Pediatric gallstone disease-Management difficulties in clinical practice

BACKGROUND

Gallstone disease (GD) is no longer an exclusive condition of adulthood, and its prevalence is increasing in pediatric age. The management and the extent of the etiological investigation of GD in children and adolescents remains controversial. This study aimed to analyze the difficulties in the work-up and management of pediatric GD patients.

METHODS

A retrospective study performed in a single tertiary center enrolled sixty-five patients with GD followed from January 2014 to June 2021. Patients were categorized conveniently according to their age at diagnosis: Group A (<10years, n=35) and Group B (≥10years, n=30). We analyzed demographic, clinical and laboratory data, ultrasonographic findings at presentation, therapeutics and complications.

RESULTS

Symptoms were more frequent in patients >10years old (p=0.001). Cholecystectomy was performed in 31 patients (47.7%). A multivariate regression logistic model identified the age >10years (OR=6.440, p=0.005) and underlying entities (OR=6.823, p=0.017) as independent variables to perform surgery. Spontaneous resolution of GD was more common in children <2years old. A multivariate regression logistic model showed a trend for those >10years old to develop more complications. Two out of 18 patients were diagnosed with ABCB4 gene mutations in heterozygosity.

CONCLUSIONS

Decision-making on cholecystectomy remains challenging in asymptomatic patients. Identifying predictive factors for the development of complications has proven difficult. However, we found a trend toward the development of complications in individuals older than 10years.

Spontaneous Postpartum Pneumomediastinum (Hamman's Syndrome): A Case Report and Review of Chest Pain Management in the Immediate Postpartum Period

Spontaneous pneumomediastinum is a rare condition in the postpartum period, characterized by symptoms such as dyspnea, chest pain, subcutaneous neck edema, tachycardia, crepitus, dysphonia, and dysphagia. The Valsalva maneuver, commonly performed during the second stage of vaginal delivery, has been implicated as a key precipitating factor in the pathogenesis of this condition. We report the case of a 25-year-old woman (G1P1001, 39w5d), with a history of smoking, who developed postpartum dyspnea and chest pain 24 hours following an uncomplicated vaginal delivery. A comprehensive diagnostic workup, including a CT scan with intravenous contrast, confirmed severe pneumomediastinum. The patient was managed conservatively with analgesics, supplemental oxygen, and close clinical monitoring. A follow-up chest CT performed 24 hours later demonstrated interval improvement of the pneumomediastinum and an esophagogram excluded the presence of an esophageal tear or rupture. Although spontaneous pneumomediastinum is a rare obstetric complication of normal childbirth, it can present dramatically with chest pain, dyspnea, and hemodynamic instability. Diagnosis is established through a combination of history, clinical presentation, and radiographic findings. Management is conservative and includes analgesics, rest, supplemental oxygen therapy, and bronchodilators. Importantly, other potentially life-threatening causes of postpartum chest pain and dyspnea must be carefully ruled out to ensure timely and appropriate treatment.

The Silent Bleeder: A Case of Recurrent Hemorrhage From a Dieulafoy's Lesion

Dieulafoy's lesion is a rare but potentially life-threatening cause of gastrointestinal (GI) bleeding. We report the case of a 75-year-old woman with a history of transient ischemic attack (TIA), hypertension, chronic obstructive pulmonary disease (COPD), and non-small cell lung cancer (NSCLC), who presented with dizziness, nausea, and abdominal pain. Initial evaluations revealed progressive anemia, though no source of bleeding was identified on imaging, nor were there external signs of bleeding. Endoscopy later confirmed an actively bleeding Dieulafoy's lesion, which was successfully treated with hemoclips. This case highlights the diagnostic challenges of Dieulafoy's lesion due to its intermittent bleeding and nonspecific presentation. Endoscopic intervention remains the first-line treatment, and early recognition is crucial to prevent life-threatening complications.

Deficient SARS-CoV-2 hybrid immunity during inflammatory bowel disease

Patients with Inflammatory Bowel Disease (IBD) undergoing immunosuppressive therapies face heightened susceptibility to severe COVID-19. An in-depth understanding of systemic inflammation and cellular immune responses after SARS-CoV-2 vaccination and breakthrough infections (BTI) is required for optimizing vaccine strategies in this population. While the prevalence of high serological responders post- third COVID-19 vaccine dose was lower, and the antibody waning was higher in IBD patients than in healthy donors (HD), IBD patients showed an increase in anti-RBD Wild Type IgG levels and cross-reactive Spike -specific memory B cells following BTI. However, there was no significant enhancement in cellular immune responses against anti-SARS-CoV-2 post-BTI, with responses instead characterized by activation of SARS-CoV-2 specific and also bystander CD8 T cells. These results suggest a complex interaction between chronic inflammation in IBD and the generation of new immune responses, highlighting the need for tailored vaccine regimens and anti-inflammatory therapies to boost cellular immunity against SARS-CoV-2.

Assessment of residual gastric volume by ultrasound prior to upper endoscopy: a prospective cohort study

PURPOSE

Pulmonary aspiration is an adverse event with high morbidity and mortality. Despite fasting for > 8 hr, some patients still have residual gastric volume and are thus at risk of aspiration. We aimed to determine the accuracy of gastric ultrasound in assessing residual gastric content in patients undergoing upper gastrointestinal endoscopy.

METHODS

In a prospective cohort study, we performed gastric ultrasound immediately before upper gastrointestinal endoscopy in a sample of 294 patients. We categorized the ultrasound results as high risk of aspiration when the fluid volume was > 1.5 mL·kg-1 or when there was thick/solid content. We applied Spearman's test to determine the correlation between aspirated volume and ultrasound-estimated volume using three mathematical models. We assessed the method's accuracy by calculating its sensitivity and specificity.

RESULTS

We included 282 patients in the analysis. The incidence of residual gastric contents was 5%. There were no aspiration events. Prokinetic use (relative risk [RR], 7.5; 95% confidence interval [CI], 1.9 to 29.1; P < 0.01), previous stroke (RR, 4.0; 95% CI, 1.2 to 13.6; P = 0.02), and male sex (RR, 3.3; 95% CI, 1.2 to 9.4; P = 0.02) were significantly more frequent among those with residual gastric content. The ultrasonography's specificity and sensitivity to predict gastric content at risk of aspiration were 100% and 77%, respectively, with a positive predictive value of 100% and a negative predictive value of 99%.

CONCLUSION

Ultrasonography was an effective way to assess residual gastric content, which can help improve patient safety.

Evaluation of the dynamics of nutrients and potentially toxic elements along a major river in Ethiopia using multivariate statistical techniques: Implications of possible co-occurrences

This study utilized established field and laboratory methods and multivariate statistical tools to evaluate the nutrient and potentially toxic elements (PTEs) distribution, identify possible sources, and determine potential co-existence in the Awash River. The levels of soluble reactive phosphorus (SRP), total phosphorus (TP), NO3-N, Mn, Ni, Cr, and Cu generally increased downstream in the upper Awash, with the highest respective values of 0.70, 1.34, 1.19, 1.58, 1.03, 0.85, and 0.11 mg L-1 at the inlet to Lake Koka. Sites found downstream of the inflow of Lake Beseka and Metehara town showed the highest levels of Fe, B, Zn, and dissolved silica. Principal components and correlation analysis findings revealed strong associations (r ≥ 0.80, p < 0.05) between nutrient parameters (SRP, TP, and NO3-N) and PTEs (Cu, Ni, Mn, and Cr), implying common origins and potential co-occurrences. The potential co-occurrences of these parameters may strengthen their potential individual impacts due to complex interactions.

Analysis of Risk Factors, Treatment Patterns, and Survival Outcomes After Emergency Presentation With Colorectal Cancer: A Prospective Multicenter Cohort Study in Nigeria

BACKGROUND AND OBJECTIVES

Prospective data on presentation and outcomes of colorectal cancer (CRC) in Nigeria are limited; however, emergency presentation with advanced disease is thought common.

METHODS

Consecutive CRC patients presenting at six sites over 6 years were included. Risk factors for emergency presentation were evaluated using logistic regression methods. Overall survival (OS) was compared between emergent and elective patients using Kaplan-Meier methods and the log-rank test.

RESULTS

Of 535 patients, 30.7% presented emergently. Median age was 56 years, 55% were men, and 5.0% reported a cancer family history. Emergency patients had more proximal cancers (42.1% vs. 24.0%), Stage IV disease (61.6% vs. 40.2%; p < 0.001), lower household income (₦35 000/month vs. ₦50 000/month), lower education levels (p = 0.008) and accessed care with nonmotorized transport (50.6% vs. 37.2%; p = 0.005). Median OS was shorter in the emergency group (6.4 vs. 17.4 months; p < 0.001). Across clinical stages, emergency presentation was associated with worse OS (Stage IV median OS 4.8 vs. 9.4 months; p = 0.002). Surgery improved survival in both groups, although emergency patients had higher 30-day postoperative mortality (23.2% vs. 9.1%; p < 0.001).

CONCLUSIONS

Emergent Nigerian CRC patients have worse OS than elective patients. Cancer control efforts should focus on faster cancer detection, early presentation, diagnosis, and treatment.

The effect of tumor resection on intestinal microbiota dysbiosis in patients with right-sided colon cancer

PURPOSE

This study aimed to determine the effect of tumor resection on dysbiosis of the intestinal microbiota in patients with right-sided colon cancer.

