Risk factors for upper gastrointestinal bleeding among aspirin users: An old issue with new findings from a population-based cohort study. J Formos Med Assoc. 2019;118:939-944. [PMID: 30366771 DOI: 10.1016/j.jfma.2018.10.007]

Bleeding in patients on concurrent treatment with a selective serotonin reuptake inhibitor (SSRI) and low-dose acetylsalicylic acid (ASA) compared with SSRI or low-dose ASA alone-A systematic review and meta-analysis

AIMS

The aim of this study was to systematically review whether concurrent treatment with an SSRI and low-dose ASA increases the risk of bleeding compared with treatment with an SSRI alone or ASA alone.

METHODS

Medline, Embase, the Cochrane Library, PsycINFO and Web of Science (from database inception to January 2023) were searched according to PICO: P = patients on treatment with an SSRI and/or low-dose ASA; I = intervention: SSRI + ASA; C = comparison: ASA or SSRI alone; O = outcomes: bleeding/major bleeding. The included articles were assessed using checklists. Studies without major risk of bias formed the basis for the conclusions. Extracted data were pooled using random-effects meta-analyses. Certainty of evidence was assessed according to GRADE.

RESULTS

Twenty-four studies met the PICO and were included. One randomized and six nonrandomized studies were assessed not to have major risk of bias. Regarding SSRI + ASA vs. ASA only, the pooled hazard ratio of three nonrandomized studies (n = 38 467) was 1.37 (95% confidence interval: 1.10; 1.70; I2 = 0%), and the pooled odds ratio of two nonrandomized studies (n = 28 296) was 0.95 (0.77; 1.19; I2 = 0%). Regarding SSRI + ASA vs. SSRI only, the randomized controlled trial (n = 1048) reported a hazard ratio of 1.82 (0.66; 5.02), the hazard ratio being 1.60 (1.24; 2.06) for ASA vs. placebo in patients without SSRI treatment; and one nonrandomized controlled study (n = 18 920) reported an incidence rate ratio of 1.03 (0.96; 1.12).

CONCLUSIONS

The compiled evidence was too uncertain to support an interaction when an SSRI is added to low-dose ASA. Low-dose ASA added to an SSRI may imply an increased risk of bleeding primarily attributable to the initiation of ASA.

Assessing peptic ulcer risk with the HAMPROW score in the general Chinese population

The timely identification of individuals at high risk for peptic ulcers (PUs) is vital in preventing gastrointestinal bleeding after antiplatelet therapy. This study was designed to determine PU risk factors and develop a risk assessment model for PU detection in the general Chinese population. In a prospective dataset, clinical data from individuals undergoing gastroscopic evaluation between April 2019 and May 2022 were recorded. PUs were defined as mucosal defects exceeding 5 mm confirmed via gastroscopy. Participants were categorized into development (April 2019 to April 2021) and validation (May 2021 to May 2022) sets based on chronological order. LASSO-derived logistic regression analysis was employed to create a score, which was further validated via temporal validation. A total of 902 patients were ultimately enrolled, 204 (22.6%) of whom had PUs based on endoscopic findings. In the development cohort (n = 631), seven independent risk factors emerged: male sex (OR = 2.35, P = 0.002), white blood cell (WBC) count (OR = 1.16, P = 0.010), red blood cell (RBC) count (OR = 0.49, P < 0.001), globulin level (OR = 0.92, P = 0.004), albumin level (OR = 0.94, P = 0.020), pepsinogen I (PGI) level (OR = 1.01, P < 0.001), and positive Helicobacter pylori (HP) antibody (OR = 2.50, P < 0.001). Using these factors, a nomogram (HAMPROW score [hazard ratio (HP) antibody, albumin, male, PGI, RBC, globulin, and WBC]) was developed for individual PU prediction. The ability of the HAMPROW score to predict survival was confirmed with AUCs of 0.854 (95% CI 0.816-0.891) and 0.833 (95% CI 0.771-0.895) in the development and validation sets, respectively. In conclusion, the HAMPROW score can be used to screen for PUs effectively in the general Chinese population, facilitating personalized early detection of high risk of gastrointestinal bleeding before antiplatelet therapy.

