Physicians' knowledge, attitude, and prescribing behavior regarding stress ulcer prophylaxis in China: a multi-center study

An Updated Review and a Case Report: Stress Ulcer Prophylaxis

After encountering a unique patient case, we revisit the updated literature on stress ulcer prophylaxis with more updated studies. A 47-year-old male came to the hospital and was found to have acute cholecystitis. After undergoing urgent cholecystectomy, the patient developed melena and a 6 mg/dL drop from 12.5 g/dL to 6.5 g/dL in hemoglobin. He was found to have a gastric ulcer and was started on a proton pump inhibitor, which posed the question of whether or not stress ulcer prophylaxis was indicated. Therefore, the pathophysiology of stress ulcer prophylaxis is refreshed, discussing the various mechanisms through which stress ulcers form in a clinical context. Then, the main risk factors and indications for stress ulcer prophylaxis are defined based on current literature, further investigating whether or not stress ulcer prophylaxis has shown benefit and protection in various patient groups. Additionally, this review discusses the adverse effects of stress ulcer prophylaxis, including dysbiosis, community-acquired pneumonia, nutritional deficiencies, drug interactions, and fractures. Finally, inappropriate stress ulcer prophylaxis and contributing factors to overutilization are discussed, and alternative approaches to prevent stress ulcer formation are covered, including early enteral nutrition. Overall, there are mixed conclusions on the effectiveness of stress ulcer prophylaxis in noncritical patients. There are many adverse effects and unnecessary costs associated with inappropriate administration, and many studies have found that it should be reserved for specific clinical indications.

Assessment of Awareness and Knowledge of Proton Pump Inhibitors Among the General Population in the Qassim Region, Saudi Arabia

OBJECTIVE

This descriptive observational cross-sectional study aimed to assess the general population's awareness, attitudes, and behaviours towards proton pump inhibitor (PPI) usage, as well as their knowledge about associated side effects, in the Qassim region of Saudi Arabia.

METHODS

An autonomous online survey was conducted from June 15, 2023, to September 1, 2023, using social media. The survey targeted adult residents of Qassim and collected a total of 1090 respondents. Data analysis employed descriptive statistics, chi-square tests, and probit regression using R version 4.3.1 (RStudio, Boston, MA). A significance level of p<0.05 was utilized to interpret the results.

RESULTS

A total of 1050 samples, limited to residents of Qassim, were analyzed. Significant associations were observed between awareness of PPIs and factors such as side effects (adjOR = 1.19, 99% CI: 1.08-1.31), widespread PPI use (adjOR = 1.24, 99% CI: 1.12-1.38), PPI usage (adjOR = 2.47, 99% CI: 2.18-2.82), and optimal PPI timing (adjOR = 1.30, 99% CI: 1.13-1.50). Additionally, age, educational attainment, and employment in the medical field significantly influenced awareness gaps related to potential side effects, PPI prevalence, adherence to medical prescriptions, and optimal timing for PPI usage.

CONCLUSION

The current study concludes that a significant portion of individuals in the Qassim region lack awareness regarding the potential side effects of PPI usage. Comprehensive healthcare education is required to bridge awareness gaps regarding PPIs and foster informed medication practices. By grasping the intricacies of individual perceptions, medical engagement, and demographic factors, healthcare providers and policymakers can collaboratively empower individuals in the Qassim region to make informed choices regarding their health and medication usage.

The hidden blood loss and its factors in patients undergoing minimally invasive knee arthroscopy

Background

With respect to knee arthroscopy, assessing the amount of hidden blood loss is of great importance to avoid potential complications such as fever, anemia, difficulty in wound healing and wound infection. The current study aims to investigate the hidden blood loss and its factors in patients who underwent minimally invasive knee arthroscopy.

Methods

Consecutive patients with knee joint injury, who underwent arthroscopic minimally invasive treatment, were enrolled from January 2019 to November 2020 and were retrospectively studied. Demographic information on these patients, such as medical history and biochemical parameters, was collected. The hidden blood loss was calculated. Multivariate linear regression analysis was used to confirm independent factors associated with hidden blood loss.

Results

Finally, a total of 100 patients aged 44.78 ± 13.67 (range 17–66) years were reviewed, and it was found that a substantial amount of [387.02 ± 252.56 (range 18.89–1130.06) ml] hidden blood loss occurred after minimally invasive knee arthroscopy. Univariate analysis showed that this hidden blood loss was negatively correlated with age, gender, postoperative hemoglobin, and postoperative hematocrit (all P < 0.05), while it was positively correlated with body mass index (BMI), length of hospital stay, preoperative red blood cells, preoperative hemoglobin, preoperative hematocrit, blood volume, and the presence of medical conditions (all P < 0.05). Further multivariate linear regression indicated that preoperative hematocrit, blood volume, and postoperative hematocrit were independent factors associated with actual blood loss, and preoperative hematocrit, blood volume, postoperative hematocrit, and gender were independent factors associated with hidden blood loss, respectively (all P < 0.05).

Conclusion

Preoperative hematocrit, preoperative blood volume, postoperative hematocrit, and gender are the influencing factors of hidden blood loss in patients undergoing minimally invasive treatment under knee arthroscopy. More attention should be paid to hidden blood loss and its factors during the perioperative period.

CYP2C19 Gene Profiling as a Tool for Personalized Stress Ulcer Prophylaxis With Proton Pump Inhibitors in Critically Ill Patients - Recommendations Proposal

To this date, there are no recommendations for personalized stress ulcer prophylaxis (SUP) in critical care that would take the patient's individual genetic predispositions into account. Of drugs used for this purpose, proton pump inhibitors (PPIs) are the first-choice drugs in intensive care unit patients. The degradation of proton pump inhibitors is mediated by cytochrome P450 (CYP) enzymes; in particular, CYP2C19 and, to a lesser extent, CYP3A4 are involved. Expression and metabolic activity of, namely in, CYP2C19 is significantly affected by single nucleotide polymorphisms, the drug metabolization rate varies greatly from ultrarapid to poor and likely influences the optimal dosage. As these CYP2C19 predictive phenotypes via CYP2C19 haplogenotypes (rs12248560/rs4244285) can be relatively easily determined using the current standard equipment of hospital laboratories, we prepared a set of recommendations for personalized PPI-based stress ulcer prophylaxis taking into account the patient's CYP2C19 predictive phenotype determined in this way. These recommendations are valid, in particular, for European, American and African populations, because these populations have the high representations of the CYP2C19^*17 allele associated with the overexpression of the CYP2C19 gene and ultrarapid degradation of PPIs. We propose the CYP2C19 gene profiling as a tool for personalized SUP with PPI in critically ill patients.