METHODS

This study utilized a longitudinal design to explore the outcomes of patients diagnosed with right-sided colon cancer who underwent surgical resection at Dr. M. Djamil General Hospital from July to December 2023. We excluded patients with a documented history of comorbidities, specifically those affecting the digestive system. To compare the microbiota (genus and phylum) between patients with right-sided colon cancer and the control group, we conducted bivariate analyses using the independent t-test or Mann-Whitney test. Furthermore, we employed the dependent t-test or Wilcoxon test to assess changes in the dysbiosis of the microbiota (genus and phylum) before and after resection. A P-value of <0.05 was considered statistically significant.

RESULTS

This study included a total of 21 patients diagnosed with right-sided colon cancer. In the control group, Bacteroidetes constituted the highest proportion of intestinal microbiota, accounting for 56.34%. Prior to tumor resection, the intestinal microbiota of patients exhibited Proteobacteria as the predominant phylum, representing 52.97%. Following tumor resection, Bacteroidetes remained the most prevalent, comprising 50.9% of the intestinal microbiota. Significant variations in the levels of Proteobacteria, Verrucomicrobia, and Cyanobacteria/Chloroplast were observed in the intestinal microbiota of patients with right-sided colorectal cancer before and after tumor excision (all P=0.001).

CONCLUSIONS

The microbiome of patients with right-sided colorectal cancer differed significantly from that of the control group. However, following tumor resection, the microbiome composition of these patients became more similar to that observed in the control group.

Epidemiology of elderly burn patients in the United States: Mortality patterns and risk factors revealed by CDC WONDER database

INTRODUCTION

Burn-related fatalities pose a significant global public health challenge, with a substantial impact on the elderly population. This study examines two decades of burn-related mortality data in the United States, aiming to understand the trends, disparities, and contributing factors among adults aged 65 and older.

OBJECTIVES

The primary objectives of this study are to (1) analyze the trends in burn-related mortality rates among older adults, (2) investigate disparities based on gender, race and geographic regions, and (3) identify comorbidities and complications associated with burn-related deaths in this demographic.

METHODS

Data were obtained from the Centers for Disease Control and Prevention (CDC) using the National Center for Health Statistics database. The study cohort consists of individuals aged 65 and older who experienced burn-related deaths between 1999 and 2020. Various demographic variables, including age, sex, race/ethnicity, and location of death, were considered. The study also examined urban-rural classifications and regional differences. Mortality rates were calculated and adjusted for age. Joinpoint regression analysis was employed to assess trends in age-adjusted mortality rates over time. Modes of death and common comorbidities and complications were analyzed.

RESULTS

Between 1999 and 2020, a total of 96,498 older adults succumbed to burn injuries in the United States. Analysis revealed a concerning increase in burn-related mortality rates from 2012 onwards. Demographic disparities were evident, with older men consistently exhibiting higher mortality rates compared to women. Racial disparities were observed, with Black individuals experiencing the highest mortality burden. Geographic analysis indicated elevated mortality rates in Western states and rural areas. Accidents emerged as the leading cause of death, with ischemic heart disease and hypertensive diseases being prevalent comorbidities. Complications, with septicemia being the most common, contribute significantly to mortality.

CONCLUSION

Our analysis of 20 years of burn-related mortality data from the CDC reveals alarming trends in the United States. Unlike global trends, mortality rates have stagnated from 1999 to 2020, indicating a persistent public health challenge. Black individuals aged over 65 bear the brunt of burn-related mortality, facing the highest age-adjusted rates among all racial groups. Regional disparities are stark, with states in the top 90 % exhibiting significantly higher age-adjusted mortality rates compared to those in the bottom 10 %. Moreover, rural areas consistently report higher mortality rates than urban areas. Ischemic heart disease, hypertensive diseases, and other heart-related conditions emerge as prevalent comorbidities. To effectively reduce burn-related injuries and fatalities, targeted public health policies are imperative. These interventions must prioritize high-risk populations and adopt culturally sensitive approaches to promote safety. Additionally, enhancing access to healthcare and fire safety education is vital for mitigating the burden of burn-related mortality among the elderly population.

European guidelines for the diagnosis and treatment of pancreatic exocrine insufficiency: UEG, EPC, EDS, ESPEN, ESPGHAN, ESDO, and ESPCG evidence-based recommendations

Pancreatic exocrine insufficiency (PEI) is defined as a reduction in pancreatic exocrine secretion below the level that allows the normal digestion of nutrients. Pancreatic disease and surgery are the main causes of PEI. However, other conditions and upper gastrointestinal surgery can also affect the digestive function of the pancreas. PEI can cause symptoms of nutritional malabsorption and deficiencies, which affect the quality of life and increase morbidity and mortality. These guidelines were developed following the United European Gastroenterology framework for the development of high-quality clinical guidelines. After a systematic literature review, the evidence was evaluated according to the Oxford Center for Evidence-Based Medicine and the Grading of Recommendations Assessment, Development, and Evaluation methodology, as appropriate. Statements and comments were developed by the working groups and voted on using the Delphi method. The diagnosis of PEI should be based on a global assessment of symptoms, nutritional status, and a pancreatic secretion test. Pancreatic enzyme replacement therapy (PERT), together with dietary advice and support, are the cornerstones of PEI therapy. PERT is indicated in patients with PEI that is secondary to pancreatic disease, pancreatic surgery, or other metabolic or gastroenterological conditions. Specific recommendations concerning the management of PEI under various clinical conditions are provided based on evidence and expert opinions. This evidence-based guideline summarizes the prevalence, clinical impact, and general diagnostic and therapeutic approaches for PEI, as well as the specifics of PEI in different clinical conditions. Finally, the unmet needs for future research are discussed.

A novel surgical technique for repairing duodenal and bile duct perforations following endoscopic retrograde cholangiopancreatography

Duodenal perforation (DP), though rare, is a severe complication of Endoscopic retrograde cholangiopancreatography (ERCP) with high mortality rates. This report introduces a novel surgical approach for repairing a complex combined bile duct and duodenal perforation. A 37-year-old male with recurrent pyloric stenosis and choledocholithiasis, previously treated with multiple procedures, presented with gastric outlet and bile duct obstruction. Following a complex ERCP, he developed a large combined duodenal and bile duct perforation requiring urgent surgical intervention. A 40% circumferential duodenal perforation combined with bile duct perforation was repaired using a novel approach: a vascularized isolated distal gastric pouch was created and anastomosed to the duodenal and bile duct defects. A Roux-en-Y gastrojejunostomy was performed, and the patient recovered in stable condition. When traditional reconstruction is not feasible for DP, an isolated, vascularized distal gastric pouch offers a less invasive alternative and reduces the risk of morbidity.

Prevalence and Factors Associated With Proton Pump Inhibitors (PPIs) Use: A Cross-Sectional Study of PERSIAN Guilan Cohort Study

Background and Aims

Proton pump inhibitors (PPIs) are used extensively in the treatment of patients with upper gastrointestinal disorders. In this study, we aimed to investigate the prevalence of PPI consumption and related factors in the Prospective Epidemiological Research Studies in Iran (PERSIAN) Guilan Cohort study (PGCS) population.

Methods

This was a cross-sectional study form the PGCS, and investigated 10,520 participants for PPI consumption, which were divided into two groups: users and nonusers. Demographical data, clinical characteristics, and PPI types were recorded. The data were analyzed using SPSS version 16 and GraphPad Prism version 9, and a significance level of 0.05 was considered.

Results

The prevalence of PPI use in the overall participants was 4.8%, and it was higher in females compared to males (6.1% vs. 3.3%). According to the regression analysis, being in the overweight category was associated with a 26% lower likelihood of PPI use (p = 0.021). Low physical activity was linked to a 1.72-fold higher odds of PPI consumption (p < 0.001). Individuals with reflux, multiple underlying diseases, and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) had significantly higher odds ratios for PPI consumption (p < 0.001).

Conclusion

This study highlights the concerning trend of increasing PPI use and identifies low physical activity, reflux, multiple underlying diseases, and NSAID use associated with higher risk of PPI use. It emphasizes the need for caution in prescribing PPIs and raising awareness among both healthcare providers and patients about the potential risks and side effects.

Hepatic Rupture in HELLP Syndrome: Report of Two Patients and a Review of Peripartum Surgical Care and Transfusion

Herein, we report the cases of two patients with hemolysis, elevated liver enzymes, and low platelets syndrome who underwent emergent Cesarean sections that were complicated by massive hemorrhage due to undiagnosed hepatic rupture. Intraoperative General Surgery team intervention, early activation of massive transfusion protocol, hemostatic resuscitation, and transfer to ICU resulted in the survival of both patients.

Hemochromatosis

Hemochromatosis is an inheritable condition that mainly affects White populations of European descent. Most patients remain asymptomatic, but others develop advanced organ damage that reduces quality of life and long-term survival. Arthropathy, diabetes mellitus, cirrhosis, hypogonadotropic hypogonadism, and cardiomyopathy are key clinical manifestations. Primary care and hospital medicine physicians play an essential role in early identification of this disease, which can be accomplished via standard hematologic testing. Early diagnosis and therapeutic phlebotomy improve clinical outcomes.