Guidelines on optimizing the use of proton pump inhibitors: PPI stewardship

Proton pump inhibitors (PPIs) have been available for over three decades and are among the most commonly prescribed medications. They are effective in treating a variety of gastric acid-related disorders. They are freely available and based on current evidence, use of PPIs for inappropriate indications and duration appears to be common. Over the years, concerns have been raised on the safety of PPIs as they have been associated with several adverse effects. Hence, there is a need for PPI stewardship to promote the use of PPIs for appropriate indication and duration. With this objective, the Indian Society of Gastroenterology has formulated guidelines on the rational use of PPIs. The guidelines were developed using a modified Delphi process. This paper presents these guidelines in detail, including the statements, review of literature, level of evidence and recommendations. This would help the clinicians in optimizing the use of PPIs in their practice and promote PPI stewardship.

Associations between COVID-19 therapies and inpatient gastrointestinal bleeding: A multisite retrospective study

Little data is available regarding the incidence of gastrointestinal bleeding in adults hospitalized with COVID-19 infection and the influence of patient comorbidities and demographics, COVID-19 therapies, and typical medications used. In this retrospective study, we utilized the National COVID Cohort Collaborative to investigate the primary outcome of the development of gastrointestinal bleeding in 512 467 hospitalized US adults (age >18 years) within 14 days of a COVID-19 infection and the influence of demographics, comorbidities, and selected medications. Gastrointestinal bleeding developed in 0.44% of patients hospitalized with COVID-19. Comorbidities associated with gastrointestinal bleeding include peptic ulcer disease (adjusted odds ratio [aOR] 10.2), obesity (aOR 1.27), chronic kidney disease (aOR 1.20), and tobacco use disorder (aOR 1.28). Lower risk of gastrointestinal bleeding was seen among women (aOR 0.76), Latinx (aOR 0.85), and vaccinated patients (aOR 0.74). Dexamethasone alone or with remdesivir was associated with lower risk of gastrointestinal bleeding (aOR 0.69 and aOR 0.83, respectively). Remdesivir monotherapy was associated with upper gastrointestinal bleeding (aOR 1.25). Proton pump inhibitors were more often prescribed in patients with gastrointestinal bleeding, likely representing treatment for gastrointestinal bleeding rather than a risk factor for its development. In adult patients hospitalized with COVID-19, the use of dexamethasone alone or in combination with remdesivir is negatively associated with gastrointestinal bleeding. Remdesivir monotherapy is associated with increased risk of upper gastrointestinal bleeding.

Proton pump inhibitors and gastroprotection in patients treated with antithrombotic drugs: A cardiologic point of view

Aspirin, other antiplatelet agents, and anticoagulant drugs are used across a wide spectrum of cardiovascular and cerebrovascular diseases. A concomitant proton pump inhibitor (PPI) treatment is often prescribed in these patients, as gastrointestinal complications are relatively frequent. On the other hand, a potential increased risk of cardiovascular events has been suggested in patients treated with PPIs; in particular, it has been discussed whether these drugs may reduce the cardiovascular protection of clopidogrel, due to pharmacodynamic and pharmacokinetic interactions through hepatic metabolism. Previously, the concomitant use of clopidogrel and omeprazole or esomeprazole has been discouraged. In contrast, it remains less known whether PPI use may affect the clinical efficacy of ticagrelor and prasugrel, new P2Y12 receptor antagonists. Current guidelines recommend PPI use in combination with antiplatelet treatment in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids, or non-steroidal anti-inflammatory drugs, and Helicobacter pylori (H. pylori) infection. In patients taking oral anticoagulant with risk factors for gastrointestinal bleeding, PPIs could be recommended, even if their usefulness deserves further data. H. pylori infection should always be investigated and treated in patients with a history of peptic ulcer disease (with or without complication) treated with antithrombotic drugs. The present review summarizes the current knowledge regarding the widespread combined use of platelet inhibitors, anticoagulants, and PPIs, discussing consequent clinical implications.

Association between chronic kidney disease and major hemorrhage in older persons: data from the ASPREE randomized trial

Introduction

Data on the association between chronic kidney disease (CKD) and major hemorrhage in older adults are lacking.

