrieved and reviewed. DNA was isolated from selected tissues. Desirable quality check using Qubit and Nanoquant machine was done, and desirable libraries prepared were loaded into the sequencer for sequencing. Using Illumina BaseSpace and Illumina Variant interpreter, generated FastQ data were treated for annotation, alignment, and mapping with reference genome. Sequencing-runs with Phred-score ≥ 30 were selected as desirable runs. Finally, the variants were validated on NCBI-dsSNP and Ensembl databases for clinical consequence interpretations.

RESULTS

Overall, patient distribution consists of 12(40%) females and 18 (60%) males with mean age (53.2 + 5.3). most patients were in TNM stage-3: 53.3% (15/30) and the least was Stage-4: 20%(6/30) respectively. Overall, 73.3%: (22/30) completed the sequencing, and 552 mutations involving 29 genes and 12 chromosomes were detected. The most upregulated variants are KIT:68(12.3%), FGFR4:61(11.1%), EGFR:60(10.9%), ALK:53(9.6%), DCUN1D1:41(7.4%), PDGFR:40(7.2%), KRAS:33(6.0%), CDK4:27(4.9%), FGFR3:26(4.7%), MTOR:14(2.6), while NRAS, CDK6, PIK3CA, and RET each has 13(2.4%) apiece. Chromosomes 4:134/55(24.2%), chr7:84/552(15.2%), chr12:71/552(12.9%), chr5:64/552(11.6%), chr2:61/552(11.1%), chr3:54/552(9.8%), and chr1:43/552(7.8%) are the most involved chromosomes. Nine genes (APC, NRAS, ALK, PIK3CA, KRAS, IDH1, FGFR1, ERBB2, and ESR1) are identified as pathogenic-causing variants in CRC.

CONCLUSION

This is the first NGS-based molecular study on FFPE-CRC tissues in hospital-USM that showed the most upregulated variants in CRC and identified nine genes as crucial pathogenic variants.

Reduced Expression of SATB2 in Colorectal Cancer and Its Association with Demographic and Clinicopathological Parameters

Special AT-rich sequence-binding protein 2 (SATB2), as a nuclear matrix-associated protein and transcription factor engaged in chromatin remodeling and the regulation of gene expression, plays an important role in growth and development processes. SATB2 has been shown to have tissue-specific expression, also related to some cancers, including colorectal cancer (CRC). The aim of this study was to compare SATB2 gene expression in tumor and matched non-involved colorectal tissues obtained from CRC patients, and to investigate its association with clinicopathological and demographic parameters, as well as patients' overall survival. SATB2 mRNA levels in the tested tissues were assessed by quantitative polymerase chain reaction, while SATB2 protein expression was determined by immunohistochemistry. We found that the average levels of both SATB2 mRNA and protein were significantly lower in tumor specimens than in matched non-involved colon tissues. Moreover, SATB2 immunoreactivity was associated with patients' sex, tumor localization, and grade of differentiation. Lower immunoreactivity of SATB2 protein was noted in high-grade tumors, in women, and in tumors located in the cecum, ascending, and transverse colon. However, the results of the present study did not show an association between SATB2 expression levels and patients' overall survival. Our findings indicate the involvement of impaired SATB2 expression, significantly reduced in high-grading tumors, in the pathogenesis of CRC, while its sex- and localization-specificity should be further elucidated.

Proton Pump Inhibitor Use and Its Association with Lung Cancer Likelihood and Mortality: A Nationwide Nested Case-Control Study in Korea

BACKGROUND/OBJECTIVES

Proton pump inhibitors (PPIs) are widely used for acid-related gastrointestinal disorders, but their potential association with lung cancer risk and mortality remains underexplored and debated. This study sought to investigate the association between PPI use and lung cancer likelihood and mortality, focusing on the impact of PPI exposure history and duration.

METHODS

This study utilized data from 6795 lung cancer patients, 27,180 matched controls, and 4257 deceased and 2538 surviving lung cancer patients from the Korean National Health Insurance Service's Health Screening Cohort (2002-2019). Propensity score overlap weighting and logistic regression models were applied to assess the correlations between PPI usage history and duration with lung cancer risk and mortality, while standardized differences ensured balanced baseline characteristics.

