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Summary: Background: The incidence of major gastrointestinal bleeding (GIB) in patients on low‐dose direct‐acting oral anticoagulants (DOACs) is relatively unknown. Estimates from randomised controlled trials (RCTs) are lacking. Aims: To assess GIB incidence and predictors from RCT data of patients on aspirin, low‐dose rivaroxaban, or both. Methods: This was a secondary analysis of RCT data wherein patients received aspirin 100 mg daily and rivaroxaban 2.5 mg b.d., aspirin alone, or rivaroxaban 5 mg b.d. Patients were followed from 2013 to 2016 at 602 centres. Outcomes included overall, upper, and lower GIB. We employed multivariable logistic regression to yield odds ratios (ORs) and 95% confidence intervals for potential exposures. Results: Among 27,395 patients, the annual incidence of GIB on rivaroxaban 2.5 mg b.d. with aspirin was 801.7 per 100,000 compared with 372.3 in 100,000 for aspirin. Age (OR 4.16, 2.53–6.82 for ≥75 vs. 55–64), peptic ulcer disease (PUD, OR 1.57, 1.01–2.44), liver disease (OR 2.09, 1.01–4.33), hypertension (OR 1.42, 1.04–1.94), and smoking (OR 1.85, 1.26–2.73) were associated with overall GIB. Kidney disease (OR 1.68, 1.12–2.51) was significantly associated with upper GIB, whereas diverticular disease (OR 3.75, 1.88–7.49) was associated with lower GIB. Addition of rivaroxaban to aspirin was associated more with lower GIB (OR 2.82, 1.64–4.84) than upper GIB (OR 1.86, 1.18–2.92). Conclusions: We established incidences and identified risk factors for GIB in users of low‐dose DOACs. Novel risk factors included current or former smoking and diverticulosis. Future studies should aim to validate these risk factors. [ABSTRACT FROM AUTHOR]

AbstractIntroductionMethodsResultsConclusionLower gastrointestinal bleeding (LGIB) is a common cause of emergency hospitalization and may require readmission for re-bleeding. A novel adhesive endoscopic hemostatic powder (UI-EWD/NexpowderTM, Nextbiomedical, Incheon, South Korea) has been developed and recently utilized for LGIB hemostasis. The aim of the current study was to assess the efficacy and safety of UI-EWD as a rescue therapy for the treatment of refractory LGIB.In this study, a total of 59 consecutive patients with LGIB who experienced initial hemostasis failure with conventional endoscopic therapy were enrolled into this multicenter single-arm study. These patients subsequently underwent UI-EWD application for the refractory LGIB hemostasis. We evaluated the success rate of hemostasis, re-bleeding rate within 30 d, and adverse events related to UI-EWD.UI-EWD was successfully administered to the bleeding sites in all enrolled refractory bleeding patients. Hemostasis was achieved in the entirety of the 59 patients (100%). The cumulative re-bleeding rate within 30 d was 8.5% (5/59). There were no UI-EWD-related adverse events, such as perforation nor embolism.Based on our results, the utilization of UI-EWD demonstrated a remarkable success rate in achieving hemostasis for refractory LGIB, while also exhibiting promising outcomes in reducing the re-bleeding rate within a 30-day period. Particularly, UI-EWD exhibits a favorable safety profile across all segments of the colon in cases of refractory LGIB. [ABSTRACT FROM AUTHOR]