Methods

We used data from a double-blind randomized controlled trial of aspirin in persons aged ≥ 70 years with prospective capture of bleeding events, including hemorrhagic stroke and clinically significant bleeding. CKD was defined as an estimated glomerular filtration rate (eGFR) < 60 ml/min per 1.73 m² and/or urinary albumin-to-creatinine ratio (UACR) ≥ 3 mg/mmol (26.6 mg/g). We compared bleeding rates in those with and without CKD, undertook multivariable analyses, and explored effect modification with aspirin.

Results

Of 19,114 participants, 17,976 (94.0%) had CKD status recorded, of whom 4952 (27.5%) had CKD. Participants with CKD had an increased rate of major bleeding events compared with those without CKD (10.4/1000 vs. 6.3/1000 person-years [py], respectively) and increased bleeding risk (risk ratio [RR] 1.60; 95% confidence interval [CI]: 1.40, 1.90 for eGFR < 60 ml/min per 1.73 m²) and RR (2.10; 95% CI: 1.70, 2.50) for albuminuria. In adjusted analyses, CKD was associated with a 35% increased risk of bleeding (hazard ratio [HR] 1.37; 95% CI: 1.15, 1.62; P < 0.001). Other risk factors were older age, hypertension, smoking, and aspirin use. There was no differential effect of aspirin on bleeding by CKD status (test of interaction P = 0.65).

Conclusion

CKD is independently associated with an increased risk of major hemorrhage in older adults. Increased awareness of modifiable risk factors such as discontinuation of unnecessary aspirin, blood pressure control, and smoking cessation in this group is warranted.

Use of serotonin reuptake inhibitor antidepressants and the risk of bleeding complications in patients on anticoagulant or antiplatelet agents: a systematic review and meta-analysis

BACKGROUND

Serotonin reuptake inhibitor (SRI) antidepressants are implicated in increasing the risk of bleeding among users; however, the comparative increase in bleeding risk with concurrent antithrombotic therapy (anticoagulant or antiplatelet) remains unclear. As such, we performed a systematic review and meta-analysis of all available evidence to evaluate the effects of SRI and the risk of bleeding complications among patients receiving antithrombotic therapy.

METHODS

We searched Medline, Embase, PubMed, PsycINFO, Cochrane Library, Web of Science, Scopus, CINAHL, and grey literature (Google Scholar and preprint reports) up to 26 November, 2020, with no language restrictions (updated on 31 July 2021). The primary outcome of interest was major bleeding. Secondary outcomes included intracranial haemorrhage, gastrointestinal bleeding, and any bleeding events. We used a random-effects model meta-analysis to estimate the odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

We did not identify any randomised studies but found 32 non-randomized studies (cohort or case-control) with 1,848,285 patients that fulfilled the study selection criteria and were included in the meta-analysis. Among individuals receiving anticoagulants (13 studies), SRI users experienced a statistically higher risk of major bleeding compared to non-SRI users: pooled OR was 1.39 (95% CI, 1.23-1.58; p < .001; moderate heterogeneity). Among individuals receiving antiplatelet therapy (2 studies), SRI users were associated with an increased risk of major bleeding: pooled OR was 1.45 (95% CI, 1.17-1.80; p = .001; low heterogeneity). For secondary outcomes, the use of SRI among individuals treated with antithrombotic therapy revealed a higher risk of gastrointestinal bleeding or any bleeding events, whereas only anticoagulant use was illustrated an increased risk of intracranial haemorrhage.

CONCLUSIONS

The use of SRI antidepressants among patients treated with antithrombotic therapy (either anticoagulant or antiplatelet) is associated with a higher risk of bleeding complications, suggesting that caution is warranted in co-prescription.

PROSPERO REGISTRATION

CRD42018083917KEY MESSAGESIn this meta-analysis of 32 non-randomized studies, SRI users were associated with the risk of bleeding complications compared to non-SRI users, with concurrent antithrombotic use (either anticoagulant or antiplatelet).The risk was consistently elevated across types of bleeding events (major bleeding, gastrointestinal bleeding, or any bleeding events), whereas only anticoagulant use was associated with intracranial haemorrhage.To promote the rational use of medicines, our findings suggest that the risk-benefit ratio must account for the clear efficacy of SRI against safety concerns in terms of bleeding risks.