RESULTS

Overall, PPI use was modestly associated, with a 19% increased likelihood of lung cancer occurrence (95% confidence intervals (CI): 1.12-1.26). Interestingly, prolonged PPI use (≥30 days) was linked to a 13% reduction in lung cancer incidence (95% CI: 0.80-0.94), particularly in subgroups such as older adults (≥70 years), individuals with gastroesophageal reflux disease (GERD) or hypertension, and those with low alcohol consumption. Conversely, overall PPI usage was linked with a 36% increased mortality likelihood among lung cancer patients (95% CI: 1.20-1.55), with prolonged use further correlating with a 27% higher mortality risk (95% CI: 1.05-1.53), especially in high-risk subgroups, including smokers, underweight individuals, and those with hypercholesterolemia or GERD.

CONCLUSIONS

These findings may suggest a complex and context-dependent relationship between PPI use and lung cancer outcomes, emphasizing the need for individualized risk assessments and careful prescribing practices.

Red wine consumption activates the erythropoietin-erythroferrone-hepcidin erythropoietic pathway in both apparently healthy individuals and patients with type 2 diabetes

Alcohol consumption is associated with reduced expression of hepcidin, a key iron-regulatory hormone, which may lead to accumulation of iron in the body. Although polyphenols from wine may have effects on hepcidin expression and iron absorption contrary to that of alcohol, we recently showed that consumption of 300 ml of red wine for 3 weeks, after an alcohol-free lead-in period of 2 weeks, resulted in decreased serum hepcidin in apparently healthy individuals (n = 13) and subjects with type 2 diabetes (T2D) (n = 18). To determine the mechanism of decrease in hepcidin after wine intervention, additional biochemical analyses of spare serum samples from the same subjects were performed. The decrease in hepcidin was accompanied by increased erythropoietin levels in both groups, while the increase in erythroferrone reached statistical significance only in the T2D group. These results suggest activation of the erythropoietin-erythroferrone-hepcidin pathway by red wine consumption. As an indicator of the activation of the erythropoietin-erythroferrone-hepcidin pathway we observed an increase in the red cell distribution width in both groups and in the reticulocyte count in the T2D group, while serum ferritin decreased. Our study reveals a novel biological effect of wine that may be important in conditions influencing iron homeostasis and functions of hepcidin in general.

The potential roles of gut microbiome in porto-sinusoidal vascular disease: an under-researched crossroad

Accumulating evidence indicates that patients with liver diseases exhibit distinct microbiological profiles, which can be attributed to the bidirectional relationship of the gut-liver axis. Porto-sinusoidal vascular disease (PSVD) has recently been introduced to describe a group of vascular diseases of the liver, involving the portal venules and sinusoids. Although the pathophysiology of PSVD is not yet fully understood, several predisposing conditions, including immunodeficiency, inflammatory bowel disease, abdominal bacterial infections are associated with the increasing in intestinal permeability and microbial translocation, supporting the role of altered gut microbiota and gut-derived endotoxins in PSVD etiopathogenesis. Recent studies have proposed that the gut microbiome may play a crucial role in the pathophysiology of intrahepatic vascular lesions, potentially influencing the onset and progression of PSVD in this context. This review aims to summarize the current understanding of the gut microbiome's potential role in the pathogenesis of hepatic microvascular abnormalities and thrombosis, and to briefly describe their interactions with PSVD. The insights into gut microbiota and their potential influence on the onset and progression of PSVD may pave the way for new diagnostic, prognostic, and therapeutic strategies.

Plasma n-3 Polyunsaturated Fatty Acid Levels and Colorectal Cancer Risk in the UK Biobank: Evidence of Nonlinearity, as Well as Tumor Site- and Sex-Specificity

BACKGROUND

The relationship between omega-3 polyunsaturated fatty acid (n-3 PUFA) intake and colorectal cancer risk is unclear. Blood n-3 PUFA concentration is a biomarker of dietary n-3 PUFA intake. We examined the relationship between plasma n-3 PUFA concentrations and colorectal cancer risk in UK Biobank (UKBB) participants.

METHODS

We analyzed the relationship between tertiles (T) of plasma total n-3 PUFAs and n-3 PUFA docosahexaenoic acid (DHA) levels, and overall colorectal cancer (also stratified by tumor location and sex) risk. Cox proportional hazards regression models were adjusted for clinical covariates. Nonlinearity was tested by restricted cubic splines.

