REVISE: Re-Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol

INTRODUCTION

The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE.

METHODS AND ANALYSIS

REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial.

ETHICS AND DISSEMINATION

All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide.

TRIAL REGISTRATION NUMBER

NCT03374800.

Incidence of constipation and associated factors in the period of lockdown during COVID-19 pandemic: protocol for a systematic review and meta-analysis

INTRODUCTION

The lifestyle and habit changes that have emerged as a result of quarantine measures may have had a negative impact on defecation habits. However, there is a lack of data on combined estimates of its occurrence and prevalence.

METHODS AND ANALYSIS

We will conduct a systematic search for observational studies on PubMed/MEDLINE, Web of Science, Cochrane Library, EMBASE, CNKI, SinoMed, VIP China Science and Technology Journal database, Chinese Biomedical Databases and Wanfang Data. The search will include literature published from the inception of the databases to September 2022. Two authors will independently screen articles and extract data based on predefined inclusion and exclusion criteria. The risk of bias in the included studies will be evaluated using the Newcastle-Ottawa Scale for observational studies. Statistical analysis will be performed using Review Manager software V.5.4 and STATA V.16.0 software. Heterogeneity among studies will be assessed using the Q statistical test and I2 statistical tests. In case of significant heterogeneity, subgroup analysis and sensitivity analysis will be conducted to explore the source of heterogeneity. Sensitivity analyses will also be performed to assess the reliability of the study findings. If feasible, a meta-analysis will be conducted. Otherwise, a descriptive synthesis will be performed using a best-evidence synthesis approach. The primary outcome of interest will be the prevalence of constipation. The secondary outcomes will involve examining the association of risk factors. To evaluate potential publication bias, we will use both the Begg funnel plot and Egger's weighted regression statistics. Furthermore, to accurately assess the quality of evidence for our primary outcome, we will employ the Grading of Recommendations Assessment, Development and Evaluation system.

ETHICS AND DISSEMINATION

This systematic review protocol will only consider published studies available in databases and will not include individual patient data. Therefore, ethical approval is not required, and the findings will be published in a peer-reviewed journal.

PROSPER REGISTRATION NUMBER

CRD42022366176.

Chinese herbal medicine as adjuvant treatment for postoperative nausea and vomiting in patients undergoing laparoscopic surgery: a protocol for systematic review and meta-analysis

INTRODUCTION

Postoperative nausea and vomiting (PONV) is a distressing symptom that patients often complain of even after less invasive surgery such as laparoscopic surgery (LS). If PONV is not well managed, patient recovery and postoperative quality of life are adversely affected. Although various drugs have been administered to prevent PONV, their effectiveness is limited, and adverse effects are numerous. Although herbal medicines have been widely used to manage various gastrointestinal symptoms, including nausea and vomiting, scientific evidence of their effects is lacking. This protocol is intended for a systematic review to analyse the efficacy and safety of Chinese herbal medicines for PONV after LS through a meta-analysis.

METHODS AND ANALYSIS

Randomised controlled trials, reported until June 2022, will be retrieved from electronic databases such as Medline, EMBASE and Cochrane Library. We will compare the effects of herbal medicine in patients presenting with PONV after LS with those of Western medicine, placebo and no treatment. If sufficient studies are identified, we will evaluate the combined effects of herbal and Western medicine. The incidence of nausea and vomiting will be considered the primary outcome. Secondary outcomes will include the intensity of complaints, quality of life and incidence of adverse events. Two independent reviewers will collect data based on the Preferred Reporting Items for Systematic Review and Meta-Analyses statement, evaluate the quality of each study using the Cochrane risk-of-bias tool and synthesise the results via meta-analysis, if possible.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. The results of this study will be disseminated to peer-reviewed journals and posters.

PROSPERO REGISTRATION NUMBER

CRD42022345749.

Prevalence and associated factors of acute gastroenteritis in children and adolescents aged from 6 to 17 years old: a cross-sectional study based on the National Health and Nutrition Examination Survey database 1999-2018

OBJECTIVE

To explore the prevalence of acute gastroenteritis (AGE) and associated factors in children and adolescents in the USA from 1999 to 2018 using nationally representative data.

DESIGN

A retrospective cross-sectional study.

SETTING

The National Health and Nutrition Examination Survey (NHANES) database.

PARTICIPANTS

25 361 children and adolescents aged 6-17 years old.

PRIMARY AND SECONDARY OUTCOME MEASURES

Whether the patient suffered from AGE.

