Psychological, Physiological, and Physical Effects of Resistance Training and Personalized Diet in Celiac Women

Background

Gluten intolerance is a systemic process of autoimmune nature; it develops in genetically predisposed subjects with gluten ingestion. The only treatment for celiac disease (CD) is a lifelong strict gluten-free diet (GFD). This study was designed to evaluate adherence to a GFD, risk of an eating disorder, and nutritional status in adult CD patients undergoing different interventions.

Methods

A total of 28 Spanish women, aged 40 years or more, took part in a randomized controlled trial. Each group received a different intervention: group 1, gluten-free nutrition plan + exercise (GFD + E); group 2, gluten-free nutrition plan (GFD); group 3, celiac controls (NO-GFD); and group 4, non-celiac controls (CONTROL). The training was prescribed by a sport scientist. It was based on resistance training with elastic bands; beforehand a warm-up was performed and the resistance was increased progressively. The variables studied were adherence to the GFD, risk of eating disorders, blood values, and body composition.

Results

Celiac women with personalized nutritional planning presented greater adherence to a gluten-free diet (p < 0.001). Regarding leukocytes, significant differences were observed between the GFD and control groups (p = 0.004). Perimeters and folds did not decrease significantly.

Conclusion

Women with celiac disease who follow an adapted and personalized diet have a better adherence to a GFD compared to those who follow a non-professional diet, and therefore have a better immune system status (blood leukocytes).

Immunity-related GTPase IRGM at the intersection of autophagy, inflammation, and tumorigenesis

The human immunity-related GTPase M (IRGM) is a GTP-binding protein that regulates selective autophagy including xenophagy and mitophagy. IRGM impacts autophagy by (1) affecting mitochondrial fusion and fission, (2) promoting the co-assembly of ULK1 and Beclin 1, (3) enhancing Beclin 1 interacting partners (AMBRA1, ATG14L1, and UVRAG), (4) interacting with other key proteins (ATG16L1, p62, NOD2, cGAS, TLR3, and RIG-I), and (5) regulating lysosomal biogenesis. IRGM also negatively regulates NLRP3 inflammasome formation and therefore, maturation of the important pro-inflammatory cytokine IL-1β, impacting inflammation and pyroptosis. Ultimately, this affords protection against chronic inflammatory diseases. Importantly, ten IRGM polymorphisms (rs4859843, rs4859846, rs4958842, rs4958847, rs1000113, rs10051924, rs10065172, rs11747270, rs13361189, and rs72553867) have been associated with human inflammatory disorders including cancer, which suggests that these genetic variants are functionally relevant to the autophagic and inflammatory responses. The current review contextualizes IRGM, its modulation of autophagy, and inflammation, and emphasizes the role of IRGM as a cross point of immunity and tumorigenesis.

Association of inferior vena cava diameter ratio with outcomes in patients with gastrointestinal bleeding

Objective

To examine the association of inferior vena cava (IVC) diameter ratio measured using computed tomography with outcomes in patients with gastrointestinal bleeding (GIB).

Methods

A single-center retrospective observational study was conducted on consecutive patients with GIB who presented to the emergency department. The IVC diameter ratio was calculated by dividing the maximum transverse and anteroposterior diameters perpendicular to it. The association of the IVC diameter ratio with outcomes was examined using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. The area under the receiver operator characteristic curve (AUC) of the IVC diameter ratio was calculated, and the sensitivity and specificity, including the cutoff values, were computed.

Results

In total, 585 patients were included in the final analysis. The in-hospital mortality rate was 4.6% (n=27). The IVC diameter ratio was significantly associated with higher in-hospital mortality in multivariable logistic regression analysis (odds ratio, 1.793; 95% confidence interval [CI], 1.239–2.597; P=0.002). The AUC of the IVC diameter ratio for in-hospital mortality was 0.616 (95% CI, 0.498–0.735). With a cutoff of the IVC diameter ratio (≥2.1), the sensitivity and specificity for predicting in-hospital mortality were 44% (95% CI, 26%–65%) and 71% (95% CI, 67%–75%), respectively.

Conclusion

The IVC diameter ratio was independently associated with in-hospital mortality in patients with GIB. However, the AUC of the IVC diameter ratio for in-hospital mortality was low.

Radiomics analysis of contrast-enhanced CT for staging liver fibrosis: an update for image biomarker

BACKGROUND

To establish and validate a radiomics-based model for staging liver fibrosis at contrast-enhanced CT images.

MATERIALS AND METHODS

This retrospective study developed two radiomics-based models (R-score: radiomics signature; R-fibrosis: integrate radiomic and serum variables) in a training cohort of 332 patients (median age, 59 years; interquartile range, 51-67 years; 256 men) with biopsy-proven liver fibrosis who underwent contrast-enhanced CT between January 2017 and December 2020. Radiomic features were extracted from non-contrast, arterial and portal phase CT images and selected using the least absolute shrinkage and selection operator (LASSO) logistic regression to differentiate stage F3-F4 from stage F0-F2. Optimal cutoffs to diagnose significant fibrosis (stage F2-F4), advanced fibrosis (stage F3-F4) and cirrhosis (stage F4) were determined by receiver operating characteristic curve analysis. Diagnostic performance was evaluated by area under the curve, Obuchowski index, calibrations and decision curve analysis. An internal validation was conducted in 111 randomly assigned patients (median age, 58 years; interquartile range, 49-66 years; 89 men).

RESULTS

In the validation cohort, R-score and R-fibrosis (Obuchowski index, 0.843 and 0.846, respectively) significantly outperformed aspartate transaminase-to-platelet ratio (APRI) (Obuchowski index, 0.651; p < .001) and fibrosis-4 index (FIB-4) (Obuchowski index, 0.676; p < .001) for staging liver fibrosis. Using the cutoffs, R-fibrosis and R-score had a sensitivity range of 70-87%, specificity range of 71-97%, and accuracy range of 82-86% in diagnosing significant fibrosis, advanced fibrosis and cirrhosis.

CONCLUSION

Radiomic analysis of contrast-enhanced CT images can reach great diagnostic performance of liver fibrosis.

Quality of Life in Teenagers and Adults With Coeliac Disease: From Newly Spanish Coeliac Disease Questionnaire Validation to Assessment in a Population-Based Study

Background

Coeliac disease (CD) is an immune-mediated systemic disorder elicited by the ingestion of gluten in genetically predisposed individuals. Gluten restriction in CD sufferers leads to numerous limitations in various aspects of daily life and can significantly impact the quality-of-life (QoL). The specific and widely used Coeliac Disease Questionnaire (CDQ) is an excellent tool to evaluate QoL in patients with CD, assessing physical, psychological, and social domains. This questionnaire is unavailable in Spain. Therefore, our study is the first to translate, culturally adapt, validate, and apply the Spanish version of CDQ to a representative sample of Spanish teenagers and adults with CD.

Methods

A total of 153 CD participants with biopsy-proven and self-reported gluten-free adherence were included in the cross-sectional study, which included four stages: (1) translation and retranslation of the French CDQ version into Spanish; (2) cultural adaptation and semantic evaluation; (3) CDQ validation through the internal consistency determination and reproducibility of the QoL; and (4) application of the questionnaire to Spanish teenagers and adults with CD and estimation of QoL using EQ-5D.

Results

The internal consistency and test–retest reliability of the Spanish CDQ were satisfactory and no ceiling or floor effects were detected. Significant correlations were identified between the CDQ scales, and the instrument for validation covering similar dimensions of the QoL was identified. The mean CDQ total score was 131.03 ± 24.1, and the social domain had the highest rating. There was no correlation between the time spent on a gluten-free diet and QoL. A significantly higher QoL score was reported among males and adolescents in the 15–17 age groups.

Conclusion

The newly Spanish CDQ is an appropriate tool to assess the QoL of the teenager and adult patients with CD. This study highlights the importance of identifying the affected scales to address actions to reduce the impact of the gluten-free diet burden of the coeliac patients and maintain public health regulations that support patients with chronic diseases such as CD.