RESULTS

There were 2,602 incident colorectal cancer cases in 234,598 UKBB participants with baseline plasma fatty acid data (mean follow-up 13.4 years). There was an inverse association between the plasma total n-3 PUFA level [T2 HR = 0.88 (95% confidence interval, 0.80-0.97) compared with the T1 reference; T3 = 0.91 (0.83-1.00)], as well as the plasma DHA concentration [T2 = 0.89 (0.80-0.98); T3 = 0.91 (0.82-1.00)], and colorectal cancer risk. The relationship was nonlinear [P for nonlinearity = 0.14 (total n-3 PUFAs) and 0.008 (DHA)], with a plateau effect at the highest n-3 PUFA concentrations. The relationship was more pronounced for proximal colon cancer [T2 = 0.82 (0.69-0.97); T3 = 0.76 (0.64-0.90) for DHA] and was evident for males [T2 = 0.84 (0.74-0.95); T3 = 0.89 (0.78-1.00)], but not for females.

CONCLUSIONS

Higher plasma n-3 PUFAs are associated with reduced colorectal cancer risk in the UKBB.

IMPACT

Nonlinearity, as well as tumor site and sex specificities, of the inverse relationship between plasma n-3 PUFA levels and colorectal cancer risk, if confirmed in other diverse populations, has significant implications for nutritional prevention guidelines.

Tranexamic acid as treatment for acute gastrointestinal bleeding: A comprehensive systematic review and meta-analysis

INTRODUCTION

Gastrointestinal (GI) bleeding is a common and potentially life-threatening medical emergency. Despite advancements in therapy, mortality rates associated with GI bleeding remain high (2.4% to 11%). Tranexamic acid (TXA) has been proposed as a treatment. However, the HALT-IT trial questioned its efficacy and safety, showing no significant reduction in death and potential thrombotic complications. This meta-analysis aims to evaluate the effectiveness and safety of TXA in treating acute GI bleeding.

METHODS

This systematic review and meta-analysis followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines. In October 2024 a comprehensive literature search was conducted using relevant MeSh terms and keywords in 11 databases. We included patients with acute GI bleeding treated with TXA and compared it with either a placebo or standard treatment. Outcomes such as mortality, need for blood transfusion, surgery and thrombotic events were studied.

RESULTS

The search identified 6810 articles. After screening, 23 studies were included, encompassing 2,061,231 participants. Our meta-analysis demonstrated that TXA significantly reduced rebleeding rates overall (RR: 0.81, 95% CI: 0.87-0.97). This effect was even more pronounced in studies with a lower risk of bias. Additionally, TXA use was associated with a mortality reduction when administered through both oral and intravenous routes (RR: 0.56, 95% CI: 0.35-0.89) and in cases of upper GI bleeding (RR: 0.72, 95% CI: 0.59-0.87). However, TXA was linked to a significant increase in mortality in patients with lower GI bleeding (RR: 1.67, 95% CI: 1.44-1.93) and overall reduction when only randomized controlled trials (RCTs) were included (RR:0.83, 95% CI; 0.70 to 0,97, I2=0%). Other variables, such as the overall need for blood transfusions (RR: 1.03, 95% CI: 0.80-1.32), thrombotic events (RR: 1.30, 95% CI: 0.75-2.23) and the need for surgical intervention (RR: 0.78, 95% CI: 0.57-1.09), did not reach statistical significance. However, when considering only low risk of bias studies the need for surgical interventions was significantly reduced (RR: 0.85, 95% CI: 0.75 to 0.97, I2=0%).

CONCLUSIONS

Our findings suggest that TXA significantly reduces rebleeding in patients, particularly in upper gastrointestinal bleeding (UGIB) and reduces need for surgical intervention when excluding high risk of bias studies. The findings also demonstrated a significant reduction in mortality, particularly in certain sub-groups. There was no definitive evidence that its use is associated with thromboembolictic events. These results highlight the potential benefit of TXA without dismissing the need for cautious interpretation and individualized patient management when considering TXA for GI bleeding.

Endoscopic clipping combined with cyanoacrylate injection vs. transjugular intrahepatic portosystemic shunt in the treatment of isolated gastric variceal bleeding: Randomized controlled trial

OBJECTIVES

Although the incidence of isolated gastric varices type 1 (IGV1) bleeding is low, the condition is highly dangerous and associated with high mortality, making its treatment challenging. We aimed to compare the safety and efficacy of endoscopic clipping combined with cyanoacrylate injection (EC-CYA) vs. transjugular intrahepatic portosystemic shunt (TIPS) in treating IGV1.

METHODS

In a single-center, randomized controlled trial, patients with IGV1 bleeding were randomly assigned to the EC-CYA group or TIPS group. The primary end-points were gastric variceal rebleeding rates and technical success. Secondary end-points included cumulative nonbleeding rates, mortality, and complications.