The Effects of Opioid Administration on Clostridioides Difficile Infection: A Retrospective Cohort Study

Background: Clostridioides difficile (C. difficile) is a leading cause of healthcare-associated infections. Using opioids while infected with C. difficile may hypothetically lead to reduced clearance of the organism and higher risk of progressing to severe or fulminant infection. Objective: The objective of this study was to determine if opioid use leads to worsening of C. difficile infection. Methods: This was a single-center, retrospective cohort study of patients with C. difficile infection. The primary endpoint was progression to severe or fulminant disease, defined as serum creatinine greater than 1.5 mg/dL or over 50% of baseline, white blood cells above 15,000 cells/mm3, shock requiring vasopressors, ileus, toxic megacolon, or vancomycin dose increase. Secondary outcomes included hospital length of stay and time to resolution of diarrhea. The groups were stratified based on average morphine milligram equivalents received during the treatment. Results: A total of 73 patients were included in the non-opioid group and 93 patients in the opioid group. The composite outcome occurred in 16 patients (21.9%) without opioids vs 26 patients (28.0%) with opioids; (P = 0.37). The average length of stay was 7.2 days without opioids and 9.3 days with opioids (P = 0.11) and the average time to resolution of diarrhea was 3.5 days without opioids and 5.5 days with opioids (P = 0.40). Conclusion: There was no significant difference in the rate of progression to severe or fulminant disease. There was a numerical trend towards increase in progression in patients who had opioids, primarily driven by those who had higher dosages of opioids used.

Porto-Sinusoidal Vascular Disease and Downhill Varices: Separate Clinical Entities?

Introduction

Porto-sinusoidal vascular disease (PSVD) is an entity characterized by the absence of histologic liver cirrhosis and the detection of specific or non-specific histological findings, irrespective of the presence of portal hypertension (PHT). The pathogenesis remains poorly understood. Pulmonary arterial hypertension (PAH), independently of the presence of PHT, can be associated with an increase in central venous pressure, which can rarely lead to the development of downhill varices in the proximal esophagus.

Case Presentation

A 53-year-old woman, with an unremarkable medical and pharmacological history, presented with a 3-day history of melena, epigastric pain and hematemesis. Physical examination revealed bilateral peripheral edema of the legs. Laboratory findings included severe anemia, normal hepatic enzymology, and NT-proBNP 1,748 pg/mL. Endoscopy showed large proximal esophageal varices and mild hypertensive gastropathy. A complete liver disease etiology panel was negative. Ultrasound showed an irregular liver surface, splenomegaly, and dilated supra-hepatic veins and inferior vena cava. Echocardiogram revealed significant cardiac valve and cavity abnormalities, especially on the right side, as well as moderate to severe PAH. Diuretics therapy was started with clinical improvement. Beta-blockers were suspended due to intolerance. There were no images suggestive of portosystemic collateralization on angiography. Re-evaluation endoscopy showed large but reduced esophageal varices, without red spots. Cardiopulmonary hemodynamic assessment revealed moderate PAH (40 mm Hg). Liver hemodynamic study revealed non-clinically significant sinusoidal PHT. Transjugular liver biopsy revealed nodular regenerative hyperplasia suggestive of PSVD.

Discussion/Conclusion

The case was complex and presented diagnostic challenges, illustrating the uncommonly reported association between PSVD and porto-pulmonary hypertension and the importance of the transjugular liver biopsy and pressure measurements to confirm both diagnoses.

Gastrointestinal bleed mortality disparities in patients with atrial fibrillation: A cross-sectional analysis 1999-2020

Introduction

Gastrointestinal bleeding (GIB) is often encountered among patients with atrial fibrillation (AF) due to the use of anticoagulation. This study assesses disparities in GIB-related mortality among decedents with AF in the United States.

Methods

GIB mortality data in patients with AF from 1999 to 2020 was queried from the CDC database. Decedent demographic information (age, sex, race and ethnicity, and geographic residence) was obtained from death certificates. We calculated age-adjusted mortality rates (AAMRs) through the direct method and estimated the annual percentage change (APC) in mortality using log-linear regression models.

Results

From 11,209 GIB-related deaths among AF decedents, we observed an increase in AAMR from 0.12 in 1999 to 0.21 in 2020, particularly during the 2009 to 2020 period (APC +4.8, p < .001). Disproportionate mortality rates were noted in males (AAMR 0.18) and White populations (AAMR 0.15) as compared to females (AAMR 0.13) and Black populations (AAMR 0.10), respectively. Rural regions also reported higher mortality (AAMR 0.18) than urban areas (AAMR 0.14). Mortality shifts in urban regions remained stagnant from 1999 to 2009 (APC -0.15, p = .806) followed by an increase from 2009 to 2020 (APC +4.83, p < .001). However, mortality increased consistently from 1999 to 2020 in rural regions (APC +4.08, p < .001). The Northeast US exhibited the highest mortality rate (AAMR 0.18), followed by the Midwest (AAMR 0.16), West (AAMR 0.14), and South (AAMR 0.13).

Conclusions

Disparities in GIB mortality among AF decedents were identified. These findings accentuate the need for targeted interventions to mitigate GIB risks in vulnerable subgroups.

Efficacy and safety of anticoagulation in asymptomatic cirrhotic patients with portal vein thrombosis: a systematic review and meta-analysis

BACKGROUND

The role of anticoagulation in asymptomatic cirrhotic patients with portal vein thrombosis (PVT) remains unclear. This study aims to evaluate the efficacy and safety of anticoagulation in this patient population.

METHODS

We systematically searched PubMed, Web of Science, Cochrane Library, and Embase up to August 2024. The primary outcomes analyzed were PVT recanalization, progression of PVT, bleeding events, and mortality. Odds ratios (OR) with 95% confidence intervals (CI) were calculated for dichotomous variables.

RESULTS

Seventeen studies, including randomized controlled trials (RCTs) and observational studies, were included in the analysis. Compared to no intervention, anticoagulation significantly increased the PVT recanalization rate (OR = 3.89, p < .001) and decreased the PVT progression rate (OR = 0.28, p < .001) as well as overall mortality (OR = 0.66, p = .008). Importantly, anticoagulation did not significantly increase the bleeding rate (OR = 1.21, p = .41). Subgroup analysis revealed a greater benefit in PVT recanalization within the short-term treatment subgroup (≤ 6 months) compared to long-term treatment subgroup (> 6 months), and in the Asian subgroup compared to the European or United States of America (USA) subgroup. In the Warfarin subgroup, while the total bleeding rate increased significantly, there was no significant rise in major bleeding events. Additionally, a downward trend in variceal bleeding was observed in the Asian subgroup (OR = 0.44; 95% CI: 0.19-1.04; p = .06).

CONCLUSION

Anticoagulation is both safe and effective for asymptomatic cirrhotic patients with PVT. It not only treats PVT and reduces all-cause mortality, but also does so without significantly increasing the risk of bleeding events.

Hybrid Extended Totally Extraperitoneal Transversus Abdominis Release for Ruptured Incisional Hernia Etiologically Very Similar to Flood Syndrome: A Case Report

INTRODUCTION

The rupture of an umbilical hernia, which is known as Flood syndrome, is a rare and life-threatening complication of liver cirrhosis. Herein, we report the successful repair of a ruptured incisional hernia accompanied by liver cirrhosis.

CASE PRESENTATION

A female in her 40s with a history of alcoholic cirrhosis and ruptured acute umbilical hernia treated by primary closure 6 months earlier presented with ascites leakage from abdominal skin. She was diagnosed with a ruptured incisional hernia accompanied by massive ascites. We started preoperative management with topical corticosteroids and oral diuretics. Nine months after the first visit, hybrid herniorrhaphy, extended totally extraperitoneal transversus abdominis release (eTEP-TAR) was performed. The patient has since been well without any sign of recurrence for 2 years.

CONCLUSIONS

We experienced a successful treatment of a ruptured incisional hernia accompanied by liver cirrhosis. Preoperative management and surgical strategies are important for the treatment of ruptured incisional hernia and Flood syndrome.

Endoscopic hemostasis with a self-expandable metal stent as bridge therapy for hemobilia

Background and study aims

Management of hemobilia is often challenging. Recently, endoscopic hemostasis with a self-expandable metal stent (SEMS) has shown promising efficacy for controlling bleeding at the endoscopic sphincterotomy site. This study aimed to assess efficacy and feasibility of endoscopic hemostasis as bridge therapy for hemobilia.

Patients and methods

Patients with hemobilia between 2008 and 2023 were retrospectively reviewed. We compared efficacy of hemostasis between the initial endoscopic hemostasis group (ENDO group) and the initial angiographic embolization group (EMBO group). The primary outcome was initial hemostasis success rate and the secondary outcomes were delayed bleeding rate, subsequent embolization rate, 28-day mortality, transfusion amount, time to first hemostasis, total hemobilia time, and incidence of hypovolemic shock.

Results

A total of 26 patients with hemobilia were included in this study and 17 patients (65.4%) were identified as the ENDO group and nine patients (34.6%) were classified as the EMBO group. The success rate of initial hemostasis was 88.2% (15/17) in the ENDO group and 100% (9/9) in the EMBO group ( P = 0.529). The rate of delayed bleeding in the ENDO group was 17.6% (3/17) and 0.0% (0/9) in the EMBO group ( P = 0.529). Total hemobilia time was shorter in the ENDO group than in the EMBO group (mean: 281.5 ± 1022.4 minutes vs. 5002.8 ± 7982.6 minutes; P < 0.001) Stent insertion depth was associated with successful hemostasis without delayed bleeding. ( P = 0.015).