Editorial Commentary: Prophylaxis Against Deep Venous Thrombosis Should Be the Norm After Knee Arthroscopy

Knee arthroscopy has low complication rates overall, and most complications are not overly disabling. Yet one of the most concerning complications is venous thromboembolism, and pulmonary embolism (PE), in particular. The combination of low rate of venous thromboembolism in knee arthroscopy but high potential cost in the event of PE makes for a challenging risk-benefit analysis in the decision for whether to use thromboprophylaxis. Research is inherently difficult due to the infrequency of deep venous thrombosis and PE, leaving orthopaedic surgeons to fill in the gaps with clinical judgement. Risk stratification based on patient risk factors (e.g., oral contraceptives, renal disease, cardiovascular disease) and specific surgical procedure (e.g., meniscectomy, anterior cruciate ligament reconstruction) are important to define the highest-risk patients that may warrant stronger anticoagulation. Yet even in low-risk patients, given the potential severity of a PE and safety of aspirin, surgeons should consider aspirin as thromboprophylaxis.

Aspirin Use to Prevent Cardiovascular Disease and Colorectal Cancer: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Low-dose aspirin is used for primary cardiovascular disease prevention and may have benefits for colorectal cancer prevention.

OBJECTIVE

To review the benefits and harms of aspirin in primary cardiovascular disease prevention and colorectal cancer prevention to inform the US Preventive Services Task Force.

DATA SOURCES

MEDLINE, PubMed, Embase, and the Cochrane Central Register of Controlled Trials through January 2021; literature surveillance through January 21, 2022.

STUDY SELECTION

English-language randomized clinical trials (RCTs) of low-dose aspirin (≤100 mg/d) compared with placebo or no intervention in primary prevention populations.

DATA EXTRACTION AND SYNTHESIS

Single extraction, verified by a second reviewer. Quantitative synthesis using Peto fixed-effects meta-analysis.

MAIN OUTCOMES AND MEASURES

Cardiovascular disease events and mortality, all-cause mortality, colorectal cancer incidence and mortality, major bleeding, and hemorrhagic stroke.

RESULTS

Eleven RCTs (N = 134 470) and 1 pilot trial (N = 400) of low-dose aspirin for primary cardiovascular disease prevention were included. Low-dose aspirin was associated with a significant decrease in major cardiovascular disease events (odds ratio [OR], 0.90 [95% CI, 0.85-0.95]; 11 RCTs [n = 134 470]; I2 = 0%; range in absolute effects, -2.5% to 0.1%). Results for individual cardiovascular disease outcomes were significant, with similar magnitude of benefit. Aspirin was not significantly associated with reductions in cardiovascular disease mortality or all-cause mortality. There was limited trial evidence on benefits for colorectal cancer, with the findings highly variable by length of follow-up and statistically significant only when considering long-term observational follow-up beyond randomized trial periods. Low-dose aspirin was associated with significant increases in total major bleeding (OR, 1.44 [95% CI, 1.32-1.57]; 10 RCTs [n = 133 194]; I2 = 4.7%; range in absolute effects, 0.1% to 1.0%) and in site-specific bleeding, with similar magnitude.

CONCLUSIONS AND RELEVANCE

Low-dose aspirin was associated with small absolute risk reductions in major cardiovascular disease events and small absolute increases in major bleeding. Colorectal cancer results were less robust and highly variable.

Advances in prevention and treatment of digestive tract damage induced by antithrombotic therapy with traditional Chinese and Western medicine

The incidence of cardiovascular diseases has increased due to the aging of the population. Therefore, antithrombotic therapy is increasingly prescribed for cardiovascular prevention. However, long-term use of antithrombotic drugs can cause damage to the digestive tract. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antithrombotic therapy. In order to minimize the digestive tract damage induced by antithrombotic drugs, there are several strategies available, including reducing modifiable risk factors, using the most optimal antithrombotic regimen to ensure gastrointestinal risk-cardiovascular benefit balance, and using gastroprotective agents. In recent years, researchers are attempting to find new solutions from traditional Chinese medicine. Studies have shown that traditional Chinese medicine has its own characteristics and clinical advantages in preventing and treating diseases. In this review, we provide a summary of recent updates regarding gastrointestinal damage induced by antithrombotic therapy as well as its prevention and treatment with both traditional Chinese and Western medicine.