RESULTS

A total of 156 patients between January 2019 and April 2023 were selected and randomly assigned to the EC-CYA group (n = 76) and TIPS group (n = 80). The technical success rate was 100% for both groups. The rebleeding rates were 14.5% in the EC-CYA group and 8.8% in the TIPS group, showing no significant difference (P = 0.263). Kaplan-Meier analysis revealed that the cumulative nonbleeding rates at 6, 12, 24, and 36 months for the two groups lacked statistical significance (P = 0.344). Similarly, cumulative survival rates at 12, 24, and 36 months for the two groups were not statistically significant (P = 0.916). The bleeding rates from other causes were 13.2% and 6.3% for the respective groups, showing no significant difference (P = 0.144). No instances of ectopic embolism were observed in either group. The incidence of hepatic encephalopathy (HE) in the TIPS group was statistically higher than that in the EC-CYA group (P = 0.001).

CONCLUSION

Both groups are effective in controlling IGV1 bleeding. Notably, EC-CYA did not result in ectopic embolism, and the incidence of HE was lower than that observed with TIPS.

Differential Colorectal Cancer Mortality Across Racial and Ethnic Groups: Impact of Socioeconomic Status, Clinicopathology, and Treatment-Related Factors

INTRODUCTION

Non-Hispanic Black (Black) colorectal cancer (CRC) patients have a higher risk of mortality than most other racial/ethnic groups. Limited studies examine the contribution of socioeconomic (SES), clinicopathologic, or treatment variations to mortality disparities. This retrospective cohort investigation examined the extent to which SES, clinicopathologic, and treatment factors explain racial/ethnic differences in CRC mortality.

METHODS

We studied 146,515 individuals, 18+ years old, with a confirmed diagnosis of CRC within 2010-2017, identified from the Surveillance, Epidemiology, and End Results (SEER) database. We performed Cox regression analyses to examine the association of race and ethnicity, surgery type, and tumor site with all-cause mortality and CRC-specific mortality. We then performed mediation analysis to quantify the extent to which mortality differences were mediated by SES, clinicopathologic, and treatment factors.

RESULTS

Black patients had a significantly higher hazard of all-cause mortality than non-Hispanic White (White) patients. The White versus Black patients' comparison demonstrated that variations in SES and clinicopathologic factors significantly explained 46.63% (indirect effect HR: 0.92, 95% CI 0.91-0.93) and 10.87% (indirect effect HR: 0.98, 95% CI 0.97-0.99) of the excess all-cause mortality among Black patients, respectively. The Hispanic versus Black comparisons identified SES as the most influential mediator, explaining 19.68% of the excess all-cause mortality. The proportions mediating for CRC-specific mortality showed comparable outcomes to all-cause mortality.

CONCLUSION

Black patients had a greater risk for all-cause mortality and CRC-specific mortality attributed to SES and clinicopathologic variations compared to other racial/ethnic groups. Future studies should investigate equity in healthcare through interventions addressing SES-related disparities.

Combined antifungal therapy with immunostimulation for refractory cutaneous and peritoneal mucormycosis caused by Rhizopus microsporus

Mucormycosis is a fungal infection typically affecting immunocompromised patients. Here, we report a severe case of invasive cutaneous and peritoneal mucormycosis caused by Rhizopus microsporus, successfully treated with a combination of antifungal therapy, PD-1 inhibitor, and interferon-gamma. We highlight the importance of personalized immunotherapy in refractory cases of invasive mucormycosis.

Association of microscopic colitis and enteropathy due to olmesartan

We report the case of a patient with severe chronic diarrhea. He was admitted on multiple occasions for this reason, with the cause remaining undetected. After obtaining a detailed medical history and performing several studies, the patient was diagnosed with microscopic colitis and enteropathy due to Olmesartan. In the literature, both diseases appear concurrently only in a few cases. Here we highlight the importance of conducting a comprehensive medical history and maintaining high clinical suspicion to avoid delays in the diagnosis of these uncommon pathologies, as well as unnecessary tests and empirical treatments.

Utility of Advanced Age as a Predictor of Outcomes in Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt

INTRODUCTION

Transjugular intrahepatic portosystemic shunt (TIPS) is an effective intervention for managing major complications of cirrhosis including refractory ascites, hydrothorax, and variceal bleed. The impact of advanced age on outcomes of TIPS has not been studied comprehensively. Therefore, we aimed to study optimal advanced age cutoff in context of MELD score for patients undergoing TIPS.