Conclusions

Endoscopic hemostasis using SEMS for hemobilia appeared to be a feasible bridge therapy.

Cost-Utility Analysis of Non-Invasive Tests to Initiate Hepatocellular Carcinoma Surveillance in Metabolic Dysfunction-Associated Steatotic Liver Disease

BACKGROUND AIMS

Non-invasive tests (NITs), e.g. Fibrosis-4 Index (FIB-4) and vibration-controlled elastography (VCTE), have been used to identify metabolic dysfunction-associated steatotic liver disease (MASLD) patients at high risks for hepatocellular carcinoma (HCC). This study investigates the cost-effectiveness of NITs to identify MASLD patients with advanced liver fibrosis and initiate HCC surveillance.

METHODS

A cost-utility analysis using a Markov model compared no use of NITs with three NIT strategies: 1) FIB-4 and VCTE (FIB-4/VCTE), 2) FIB-4 alone, and 3) VCTE alone to identify advanced liver fibrosis and initiate HCC surveillance with biannual ultrasonography with alpha-fetoprotein in 4 MASLD populations: 1) general MASLD patients, 2) MASLD patients with body mass index (BMI) >30 kg/m2, 3) MASLD patients with diabetes, and 4) MASLD patients with three metabolic traits (diabetes, hypertension and BMI >30).

RESULTS

FIB-4/VCTE was the most cost-effective approach across all groups, showing the lowest ICER, followed by FIB-4 alone and VCTE alone. In the general MASLD population, both FIB-4/VCTE and FIB-4 alone were cost-effective in the US, while only FIB-4/VCTE was cost-effective in Thailand. For MASLD patients with BMI >30, all strategies were cost-effective in the US, while only FIB-4/VCTE was cost-effective in Thailand. In MASLD patients with diabetes or 3 metabolic traits, all strategies were cost-effective in the US, while FIB-4/VCTE and FIB-4 alone were cost-effective in Thailand.

CONCLUSIONS

Using FIB-4/VCTE to initiate HCC surveillance is cost-effective for MASLD patients. If VCTE is unavailable, FIB-4 alone is a cost-effective alternative for MASLD patients with diabetes or 3 metabolic traits.

Adverse events in different administration routes of amiodarone: a pharmacovigilance study based on the FDA adverse event reporting system

Background

Arrhythmias are prevalent cardiac disorders with significant impacts on patient quality of life and mortality. Amiodarone, a class III antiarrhythmic agent, is widely used to manage both atrial and ventricular arrhythmias due to its efficacy in prolonging the cardiac action potential and its multiple antiarrhythmic properties. While clinical trials have highlighted the safety and efficacy of amiodarone, there is limited real-world data on adverse events (AEs) associated with different administration routes. This study aims to address this gap by utilizing the U.S. Food and Drug Administration's Adverse Event Reporting System (FAERS) to investigate the spectrum and timing of AEs related to amiodarone administration through disproportionality analysis and stratification methods.

Methods

Data from the FAERS database were analyzed using disproportionality analysis and reporting odds ratio (ROR) methods for comparative analysis, and the Weibull distribution for time-to-adverse-event analysis. The study examined data from 2004 through the first quarter of 2024 to analyze adverse event signals and the time of occurrence between intravenous and oral amiodarone administration.

Results

A total of 16,749 records of adverse reactions associated with amiodarone were identified. Among these, 2,412 events were related to intravenous amiodarone, and 8,220 events were related to oral amiodarone. The analysis revealed that cardiac and hepatic AEs were more common with intravenous administration, while pulmonary and thyroid-related AEs were more frequent with oral administration. Furthermore, the onset of adverse reactions varied significantly between the routes. The Weibull distribution analysis showed a median onset time of 5 days for intravenous administration compared to 74 days for oral administration. Both routes exhibited early failure-type signals, indicating a decreasing risk of AEs over time.

Conclusion

Amiodarone exhibits varying adverse drug reactions and onset times across different routes of administration. Clinicians should carefully consider these differences when selecting the administration route to balance the risks of adverse reactions with therapeutic benefits.

Evaluation of drug-drug interaction between rosuvastatin and tacrolimus and the risk of hepatic injury in rats

Multimorbidity, therapeutic complexity, and polypharmacy, which greatly increases the risk of drug-drug interactions (DDIs) and adverse medical outcomes, have become important and growing challenges in clinical practice. Statins are frequently prescribed to manage post-transplant dyslipidemia and reduce overall cardiovascular risk in solid organ transplant recipients. This study aimed to determine whether rosuvastatin has significant DDIs with tacrolimus (the first-line immunosuppressant) and to evaluate the risk of hepatotoxicity associated with concomitant therapy. We first studied whether a rat model could be established to assess the magnitude of rosuvastatin-tacrolimus DDI. The liver function index and histopathological examination were performed to investigate the characteristics of hepatotoxicity in the presence and absence of DDI. The clinical DDI potential between rosuvastatin and tacrolimus was also explored. Single-dose intravenous administration of tacrolimus did not significantly affect the area under the plasma concentration-time curve (AUC0-∞), clearance (CL), and volume of distribution at steady-state (Vss) of rosuvastatin in rats, despite a 96.7% increase in the rosuvastatin maximum plasma concentration (P = 0.024). Multiple doses of intravenous tacrolimus had no effect on the systemic disposition of rosuvastatin, but significantly increased aspartate transaminase (AST) by 42.6% (P = 0.043). Multiple doses of intravenous tacrolimus and rosuvastatin significantly altered the disposition of rosuvastatin, reducing alanine aminotransferase (ALT) and AST by 38.3% (P = 0.040) and 31.6% (P = 0.019), respectively. Histological evaluation of the liver specimens revealed patterns of drug-induced liver injury in rats. At clinically relevant doses, tacrolimus was predicted to be unable to cause pharmacokinetic interactions with rosuvastatin through basic models. The concomitant administration of tacrolimus and rosuvastatin has a minor impact on rosuvastatin pharmacokinetics; however, mild hepatotoxicity has been observed in rats.

Proton pump inhibitors and all-cause mortality risk among cancer patients

BACKGROUND

Proton pump inhibitors (PPIs) are widely used, including among cancer patients, to manage gastroesophageal reflux and other gastric acid-related disorders. Recent evidence suggests associations between long-term PPI use and higher risks for various adverse health outcomes, including greater mortality.

AIM

To investigate the association between PPI use and all-cause mortality among cancer patients by a comprehensive analysis after adjustment for various confounders and a robust methodological approach to minimize bias.

METHODS

This retrospective cohort study used data from the TriNetX research network, with electronic health records from multiple healthcare organizations. The study employed a new-user, active comparator design, which compared newly treated PPI users with non-users and newly treated histamine2 receptor antagonists (H2RA) users among adult cancer patients. Newly prescribed PPIs (esomeprazole, lansoprazole, omeprazole, pantoprazole, or rabeprazole) users were compared to non-users or newly prescribed H2RAs (cimetidine, famotidine, nizatidine, or ranitidine) users. The primary outcome was all-cause mortality. Each patient in the main group was matched to a patient in the control group using 1:1 propensity score matching to reduce confounding effects. Multivariable Cox regression models were used to estimate hazard ratios (HRs) and 95% confidence interval (CI).

RESULTS

During the follow-up period (median 5.4 ± 1.8 years for PPI users and 6.5 ± 1.0 years for non-users), PPI users demonstrated a higher all-cause mortality rate than non-users after 1 year, 2 years, and at the end of follow up (HRs: 2.34-2.72). Compared with H2RA users, PPI users demonstrated a higher rate of all-cause mortality HR: 1.51 (95%CI: 1.41-1.69). Similar results were observed across sensitivity analyses by excluding deaths from the first 9 months and 1-year post-exposure, confirming the robustness of these findings. In a sensitivity analysis, we analyzed all-cause mortality outcomes between former PPI users and individuals who have never used PPIs, providing insights into the long-term effects of past PPI use. In addition, at 1-year follow-up, the analysis revealed a significant difference in mortality rates between former PPI users and non-users (HR: 1.84; 95%CI: 1.82-1.96).

CONCLUSION

PPI use among cancer patients was associated with a higher risk of all-cause mortality compared to non-users or H2RA users. These findings emphasize the need for cautious use of PPIs in cancer patients and suggest that alternative treatments should be considered when clinically feasible. However, further studies are needed to corroborate our findings, given the significant adverse outcomes in cancer patients.

Impact of obstructive jaundice on outcomes in acute biliary pancreatitis: a retrospective study

OBJECTIVE

To examine the effects of obstructive jaundice on the outcomes of patients with acute biliary pancreatitis.

METHODS

A retrospective chart review was conducted on 332 cases of acute biliary pancreatitis admitted to Rambam Health Care Campus, Israel, from January 1st, 2018, to December 31st, 2021. Patients were categorized based on the presence or absence of obstructive jaundice. Various clinical, laboratory, and radiological parameters were analyzed, including severity prediction scores, length of stay, interventions, and complications.

RESULTS

Obstructive jaundice was observed in 136 patients, while 196 patients had no jaundice. Initial predictive scores (Ranson and Glasgow-Imrie) indicated higher severity in the jaundiced group, but this difference did not translate into significant variations in the final outcomes. Endoscopic procedures and sonography were more frequently performed in jaundiced patients, affecting the diagnosis and management. Cholecystectomy was performed sooner in the jaundiced group, leading to fewer recurrent admissions.