RESULTS

Totally 1882 suffered from AGE. The overall monthly prevalence of AGE in children and adolescents was 7.69%. From 1999 to 2018, the prevalence of AGE in the USA had been decreasing over time. The decreasing trend was observed in all subgroups, including age, gender, body mass index (BMI), education level, poverty index and eating food at the restaurant. There were two small upticks from 2003 to 2007 and 2013 to 2015. AGE was negatively associated with male compared with female (OR=0.86, 95% CI: 0.73 to 0.99, p=0.035), Mexican American (OR=0.82, 95% CI: 0.70 to 0.97, p=0.018) and non-Hispanic Black (OR=0.80, 95% CI: 0.69 to 0.93, p=0.003) compared with non-Hispanic White. AGE was positively associated with obesity compared with underweight and normal weight (OR=1.37, 95% CI: 1.15 to 1.62, p<0.001).

CONCLUSION

The monthly prevalence of AGE was 7.69% and showed a downward trend from 1999 to 2018 in the USA.

Upper gastrointestinal tract involvement of Crohn disease: clinical implications in children and adolescents

Crohn disease (CD) is a multifactorial inflammatory disorder that can affect all segments of the gastrointestinal (GI) tract but typically involves the ileum and/or colon. To assess patient prognosis and choose appropriate treatment, it is necessary to accurately evaluate the factors influencing poor outcomes, including disease phenotype. Pediatric CD involving the upper GI (UGI) tract has become increasingly recognized with the introduction of routine upper endoscopy with biopsies for all patients and the increased availability of accurate small bowel evaluations. Most clinical manifestations are mild and nonspecific; however, UGI involvement should not be overlooked since it can cause serious complications. Although controversy persists about the definition of upper GI involvement, aphthoid ulcers, longitudinal ulcers, a bamboo jointlike appearance, stenosis, and fistula are endoscopic findings suggestive of CD. In addition, the primary histological findings, such as focally enhanced gastritis and noncaseating granulomas, are highly suggestive of CD. The association between UGI involvement and poor prognosis of CD remains controversial. However, the unstandardized definition and absence of a validated tool for evaluating disease severity complicate the objective assessment of UGI involvement in CD. Therefore, more prospective studies are needed to provide further insight into the standardized assessment of UGI involvement and longterm prognosis of CD. Our review summarizes the findings to date in the literature as well as UGI involvement in CD and its clinical implications.

Profile of Helicobacter pylori cagA &vacA genotypes and its association with the spectrum of gastroduodenal disease

PURPOSE

Globally, H. pylori virulence factors cagA and vacA genotypes and its variation is leading to the austere form of the gastroduodenal disease. Our objectives were to detect H. pylori in dyspeptic patients from biopsy samples with the validation of the various existing diagnostic tools and to screen the cagA, vacA genotypes profile from biopsy specimens and how it impacts in progression of gastroduodenal disease in southern India.

METHODS

374 patients who attended endoscopy unit at Kasturba Hospital, Manipal with their consent obtained their biopsies. H. pylori were detected by HPE, Culture, RUT and PCR and its virulence gene were patterned with PCR.

RESULTS

The positive rate of H. pylori by HPE, RUT, Culture and PCR were 51.33%, 47.1%, 32.4% and 50.3% respectively and comparison by Bayesian LCMs analysis showed PCR is superior among them. The frequency of H. pylori virulence gene viz cagPAI (cagA) were 80.9%, and vacA alleles-s1m1 (42%), s1m2 (33%) and s2m2 (25%) genotypes by PCR respectively. Four combinations of cagA/vacA genotypes were noted, majority of strains harboured cagA⁺/vacA s1m1 genotypes (42.6%), interestingly this hyper-virulent strain more frequently seen in severe gastroduodenal disease whereas cagPAI negative strains as well as cagA^-/vacA s2m2 combinations (19.1%) are seen most commonly in functional dyspepsia cases and depicted significant association by Chi-square test.

CONCLUSIONS

This study validates and compares the existing diagnostic methods for detecting H. pylori in biopsies. Also, it reveals some pattern of virulence gene combination will play a vital role in disease progression.

Diversity of 3' variable region of cagA gene in Helicobacter pylori strains isolated from Chinese population

Background

The cytotoxin-associated gene A (cagA) is one of the most important virulence factors of Helicobacter pylori (H. pylori). There is a highly polymorphic Glu-Pro-Ile-Tyr-Ala (EPIYA) repeat region in the C-terminal of CagA protein. This repeat region is thought to play an important role in the pathogenesis of gastrointestinal diseases. The aim of this study was to investigate the diversity of cagA 3′ variable region and the amino acid polymorphisms in the EPIYA segments of the CagA C-terminal region of H. pylori, and their association with gastroduodenal diseases.

Methods

A total of 515 H. pylori strains from patients in 14 different geographical regions of China were collected. The genomic DNA from each strain was extracted and the cagA 3′ variable region was amplified by polymerase chain reaction (PCR). The PCR products were sequenced and analyzed using MEGA 7.0 software.