METHODS

A single-center retrospective analysis of all adult patients with cirrhosis, who underwent TIPS between 2002 and 2020 was performed. Univariate and multivariate analyses were conducted to determine the development of hepatic encephalopathy (HE) and mortality at 30 days and 1 year. The impact of various age groups (55, 60, 65, and 70 years) and MELD score cutoffs on mortality were elucidated.

RESULTS

A total of 225 patients were included. No significant associations were found between advanced age and short-term mortality (p = 0.410), short-term development of HE (p = 0.846), or secondary post-TIPS outcomes such as rebleed or need for paracentesis. However, advanced age was associated with significant differences in post TIPS mortality (p = 0.026) and inpatient development of HE (p = 0.032) at 1-year. These associations were confirmed in multivariate models. Area under the covariate adjusted receiver operating curve (AUROC) identified optimal age and MELD cutoffs as 60 years and 15 for 1-year mortality, respectively. An optimal age cutoff of 54 was identified for 1-year HE.

CONCLUSIONS

Advanced age is strongly associated with 1-year mortality and 1-year development of HE post-TIPS. Poorer post-TIPS outcomes were further observed in patients with higher MELD. Therefore, during selection of advanced age patients for TIPS, MELD score should be considered for better long-term outcomes.

Comparative gastrointestinal organoid models across species: A Zoobiquity approach for precision medicine

Gastrointestinal (GI) health underpins systemic well-being, yet the complexity of gut physiology poses significant challenges to understanding disease mechanisms and developing effective, personalized therapies. Traditional models often fail to capture the intricate interplay between epithelial, mesenchymal, immune, and neuronal cells that govern gut homeostasis and disease. Over the past five years, advances in organoid technology have created physiologically relevant, three-dimensional GI models that replicate native tissue architecture and function. These models have revolutionized the study of autoimmune disorders, homeostatic dysfunction, and pathogen infections, such as norovirus and Salmonella, which affect millions of humans and animals globally. In this review, we explore how organoids, derived from intestinal and pluripotent stem cells, are transforming our understanding of GI development, disease etiology, and therapeutic innovation. Through the "Zoobiquity" paradigm and "One Health" framework, we highlight the integration of companion animal organoids, which provide invaluable insights into shared disease mechanisms and preclinical therapeutic development. Despite their promise, challenges remain in achieving organoid maturation, expanding immune and neuronal integration, and bridging the gap between organoid responses and in vivo outcomes. By refining these cutting-edge platforms, we can advance human and veterinary medicine alike, fostering a holistic approach to health and disease.

Markedly elevated liver enzymes in pregnancy: A 10-year review of cases in a tertiary maternal hospital in Brisbane, Australia

Abnormalities of liver function are common during pregnancy. This retrospective study examined the incidence, aetiology and adequacy of investigation of pregnant women with markedly elevated aspartate aminotransferase and/or alanine transaminase levels (more than 10-fold of the upper limit of normal) over a ten-year period at a tertiary referral maternity hospital in Brisbane, Australia. Three hundred and twenty-three women were found to have markedly elevated liver enzymes, representing 0.56% of pregnancies with known delivery outcomes. Two hundred and sixty-four cases (82%) were due to pregnancy-specific causes. No cause was identified in 12 women (3.8%) despite investigation. No adverse maternal, fetal or neonatal outcome occurred in these pregnancies where no cause was identified for markedly elevated liver enzymes. A further six women (1.9%) did not have comprehensive investigation into underlying aetiologies of elevated liver enzymes.

Process and outcome differences in the care of patients undergoing elective and emergency right hemicolectomy

INTRODUCTION

Up to 30% of patients with colorectal cancer present as an emergency and have worse outcomes than elective patients. Compared with left-sided cancers, malignancies arising in the right colon are significantly under-researched. We sought to compare cancer care quality and clinical outcomes between emergency and elective presentations of right-sided colon cancer (RCC).

METHODS

This multicentre, retrospective study included all patients who underwent operative management for a RCC, from 1 April 2017 to 31 March 2022. Data were collected from electronic patient records, and host and tumour factors as well as outcomes between emergency and elective cohorts were compared.

RESULTS

Overall, 806 patients (median age 72 years) were included. Some 175 patients (22%) presented as an emergency: 140 in obstruction and 35 with tumour perforation, compared with 1 patient with tumour perforation in the elective group (p < 0.001). The emergency group had higher rates of postoperative complications (59.1% vs 20.0%, p < 0.001), increased 90-day mortality (13.7% vs 1.3%, p < 0.001) and a longer hospital stay (5 vs 10 days, p < 0.001). From the emergency cohort only 29.2% of eligible patients received adjuvant chemotherapy and in multivariate regression analysis emergency presentation was associated with a decreased likelihood of receiving adjuvant chemotherapy (odds ratio 0.26 [0.14-0.47], p < 0.001).