Management of Acute Lower Gastrointestinal Bleeding: A Survey to Assess Adherence to Guidelines Across the United Kingdom and Ireland

Introduction: Acute gastrointestinal bleeding (GIB) is a common surgical problem requiring hospitalization in the United Kingdom (UK) and Ireland. The first UK lower gastrointestinal bleeding (LGIB) management guidelines were published in 2019 by the British Society of Gastroenterology (BSG). We aimed to evaluate self-reported adherence to BSG clinical guidance (CG) within the UK and Ireland.

Methods and materials: A Questionnaire was designed based on LGIB BSG CG 2019 using Google Forms (Google LLC, Mountain View, CA). This was distributed to surgical consultants and senior surgical practitioners (specialists, Trust grade registrars, and specialist registrars) across different centers in the UK and Ireland over four weeks (13th March to 5th April 2021). Data were analyzed using Statistical Package for Social Sciences (SPSS) version 27 (IBM Corp., Armonk, NY, USA).

Results: A total of 64 responses were recorded from 18 different centers in the UK and Ireland. The ratio of consultants and registrars was almost the same (34:30, 53.1%:46.9%). The majority of respondents were from colorectal surgery (65.6%, n=42) followed by general surgeons (23.4%, n=15). A total of 41 respondents (64.1%) admitted that BSG CG 2019 were practically applicable at their center. Approximately 75% of respondents did not use or were unaware of the Shock index or Oakland score to stratify patients. That translated into 59% opting to admit patients with a minor bleed. Around 36% wanted to perform a CT angiogram for a stable major bleed, while 37% were unaware of the interventional radiology (IR) referral pathway.

Conclusion: There is patchy adherence to the guidelines leading to significant variations in LGIB management practice and avoidable admissions.

Influence of Gluten-Free Diet on Gut Microbiota Composition in Patients with Coeliac Disease: A Systematic Review

The aim of this study was to assess the changes in microbiota composition during a gluten-free diet (GFD) in coeliac disease (CD) patients. The systematic search followed databases such as PUBMED (MEDLINE), SCOPUS, WEB OF SCIENCE and EMBASE. Out of 843 initially screened papers, a total number of 13 research papers were included. A total of 212 patients with CD on GFD, in comparison to 174 healthy individuals and 176 untreated patients with CD, were examined. Analysis of the microbial community based primarily on faecal samples and duodenal biopsies. Bifidobacterium was noticed to be less abundant in the study group than in both control groups, while the abundance of Bacteroides was more numerous in the group of CD patients on GFD. Staphylococcaceae prevailed in untreated CD patients. Despite the fact that the GFD was not able to fully restore commensal microorganism abundance, the treatment was associated with the greater abundance of selected beneficial bacteria and lower presence of pathogenic bacteria associated with worsening of CD symptoms.

Tourette syndrome research highlights from 2020

We present here research from 2020 relevant to Tourette syndrome (TS). The authors briefly summarize a few reports they consider most important or interesting.

Comparison of Risk Scores for Lower Gastrointestinal Bleeding: A Systematic Review and Meta-analysis

IMPORTANCE

Clinical prediction models, or risk scores, can be used to risk stratify patients with lower gastrointestinal bleeding (LGIB), although the most discriminative score is unknown.

OBJECTIVE

To identify all LGIB risk scores available and compare their prognostic performance.

DATA SOURCES

A systematic search of Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from January 1, 1990, through August 31, 2021, was conducted. Non-English-language articles were excluded.

STUDY SELECTION

Observational and interventional studies deriving or validating an LGIB risk score for the prediction of a clinical outcome were included. Studies including patients younger than 16 years or limited to a specific patient population or a specific cause of bleeding were excluded. Two investigators independently screened the studies, and disagreements were resolved by consensus.

DATA EXTRACTION AND SYNTHESIS

Data were abstracted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guideline independently by 2 investigators and pooled using random-effects models.

MAIN OUTCOMES AND MEASURES

Summary diagnostic performance measures (sensitivity, specificity, and area under the receiver operating characteristic curve [AUROC]) determined a priori were calculated for each risk score and outcome combination.

RESULTS

A total of 3268 citations were identified, of which 9 studies encompassing 12 independent cohorts and 4 risk scores (Oakland, Strate, NOBLADS [nonsteroidal anti-inflammatory drug use, no diarrhea, no abdominal tenderness, blood pressure ≤100 mm Hg, antiplatelet drug use (nonaspirin), albumin <3.0 g/dL, disease score ≥2 (according to the Charlson Comorbidity Index), and syncope], and BLEED [ongoing bleeding, low systolic blood pressure, elevated prothrombin time, erratic mental status, and unstable comorbid disease]) were included in the meta-analysis. For the prediction of safe discharge, the AUROC for the Oakland score was 0.86 (95% CI, 0.82-0.88). For major bleeding, the AUROC was 0.93 (95% CI, 0.90-0.95) for the Oakland score, 0.73 (95% CI, 0.69-0.77) for the Strate score, 0.58 (95% CI, 0.53-0.62) for the NOBLADS score, and 0.65 (95% CI, 0.61-0.69) for the BLEED score. For transfusion, the AUROC was 0.99 (95% CI, 0.98-1.00) for the Oakland score and 0.88 (95% CI, 0.85-0.90) for the NOBLADS score. For hemostasis, the AUROC was 0.36 (95% CI, 0.32-0.40) for the Oakland score, 0.82 (95% CI, 0.79-0.85) for the Strate score, and 0.24 (95% CI, 0.20-0.28) for the NOBLADS score.

CONCLUSIONS AND RELEVANCE

The Oakland score was the most discriminative LGIB risk score for predicting safe discharge, major bleeding, and need for transfusion, whereas the Strate score was best for predicting need for hemostasis. This study suggests that these scores can be used to predict outcomes from LGIB and guide clinical care accordingly.

Corticosteroid plus glycyrrhizin therapy for chronic drug- or herb-induced liver injury achieves biochemical and histological improvements: a randomised open-label trial

BACKGROUND

Treatment of chronic drug-induced liver injury (DILI) or herb-induced liver injury(HILI) is an important and unresolved challenge. There is no consensus regarding the indications for corticosteroids for chronic DILI/HILI.

AIMS

To investigate the efficacy and safety of corticosteroid plus glycyrrhizin for patients with chronic DILI/HILI.

METHODS

This was a randomised open-label trial. Eligible patients with causality assessment using the updated RUCAM were randomly assigned (1:1) either to the steroid treatment group (48-week stepwise dose reduction of methylprednisolone plus glycyrrhizin) or control group (glycyrrhizin alone). Liver biopsies were performed at baseline and at the end of the 48-week treatment period. The primary outcome was the proportion of patients with sustained biochemical response (SBR). The secondary outcomes were improvement in liver histology, time to biochemical normalisation and safety.

RESULTS

Of 80 participants, 70 (87.5%) completed the trial. The patients were predominantly female (77.5%), aged >40 years (77.5%) and had a hepatocellular injury pattern of DILI (71.2%). Compared to the control group, the treatment group showed a higher proportion of SBR (94.3% vs. 71.4%, p = 0.023), shorter biochemical normalisation time and histological improvements in both histological activity and fibrosis. The DILI and HILI subgroups, as well as the autoimmune hepatitis (AIH)-like DILI and non-AIH-like subgroups, showed comparable responses. No severe adverse events were observed during the trial.

CONCLUSION

This study provides the first clinical evidence that corticosteroid plus glycyrrhizin therapy for chronic DILI with or without AIH-like features can achieve both biochemical response and histological improvements with good safety. (ClinicalTrials.gov, NCT02651350).