Results

A total of 503 (97.7%) H. pylori strains were cagA-positive and 1,587 EPIYA motifs were identified, including 12 types of EPIYA or EPIYA-like sequences. In addition to the four reported major segments, several rare segments (e.g., B′, B″ and D′) were defined and 20 different sequence types (e.g., ABD, ABC) were found in our study. A total of 481 (95.6%) strains carried the East Asian type CagA, and the ABD subtypes were most prevalent (82.1%). Only 22 strains carried the Western type CagA, which included AC, ABC, ABCC and ABCCCC subtypes. The CagA-ABD subtype had statistical difference in different geographical regions (P = 0.006). There were seven amino acid polymorphisms in the sequences surrounding the EPIYA motifs, among which amino acids 893 and 894 had a statistical difference with gastric cancer (P = 0.004).

Conclusions

In this study, 503 CagA sequences were studied and analyzed in depth. In Chinese population, most H. pylori strains were of the CagA-ABD subtype and its presence was associated with gastroduodenal diseases. Amino acid polymorphisms at residues 893 and 894 flanking the EPIYA motifs had a statistically significant association with gastric cancer.

Clinical application of gastrointestinal contrast-enhanced ultrasonography in diagnosis of gastric duodenal diseases

Gastrointestinal contrast-enhanced ultrasound examination is performed by giving patients an oral gastrointestinal ultrasound developer to enhance the imaging of the gastrointestinal structure, which can significantly reduce or even eliminate the interference of gastrointestinal gas and effectively reflect the gastric and duodenal lesions as well as their size, shape, and echo, with high diagnostic accuracy. This article mainly expounds the application of gastrointestinal contrast-enhanced ultrasonography in gastric and duodenal diseases to provide reference for clinicians.

Risk of death among users of Proton Pump Inhibitors: a longitudinal observational cohort study of United States veterans

OBJECTIVE

Proton pump inhibitors (PPIs) are widely used, and their use is associated with increased risk of adverse events. However, whether PPI use is associated with excess risk of death is unknown. We aimed to examine the association between PPI use and risk of all-cause mortality.

DESIGN

Longitudinal observational cohort study.

SETTING

US Department of Veterans Affairs.

PARTICIPANTS

Primary cohort of new users of PPI or histamine H2 receptor antagonists (H2 blockers) (n=349 312); additional cohorts included PPI versus no PPI (n=3 288 092) and PPI versus no PPI and no H2 blockers (n=2 887 030).

MAIN OUTCOME MEASURES

Risk of death.

RESULTS

Over a median follow-up of 5.71 years (IQR 5.11-6.37), PPI use was associated with increased risk of death compared with H2 blockers use (HR 1.25, CI 1.23 to 1.28). Risk of death associated with PPI use was higher in analyses adjusted for high-dimensional propensity score (HR 1.16, CI 1.13 to 1.18), in two-stage residual inclusion estimation (HR 1.21, CI 1.16 to 1.26) and in 1:1 time-dependent propensity score-matched cohort (HR 1.34, CI 1.29 to 1.39). The risk of death was increased when considering PPI use versus no PPI (HR 1.15, CI 1.14 to 1.15), and PPI use versus no PPI and no H2 blockers (HR 1.23, CI 1.22 to 1.24). Risk of death associated with PPI use was increased among participants without gastrointestinal conditions: PPI versus H2 blockers (HR 1.24, CI 1.21 to 1.27), PPI use versus no PPI (HR 1.19, CI 1.18 to 1.20) and PPI use versus no PPI and no H2 blockers (HR 1.22, CI 1.21 to 1.23). Among new PPI users, there was a graded association between the duration of exposure and the risk of death.

CONCLUSIONS

The results suggest excess risk of death among PPI users; risk is also increased among those without gastrointestinal conditions and with prolonged duration of use. Limiting PPI use and duration to instances where it is medically indicated may be warranted.

pylori infection, some risk factors and gastroduodenal diseases in coal miners

AIM: To search for the risk factors that influences the prevalence rate of gastroduodenal diseases in coal miners, and to seek protection for the health of coal miners.

METHODS: A total of 340 coal miners from three coalmines were chosen by the method of stratified random cluster sampling. Face to face interview was conducted to fill the unified questionaire. Gastroendoscopy were performed in 306 subjects to detect the situation of gastroduodenal diseases according to Sydney system of diagnosis. At the same time, mucosal biopsies were taken according to the regulated location for H. pylori culture and pathological examination. Blood samples were obtained to detect the anti-H. pylori U-IgG by enzyme-linked immunosorbent assay (ELISA).

RESULTS: The prevalence rate of gastroduodenal diseases in coal miners was 77.8% (68.5% in ground coal miners, 80.7% in underground miners). The prevalence rate of gastroduodenal diseases was 85.0% in coal miners with H. pylori infection, and 58.6% in those without H. pylori infection; it was 79.5% in coal miners who drank alcohol and 66.7% in those who didn't drink.

CONCLUSION: Alcohol-drinking, career, and H. pylori infection were risk factors of gastroduodenal diseases, and dust exposure was also a risk factor in underground coal miners.