CONCLUSION

The outcomes of jaundiced and non-jaundiced patients with acute biliary pancreatitis were found to be similar, despite initial predictions of worse outcomes in the jaundiced population. A lower threshold for initiation of rigorous treatment, including more frequent endoscopic procedures, administration of antibiotics and early surgical intervention may facilitate these results. Further studies with a larger sample size and long-term follow-up are warranted to validate these findings.

From Pathophysiology to Practice: Evolving Pharmacological Therapies, Clinical Complications, and Pharmacogenetic Considerations in Portal Hypertension

Background: Portal hypertension is a major complication of chronic liver diseases, leading to serious issues such as esophageal variceal bleeding. The increase in portal vein pressure is driven by both an organic component and a functional component, including tonic contraction of hepatic stellate cells. These processes result in a pathological rise in intrahepatic vascular resistance, stemming from partial impairment of hepatic microcirculation, which is further exacerbated by abnormalities in extrahepatic vessels, including increased portal blood flow. Objectives: This review aims to provide a comprehensive overview of the evolving pharmacological therapies for portal hypertension, with consideration and discussion of pathophysiological mechanisms, clinical complications, and pharmacogenetic considerations, highlighting potential directions for future research. Methods: A review of recent literature was performed to evaluate current knowledge and potential therapeutic strategies in portal hypertension. Results: For over 35 years, non-selective beta-blockers have been the cornerstone therapy for portal hypertension by reducing portal vein inflow as an extrahepatic target, effectively preventing decompensation and variceal hemorrhages. However, since not all patients exhibit an adequate response to non-selective beta-blockers (NSBBs), and some may not tolerate NSBBs, alternative or adjunctive therapies that enhance the effects of NSBBs on portal pressure are being investigated in preclinical and early clinical studies. Conclusions: A better understanding of pharmacogenetic factors and pathophysiological mechanisms could lead to more individualized and effective treatments for portal hypertension. These insights highlight potential directions for future research.

Understanding immunological insights of liver transplantation: a practice for attaining operational tolerance

Liver transplantation has been at the forefront of medical research, with efforts concentrated on understanding the intricate cellular and molecular dynamics involved this complex procedure. This body of work has chronicled critical clinical advancements, identified challenges, and highlighted progressive improvements in surgical practices. These concerted efforts have significantly contributed to the evolution and enhancement of liver transplantation, elevating it to its current level of sophistication. A successful liver transplant now demands an integrated, multidisciplinary approach that includes not only expanding the donor pool from deceased to living donors but also embracing advances in surgical methods, efficiently managing post-transplant complications, and, importantly, achieving operational tolerance. The latter, operational tolerance, is a state wherein the recipient's immune system is coaxed into accepting the transplanted organ without the long-term use of immunosuppressive drugs, thereby minimizing potential side effects, and improving quality of life. Understanding the critical immune mechanisms that aim to prevent graft rejection is essential from an immunological perspective. This review aims to highlight the crucial areas of host versus graft immune responses, making a clear distinction between organs received from living and deceased donors. It examines how these immune responses, both innate and adaptive, are initiated and proposes the exploration of molecular docking sites as a strategy to curb unwanted immune reactions. Additionally, this review explores the promising potential of biomarkers in predicting graft rejection, and emphasizes the importance of achieving tolerance and the continuous quest for innovative strategies to enhance the success and longevity of liver transplants.

Carbon dioxide shapes parasite-host interactions in a human-infective nematode

Skin-penetrating nematodes infect nearly one billion people worldwide. The developmentally arrested infective larvae (iL3s) seek out hosts, invade hosts via skin penetration, and resume development inside the host in a process called activation. Activated infective larvae (iL3as) traverse the host body, ending up as parasitic adults in the small intestine. Skin-penetrating nematodes respond to many chemosensory cues, but how chemosensation contributes to host seeking and intra-host navigation-two crucial steps of the parasite-host interaction-remains poorly understood. Here, we investigate the role of carbon dioxide (CO2) in promoting host seeking and intra-host navigation in the human-infective threadworm Strongyloides stercoralis. We show that S. stercoralis exhibits life-stage-specific behavioral preferences for CO2: iL3s are repelled, non-infective larvae and adults are neutral, and iL3as are attracted. CO2 repulsion in iL3s may prime them for host seeking by stimulating dispersal from host feces, while CO2 attraction in iL3as may direct worms toward high-CO2 areas of the body, such as the lungs and intestine. We also identify sensory neurons that detect CO2; these neurons display CO2-evoked calcium activity, promote behavioral responses to CO2, and express the receptor guanylate cyclase Ss-GCY-9. Finally, we develop an approach for generating stable knockout lines in S. stercoralis and use this approach to show that Ss-gcy-9 is required for CO2-evoked behavioral responses in both iL3s and iL3as. Our results highlight chemosensory mechanisms that shape the interaction between parasitic nematodes and their human hosts and may aid in the design of novel anthelmintics that target the CO2-sensing pathway.

Microbiota-induced S100A11-RAGE axis underlies immune evasion in right-sided colon adenomas and is a therapeutic target to boost anti-PD1 efficacy

BACKGROUND

Tumourigenesis in right-sided and left-sided colons demonstrated distinct features.

OBJECTIVE

We aimed to characterise the differences between the left-sided and right-sided adenomas (ADs) representing the early stage of colonic tumourigenesis.

DESIGN

Single-cell and spatial transcriptomic datasets were analysed to reveal alterations between right-sided and left-sided colon ADs. Cells, animal experiments and clinical specimens were used to verify the results.

RESULTS

Single-cell analysis revealed that in right-sided ADs, there was a significant reduction of goblet cells, and these goblet cells were dysfunctional with attenuated mucin biosynthesis and defective antigen presentation. An impairment of the mucus barrier led to biofilm formation in crypts and subsequent bacteria invasion into right-sided ADs. The regions spatially surrounding the crypts with biofilm occupation underwent an inflammatory response by lipopolysaccharide (LPS) and an apoptosis process, as revealed by spatial transcriptomics. A distinct S100A11+ epithelial cell population in the right-sided ADs was identified, and its expression level was induced by bacterial LPS and peptidoglycan. S100A11 expression facilitated tumour growth in syngeneic immunocompetent mice with increased myeloid-derived suppressor cells (MDSC) but reduced cytotoxic CD8+ T cells. Targeting S100A11 with well-tolerated antagonists of its receptor for advanced glycation end product (RAGE) (Azeliragon) significantly impaired tumour growth and MDSC infiltration, thereby boosting the efficacy of anti-programmed cell death protein 1 therapy in colon cancer.

CONCLUSION

Our findings unravelled that dysfunctional goblet cells and consequential bacterial translocation activated the S100A11-RAGE axis in right-sided colon ADs, which recruits MDSCs to promote immune evasion. Targeting this axis by Azeliragon improves the efficacy of immunotherapy in colon cancer.

Prevalence and Risk Factors of Waterborne and Foodborne Protozoan Pathogens in Kenya: A One Health Perspective

Intestinal infections affect approximately 450 million people globally, predominantly impacting children and immunocompromised individuals in low- and middle-income countries (LMICs) due to inadequate water, sanitation, and hygiene (WASH) conditions, poverty, malnutrition, and low literacy. In Kenya, the prevalence of intestinal infections is elevated by warm tropical climates and socioeconomic factors. This scoping review evaluates the national prevalence, risk factors, and contamination sources of intestinal protozoa in Kenya, using a One Health approach to synthesize existing data from various human, animal, and environmental studies. A comprehensive literature search identified 292 studies, of which 67 met the inclusion criteria, covering the period from 1966 to 2024. The review found that most studies utilized stool microscopy, a method with limited sensitivity, and largely focused on vulnerable human populations, with minimal investigation into environmental reservoirs. Key protozoa identified included Entamoeba histolytica, Cryptosporidium, and Giardia, with transmission driven by poor WASH conditions, environmental factors, and close human-animal interactions. The findings highlight significant gaps in environmental surveillance and suggest the need for a robust, integrated One Health approach to better understand and control protozoan infections in Kenya.

Influence of Mesalazine on Ferroptosis-Related Gene Expression in In Vitro Colorectal Cancer Culture

Background/Objectives: Colorectal cancer (CRC) is one of the most common oncological disorders. Its fundamental treatments include surgery and chemotherapy, predominantly utilizing 5-fluorouracil (5-FU). Despite medical advances, CRC continues to present a high risk of recurrence, metastasis and low survival rates. Consequently, significant emphasis has been directed towards exploring novel types of cell death, particularly ferroptosis. Ferroptosis is characterized by iron imbalance and the accumulation of lipid peroxides and reactive oxygen species (ROS), leading to cellular damage and death. Thus, the discovery of safe inducers of ferroptosis, offering new hope in the struggle against CRC, remains crucial. In this study, we applied the concept of drug repositioning, selecting mesalazine (MES), a non-steroidal anti-inflammatory drug (NSAID), for investigation. Methods: The study was conducted on the colon cancer cell line DLD-1 and normal intestinal epithelial cells from the CCD 841 CoN cell line. Both cell lines were treated with MES solutions at concentrations of 10, 20, 30, 40, and 50 mM. Cytotoxicity was assessed using the MTT assay, while ferroptosis-related gene expression analysis was performed using oligonucleotide microarrays, with RT-qPCR used for validation. Results: MES effectively reduces the viability of DLD-1 cells while minimally affecting normal intestinal cells. Subsequent oligonucleotide microarray analysis revealed that MES significantly alters the expression of 56 genes associated with ferroptosis. Conclusions: Our results suggest that MES may induce ferroptosis in CRC, providing a foundation for further research in this area.