V Spanish Consensus Conference on Helicobacter pylori infection treatment

Helicobacter pylori infection is very common in the Spanish population and represents the main cause of chronic gastritis, peptic ulcer, and gastric cancer. The last iteration of Spanish consensus guidelines on H. pylori infection was conducted in 2016. Recent changes in therapeutic schemes along with increasing supporting evidence were key for developing the V Spanish Consensus Conference (May 2021). Fourteen experts performed a systematic review of the scientific evidence and developed a series of recommendations that were subjected to an anonymous Delphi process of iterative voting. Scientific evidence and the strength of the recommendation were classified using GRADE guidelines. An eradication therapy, when prescribed empirically, is considered acceptable when it reliably achieves, or preferably surpass, 90% cure rates. Currently, only quadruple therapies (with or without bismuth) and generally lasting 14 days, accomplish this goal in first- and second-line therapies. A non-bismuth quadruple concomitant regimen (proton pump inhibitor, clarithromycin, amoxicillin, and metronidazole) or a quadruple bismuth-based combination (proton pump inhibitor, bismuth, tetracycline, and metronidazole), are recommended as first-line regimens. Rescue therapies after eradication failure and management of H. pylori infection in peptic ulcer disease were also reviewed.

Centella asiatica extract protects against cisplatin-induced hepatotoxicity via targeting oxidative stress, inflammation, and apoptosis

This study was designed to investigate the protective effects of Centella asiatica (CA) on cisplatin-induced hepatotoxicity and to clarify the underlying mechanism by biochemical, molecular, immunohistochemical, and histopathological analyses. Rats were pre-treated with two doses of CA (100 and 200 mg/kg, p.o.) for 14 consecutive days. Then, on the 15th day, hepatotoxicity was induced by a single cisplatin injection (10 mg/kg i.p.). On the 18th day, the rats were euthanized. CA effectively alleviated cisplatin-induced hepatic injury via reduction in AST, ALT, and ALP enzymes and a decrease in oxidative stress (decreased MDA and ROS, and increased SOD, CAT, and GSH). CA also mitigated the inflammatory damage by the inhibition of TNF-α, IL-1β, and NF-κB. The liver expression of caspase-3 and Bax was downregulated, while Bcl-2 was upregulated. Moreover, immunohistochemical results confirmed the recovery with CA by downregulation of iNOS and 8-OHdG expression. These results showed that with its antioxidant, anti-inflammatory, and anti-apoptotic activities, CA could help alleviate the hepatotoxic effects of cisplatin chemotherapy.

Biomarkers for the diagnosis and monitoring of celiac disease: can you count on me?

PURPOSE OF REVIEW

Different markers are available to diagnose and monitor celiac disease (CeD); however, the concordance among them and their efficacy are still controversial. We aim at defining the efficacy of CeD biomarkers, their advantages and limits.

RECENT FINDINGS

CeD diagnostic criteria are widely accepted, being a positive serology and duodenal atrophy (according to the Marsh-Oberhuber score) the main hallmarks. Flow cytometry and other molecular biomarkers support the diagnosis of refractory CeD. On the other side, CeD monitoring is less defined, as the biomarkers are not always reliable. To date, the reference standard to detect mucosal healing is represented by duodenal histology, but its timing and significance are debated. Novel scores may better define the trend of mucosal damage and MicroRNAs are among the innovative noninvasive biomarkers. The assessment of a correct gluten-free diet (GFD) is another aspect of CeD monitoring, based upon questionnaires and recently developed tools such as dosage of urinary or faecal gluten immunogenic peptides.

SUMMARY

Clinicians lack of a widely acknowledged tools to monitor CeD and GFD. Here, we present the efficacy of the most used markers.

The global burden of coeliac disease: opportunities and challenges

Coeliac disease is a systemic disorder characterized by immune-mediated enteropathy, which is caused by gluten ingestion in genetically susceptible individuals. The clinical presentation of coeliac disease is highly variable and ranges from malabsorption through solely extra-intestinal manifestations to asymptomatic. As a result, the majority of patients with coeliac disease remain undiagnosed, misdiagnosed or experience a substantial delay in diagnosis. Coeliac disease is diagnosed by a combination of serological findings of disease-related antibodies and histological evidence of villous abnormalities in duodenal biopsy samples. However, variability in histological grading and in the diagnostic performance of some commercially available serological tests remains unacceptably high and confirmatory assays are not readily available in many parts of the world. Currently, the only effective treatment for coeliac disease is a lifelong, strict, gluten-free diet. However, many barriers impede patients' adherence to this diet, including lack of widespread availability, high cost, cross-contamination and its overall restrictive nature. Routine follow-up is necessary to ensure adherence to a gluten-free diet but considerable variation is evident in follow-up protocols and the optimal disease management strategy is not clear. However, these challenges in the diagnosis and management of coeliac disease suggest opportunities for future research.

Endoscopic clipping in non-variceal upper gastrointestinal bleeding treatment

Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions.

Drug monitoring in systemic lupus erythematosus

Therapeutic drug monitoring (TDM) is not yet accepted by systemic lupus erythematosus (SLE) treatment guidelines. Studies in SLE, however, have proven benefit in three areas: identification of non-adherence or poor adherence; targets for clinical benefit; and ranges of toxicity. This review covers the data on three medications commonly used for SLE, drawing on studies from both the SLE and non-SLE literature.

AGA Clinical Practice Update on De-Prescribing of Proton Pump Inhibitors: Expert Review

DESCRIPTION

Proton pump inhibitors (PPIs) are among the most commonly used medications in the world. Developed for the treatment and prevention of acid-mediated upper gastrointestinal conditions, these agents are being used increasingly for indications where their benefits are less certain. PPI overprescription imposes an economic cost and contributes to polypharmacy. In addition, PPI use has been increasingly linked to a number of adverse events (PPI-associated adverse events [PAAEs]). Therefore, de-prescribing of PPIs is an important strategy to lower pill burden while reducing real costs and theoretical risks. The purpose of this clinical update was to provide Best Practice Advice (BPA) statements about how to approach PPI de-prescribing in ambulatory patients.

METHODS

Our guiding principle was that, although PPIs are generally safe, patients should not use any medication when there is not a reasonable expectation of benefit based on scientific evidence or prior treatment response. Prescribers are responsible for determining whether PPI use is absolutely or conditionally indicated and, when uncertainty exists, to incorporate patient perspectives into PPI decision making. We collaboratively outlined a high-level "process map" of the conceptual approach to de-prescribing PPIs in a clinical setting. We identified the following 3 key domains that required BPA guidance: documentation of PPI indication; identifying suitable candidates for consideration of de-prescribing; and optimizing successful de-prescribing. Co-authors drafted 1 or more potential BPAs, supported by literature review, for each domain. All co-authors reviewed, edited, and selected or rejected draft BPAs for inclusion in the final list submitted to the American Gastroenterological Association Governing Board. Because this was not a systematic review, we did not carry out a formal rating of the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: All patients taking a PPI should have a regular review of the ongoing indications for use and documentation of that indication. This review should be the responsibility of the patient's primary care provider. BEST PRACTICE ADVICE 2: All patients without a definitive indication for chronic PPI should be considered for trial of de-prescribing. BEST PRACTICE ADVICE 3: Most patients with an indication for chronic PPI use who take twice-daily dosing should be considered for step down to once-daily PPI. BEST PRACTICE ADVICE 4: Patients with complicated gastroesophageal reflux disease, such as those with a history of severe erosive esophagitis, esophageal ulcer, or peptic stricture, should generally not be considered for PPI discontinuation. BEST PRACTICE ADVICE 5: Patients with known Barrett's esophagus, eosinophilic esophagitis, or idiopathic pulmonary fibrosis should generally not be considered for a trial of de-prescribing. BEST PRACTICE ADVICE 6: PPI users should be assessed for upper gastrointestinal bleeding risk using an evidence-based strategy before de-prescribing. BEST PRACTICE ADVICE 7: Patients at high risk for upper gastrointestinal bleeding should not be considered for PPI de-prescribing. BEST PRACTICE ADVICE 8: Patients who discontinue long-term PPI therapy should be advised that they may develop transient upper gastrointestinal symptoms due to rebound acid hypersecretion. BEST PRACTICE ADVICE 9: When de-prescribing PPIs, either dose tapering or abrupt discontinuation can be considered. BEST PRACTICE ADVICE 10: The decision to discontinue PPIs should be based solely on the lack of an indication for PPI use, and not because of concern for PAAEs. The presence of a PAAE or a history of a PAAE in a current PPI user is not an independent indication for PPI withdrawal. Similarly, the presence of underlying risk factors for the development of an adverse event associated with PPI use should also not be an independent indication for PPI withdrawal.