CONCLUSIONS

Both short- and long-term outcomes after emergency presentation of RCC are poor, with inadequate access to subsequent chemotherapy. Strategies addressing emergency presentations of left-sided tumours have moved towards temporisation and elective surgery. Delaying major resectional surgery for optimisation may improve outcomes and access to adjuvant therapies for RCC.

Assessment of Helicobacter pylori infection in Lebanon: Endoscopic and histopathological findings

Helicobacter pylori (H. pylori), a pervasive pathobiont, colonizes the gastric mucosa and plays a crucial role in the pathogenesis of several gastroduodenal pathologies ranging from chronic gastritis to more severe disorders including peptic ulcer disease, gastric mucosa-associated lymphoid tissue lymphoma, and gastric adenocarcinoma. In symptomatic patients, endoscopy and histological examination of the gastric mucosa are the preferred tests for diagnosing H. pylori. Our study aimed to identify the frequency of H. pylori and its association with endoscopic and histopathological findings in adult Lebanese patients. Thus, 332 symptomatic adult patients, attending the Endoscopy unit of Makassed General Hospital in Beirut, were enrolled in this cross-sectional study. Overall, 14.16 % of the patients were infected with H. pylori, with male predominance. The most common endoscopic findings were gastritis and gastropathy. Moreover, H. pylori infection was significantly associated with gastric ulcers and duodenitis. On the other hand, active gastritis and chronic gastritis were the most common histopathological findings. Chronic gastritis was more frequent in H. pylori-positive patients. The association between endoscopic diagnosis and histopathological findings was then assessed. It was shown that gastropathy was significantly associated with chronic gastritis. In addition, gastric ulcer was significantly related to active gastritis and chronic gastritis. In conclusion, this study reported various endoscopic findings in H. pylori-positive patients based on the Kyoto classification. This highlights the importance of invasive diagnosis in symptomatic patients. Therefore, a combination-based approach including endoscopic and histopathological findings remains crucial in clinical practice for a definitive and accurate diagnosis of H. pylori infection and related disorders, especially in resource-limited settings.

Terazosin, a repurposed GPR119 agonist, ameliorates mitophagy and β-cell function in NAFPD by inhibiting MST1-Foxo3a signalling pathway

GPR119 agonists are being developed to safeguard the function of pancreatic β-cells, especially in the context of non-alcoholic fatty pancreas disease (NAFPD) that is closely associated with β-cell dysfunction. This study aims to employ a drug repurposing strategy to screen GPR119 agonists and explore their potential molecular mechanisms for enhancing β-cell function in the context of NAFPD. MIN6 cells were stimulated with palmitic acid (PA), and a NAFPD model was established in GPR119-/- mice fed with a high-fat diet (HFD). Terazosin, identified through screening, was utilized to assess its impact on enhancing β-cell function via the MST1-Foxo3a pathway and mitophagy. Terazosin selectively activated GPR119, leading to increased cAMP and ATP synthesis, consequently enhancing insulin secretion. Terazosin administration improved high blood glucose, obesity, and impaired pancreatic β-cell function in NAFPD mice. It inhibited the upregulation of MST1-Foxo3a expression in pancreatic tissue and enhanced damaged mitophagy clearance, restoring autophagic flux, and improving mitochondrial quantity and structure in β-cells. Nevertheless, GPR119 deficiency negated the positive impact of terazosin on pancreatic β-cell function in NAFPD mice and abolished its inhibitory effect on the MST1-Foxo3a pathway. Terazosin activates GPR119 on the surface of pancreatic β-cells, enhancing mitophagy and alleviating β-cell dysfunction in the context of NAFPD by suppressing the MST1-Foxo3a signalling pathway. Terazosin could be considered a priority treatment for patients with concomitant NAFPD and hypertension.

The management of splanchnic vein thrombosis in acute pancreatitis: a global DELPHI consensus study

BACKGROUND

Splanchnic vein thrombosis (SpVT) occurs in 17%-23 % of acute pancreatitis cases. Serious sequelae include hepatic and bowel ischaemia. However, management with therapeutic anticoagulation remains controversial due to potential bleeding risk. We aim to determine the level of consensus on prognosis, diagnosis, management, and outcomes of SpVT through a DELPHI process.