Severe symptomatic hypocalcemia due to Cyclospora cayetanensis infestation: A rare case

Introduction

Severe hypocalcemia can affect multiple systems, causing a wide variety of symptoms ranging from muscle weakness to twitching. In severe cases, it can lead to heart rhythm disturbances and seizures. A rare cause of hypocalcemia is due to malabsorption associated with prolonged gastroenteritis.

Case presentation

We present a 35-year-old female with persistent watery diarrhea of eight weeks presented with neuromuscular symptoms. Trousseau sign and Chvostek sign were positive bilaterally. Laboratory test results revealed severe hypokalemia, hypocalcemia, and anemia, with prolonged QT interval in electrocardiogram (EKG). Her stool polymerase chain reaction (PCR) revealed Cyclospora cayetanensis. Her electrolytes were appropriately replaced during her hospital stay. The patient was successfully treated with trimethoprim-sulfamethoxazole, calcium, and oral iron supplementation.

Conclusion

This case demonstrates a unique presentation of a healthy young female with symptomatic hypocalcemia resulting from malabsorption due to Cycolospora cayetanensis. This case emphasizes the importance of early diagnosis using newer techniques, such as polymerase chain reaction (PCR) for parasite DNA, which can result in appropriate diagnosis and timely treatment.

Elevated serum CA 19-9 level mimicking pancreaticobiliary carcinoma from a hepatic abscess: case report and literature review

Serum levels of the tumor marker CA 19-9 are widely utilized in the diagnosis and monitoring pancreatic and biliary malignancies. However, serum levels of CA 19-9 have also been reportedly elevated in non-malignant conditions. Here, we present the rare case of a 65-year-old woman with a history of gallbladder malignancy who was found to have a new hepatic lesion on surveillance CT with an associated elevation in CA 19-9 to 5,866 U/mL. Drainage of the lesion and treatment with antibiotics resulted in a rapid decline in CA 19-9 levels, indicating that the elevation in CA 19-9 was due to a benign hepatic lesion. We review eight similar reported cases of CA 19-9 elevations due to benign hepatic abscesses, thereby highlighting a need to interpret the tumor marker with caution.

Emergency Care for Refugee Patients at Suceava Hospital, Romania: Challenges and Insights from the First Year of the Russian-Ukrainian Conflict

BACKGROUND

The ongoing military conflict in Ukraine has had a devastating impact on children's health, exposing them to a range of illnesses. The aim of this study was to analyze the most common medical conditions among Ukrainian children since the beginning of the conflict, with a focus on identifying and understanding these problems in a wartime setting.

METHOD

To assess the health status of affected children, we collected data from 422 pediatric patients who presented to the emergency department. The analysis included reviewing medical records, documenting the nature of illness, treatments administered, and the need for hospitalization.

RESULTS

Preliminary results indicate that interstitial pneumonia, contusions, gastroenterocolitis, and traumatic brain injury were the most common conditions. Of the 422 children studied, 80% received appropriate care without hospitalization, while 20% were admitted for further evaluation.

CONCLUSIONS

Interstitial pneumonia was diagnosed in 23% of patients, highlighting the vulnerability of the respiratory system under conflict conditions. Contusions were predominant among musculoskeletal injuries, accounting for 81% of cases, and gastroenterocolitis was diagnosed in 46% of patients, reflecting the impact of poor living conditions.

'Sneaky' uninflamed oesophageal candidiasis: morphological clues and comparison with candidiasis associated with inflammation

AIMS

Candida esophagitis is usually readily identified on routine H&E-stained sections as the infection typically presents with prominent acute inflammation as a clue to search for organisms. However, in some cases, inflammation is absent, and detection of organisms relies on the observation of zones exhibiting parakeratosis with a delicate 'flaky' appearance. Our study aimed to establish a correlation between the histomorphology of oesophageal candidiasis and an associated clinical profile.

METHODS

We reviewed 53 sequential biopsy specimens from patients with Candida esophagitis collected over 1 year. Biopsies were assessed for acute inflammation, intraepithelial lymphocytosis and lymphoid aggregates. Patients' medical records were reviewed for data on age, gender, race, immune status, smoking, corticosteroid use, HIV status and organ transplantation history. Correlations between these factors and histomorphological patterns were assessed using test.

RESULTS

Of the 53 biopsies, 20 lacked acute inflammation and 33 had it. 15 biopsies showed both acute and lymphoid inflammation and 5 showed lymphocytosis only. Among 16 smokers, 6 (37%) had acute inflammation and 10 (63%) had parakeratosis. In non-smokers, 24 (71%) had acute inflammation and 10 (29%) had parakeratosis. A significant correlation was found between smoking and absence of acute neutrophilic infiltration (p=0.025), but no other clinical factor was associated with inflammatory patterns.

CONCLUSIONS

Candida esophagitis can be uninflamed with 'flaky' parakeratosis or associated with acute inflammation or lymphocytosis with or without neutrophilic infiltration. Inflammation was often absent in smokers, suggesting synergistic local immunosuppressive effect is this overall immunosuppressed population.

Detection of Eimeria oocysts in chicken feces using flotation recovery with sucrose or saturated saline solution

PURPOSE

Flotation methods are widely used to detect oocysts/cysts of protozoans and eggs of helminths, except trematodes. However, details regarding the concentration and recovery rates of these parasites are poorly understood.

METHODS

Using Eimeria tenella oocysts as a model parasite, the present study evaluated three check points: (1) the proportion of parasites that remain floating in flotation solution (sucrose or saturated saline) during centrifugation, (2) the proportion of oocysts that naturally float after addition of flotation solution after centrifugation, and (3) the rate of recovery on cover slips after completion of the flotation protocol.

RESULTS

After centrifugation in sucrose solution and saturated saline solution, 82.4% and 60.3% of oocysts floated, respectively. After addition of flotation solution after the final centrifugation step, the recovery rates for oocysts that naturally floated again for 30 min in sucrose and saturated saline were 39.2% and 38.2%, respectively. The recovery rate on cover slips as the final step after performing a commonly used flotation method was 36.4% in sucrose solution (the rate for saturated saline solution could not be assessed due to rapid crystallization).

CONCLUSION

Our results suggest that floating oocysts could have become dispersed by the addition of flotation solution, and not all of these oocysts remained floating after an additional 30 min of settling time although collection on cover slips could be effective for accurate recovery.

Novel insights into carbohydrate-to-fiber ratio and constipation: NHANES findings suggest a turning point

BACKGROUND

Constipation, a widespread global issue, prompted an investigation into the intricate relationship between dietary factors and this condition. This study delves into the association between carbohydrate-to-fiber (CF) ratio and constipation, employing data from the National Health and Nutrition Examination Survey (NHANES) and a comprehensive meta-analysis.

METHODS

Utilizing NHANES data (2005-2010) from 7752 adults, constipation was defined based on stool type (Bristol Stool Form Scale types 1 or 2). The CF ratio was calculated, revealing an L-shaped, non-linear association with constipation. A meta-analysis of 16 studies (1626 participants) confirmed a positive effect of dietary fiber on constipation, emphasizing the robustness of the findings.

RESULTS

Among participants, constipation prevalence stood at 13.98%. The CF ratio exhibited a turning point at 26.92/day, with adjusted odds ratios for constipation indicating a decrease with higher CF ratios. Meta-analysis results supported these findings, demonstrating a significant positive effect of dietary fiber on constipation.

CONCLUSION

This study illuminates a nuanced relationship between CF ratio and constipation, suggesting a critical turning point at 26.92/day. These findings underscore the importance of dietary assessment, offering valuable insights for clinicians and individuals. Further prospective research is warranted to validate the CF ratio as a robust dietary assessment tool.

ATAD2 and TWIST1 Interaction Promotes MYC Activation in Colorectal Carcinoma

ATPase family AAA domain-containing protein 2 (ATAD2) is significantly up-regulated in many cancer types and contributes to poor patient outcomes. ATAD2 exhibits a multidomain architecture comprising an N-terminal acidic domain, two AAA+ ATPase domains, a bromodomain, and a C-terminal domain. The AAA+ ATPase domain facilitates protein oligomerization and ATP binding, while the bromodomain recognizes acetylated lysine in histones and nonhistone proteins. ATAD2 involvement in cancer extends across multiple signaling pathways, such as Rb-E2F1, PI3K/AKT, and TGF-β1/Smad3, which promotes cell proliferation and cancer progression. Herein, we report that ATAD2 directly interacts with TWIST1, and both N-terminal regions of proteins mediate the interaction. Immunofluorescence experiments suggested that ATAD2 and TWIST1 primarily colocalize in the nucleus. Notably, our qPCR results revealed the functional significance of ATAD2-TWIST1 interaction by demonstrating their synergistic effect on the transcriptional activation of MYC in colorectal carcinoma cell lines. Moreover, the ChIP-qPCR result further indicates that ATAD2 and TWIST1 significantly localize in the promoter of the MYC gene. In addition, analysis of The Cancer Genome Atlas (TCGA) and Clinical Proteomic Tumor Analysis Consortium (CPTAC) data suggests a correlation between ATAD2, TWIST1, and MYC overexpression and poor survival rates in colorectal carcinoma. Lastly, the overexpression of ATAD2 and TWIST1 enhances cell proliferation, emphasizing their role in colorectal carcinoma progression through MYC activation. Together, these results suggest that ATAD2 is a crucial factor in TWIST1-dependent MYC gene activation, resulting in an active ATAD2-TWIST1-MYC axis that contributes to colon cancer cell proliferation.