Evaluation of the visibility of bleeding points using red dichromatic imaging in endoscopic hemostasis for acute GI bleeding (with video)

BACKGROUND AND AIMS

We aimed to clarify whether red dichromatic imaging (RDI), a new type of image-enhanced endoscopy, improves the visibility of bleeding points in acute GI bleeding (AGIB) compared with white-light imaging (WLI).

METHODS

Images and videos of bleeding points acquired with WLI and RDI during endoscopic hemostasis for AGIB were retrospectively compared. In images, the color difference between bleeding points and surrounding blood was analyzed. In videos, 4 expert and 4 trainee endoscopists evaluated the visibility on a scale of 1 (undetectable) to 4 (easily detectable). Furthermore, the correlation between the color difference and visibility score was evaluated.

RESULTS

We analyzed 64 lesions. The color difference was significantly higher in RDI (13.11 ± 4.02) than in WLI (7.38 ± 3.68, P < .001). The mean visibility score for all endoscopists was significantly higher in RDI (3.12 ± .51) compared with WLI (2.72 ± .50, P < .001); this was also observed in experts (3.18 ± .51 vs 2.79 ± .54, P < .001) and trainees (3.05 ± .54 vs 2.64 ± .47, P < .001). The color difference and visibility score were moderately correlated for all endoscopists (γ = .56, P < .001) and for experts (γ = .53, P < .001) and trainees (γ = .57, P < .001).

CONCLUSIONS

RDI improves the visibility of bleeding points in AGIB compared with WLI. RDI can help endoscopists at all levels of experience to recognize bleeding points by enhancing the color contrast relative to surrounding blood.

An Assessment of Naturopathic Treatments, Health Concerns, and Common Comorbid Conditions in Fibromyalgia Patients: A Retrospective Medical Record Review

Background: Fibromyalgia (FM) is characterized by chronic pain, with allodynia and hyperalgesia being the most common signs. Many patients with FM explore, express interest, and use complementary and alternative medicine to help manage symptoms and improve quality of life. However, little is known about the clinical recommendations provided by naturopathic doctors (NDs). Objective: To describe trends in assessment and treatment of patients with FM by NDs. Methods: Retrospectively, medical records of 200 patients with the FM ICD-10 code were reviewed from the Robert Schad Naturopathic Clinic. Of these records, 70 met inclusion criteria and were further analyzed. Comorbid conditions, health concerns, physical and psychological examinations, and treatment were recorded. Patients were excluded if informed consent for research was not signed. The project was approved by the Research Ethics Board of the Canadian College of Naturopathic Medicine. Results: Seventy patients met criteria and were included in the current analysis. Most patients identified as female (96%). Vitamin D (57%), magnesium (54%), omega-3 fish oil (53%), acupuncture by an acupuncturist (53%) or an ND (40%), B12 orally or by injection (40%), and probiotics (40%) were highly utilized treatments. A past/current medical history of digestive complaints (64%) and depression/mental illness (63%) were common comorbidities, alongside a history of arthritic conditions (53%) and anxiety (43%). A family history of arthritic conditions (47%) was also prevalent. The Widespread Pain Index and Symptom Severity tool (43%) was used to assess pain and other symptoms. No adverse effects of treatment were readily identifiable. Conclusion: Findings from this study reveal elements of both consistency and variability in the treatment recommendations from NDs in a teaching clinic environment. Future research that assesses or compares treatment recommendations for FM in other settings may be informative to better understand health services, the nature of individualized care, and patient experiences.

Long-term functional outcomes and mortality after hospitalization for extracranial hemorrhage

BACKGROUND

The effects of extracranial hemorrhage (ECH), or bleeding outside the brain, are often considered transient. Yet, there are few data on the long-term and functional consequences of ECH.

OBJECTIVE

Define the association of ECH hospitalization with functional independence and survival in a nationally representative cohort of older adults.

DESIGN

Longitudinal cohort study.

SETTINGS AND PARTICIPANTS

Data from the Health and Retirement Study from 1995 to 2016, a nationally representative, biennial survey of older adults. Adults aged 66 and above with Medicare linkage and at least 12 months of continuous Medicare Part A and B enrollment.

INTERVENTION

Hospitalization for ECH.

MAIN OUTCOMES AND MEASURES

Adjusted odds ratios and predicted likelihood of independence in all activities of daily living (ADLs), independence in all instrumental activities of daily living (IADLs) and extended nursing home stay. Adjusted hazard ratio and predicted likelihood for survival.

RESULTS

In a cohort of 6719 subjects (mean age 77, 59% women) with average follow-up time of 8.3 years (55,767 person-years), 736 (11%) were hospitalized for ECH. ECH was associated with a 15% increase in ADL disability, 15% increase in IADL disability, 8% increase in nursing home stays, and 4% increase in mortality. After ECH, subjects became disabled and died at the same annual rate as pre-ECH but never recovered to pre-ECH levels of function. In conclusion, hospitalization for ECH was associated with significant and durable declines in independence and survival. Clinical and research efforts should incorporate the long-term harms of ECH into decision-making and strategies to mitigate these effects.

Effects of a gluten challenge in patients with irritable bowel syndrome: a randomized single-blind controlled clinical trial

Non-celiac gluten sensitivity (NCGS) and irritable bowel syndrome (IBS) frequently overlap. Although, gluten-free diet (GFD) and low fermentable oligosaccharides, disaccharides, monosaccharides and polyols (FODMAP) improve the IBS clinical picture, many aspects remain unclear. Therefore, we designed a study to evaluate gluten tolerance, anxiety and quality of life in a specific study population. Fifty IBS patients were asked to follow a low FODMAP strict GFD for 6 weeks and were then randomly allocated to the following groups for a further 6 weeks: (A) receiving 8 g/day of gluten for 2 weeks; gluten-tolerating subjects received 16 g/day for 2 weeks and then 32 g/day for a further 2 weeks; (B) continuing to follow a low FODMAP strict GFD; and (C) receiving a gluten-containing diet. After the first 6 weeks, symptom scores significantly improved. Pain severity, bloating and total score were significantly decreased in the GFD and in the high-gluten groups, while the satiety score significantly increased in group C. Between-group analysis revealed significant differences for pain severity (p = 0.02), pain frequency (p = 0.04) and impact on community function (p = 0.02) at the end of the study. Our findings suggest that low FODMAP strict GFD could be prescribed in IBS patients and would reduce anxiety and improve the quality of life.

Cytotoxicity of Thiopurine Drugs in Patients with Inflammatory Bowel Disease

The effectiveness of thiopurine drugs in inflammatory bowel disease (IBD) was confirmed more than a half-century ago. It was proven that these can be essential immunomodulatory medications. Since then, they have been used routinely to maintain remission of Crohn’s disease (CD) and ulcerative colitis (UC). The cytotoxic properties of thiopurines and the numerous adverse effects of the treatment are controversial. However, the research subject of their pharmacology, therapy monitoring, and the search for predictive markers are still very relevant. In this article, we provide an overview of the current knowledge and findings in the field of thiopurines in IBD, focusing on the aspect of their cytotoxicity. Due to thiopurines’ benefits in IBD therapy, it is expected that they will still constitute an essential part of the CD and UC treatment algorithm. More studies are still required on the modulation of the action of thiopurines in combination therapy and their interaction with the gut microbiota.