METHODS

Using purposive, non-probability sampling and DELPHI methodology, 173 clinicians with experience of SpVT in acute pancreatitis were approached. From April 2022 to April 2023, a three-round DELPHI process was implemented to completion. A total of 88 statements were posed for ranking via a four-point Likert scale.

RESULTS

The mean acute pancreatitis caseload per respondent per year was 68·0, 72·6 and 73·0 for DELPHI rounds 1,2 and 3 respectively. For SpVT anatomical location, there was strong consensus favouring anticoagulation for portal vein (89·1 %) and SMV thrombosis (90·9 %), and no consensus to treat splenic vein thrombosis (47·3 %). 74·1 % rejected radiological resolution as a definitive anticoagulation endpoint. Majority consensus favoured death, bleeding risk, bowel or liver ischaemia, hospital admission length and ITU admission as significant outcomes for experimental research design.

CONCLUSION

There was significant consensus for anticoagulation treatment of SpVT of the portal and superior mesenteric veins, especially with complete occlusion by thrombosis. Randomised controlled trials are required to grade management recommendations.

Intra-abdominal Mucormycosis in an Immunocompetent Host: A Rare Presentation and Literature Review

Mucormycosis is a severe, opportunistic infection caused by Mucorales, a taxonomical group of thermotolerant fungi primarily affecting the immunocompromised. Intra-abdominal involvement in mucormycosis is a rare entity, particularly in immunocompetent individuals. We present a fatal case of gallbladder and renal mucormycosis in an immunocompetent female, leading to septic shock and death. The diagnosis was confirmed via histopathology following cholecystectomy for suspected gangrenous cholecystitis and open right nephrectomy due to kidney infarction. Quantitative polymerase chain reaction of the tissue identified the presence of Apophysomyces ossiformis. The clinical picture was confounded by ongoing sepsis due to a Klebsiella pneumoniae-infected retroperitoneal hematoma, non-specific imaging findings, and the absence of traditional risk factors for mucormycosis, leading to a delayed diagnosis. Despite surgical debridement, initiation of liposomal amphotericin B with posaconazole, and aggressive treatment in the intensive care unit, the patient succumbed to complications of mucormycosis. Despite adequate antibiotic coverage, this case underscores the importance of considering Mucorales infection in otherwise immunocompetent patients with a deteriorating clinical condition. Early diagnosis and appropriate intervention are essential in enhancing mucormycosis survivability, though mortality rates remain high in severe cases.

Sigmoid volvulus revealing large bowel cancer: A case report with a literature review

INTRODUCTION

Sigmoid volvulus (SV) is the most common type of colonic volvulus. In Tunisia, it is the second leading cause of colonic obstruction. The primary predisposing factors include chronic constipation and a high, wide mesosigmoid with a narrow root. Endoscopic detorsion and surgery are the standard treatments. The association with underlying cancer is rare but significantly alters the therapeutic approach.

CASE PRESENTATION

We present the case of a 68-year-old patient with a history of prostate hypertrophy and chronic constipation who presented with abdominal pain, biliary vomiting, and distension. Imaging revealed a sigmoid volvulus without necrosis. During laparotomy, manual counterclockwise detorsion was performed, followed by a carcinologic resection and Hartmann's procedure. The patient had an uneventful recovery and was discharged on the seventh postoperative day. Pathological findings confirmed the presence of a mucinous adenocarcinoma of the sigmoid colon.

DISCUSSION

Sigmoid volvulus is the most common type of colon volvulus, accounting for 50-90 % of cases. While SV is frequently encountered, the association with underlying sigmoid cancer is rare. To our knowledge, only five cases of malignant tumors presenting with SV have been reported in the literature. Detecting this association necessitates a change in operative technique, specifically towards a carcinological resection.

CONCLUSION

Sigmoid volvulus is the most common type of colon volvulus. It is crucial for surgeons and radiologists to be aware of its potential association with underlying colon cancer. This awareness allows for adjustments in surgical technique, ultimately leading to improved postoperative outcomes.