Evaluation of Inflammatory Markers and Clinical Outcomes in COVID-19 Patients with Concurrent Clostridioides difficile Infection: A Comparative Cohort Analysis

BACKGROUND AND OBJECTIVES

Co-infection with Clostridioides difficile (C. difficile) in COVID-19 patients has emerged as a clinical challenge associated with increased morbidity and mortality. While both infections elicit systemic inflammation, the interplay between inflammatory markers, disease severity, and outcomes in patients with COVID-19 and concurrent C. difficile infection remains poorly characterized. This study aimed to evaluate the inflammatory status and clinical outcomes of patients hospitalized with COVID-19, with and without C. difficile co-infection, and to identify the inflammatory markers most predictive of severe disease.

METHODS

We conducted a retrospective cohort study of 200 hospitalized adults with confirmed COVID-19, of whom 92 had laboratory-confirmed C. difficile infection. Baseline demographic data, comorbidities, inflammatory markers (C-reactive protein [CRP], interleukin-6 [IL-6], ferritin, neutrophil-to-lymphocyte ratio [NLR], platelet count, albumin, and derived indices such as the CRP-to-Albumin Ratio [CAR] and Prognostic Nutritional Index [PNI]) were recorded. Clinical outcomes included ICU admission, need for mechanical ventilation, length of stay, and in-hospital mortality.

RESULTS

Patients with COVID-19 and C. difficile co-infection had significantly elevated inflammatory markers (CRP, IL-6, NLR) and higher CAR, alongside lower PNI, compared to those with COVID-19 alone (p < 0.001). Inflammatory indices correlated strongly with disease severity: elevated CAR and low PNI were associated with higher odds of ICU admission and mortality (p < 0.001). Multivariate analysis identified co-infection status, increased IL-6, and elevated CAR as independent predictors of severe outcomes.

CONCLUSIONS

C. difficile co-infection in COVID-19 patients is associated with an intensified inflammatory response and worse clinical outcomes. Among the evaluated markers, CAR and PNI emerged as robust predictors of severe disease. Timely recognition of C. difficile co-infection and use of targeted anti-inflammatory and supportive therapies may improve patient management. Future studies should expand on these findings to optimize care and guide therapeutic strategies.

Predicting the risk of gastroparesis in critically ill patients after CME using an interpretable machine learning algorithm - a 10-year multicenter retrospective study

Background

Gastroparesis following complete mesocolic excision (CME) can precipitate a cascade of severe complications, which may significantly hinder postoperative recovery and diminish the patient's quality of life. In the present study, four advanced machine learning algorithms-Extreme Gradient Boosting (XGBoost), Random Forest (RF), Support Vector Machine (SVM), and k-nearest neighbor (KNN)-were employed to develop predictive models. The clinical data of critically ill patients transferred to the intensive care unit (ICU) post-CME were meticulously analyzed to identify key risk factors associated with the development of gastroparesis.

Methods

We gathered 34 feature variables from a cohort of 1,097 colon cancer patients, including 87 individuals who developed gastroparesis post-surgery, across multiple hospitals, and applied a range of machine learning algorithms to construct the predictive model. To assess the model's generalization performance, we employed 10-fold cross-validation, while the receiver operating characteristic (ROC) curve was utilized to evaluate its discriminative capacity. Additionally, calibration curves, decision curve analysis (DCA), and external validation were integrated to provide a comprehensive evaluation of the model's clinical applicability and utility.

Results

Among the four predictive models, the XGBoost algorithm demonstrated superior performance. As indicated by the ROC curve, XGBoost achieved an area under the curve (AUC) of 0.939 in the training set and 0.876 in the validation set, reflecting exceptional predictive accuracy. Notably, in the k-fold cross-validation, the XGBoost model exhibited robust consistency across all folds, underscoring its stability. The calibration curve further revealed a favorable concordance between the predicted probabilities and the actual outcomes of the XGBoost model. Additionally, the DCA highlighted that patients receiving intervention under the XGBoost model experienced significantly greater clinical benefit.

Conclusion

The onset of postoperative gastroparesis in colon cancer patients remains an elusive challenge to entirely prevent. However, the prediction model developed in this study offers valuable assistance to clinicians in identifying key high-risk factors for gastroparesis, thereby enhancing the quality of life and survival outcomes for these patients.

Autoimmune hepatitis associated with statins: a retrospective study of pharmacovigilance databases and review of the literature

BACKGROUND

Statin-associated autoimmune hepatitis (AIH) is a rare but potentially life-threatening adverse event. Currently, no studies have investigated the associationbetween AIH and different statins.

RESEARCH DESIGN AND METHODS

This retrospective analysis of statin-associated AIH utilized the FDA Adverse Event Reporting System (FAERS) database (Q1 2004 to Q1 2024) and a systematic literature review. Disproportionality and Bayesian analyses were used to detect potential AIH signals associated with statin use.

RESULTS

Among 3,581 AIH reports in the FAERS database, 337 (9.41%) were associated with statins. Among all statins, fluvastatin exhibited the strongest signal, with a relative odds ratio (ROR) of 54.85 (95% CI: 32.32-93.10). Stratified analysis revealed stronger signals in patients ≥65 years (ROR 16.83 vs 9.45) and females (ROR 13.88 vs 9.00) compared to patients <65 years and males, respectively. Statins showed a higher risk of AIH compared to evolocumab, and a similar or lower risk when compared to ezetimibe and fenofibrate. Additionally, 30 cases reported in 20 independent studies were summarized.

CONCLUSION

This study demonstrates a significant association between AIH and the use of statins, particularly among older patients and females. Further research is needed to explore additional risk factors for statin-associated AIH.

Risk of Infection in Patients With Inflammatory Bowel Disease Treated With Interleukin-Targeting Agents: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with inflammatory bowel disease (IBD) are at increased risk of infection. The aim of this study was to assess the cumulative incidence and risk of infection in patients with IBD treated with interleukin (IL)-targeting agents.

METHODS

We searched PubMed, EMBASE, and Web of Science for randomized controlled trials including patients with IBD receiving IL-targeting agents compared with patients receiving placebo or treatment that only differed from the intervention arm in the absence of an IL-targeting agent. The primary outcome of interest was the relative risk (RR) of any-grade and severe infection during the induction phase.

RESULTS

There was no difference in risk of any-grade (RR, 0.98; 95% confidence interval [CI], 0.89-1.09) or severe (RR, 0.64; 95% CI, 0.38-1.10) infection in patients receiving any IL-targeting agent compared with the control group. During the maintenance period, the cumulative incidence of any-grade infection in patients receiving IL-12/23p40-targeting agents (mean follow-up 29 weeks) was 34.82% (95% CI, 26.78%-43.32%), while the cumulative incidence of severe infection was 3.07% (95% CI, 0.93%-6.21%). The cumulative incidence of any-grade infection in patients receiving IL-23p19-targeting agents (mean follow-up 40.9 weeks) was 32.16% (95% CI, 20.63%-44.88%), while the cumulative incidence of severe infection was 1.75% (95% CI, 0.60%-3.36%). During the maintenance phase of the included studies, the incidence of infection was 30.66% (95% CI, 22.12%-39.90%) for any-grade and 1.59% (95% CI, 0.76%-2.63%) for severe infection in patients in the control group.

CONCLUSIONS

There was no difference in risk of infection between patients with IBD who received IL-targeting agents compared with the control group. Case registries and randomized controlled trials reporting the safety of IL inhibitors should provide detailed information about the risk of specific infectious complications in patients with IBD receiving IL-targeting agents.

Prevalence of Intestinal Parasitic Infections and Associated Factors Among Food Handlers in East Africa: A Systematic Review and Meta-analysis

BACKGROUND

Intestinal parasitic infections are a significant public health concern, especially among food handlers, who can transmit these infections to the public through food preparation and handling. This systematic review and meta-analysis aimed to determine the pooled prevalence and associated factors of intestinal parasitic infections among food handlers in the East African region.

METHODS

A systematic review and meta-analysis on intestinal parasitic infections among food handlers involved a comprehensive search across various databases, including Scopus, PubMed, ScienceDirect, Google Scholar, and the institution's library registers. Forty relevant articles were identified and analyzed using STATA Software version 17.0. Sensitivity analysis, publication bias assessment with Egger's test, and the Trim-and-fill meta-analysis for bias adjustment were conducted. Heterogeneity across the studies was assessed using Cochran's Q statistic and I2 statistics, and subgroup analysis computed for significant heterogeneity (I2 value ≥ 50%). A random effect model was used to determine the pooled prevalence of intestinal parasitic infections.