Gluten-free diet adherence and implications for the diagnosis of coeliac disease

Coeliac disease (CD) is an autoimmune disorder caused by the ingestion of gluten containing foods in genetically susceptible individuals, with a worldwide prevalence of up to 1%. Currently, the only available treatment is a gluten-free diet (GFD). Screening for CD is primarily performed using serum based testing for anti-tissue transglutaminase (tTG) antibodies. Patients must be on a gluten containing diet at the time of testing to ensure an accurate serological result. We investigated the prevalence of a GFD in hospital clinic settings and the general population using survey data to estimate the proportion of CD patients that may be misdiagnosed for CD based on serological tests. Data were collected at clinics of a metropolitan hospital in Sydney, Australia, and the general population. Data from Medicare Benefits Scheme and tTG results from a large Australian private laboratory were reviewed for comparison. Of 778 participants who responded to the survey, 58 (7.5%) were on a GFD. More patients attending the immunology (15.9%) and gastroenterology (12.1%) clinics adopted a GFD than those attending the diabetes (2.6%) or endocrinology (6.1%) clinics, or in the general population (4.3%). More females than males excluded gluten from their diet (p<0.0001). Medicare statistics between 2013 and 2019 demonstrated an increase in CD serological testing; however, tTG data from a private pathology highlighted a stable level of elevated tTG antibodies of 3% of total tests performed. The high number of individuals on a GFD is likely impacting the ability to accurately diagnose CD using serum-based testing.

Mitochondria as the Target of Hepatotoxicity and Drug-Induced Liver Injury: Molecular Mechanisms and Detection Methods

One of the major mechanisms of drug-induced liver injury includes mitochondrial perturbation and dysfunction. This is not a surprise, given that mitochondria are essential organelles in most cells, which are responsible for energy homeostasis and the regulation of cellular metabolism. Drug-induced mitochondrial dysfunction can be influenced by various factors and conditions, such as genetic predisposition, the presence of metabolic disorders and obesity, viral infections, as well as drugs. Despite the fact that many methods have been developed for studying mitochondrial function, there is still a need for advanced and integrative models and approaches more closely resembling liver physiology, which would take into account predisposing factors. This could reduce the costs of drug development by the early prediction of potential mitochondrial toxicity during pre-clinical tests and, especially, prevent serious complications observed in clinical settings.

Compliance with Gluten Free Diet Is Associated with Better Quality of Life in Celiac Disease

The quality of life (QOL) of patients with celiac disease (CD) can be altered by both symptoms of the disease and by the restrictions of the gluten-free diet (GFD). The objective was to determine the factors associated with better QOL in a large cohort of CD patients. A link to an online survey was sent to the members of the French Association of Gluten Intolerant People (AFDIAG). The French-Celiac Disease Questionnaire (F-CDQ), scoring from 0 to 100, was used to measure the QOL. Other data collected were sociodemographic characteristics, information on CD, purchasing and consumption habits of gluten-free products, and a self-assessment scale (ranging from 0 to 10) to determine the compliance with the GFD. Among the 907 CD patients who returned the questionnaire, 787 were analyzed (638 women (81%); median age: 49 years; 71% with self-assessed GFD compliance > 8). Their median F-CDQ was 73 (range: 59−82). In multivariate analysis, the main factors associated with a better quality of life were the long duration of the GFD, good compliance with the GFD, and the number of follow-up visits. Compliance with and duration of the GFD are associated with a better quality of life in patients with CD. Taking this into consideration would offset its restrictive aspect and improve its adherence.

Drug-induced liver injury: Pathogenesis, epidemiology, clinical features, and practical management

Drug-induced liver injury (DILI) is an important but rare adverse event which can range from mild liver enzyme elevations to liver failure, transplantation or death. A large proportion of commonly used medications, in addition to herbal and dietary supplements, can cause liver injury. DILI has been categorized as direct or idiosyncratic but indirect liver injury has emerged as a third type of drug-induced liver injury. These types of liver injury may warrant different clinical approach and treatment. Associations of HLA genotypes and risk of DILI have highlighted the importance of the immune system in the pathogenesis of DILI. Furthermore, novel agents affecting the immune response can lead to liver injury, often associated with autoimmune features in serologic tests and liver biopsies. Overall, the diagnosis of DILI remains a challenge as it is requires detailed case evaluation in addition to reviewing the hepatotoxic potentials and clinical signatures of the implicated agents. Biochemical profiles vary between agents and although individual drugs tend to portray a consistent clinicopathologic signature, many drugs have multiple signatures. Thanks to multicenter prospective studies on DILI and websites in the public domain such as LiverTox, physicians are provided with tools to investigate suspected DILI cases to increase the likelihood of establishing adiagnosis. The pathogenesis of DILI, epidemiology and current challenges in the diagnosis and management of the disease are reviewed in the paper.

VALIDATION OF THE ROCKALL SCORE IN UPPER GASTROINTESTINAL TRACT BLEEDING IN A COLOMBIAN TERTIARY HOSPITAL

ABSTRACT Background Rockall score is the most widely used prognostic scale for assessing risk of complications from non-varicose upper gastrointestinal bleeding (UGIB). Several studies have been conducted in adult populations with non-varicose UGIB in different parts of the world, with conflicting findings regarding the extent of association between the score and some morbidity and mortality outcomes. Also, there is controversy regarding the best cut-off point for the score. Moreover, no studies validating this score in Colombia have been carried out. Objective To assess the diagnostic performance of the Rockall score in predicting rebleeding and mortality in patients with non-varicose UGIB. Methods A prospective cohort study was conducted in patients requiring upper gastrointestinal endoscopy (UGIE) for non-varicose bleeding. The pre-and post-endoscopy Rockall scores were calculated and outcomes, including mortality, UGIB-associated mortality and in hospital rebleeding were determined at the 1 and 3-month time points. The association between the scores and these outcomes was assessed using the chi2 or the Fisher test, whereas the discrimination ability of the score was determined using the areas under the ROC curve (AUC). High discrimination ability was considered to exist in cases in which an AUC ≤0.7 with α=0.05 could be rejected. Results Overall, 177 patients were analyzed. In-hospital outcomes at 1 and 3 months were 12%, 17% and 23% for general mortality, 6%, 12% and 15% for UGIB mortality, and 19%, 30% and 37% for rebleeding. The post-endoscopy Rockall score was associated with the three outcomes at the three time points assessed, while the pre-endoscopy score was only associated with general mortality at the three time points, and rebleeding at 1 and 3 months. Regarding discrimination ability, although the AUC was greater than expected by randomness (0.5) in all cases, only one AUC ≤0.7 was rejected in the post-endoscopy score for in-hospital UGIB mortality (AUC=0.901; 95%CI: 0.845—0.958), at 1 month (AUC=0.836; 95%CI: 0.717—0.954) and at 3 months (AUC=0.869; 95%CI: 0.771—0.967), and for rebleeding at 1 month (AUC=0.793; 95%CI: 0.725—0.861) and at 3 months (AUC=0.806; 95%CI: 0.741—0.871). Conclusion An association was found between the Rockall score and rebleeding and mortality in patients with non-varicose UGIB. Only the post-endoscopy score had a high predictive ability for rebleeding and UGIB mortality.

Celiac Disease Revisited

Celiac disease (CD) is a systemic disease triggered by gluten ingestion in genetically predisposed individuals. It manifests primarily as an autoimmune enteropathy associated with specific circulating autoantibodies and a human leukocyte antigen haplotype (HLA-DQ2 or HLA-DQ8). It afflicts roughly 1% of the population, though the majority of patients remain undiagnosed. Diarrhea and malabsorption are classic manifestations of CD; however, both children and adults can be paucisymptomatic and present extraintestinal manifestations such as anemia, osteoporosis, and abnormal liver tests. CD screening is not recommended for the general population, and it should be focused on high-risk groups. CD diagnosis is challenging and relies on serological tests, duodenal histology, and genetic testing. Particularly difficult presentations to manage are seronegative patients, seropositive patients without villus atrophy, and patients who have started a gluten-free diet before the diagnostic workup. The only proven treatment is a lifelong gluten-free diet. We present an in-depth review on the physiopathology and management of CD, with a particular emphasis on diagnostic challenges.