Major GI bleeding in older persons using aspirin: incidence and risk factors in the ASPREE randomised controlled trial

OBJECTIVE

There is a lack of robust data on significant gastrointestinal bleeding in older people using aspirin. We calculated the incidence, risk factors and absolute risk using data from a large randomised, controlled trial.

DESIGN

Data were extracted from an aspirin versus placebo primary prevention trial conducted throughout 2010-2017 ('ASPirin in Reducing Events in the Elderly (ASPREE)', n=19 114) in community-dwelling persons aged ≥70 years. Clinical characteristics were collected at baseline and annually. The endpoint was major GI bleeding that resulted in transfusion, hospitalisation, surgery or death, adjudicated independently by two physicians blinded to trial arm.

RESULTS

Over a median follow-up of 4.7 years (88 389 person years), there were 137 upper GI bleeds (89 in aspirin arm and 48 in placebo arm, HR 1.87, 95% CI 1.32 to 2.66, p<0.01) and 127 lower GI bleeds (73 in aspirin and 54 in placebo arm, HR 1.36, 95% CI 0.96 to 1.94, p=0.08) reflecting a 60% increase in bleeding overall. There were two fatal bleeds in the placebo arm. Multivariable analyses indicated age, smoking, hypertension, chronic kidney disease and obesity increased bleeding risk. The absolute 5-year risk of bleeding was 0.25% (95% CI 0.16% to 0.37%) for a 70 year old not on aspirin and up to 5.03% (2.56% to 8.73%) for an 80 year old taking aspirin with additional risk factors.

CONCLUSION

Aspirin increases overall GI bleeding risk by 60%; however, the 5-year absolute risk of serious bleeding is modest in younger, well individuals. These data may assist patients and their clinicians to make informed decisions about prophylactic use of aspirin.

TRIAL REGISTRATION NUMBER

ASPREE. NCT01038583.

Gastroprotection in patients on antiplatelet and/or anticoagulant therapy: a position paper of National Association of Hospital Cardiologists (ANMCO) and the Italian Association of Hospital Gastroenterologists and Endoscopists (AIGO)

Aspirin and P2Y₁₂ receptor antagonists are widely used across the spectrum of cardiovascular and cerebrovascular diseases. Gastrointestinal complications, including ulcer and bleeding, are relatively common during antiplatelet treatment and, therefore, concomitant proton pump inhibitor (PPI) treatment is often prescribed. However, potential increased risk of cardiovascular events has been suggested for PPIs, and, in recent years, it has been discussed whether these drugs may reduce the cardiovascular protection by aspirin and, even more so, clopidogrel. Indeed, pharmacodynamic and pharmacokinetic studies suggested an interaction through hepatic CYP2C19 between PPIs and clopidogrel, which could translate into clinical inefficacy, leading to higher rates of cardiovascular events. The FDA and the EMA sent a warning in 2010 discouraging the concomitant use of clopidogrel with omeprazole or esomeprazole. In addition, whether the use of PPIs may affect the clinical efficacy of the new P2Y₁₂ receptor antagonists, ticagrelor and prasugrel, remains less known. According to current guidelines, PPIs in combination with antiplatelet treatment are recommended in patients with risk factors for gastrointestinal bleeding, including advanced age, concurrent use of anticoagulants, steroids or non-steroidal anti-inflammatory drugs, and Helicobacter pylori infection. Like vitamin K antagonists (VKAs), DOACs can determine gastrointestinal bleeding. Results from both randomized clinical trials and observational studies suggest that high-dose dabigatran (150 mg bid), rivaroxaban and high-dose edoxaban (60 mg daily) are associated with a higher risk of GI bleeding as compared with apixaban and warfarin. In patients taking oral anticoagulant with GI risk factor, PPI could be recommended, even if usefulness of PPIs in these patients deserves further data. Helicobacter pylori should always be searched, and treated, in patients with history of peptic ulcer disease (with or without complication). Given the large number of patients treated with antithrombotic drugs and PPIs, even a minor reduction of platelet inhibition or anticoagulant effect potentially carries a considerable clinical impact. The present joint statement by ANMCO and AIGO summarizes the current knowledge regarding the widespread use of platelet inhibitors, anticoagulants, and PPIs in combination. Moreover, it outlines evidence supporting or opposing drug interactions between these drugs and discusses consequent clinical implications.