RESULTS

The pooled prevalence of intestinal parasitic infections among food handlers was 32.27% (95% CI 27.90-36.65). The most prevalent parasites were Entamoeba histolytica/dispar 20.83% (95% CI 13.66-28%), Ascaris lumbricoides 13.84% (95% CI 10-17.68%), Giardia lamblia 8.55% (95% CI 6.03-11.06%), and hookworm 6.43% (95% CI 3.93-8.93%). Using a common knife for cutting raw meat (AOR = 2.27, 95% CI 1.21-4.31), food handler's untrimmed fingernails (AOR = 2.14, 95% CI 1.50-2.78), and no hand washing practices with soap after using the toilet (AOR = 2.25, 95% CI 1.33-3.18) were associated with higher rates of intestinal parasitic infections among food handlers.

CONCLUSIONS

Parasitic infections among food handlers were found to be significantly prevalent. Factors contributing to this high prevalence included food handlers' untrimmed fingernails, poor hand hygiene practices, and using a shared knife for chopping various food items, including raw meat. These findings emphasize the need for proper personal hygiene and sanitation practices among food handlers to prevent transmitting parasitic infections to consumers.

Inappropriate prescribing of drugs for peptic ulcer and gastro-esophageal reflux disease remains a matter of concern: Results from the LAPTOP-PPI cluster randomized trial

Background

Proton pump inhibitors (PPIs) are among the most commonly and inappropriately prescribed drugs by general practitioners (GPs), resulting in increased risk of adverse outcomes for patients and in avoidable costs for Italy's National Health Service (NHS). This study aims to assess the effectiveness of a low-cost and easily implementable informative intervention directed at GPs to enhance the appropriate prescription of PPIs.

Methods

The LAPTOP-PPI study is a pragmatic, cluster-randomized controlled trial designed to improve the appropriateness of PPI prescriptions among community-dwelling individuals aged ≥65 years. In June 2021, GPs in the Local Health Units (LHUs) of Bergamo (Northern Italy) and Caserta (Southern Italy) were randomly allocated to either an intervention group (summary reports on prescribing habits, scientific documents on the Italian Medicine Agency's therapeutic indications, strategies for PPI de-prescribing, along with educational materials for patients), and a control group (standard practice). PPI appropriateness was assessed through an algorithm specifically designed and based on NHS prescription appropriateness and reimbursement criteria. Intervention efficacy was evaluated by comparing data from the baseline period (July 1 to 31 December 2019) with those from the follow-up period (July 1 to 31 December 2021), 6 months after randomization. The analysis was performed on the intention-to-treat principle and according to GP level. To estimate the effectiveness of the intervention, we used a difference-in-differences (DID) approach.

Results

Overall, 942 GPs (540 from Bergamo and 402 from Caserta LHUs) were included in the analysis. At baseline, 171,978 patients aged ≥65 received drug prescriptions for acid-related diseases and were assessable for evaluation of appropriateness. At follow-up, this number was 137,699. The overall inappropriateness rate at baseline among GPs included in the analysis was 57.4% (std.dev. 8.4%) in the intervention arm and 57.6% (std.dev. 8.8%) in the control arm; 6 months after the intervention delivery, they were 59.2% (std.dev. 8.0%) and 58.5% (std.dev. 7.3%), respectively.

Conclusion

Given their widespread use, improving the prescription quality of PPIs is a major concern. Educational interventions for GPs and patients are routine strategies to address inappropriateness, but they appear to be insufficient for independently improving prescribing practice, especially in a critical situation such as the post-pandemic period.

Adverse Events Associated with Surgically Implanted Temporomandibular Joint Devices

INTRODUCTION

Temporomandibular disorder (TMD) is a common, yet potentially debilitating syndrome that negatively impacts patient quality of life. In patients with severe variants of TMD, temporomandibular joint (TMJ) devices have been utilized to replace the joint altogether. However, the risk profile and consequent cost-benefit ratio of these devices are largely debated. This report aimed to provide further insight on the safety of surgically implanted TMJ devices by analyzing adverse events from the Manufacturer and User Facility Device Experience (MAUDE) database.

METHODS

Inclusion criteria consisted of all MAUDE reports from January 2013 to January 2023 containing the keyword "TMJ." Duplicate reports, preimplantation events, reports extrapolated from published literature reviews, and those not related to TMJ implants were excluded from analysis. Adverse events were extracted, reviewed, and categorized according to complication type, management strategy, device manufacturer, causes of device malfunction, and reporting timeframe. Nonparametric χ2 and Levene's test were used to compare average values between groups with a two-tailed p value of 0.05 being considered statistically significant.

RESULTS

A total of 385 adverse event reports were reviewed. The most common complications were infection (59, 25.9%), ankylosis (57, 25.0%), and pain (33, 14.5%). The most common device failures were implant malposition (28, 39.4%), implant dislodgement (22, 31.0%), and screw osseointegration failure (11, 15.5%). Upon assessment of revision surgeries, those undertaken to address infections had the highest rate of device explantation (77%). In a separate analysis of 28 adverse events submitted directly by patients, infection was most common self-reported complication (42.9%). Comparison of device manufacturers revealed that Biomet implants had significantly more reports of pain (χ2 = 10.21, p = 0.003), whereas Stryker implants had more infections (χ2 = 29.87, p < 0.001).

CONCLUSION

In summary, this in-depth analysis of adverse events provides a safety profile of TMJ implants. Understanding the complication types, management strategies, and outcomes according to device manufacturer may help set patient expectations and improve patient care.

Colonic Dieulafoy Lesion as a Rare Cause of Lower Gastrointestinal Bleeding

Introduction

Dieulafoy lesion is one of the most under-recognized sources of gastrointestinal (GI) bleeding (GI), typically manifesting as acute upper gastrointestinal bleeding; endoscopy is usually the first diagnostic and therapeutic modality utilized to handle these lesions by employing a variety of procedures.

Case Report

This is a case of an 81-year-old female who was being assessed after experiencing repeated bouts of melena with hemoglobin drop. The patient had multiple comorbidities but no history of gastrointestinal bleeding. Esophagogastroduodenoscopy (EGD) revealed only Erythematous duodenopathy without active bleeding; the initial colonoscopy revealed a large amount of blood without identifying the source of bleeding; a second colonoscopy revealed classic Dieulafoy lesions in the splenic flexure, which were injected and clipped, and the bleeding ceased.

Conclusion

Dieulafoy lesions are most frequently found in the stomach and gastroesophageal junction, but they have also been documented in other parts of the gastrointestinal tract. In this particular instance, the lesions were identified in the colon, which is an unusual location for them, and they were treated endoscopically by clipping and injecting. In conclusion, colonic Dieulafoy lesions, although rare, have the potential to cause life-threatening bleeding and should be included in the differential diagnosis of lower gastrointestinal bleeding.

Rome Foundation and international neurogastroenterology and motility societies' consensus on idiopathic gastroparesis

To establish a consensus on the definition and management of idiopathic gastroparesis, international experts (selected by neurogastroenterology and motility societies and initiated by the Rome Foundation) devised 144 statements using the Delphi method, with at least 80% agreement required. This consensus defined idiopathic gastroparesis as the presence of symptoms associated with delayed gastric emptying in the absence of mechanical obstruction. Nausea and vomiting were identified as cardinal symptoms. Frequently co-existing symptoms are early satiation and postprandial fullness. Diagnosis requires the presence of these symptoms alongside delayed gastric emptying, measured by a 4 h scintigraphy or gastric emptying breath test of a mixed composition meal in the absence of mechanical obstruction. Therapeutic options with proven efficacy were sparse. Dietary adjustments, nutritional support (per guidelines from the European Society for Clinical Nutrition and Metabolism for substantial weight loss or intractable vomiting), and opioid cessation were recommended by a consensus opinion. Antiemetic and prokinetic agents were also considered potentially beneficial. This consensus offers a global perspective on idiopathic gastroparesis.

EUS-guided Drainage of Pancreatic Fluid Collections Using Lumen Apposing Metal Stents With or Without Coaxial Plastic Stents: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Co-axial plastic double pigtail stents (DPSs) are commonly placed through lumen apposing metal stents (LAMS) in patients with pancreatic fluid collections (PFCs) to decrease the risk of adverse events. In this meta-analysis, we have compared the outcomes of LAMS plus co-axial DPS versus LAMS alone in patients with PFCs.

METHODS

We reviewed several databases to identify the studies that compared outcomes of LAMS with DPS to LAMS without DPS in the treatment of PFCs. Our outcomes of interest were overall adverse events, clinical success and individual adverse events such as stent (LAMS) migration, stent occlusion, bleeding, and infection. We calculated pooled risk ratios (RR) with 95% confidence intervals (CIs) for the analysis of outcomes. We used a random effects model to analyze the data. Heterogeneity was assessed using the I 2 statistic.

RESULTS

We included 10 studies with 685 patients. Rate of overall adverse events was significantly lower in the LAMS+DPS group compared with LAMS alone, RR (95% CI) 0.58 (0.40, 0.87). There was no significant difference in the rate of clinical success between groups, RR (95% CI) 1.03 (0.94, 1.13). We found no significant difference in rate of stent occlusion between groups. Rate of infection was significantly lower in LAMS+DPS group, RR (95% CI) 0.46 (0.24, 0.85). There was no significant difference in rate of bleeding and stent (LAMS) migration between groups.

CONCLUSIONS

Addition of co-axial DPS to LAMS decreases the risk of adverse events in patients with PFCs and should be considered in all patients with PFCs.