Effects of a gluten-reduced or gluten-free diet for the primary prevention of cardiovascular disease

BACKGROUND

Cardiovascular diseases (CVD) are a major cause of disability and the leading cause of death worldwide. To reduce mortality and morbidity, prevention strategies such as following an optimal diet are crucial. In recent years, low-gluten and gluten-free diets have gained strong popularity in the general population. However, study results on the benefits of a gluten-reduced or gluten-free diet are conflicting, and it is unclear whether a gluten-reduced diet has an effect on the primary prevention of CVD.

OBJECTIVES

To determine the effects of a gluten-reduced or gluten-free diet for the primary prevention of CVD in the general population.

SEARCH METHODS

We systematically searched CENTRAL, MEDLINE, Embase, CINAHL and Web of Science up to June 2021 without language restrictions or restrictions regarding publication status. Additionally, we searched ClinicalTrials.gov for ongoing or unpublished trials and checked reference lists of included studies as well as relevant systematic reviews for additional studies.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs) and non-randomised studies of interventions (NRSIs), such as prospective cohort studies, comparing a low-gluten or gluten-free diet or providing advice to decrease gluten consumption with no intervention, diet as usual, or a reference gluten-intake category. The population of interest comprised adults from the general population, including those at increased risk for CVD (primary prevention). We excluded cluster-RCTs, case-control studies, studies focusing on participants with a previous myocardial infarction and/or stroke, participants who have undergone a revascularisation procedure as well as participants with angina or angiographically-defined coronary heart disease, with a confirmed diagnosis of coeliac disease or with type 1 diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility of studies in a two-step procedure following Cochrane methods. Risk of bias (RoB) was assessed using the Cochrane risk of bias tool (RoB2) and the 'Risk Of Bias In Non-randomised Studies - of Interventions' (ROBINS-I) tool, and the certainty of evidence was rated using the GRADE approach.

MAIN RESULTS

One RCT and three NRSIs (with an observational design reporting data on four cohorts: Health Professionals Follow-up Study (HPFS), Nurses' Health Study (NHS-I), NHS-II, UK Biobank) met the inclusion criteria. The RCT was conducted in Italy (60 participants, mean age 41 ± 12.1 years), two NRSIs (three cohorts, HPFS, NHS-I, NHS II) were conducted across the USA (269,282 health professionals aged 24 to 75 years) and one NRSI (Biobank cohort) was conducted across the UK (159,265 participants aged 49 to 62 years). Two NRSIs reported that the lowest gluten intake ranged between 0.0 g/day and 3.4 g/day and the highest gluten intake between 6.2 g/day and 38.4 g/day. The NRSI reporting data from the UK Biobank referred to a median gluten intake of 8.5 g/day with an interquartile range from 5.1 g/day to 12.4 g/day without providing low- and high-intake categories. Cardiovascular mortality From a total of 269,282 participants, 3364 (1.3%) died due to cardiovascular events during 26 years of follow-up. Low-certainty evidence may show no association between gluten intake and cardiovascular mortality (adjusted hazard ratio (HR) for low- versus high-gluten intake 1.00, 95% confidence interval (CI) 0.95 to 1.06; 2 NRSIs (3 cohorts)). All-cause mortality From a total of 159,265 participants, 6259 (3.9%) died during 11.1 years of follow-up. Very low-certainty evidence suggested that it is unclear whether gluten intake is associated with all-cause mortality (adjusted HR for low vs high gluten intake 1.00, 95% CI 0.99 to 1.01; 1 NRSI (1 cohort)). Myocardial infarction  From a total of 110,017 participants, 4243 (3.9%) participants developed non-fatal myocardial infarction within 26 years. Low-certainty evidence suggested that gluten intake may not be associated with the development of non-fatal myocardial infarction (adjusted HR for low versus high gluten intake 0.99, 95% CI 0.89 to 1.10; 1 NRSI (2 cohorts)). Lowering gluten intake by 5 g/day also showed no association on the primary prevention of non-fatal and fatal myocardial infarction (composite endpoint) in linear dose-response meta-analyses (adjusted HR 1.02, 95% CI 0.98 to 1.06; 1 NRSI (2 cohorts)). Coronary risk factors  Type 2 diabetes From a total of 202,114 participants, 15,947 (8.0%) developed type 2 diabetes after a follow-up between 22 and 28 years. There was low-certainty evidence that a lower compared with a higher gluten intake may be associated with a slightly increased risk to develop type 2 diabetes (adjusted HR 1.14, 95% CI 1.07 to 1.22; 1 NRSI (3 cohorts)). Furthermore, lowering gluten intake by 5 g/day may be associated with a slightly increased risk to develop type 2 diabetes in linear dose-response meta-analyses (adjusted HR 1.12, 95% CI 1.08 to 1.16; 1 NRSI (3 cohorts)). Blood pressure, low-density lipoprotein level, body mass index (BMI) After six months of follow-up, very low-certainty evidence suggested that it is unclear whether gluten intake affects systolic blood pressure (mean difference (MD) -6.9, 95% CI -17.1 to 3.3 mmHg). There was also no difference between the interventions for diastolic blood pressure (MD -0.8, 95% CI -5.9 to 4.3 mmHg), low-density lipoprotein levels (MD -0.1, 95% CI -0.5 to 0.3 mmol/L) and BMI (MD -0.1, 95% CI -3.3 to 3.1 kg/m²).  No study reported data on adverse events or on other outcomes. Funding sources did not appear to have distorted the results in any of the studies.

AUTHORS' CONCLUSIONS

Very low-certainty evidence suggested that it is unclear whether gluten intake is associated with all-cause mortality. Our findings also indicate that low-certainty evidence may show little or no association between gluten intake and cardiovascular mortality and non-fatal myocardial infarction. Low-certainty evidence suggested that a lower compared with a higher gluten intake may be associated with a slightly increased risk to develop type 2 diabetes - a major cardiovascular risk factor. For other cardiovascular risk factors it is unclear whether there is a difference between a gluten-free and normal diet. Given the limited findings from this review predominantly based on observational studies, no recommendations for practice can be made.

Preventive effect of rebamipide on NSAID-induced lower gastrointestinal tract injury using FAERS and JADER

Non-steroidal anti-inflammatory drugs (NSAIDs) are widely used for their antipyretic, analgesic, and anti-inflammatory properties. However, various aspects of NSAID-induced lower gastrointestinal tract injury remain unclear, and effective prophylaxis has not been established. Based on its pharmacological effect and clinical trials, rebamipide may prevent lower gastrointestinal tract injury, although this evidence is limited by the small scale of trials. The present study used the FDA Adverse Event Reporting System (FAERS) and the Japanese Adverse Event Reporting Database (JADER) to assess the efficacy of rebamipide in combination with loxoprofen and diclofenac in preventing NSAID-induced lower gastrointestinal tract injury. The calculated reporting odds ratio and 95% confidence interval (CI) for rebamipide in combination with loxoprofen and diclofenac were 1.15 (95% CI 0.88–1.51) and 1.28 (95% CI 0.82–2.01) for FAERS, and 0.50 (95% CI 0.35–0.71) and 0.43 (95% CI 0.27–0.67) for JADER, respectively. No signal was detected when combining drugs. These results suggest a prophylactic effect of rebamipide on NSAID-induced lower gastrointestinal tract injury.

Rapidly progressive dementia and intractable diarrhea: a teaching case report and a systematic review of cognitive impairment in Whipple’s disease

Objective

Methods

Results

Conclusions

Supplementary Information

Circular RNA HECTD1 Mitigates Ulcerative Colitis by Promoting Enterocyte Autophagy Via miR-182-5p/HuR Axis

OBJECTIVE

Ulcerative colitis (UC) is a chronic colitis with unknown etiology. Circular RNA (circRNA) has shown regulatory effect in many diseases, but the role of circRNA in UC is barely known. This study uncovers the function and regulatory mechanism of circRNA HECTD1 (circHECTD1) in UC.