The Risk of Gastrointestinal Hemorrhage in Low-Dose Aspirin Users with Diabetes Mellitus: Systematic Review and Meta-Analysis

Background

Our aim was to assess the risk of gastrointestinal (GI) hemorrhage associated with diabetes among patients taking low-dose aspirin (≤325 mg/day).

Methods

A systematic search was conducted for publication in English and Chinese using term equivalents for “GI hemorrhage”, “aspirin”, and “diabetes mellitus” up till April 2020. Electronic databases include PUBMED, EMBASE, Cochrane Library databases, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, and VIP Database. Two independent authors searched databases and reviewed abstracts for comprehensive studies keeping adequate study quality. Data of weighted odds ratios were statistically evaluated and potential bias was checked.

Results

Among 446 publications, eight case-control researches, including 1601 patients, were deemed for this meta-analysis. Patients with diabetes were associated with a higher risk of GI hemorrhage than patients without diabetes: the summary ORs were 3.10 (95% CI, 2.35–4.09). The heterogeneity of the reports was not significant (Chi² = 3.39, P = 0.85; I² = 0%).

Conclusion

The meta-analysis showed that aspirin users with diabetes were more likely to have GI hemorrhage. Hence, when treating diabetics with aspirin, the increased risk of GI bleeding should be taken in consideration.

Diagnostic Model for In-Hospital Bleeding in Patients with Acute ST-Segment Elevation Myocardial Infarction: Algorithm Development and Validation

Background

Bleeding complications in patients with acute ST-segment elevation myocardial infarction (STEMI) have been associated with increased risk of subsequent adverse consequences.

Objective

The objective of our study was to develop and externally validate a diagnostic model of in-hospital bleeding.

Methods

We performed multivariate logistic regression of a cohort for hospitalized patients with acute STEMI in the emergency department of a university hospital. Participants: The model development data set was obtained from 4262 hospitalized patients with acute STEMI from January 2002 to December 2013. A set of 6015 hospitalized patients with acute STEMI from January 2014 to August 2019 were used for external validation. We used logistic regression analysis to analyze the risk factors of in-hospital bleeding in the development data set. We developed a diagnostic model of in-hospital bleeding and constructed a nomogram. We assessed the predictive performance of the diagnostic model in the validation data sets by examining measures of discrimination, calibration, and decision curve analysis (DCA).

Results

In-hospital bleeding occurred in 112 of 4262 participants (2.6%) in the development data set. The strongest predictors of in-hospital bleeding were advanced age and high Killip classification. Logistic regression analysis showed differences between the groups with and without in-hospital bleeding in age (odds ratio [OR] 1.047, 95% CI 1.029-1.066; P<.001), Killip III (OR 3.265, 95% CI 2.008-5.31; P<.001), and Killip IV (OR 5.133, 95% CI 3.196-8.242; P<.001). We developed a diagnostic model of in-hospital bleeding. The area under the receiver operating characteristic curve (AUC) was 0.777 (SD 0.021, 95% CI 0.73576-0.81823). We constructed a nomogram based on age and Killip classification. In-hospital bleeding occurred in 117 of 6015 participants (1.9%) in the validation data set. The AUC was 0.7234 (SD 0.0252, 95% CI 0.67392-0.77289).

Conclusions

We developed and externally validated a diagnostic model of in-hospital bleeding in patients with acute STEMI. The discrimination, calibration, and DCA of the model were found to be satisfactory.

Trial Registration

ChiCTR.org ChiCTR1900027578; http://www.chictr.org.cn/showprojen.aspx?proj=45926

Gastrointestinal bleeding in patients admitted to cardiology: risk factors and a new risk score

OBJECTIVE

Although the early use of a risk stratification score in gastrointestinal bleeding (GIB) is recommended, so far there has been no risk score for GIB in patients admitted to the cardiology department. To describe the risk factors of GIB and develop a new risk score model in patients admitted to the cardiology department.

METHODS

A total of 633 inpatients with GIB from January 2014 to December 2018 were recruited, 4,231 inpatients with non-GIB were recruited as the control group. Multivariate logistic regression was used to describe the risk factors of GIB. A new risk score model was developed in the derivation cohort. Accuracy to predict GIB was assessed by the area under the receiver operating characteristic (AUROC) curve in the validation cohort.