Protein regulator of cytokinesis 1 regulates autophagy in hepatitis B virus‑associated liver cancer development

Hepatitis B protein x (HBx) is considered a critical contributor to hepatitis B virus (HBV)‑associated liver cancer development. Protein regulator of cytokinesis 1 (PRC1) has been implicated in hepatocarcinogenesis. However, the clinical relevance, biological functions and related regulatory mechanisms of PRC1 in HBV‑associated liver cancer have not yet been clarified. PRC1 expression profiles in liver cancer were obtained from The Cancer Genome Atlas and Gene Expression Profiling Interactive Analysis database and through reverse transcription‑quantitative polymerase chain reaction and immunohistochemistry assays. A series of in vitro and in vivo assays were used to explore the function of the PRC1 gene and the possible mechanisms through which it affects HBV‑associated liver cancer. PRC1 was overexpressed in HBV‑positive liver cancer tissues. Functional studies in vitro demonstrated that HBx induced the expression of the PRC1 gene, which promoted cell autophagy and enhanced viability, invasion and migration. Furthermore, the knockdown of the PRC1 gene or treatment with the autophagosome inhibitor 3‑methyladenine blocked the HBx‑induced autophagic flux, disrupted the formation of autophagosomes, and promoted cell apoptosis. Liver cancer xenograft animal model experiments revealed that inhibition of autophagy by 3‑methyladenine or silencing of the PRC1 gene attenuated HBx‑induced malignant behavior in vivo. The absence of autophagy inhibited the expression of Bcl‑2, induced the expression of Bax, and regulated the levels of Th1 and Th2 cytokines. These results elucidate a mechanism wherein the PRC1 gene participates in the occurrence and development of HBV‑associated liver cancer by modulating autophagy. PRC1 could be a potential therapeutic target for liver cancer.

Balloon-assisted enteroscopy in the management of adult small-bowel intussusception: a comparative analysis of with and without double-balloon enteroscopy

BACKGROUND

Adult small-bowel intussusception (ASI) is a rare condition with pathological etiologies in most patients. Previously, surgical intervention was the primary treatment modality; however, the introduction of balloon-assisted enteroscopy (BAE) has allowed preoperative BAE in some cases to confirm the leading point, thereby guiding management and reducing surgical need. In this study, we investigated whether the introduction of BAE has altered the diagnostic and therapeutic strategies for ASI by retrospectively analyzing and comparing the clinicopathological features of patients before and after its introduction.

METHODS

Fifty-three patients with ASI, initially diagnosed via abdominal computed tomography scanning at Korea University Guro Hospital from 2000 to 2023, were included in our study. Patients were grouped based on double-balloon enteroscopy (DBE) usage, and clinicopathological outcomes were compared retrospectively.

RESULTS

Of the 53 patients, 38 (71.7%) had enteroenteric-type intussusception and 15 (28.3%) had enterocolic-type intussusception. Among the patients with enteroenteric-type intussusception, 15.8% had a malignant cause, whereas in the enterocolic type, 60% had a malignant cause (p = 0.001). Of 38 patients with enteroenteric ASI, 15 (39.5%) underwent preoperative DBE. The surgical resection rate was significantly lower in the DBE group (40%) than in the non-DBE group (73.9%) (p = 0.037). Pathological diagnoses of patients who underwent surgical resection without preoperative DBE revealed 17.6% malignancies and 82.4% benign causes, including idiopathic intussusception (four cases) and Peutz-Jeghers syndrome (two cases). No morbidity, mortality, or recurrence was observed.

CONCLUSION

Preoperative BAE is a valuable diagnostic and therapeutic modality for ASI, particularly in cases of low-grade small-bowel obstruction, reducing surgical resection rates in most ASI cases. The introduction of the BAE has significantly improved ASI management, achieving high successful reduction rates and few surgical interventions. BAE should be considered a first-line diagnostic and therapeutic tool for ASI management.

Approach to anaemia in gastrointestinal disease: A position paper by the ESPGHAN Gastroenterology Committee

Anaemia is a frequent consequence of many gastrointestinal (GI) diseases in children and it can even be the initial presenting symptom of underlying chronic GI disease. The definition of anaemia is age and gender-dependent and it can be classified based on pathophysiology, red cell morphology, and clinical presentation. Although nutritional deficiencies, including GI malabsorption of nutrients and GI bleeding, play a major role, other pathophysiologic mechanisms seen in chronic GI diseases, whether inflammatory (e.g., inflammatory bowel disease) or not (e.g., coeliac disease and dysmotility), are causing anaemia. Drugs, such as proton pump inhibitors, mesalamine, methotrexate and sulfasalazine, are also a potential cause of anaemia. Not uncommonly, due to a combination of factors, such as iron deficiency and a chronic inflammatory state, the underlying pathophysiology may be difficult to decipher and a broad diagnostic work-up is required. The goal of treatment is correction of anaemia by supplementation of iron and vitamins. The first therapeutic step is to treat the underlying cause of anaemia including bleeding control, restoration of intestinal integrity and reduction of inflammatory burden. The route of iron and vitamin supplementation is guided by the severity of anaemia.