METHODS

Colonic mucosal tissues of 60 patients with active UC and 30 healthy controls were collected for H&E staining. Lipopolysaccharide (LPS) and dextran sulfate sodium (DSS) were used to induce inflammation and UC in Caco-2 cells and C57BL/6 mice where modification of circHECTD1, miR-182-5p and/or human antigen R (HuR) took place. The Caco-2 cells and the colon tissues of DSS-treated mice were collected for analysis of the expression levels of inflammatory cytokines, NLRP3 inflammasome, and autophagy-related proteins. The interactions among circHECTD1, miR-182-5p, and HuR were verified.

RESULTS

The colonic mucosal tissues of UC patients showed impaired autophagy and decreased expressions of circHECTD1 and HuR. Overexpression of circHECTD1 or HuR or inhibition of miR-182-5p suppressed inflammation and promoted autophagy of LPS-induced Caco-2 cells. The expression of HuR was promoted by circHECTD1 via miR-182-5p in Caco-2 cells. Overexpression of circHECTD1 reduced colonic injuries and inflammation by promoting autophagy in DSS-treated mice.

CONCLUSION

Overexpression of circHECTD1 alleviates UC by promoting HuR-dependent autophagy via miR-182-5p. This study highlights the therapeutic potential of circHECTD1 for UC and adds to the knowledge of circRNA in the pathogenesis of UC.

Room for Improvement in the Treatment of Helicobacter pylori Infection: Lessons from the European Registry on H. pylori Management (Hp-EuReg)

BACKGROUND

Managing Helicobacter pylori infection requires constant decision making, and each decision is open to possible errors.

AIM

The aim was to evaluate common mistakes in the eradication of H. pylori, based on the "European Registry on Helicobacter pylori management".

METHODS

European Registry on Helicobacter pylori management is an international multicentre prospective noninterventional registry evaluating the decisions and outcomes of H. pylori management by European gastroenterologists in routine clinical practice.

RESULTS

Countries recruiting more than 1000 patients were included (26,340 patients). The most common mistakes (percentages) were: (1) To use the standard triple therapy where it is ineffective (46%). (2) To prescribe eradication therapy for only 7 to 10 days (69%). (3) To use a low dose of proton pump inhibitors (48%). (4) In patients allergic to penicillin, to prescribe always a triple therapy with clarithromycin and metronidazole (38%). (5) To repeat certain antibiotics after eradication failure (>15%). (6) Failing to consider the importance of compliance with treatment (2%). (7) Not to check the eradication success (6%). Time-trend analyses showed progressive greater compliance with current clinical guidelines.

CONCLUSION

The management of H. pylori infection by some European gastroenterologists is heterogeneous, frequently suboptimal and discrepant with current recommendations. Clinical practice is constantly adapting to updated recommendations, although this shift is delayed and slow.

Long-term sequelae of drug-induced liver injury

Drug-induced liver injury (DILI) has a very variable clinical and biochemical phenotype and differs widely in severity, from mild injury to life-threatening liver failure. Chronic injury has also been reported to occur at a variable frequency, ranging from 3.4% to 39%, 6-12 months after discontinuing the implicated agent. This wide range is probably related to various definitions of chronic liver injury and variable selection of patients. The long-term sequalae of this chronic injury in terms of morbidity and mortality are unclear, although rare vanishing bile duct syndrome is associated with an unfavourable prognosis, with increased risk of chronic liver failure and need for liver transplantation. Other forms of long-term sequalae associated with DILI are progressive fibrosis, autoimmune-like hepatitis, secondary sclerosing cholangitis, sinusoidal obstruction syndrome and, as a common final stage, the development of cirrhosis, portal hypertension and its complications. Immune checkpoint inhibitors, which can cause an autoimmune-like phenotype have also recently been shown to cause sclerosing cholangitis with cytotoxic T CD8+ cell infiltration in biliary tracts. DILI has been shown to have a significant impact on health-related quality of life but very little is known about its psychological consequences in the long-term. Further investigations with structured long-term follow-up and periodic quality of life surveys are needed to assess the impact of DILI on psychological outcomes, particularly in those with chronic sequelae.

Causes of gastrointestinal bleeding in oral anticoagulant users compared to non-users in a population-based study

BACKGROUND/AIMS

Causes of gastrointestinal bleeding (GIB) in patients on oral anticoagulants (OACs) are not well established. The aims of the study were to compare the causes of GIB in patients on OACs and those not on OAC therapy.

METHODS

A nationwide study of all GIB events in patients on OACs in Iceland from 2014-2019 was conducted. Bleeding events were obtained through ICD-10 codes and review of endoscopy databases, confirmed by review of medical records. For comparison, patients not on OACs from previous Icelandic population-based studies were used.

RESULTS

Among 752 GIB events in 12,005 patients on OACs, 273 (1.9%) had verified upper and 391 (2.7%) had verified lower GIB. For lower GIB, multivariate analysis showed that OAC users were more likely to have colonic polyps (OR 6.6, 95% CI: 2.4 - 17.8, p < .001) or colorectal cancer (OR 3.7, 95% CI: 2.0 - 7.0, p < .001) but less likely to have ischemic colitis (OR 0.11, 95% CI: 0.04 - 0.26, p < .001). For upper GIB, bleeding from mucosal erosions (OR 4.0 95% CI: 2.5 - 7.9, p < .001) and angiodysplasia (OR 3.6, 95%CI: 1.5 - 8.6, p = .003) were more common in OAC users.

CONCLUSIONS

A high proportion of GIB caused by colonic polyps and colorectal cancer among OAC patients indicates that OACs treatment may facilitate cancer diagnosis. The low proportion of ischemic colitis among those on OACs suggests that OACs provide a protective effect against ischemic colitis. OACs seem to increase the bleeding from angiodysplasia and mucosal erosive disease.

Evaluation of Six Preendoscopy Scoring Systems to Predict Outcomes for Older Adults with Upper Gastrointestinal Bleeding

Objectives

To compare the ability of six preendoscopic scoring systems (ABC, AIMS65, Glasgow Blatchford score (GBS), MAP(ASH), pRS, and T-score) to predict outcomes of upper gastrointestinal bleeding (UGIB) in older adults.

Methods

This was a retrospective study of 602 older adults (age ≥ 65) presenting with UGIB at Zhongda Hospital Southeast University from January 2015 to June 2021. Six scoring systems were used to analyze all patients.

Results

ABC had the largest area under the curve (AUC) (0.833; 95% confidence interval (CI): 0.801–0.862) and was significantly higher than pRS 0.696 (95% CI: 0.658–0.733, p < 0.01) and T-score 0.667 (95% CI: 0.628–0.704, p < 0.01) in predicting mortality. MAP(ASH) (0.783; 95% CI: 0.748–0.815) performs the best in predicting intervention and was similar to GBS, T-score, ABC, and AIMS65. The AUCs for MAP(ASH) (0.732; 95% CI: 0.698–0.770), AIMS65 (0.711; 95% CI: 0.672–0.746), and ABC (0.718; 95% CI: 0.680–0.754) were fair for rebleeding, while those of GBS (0.662; 95% CI: 0.617–0.694), T-score (0.641; 95% CI: 0.606–0.684), and pRS (0.609; 95% CI: 0.569–0.648) were performed poorly. MAP(ASH) performs the best in predicting ICU admission (0.784; 95% CI: 0.749–0.816). All the five scores were significantly higher than pRS (p < 0.05 for ABC, AIMS65 and T-score, p < 0.01 for GBS and MAP).

Conclusions

Mortality, intervention, rebleeding, and ICU admission in UGIB for older adults can be predicted well using MAP(ASH). ABC is the most accurate for predicting mortality. Except for rebleeding, GBS has an acceptable performance in predicting ICU admission, mortality, and intervention. AIMS65 and T-score performed moderately, and pRS may not be suitable for the target cohort.