RESULTS

Male, coronary heart disease, hypertension, stroke, systolic blood pressure, hematocrit, plasma albumin, and alanine aminotransferase (ALT) were associated with GIB. The model had a high predictive accuracy (AUROC 0.816 and 95% CI, 0.792-0.839), which was supported by the validation cohort (AUROC 0.841 and 95% CI, 0.807~0.874). Besides, the prediction of the model was better than HAS-BLED score (AUROC 0.557; 95% CI, 0.513~0.602) and CRUSADE score (AUROC 0.791; 95%CI, 0.757~0.825), respectively. Among the inpatients with a score of 0-3, 4-7, and ≥8 points, the incidence of GIB, the proportion of inpatients requiring suspended red blood cells transfusion, length of stay, and in-hospital mortality all increased gradually (P< 0.001).

CONCLUSIONS

Male, coronary heart disease, hypertension, stroke, systolic blood pressure, hematocrit, plasma albumin, and ALT are associated with GIB. The new risk score model is an accurate risk score that predicts GIB in patients admitted to the cardiology department.

Influence of Polymorphisms Involved in Platelet Activation and Inflammatory Response on Aspirin-Related Upper Gastrointestinal Bleeding: A Case-Control Study

Background

Despite the wide benefits of aspirin and its cost-effectiveness, aspirin prescriptions have been reduced due to idiosyncratic responses in susceptible individuals. Low-dose aspirin and single-nucleotide polymorphisms (SNPs) are independently associated with increased risk of gastrointestinal hemorrhage; however, to-date, no studies investigated the SNP-aspirin interaction effect on upper gastrointestinal hemorrhage (UGIH). Therefore, we aimed to evaluate the role of 25 SNPs in multiple genes involved in platelet activation, angiogenesis and inflammatory response in aspirin-related UGIH.

Methods

A multicenter, full case–control study was conducted in patients exposed and unexposed to aspirin. Three hundred twenty-six cases diagnosed with UGIH were matched with 748 controls (1:3) by age, gender, health center, and recruitment date. Only adults of European origin were included. Participants were stratified by aspirin exposure and genotype [(Aspirin₍₋₎, wild-type), (Aspirin₍₊₎, wild-type), (Aspirin₍₊₎, genetic variation), (Aspirin₍₋₎, genetic variation)]. For each SNP, the Odds Ratio of UGIH and their 95% confidence intervals were estimated in each subgroup by using the generalized linear mixed models for dependent binomial variables. SNP-aspirin interaction effect was estimated through Relative Excess Risk due to Interaction (RERI) measures.

Results

We observed two categories of SNPs that might modify the risk magnitude of UGIH in aspirin consumers. Seven SNPs (rs1387180 A > G, rs2238631 T > C, rs1799964 T > C, rs5050 T > C/T > G, rs689466 T > C, rs1799983 T > A/T > G, and rs7756935 C > A) were “positive modifiers” associated with an excess of risk from aspirin exposure and carrying that genetic variation (1.75 ≤ RERI ≤ 4.95). On the contrary, the following nine SNPs (rs2243086 G > T, rs1131882 G > A, rs4311994 C > T, rs10120688 G > A, rs4251961 T > C, rs3778355 G > C, rs1330344 C > T, rs5275 A > G/A > T, and rs3779647 C > T) were “negative modifiers” and associated with a reduced risk in aspirin users (−2.74 ≤ RERI ≤ −0.95).

Conclusion

This preliminary study suggests that polymorphisms in genes involved in platelets activity, angiogenesis and inflammatory response might modify the risk of aspirin-related UGIH. Further studies with larger sample size and in different populations are needed to confirm our findings. If confirmed, this might have great impact on public health, thanks to aspirin’s prophylactic properties in diseases of high incidence and severity.

Endoscopic advances in the management of non-variceal upper gastrointestinal bleeding: A review

Upper gastrointestinal bleeding is defined as the bleeding originating from the esophagus to the ligament of Treitz and further classified into variceal and non-variceal gastrointestinal bleeding. Non-variceal upper gastrointestinal bleeding remains a common clinical problem globally. It is associated with high mortality, morbidity, and cost of the health care system. Despite the continuous improvement of therapeutic endoscopy, the 30-d readmission rate secondary to rebleeding and associated mortality is an ongoing issue. Available Food and Drug Administration approved traditional or conventional therapeutic endoscopic modalities includes epinephrine injection, argon plasma coagulation, heater probe, and placement of through the scope clip, which can be used alone or in combination to decrease the risk of rebleeding. Recently, more attention has been paid to the novel advanced endoscopic devices for primary treatment of the bleeding lesion and as a secondary measure when conventional therapies fail to achieve hemostasis. This review highlights emerging endoscopic modalities used in the management of non-variceal upper gastrointestinal related bleeding such as over-the-scope clip, Coagrasper, hemostatic sprays, radiofrequency ablation, cryotherapy, endoscopic suturing devices, and endoscopic ultrasound-guided angiotherapy. In this review article, we will also discuss the technical aspects of the common procedures, outcomes in terms of safety and efficacy, and their advantages and limitations in the setting of non-variceal upper gastrointestinal bleeding.

Review: Helicobacter pylori and non-malignant upper gastrointestinal diseases

This review covers recent publications investigating the relationship between Helicobacter pylori infection and gastroesophageal reflux disease, Barrett's esophagus, eosinophilic esophagitis, peptic ulcer disease (PUD), H pylori gastritis, and functional dyspepsia. In the area of gastroesophageal reflux disease, new data suggest that reflux may have a role in the transmission of H pylori infection. In addition to several observational studies, data on alterations in esophageal physiology in patients with H pylori infection are presented. Further evidence for the inverse relationship between H pylori infection and Barrett's esophagus is available in the form of a meta-analysis from the North American Barrett's and Esophageal Carcinoma Consortium. The relationship between H pylori infection and eosinophilic esophagitis remains uncertain. Although new data do not indicate a significantly lower prevalence of H pylori among patients with eosinophilic esophagitis, a meta-analysis showed a 37% reduced risk of eosinophilic esophagitis among H pylori-infected patients. Novel data are presented on the genetic variability of bacterial virulence factors and their relationship with PUD. We also report data on plasma biomarkers, which may detect progression to gastric cancer in H pylori-associated PUD. A new meta-analysis was published, which assessed the risk of PUD in low-dose aspirin users with H pylori infection. Finally, we report on the ongoing attempts to stratify patients with gastritis using endoscopic methods when compared to standard biopsy examination.

Pathways of healthcare and antibiotics use following reported gastrointestinal illness: a cross-sectional study in rural Anhui, China

OBJECTIVE

To document the factors, and their pathways, that influence healthcare and antibiotics use following reported gastrointestinal illnesses in Anhui province, China.

STUDY DESIGN

This study uses cross-sectional design, descriptive statistical analysis, pathway mapping and multivariate logistic regression modelling.

SETTING

Households in 12 villages in Anhui province, China.

PARTICIPANTS

A total of 3659 residents who: (1) held a registered rural residence and were actually living in the sampled villages when this study was conducted; (2) were aged 18 years and older and (3) were willing to participate and able to answer the survey questions.

OUTCOME MEASURES

Planned and measured variables included the occurrence of gastrointestinal illness, professional care seeking and antibiotic use due to the illness and factors influencing these measures.

RESULTS

Of the 3659 informants, 29.0% reported gastrointestinal illness episodes in the past year. Of these episodes, 50.2% led to professional care seeking and 65.4% of antibiotic use. Multivariate logistic modelling identifies that: (1) reported gastrointestinal illnesses were more frequent in north compared with middle (OR 0.569, 95% CI 0.472 to 0.686) and south (OR 0.588, 95% CI 0.492 to 0.702) Anhui, and were positively associated with age (B=0.123, p<0.05), knowledge concerning (B=0.248, p<0.05) and practice of (B=0.184, p<0.05) prevention; (2) seeking professional care and antibiotic use following the illness was linked to the severity of symptoms and geographical locations, rather than to specific pathogenic features.

CONCLUSIONS

Reported gastrointestinal illnesses are quite prevalent in the sample population and a large proportion of these have resulted in professional care and antibiotics use. The factors associated with the reported illnesses and pathways of healthcare and antibiotic use, as identified in this study, should inform future research and intervention efforts.