Pharmacotherapies for Drug-Induced Liver Injury: A Current Literature Review

Drug-induced liver injury (DILI) has become a serious public health problem. For the management of DILI, discontinuation of suspicious drug or medicine is the first step, but the treatments including drugs and supporting approaches are needed. Reference to clinical patterns and disease severity grades of DILI, the treatment drugs were considered to summarize into hepatoprotective drugs (N-acetylcysteine and Glutathione, Glycyrrhizin acid preparation, Polyene phosphatidylcholine, Bicyclol, Silymarin), anticholestatic drug (Ursodeoxycholic acid, S-adenosylmethionine, Cholestyramine), immunosuppressants (Glucocorticoids) and specific treatment agents (L-carnitine, Anticoagulants). The current article reviewed the accumulated literature with evidence-based medicine researches for DILI in clinical practice. Also the drawbacks of the clinical studies involved in the article, unmet needs and prospective development for DILI therapy were discussed.

Diagnostic error rates and associated factors for lower gastrointestinal perforation

Lower gastrointestinal perforation is rare and challenging to diagnose in patients presenting with an acute abdomen. However, no study has examined the frequency and associated factors of diagnostic errors related to lower gastrointestinal perforation. This large-scale multicenter retrospective study investigated the frequency of diagnostic errors and identified the associated factors. Factors at the level of the patient, symptoms, situation, and physician were included in the analysis. Data were collected from nine institutions, between January 1, 2015 and December 31, 2019. Timely diagnosis was defined as diagnosis at the first visit in computed tomography (CT)-capable facilities or referral to an appropriate medical institution immediately following the first visit to a non-CT-capable facility. Cases not meeting this definition were defined as diagnostic errors that resulted in delayed diagnosis. Of the 439 cases of lower gastrointestinal perforation identified, delayed diagnosis occurred in 138 cases (31.4%). Multivariate logistic regression analysis revealed a significant association between examination by a non-generalist and delayed diagnosis. Other factors showing a tendency with delayed diagnosis included presence of fever, absence of abdominal tenderness, and unavailability of urgent radiology reports. Initial misdiagnoses were mainly gastroenteritis, constipation, and small bowel obstruction. In conclusion, diagnostic errors occurred in about one-third of patients with a lower gastrointestinal perforation.

Oral Health Status of Children Living with Type 1 Diabetes Mellitus

Background: Diabetes is a well-known predisposing factor for oral diseases, so prevention in an early age is mandatory. Objective: To provide oral screening for children living with type 1 diabetes. We aimed to investigate the oral and general health indexes of T1DM children and compare these data to healthy siblings and controls. Methods: In this cross-sectional study, 120 DM patients and 78 siblings, thereafter 80 DM children and 95 controls, took part. A detailed questionnaire, panoramic radiographs, and lateral cephalograms were obtained in every orthodontic consultation. We used Pearson’s chi-square test for statistical analysis and compared the data of the study and control groups. Results: The oral health values of DM children were significantly better (DMF-T 0.83–1.3) than the national average (3.8–4.5). A total of 75% (n = 60) of the children needed orthodontic treatment for orthodontic or skeletal anomalies. The prevalence of skeletal anomalies was significantly (p < 0.05) higher among patients with diabetes mellitus (DM) than in the control group. The frequency of coeliac disease was significantly elevated compared to any literature data (1–3.5%) in the study (15%) and in the control sibling group (13%). Conclusions: Co-morbidities such as CD should get more attention as a prognostic factor for a future higher incidence of diabetes. T1DM children can be motivated and health-conscious patients with excellent oral hygiene and dental status. Orthodontic treatment can help eliminate the oral complications of DM. Special diabetes ambulances may help provide oral care for patients with DM.

Quality of life assessment in adult spinal muscular atrophy patients treated with nusinersen

OBJECTIVE

To retrospectively evaluate quality of life (QoL) in a large multicenter cohort of adult patients affected by spinal muscular atrophy (SMA) during nusinersen treatment.

METHODS

We included adult (≥ 18 years) patients clinically and genetically defined as SMA2, SMA3 and SMA4, who started nusinersen treatment in adulthood. QoL was rated by the Individualized Neuromuscular Quality of Life (INQoL) questionnaire. Concurrent motor function evaluation included the Hammersmith Functional Motor Scale Expanded (HFMSE), the Revised Upper Limb Module (RULM), the 6 min walking test (6MWT).

RESULTS

189 completed questionnaires were collected during a 14 months' treatment period. 78 patients were included (7 SMA2 and 69 SMA3 and 2 SMA4) with mean disease duration at first nusinersen administration of 33.2 years (± 12.5 years). All the scores for each INQoL domain (weakness, fatigue, activities, independence, social relationship, emotions, body images) and the derived QoL total score, significantly improved during the observation period, except the muscle locking and pain items. Exploratory analyses suggested that emotions and social relationships were more relevant issues for females compared to males. Social relationships were affected also by a longer disease duration (> 30 years). In SMA3 non-walker patients, activities ameliorate better compared to walkers. The HFMSE and RULM significantly improved from baseline; however, no associations with QoL total score and weakness, activities or independence were demonstrated.

CONCLUSION

In our cohort, adult SMA patients showed a global improvement at the INQoL assessment over 14 months of nusinersen treatment. QoL assessment is relevant to SMA multidisciplinary evaluation.

Efficacy and Safety of Antofloxacin-Based Triple Therapy for Helicobacter pylori Eradication Failure in China

AIMS

Quinolone-containing triple therapy has been considered as the second-line therapy for eradication of Helicobacter pylori (H. pylori). At present, there are no data to show the efficacy and safety of antofloxacin-based rescue therapy for the eradication of H. pylori, and this pilot clinical trial was designed.

METHODS

A total of 196 patients who failed H. pylori eradication using the clarithromycin-based or metronidazole-based triple or bismuth quadruple therapy were randomly allocated to one of the following rescue eradication therapy groups: AEA group (antofloxacin 200 mg once daily, esomeprazole 20 mg + amoxicillin 1000 mg twice daily) for 14 days, or LEA group (levofloxacin 500 mg once daily, esomeprazole 20 mg + amoxicillin 1000 mg twice daily) for 14 days. The minimal inhibitory concentrations were tested by the E-test method. The gyrA mutation was analyzed by sequencing. Follow-up ^13/14C-urea breath test was examined at 1 month after discontinuation.

RESULTS

A total of 178 eligible patients were included in this study. The eradication rate was significantly higher in AEA group than in LEA group according to both ITT (87.6% vs. 68.5%; P = 0.002) and PP analyses (90.7% vs. 70.1%; P = 0.001). ITT analyses indicated that the eradication rate was significantly higher in AEA group than in LEA group with Asn87 mutation (78.9% vs. 31.3%; P = 0.005) and levofloxacin-resistant strains (76.9% vs. 44.2%; P = 0.003). Two groups exhibited similar adverse event rates (AEA 14.6% vs. LEA 20.2%, P = 0.323).

CONCLUSIONS

The findings showed that antofloxacin may be a promising candidate in rescue therapy for H. pylori eradication failure in China.

Update on the management of upper gastrointestinal bleeding

Upper gastrointestinal bleeding is a common emergency presentation requiring prompt resuscitation and management. Peptic ulcers are the most common cause of the condition. Thorough initial management with a structured approach is vital with appropriate intravenous fluid resuscitation and use of a restrictive transfusion threshold of 7-8 g/dL. Pre-endoscopic scoring tools enable identification of patients at high risk and at very low risk who might benefit from specific management. Endoscopy should be carried out within 24 h of presentation for patients admitted to hospital, although optimal timing for patients at a higher risk within this period is less clear. Endoscopic treatment of high risk lesions and use of subsequent high dose proton pump inhibitors is a cornerstone of non-variceal bleeding management. Variceal haemorrhage results in higher mortality than non-variceal haemorrhage and, if suspected, antibiotics and vasopressors should be administered urgently, before endoscopy. Oesophageal variceal bleeding requires endoscopic band ligation, whereas bleeding from gastric varices requires thrombin or tissue glue injection. Recurrent bleeding is managed by repeat endoscopic treatment. If uncontrolled bleeding occurs, interventional radiological embolisation or surgery is required for non-variceal bleeding or transjugular intrahepatic portosystemic shunt placement for variceal bleeding.