Background: Recent studies suggest that low-molecular-weight heparin (LMWH) may play a role in mitigating the severity of acute pancreatitis (AP). This systematic review and meta-analysis aims to synthesise existing evidence on the effectiveness and safety of LMWH in the treatment of moderately-severe and severe AP. Methods: This systematic review and meta-analysis was conducted in accordance with the 2020 update of the PRISMA guidelines and the Cochrane Handbook for Systematic Reviews of Interventions. The systematic search was conducted in MEDLINE, the Cochrane Central Register of Controlled Trials, Scopus, and EMBASE, covering studies published up to February 2024. Randomised controlled trials (RCTs) and observational studies (n-RCTs) that reported the differences in the outcomes of AP for patients receiving LMWH in addition to the standard treatment (Intervention), compared to patients managed by standard treatment without LMWH (Control) were eligible. A random-effects model was used to calculate the pooled relative risk (RR) and mean differences (MD) with the corresponding 95% CI. Results: Thirteen studies were included in the meta-analysis, all published between 2004 and 2022. Eight studies were RCTs, and five were n-RCTs. Data from 13,709 patients (6.971 Interventions and 6.738 Controls) were analysed. The comparison of Intervention and Control groups showed the superiority of LMWH to standard treatments in terms of overall mortality (RR = 0.44, 95% CI = 0.31; 0.64, P < 0.0001, I2 = 51%), acute necrotic collections (RR = 0.24, 95% CI = 0.09; 0.62, P = 0.003, I2 = 0%), and organ failure (RR = 0.67, 95% CI = 0.48; 0.93, P = 0.02, I2 = 78%). The Intervention group showed superior outcomes compared with the Control group for gastrointestinal bleeding (RR = 0.64, 95% CI = 0.44; 0.94, P = 0.02, I2 = 0%), length of hospital stay (MD= − 6.08, 95% CI = − 10.08; − 2.07, P = 0.003, I2 = 98%), need for operative interventions (RR = 0.50, 95% CI = 0.29; 0.87, P = 0.01, I2 = 61%), and vascular thrombosis (RR = 0.43, 95% CI = 0.31; 0.61, P < 0.00001, I2 = 0%). Conclusions: Moderate to high-quality evidence suggests that early intervention with LMWH could improve the prognosis of non-mild AP in terms of mortality, organ failure, and decreased incidence of vascular thrombosis. In light of our findings, integrating LMWH into the treatment regimen for moderate-severe to severe AP is advocated. [ABSTRACT FROM AUTHOR]

Peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding, which has a high mortality risk. The standard therapy for acute peptic ulcer bleeding combines medication administration and endoscopic therapies. Both pharmacologic and endoscopic therapies have developed continuously in the past few decades. Proton pump inhibitors (PPIs) already reached a high efficacy in ulcer healing and have been widely used in the past few decades. Endoscopic hemostasis, which includes local epinephrine injection, heater probe coagulation, use of hemostatic clips, and/or band ligation, is highly effective with an overall hemostatic success rate of 85%–90%. However, 10%–20% of patients could not be cured by the current standard combination treatment. Recurrent ulcer bleeding, despite an initial successful hemostasis, is also a big problem for longer hospitalization stays, higher mortality, and higher complication rates, especially for malignant ulcer bleeding. How to manage all types of peptic ulcer bleeding and how to prevent early recurrent peptic ulcer bleeding remain unresolved clinical problems. Recently, several novel medications and endoscopic methods have been developed. Potassium competitive acid blockers have shown a stronger and longer acid suppression than PPI. Hemostatic powder spray and hemostatic gel emulsion are novel hemostatic weapons with emerging evidence, which are potential missing pieces of the puzzle. This literature review will go through the development of endoscopic hemostasis to the prospects of novel endoscopic treatments. [ABSTRACT FROM AUTHOR]

Background and Objectives Materials and Methods Results Conclusion To develop key performance indicators (KPI) for use in quality assessment of our institutional goal‐directed massive transfusion (GDMT).A team comprising our transfusion and emergency medicine departments carried out a cross‐sectional data analysis of GDMT in adult patients from January 2021 to December 2022. The study was rooted in the Define, Measure, Analyse, Improve, Control (DMAIC) approach. Features of KPIs were (a) importance, (b) scientific soundness and (c) feasibility. Study parameters were defined and analysed using measures of central tendencies and benchmark comparison.Ninety‐two massive transfusion events occurred and 1405 blood components were used. Trauma was the leading cause, followed by postpartum haemorrhage and upper gastrointestinal bleeding. Appropriate GDMT activation was observed only in 43.47% of events. The turnaround time (TAT) was within the benchmark in 85.8% of events with an average of 16 ± 10 min. The average utilization of blood components was 20.5 (interquartile range [IQR] = 11.3) in the appropriate group and 5.5 (IQR = 4.25) in the inappropriate group with a wastage rate of 3.5%. Duration of activation was 6.19 ± 4.59 h, and the adherence to thromboelastography was 66.3%. Overall mortality was 45.65%, and the average duration of hospital stay was 6.1 ± 5.9 days.The KPIs developed were easy to capture, and the analysis provided a comprehensive approach to the quality improvement of the GDMT protocol. [ABSTRACT FROM AUTHOR]

This document is a guideline published by the British Society for Haematology on the measurement of heparin, direct oral anticoagulants, and other non-coumarin anticoagulants and their effects on laboratory assays. The guideline provides recommendations for healthcare professionals in the UK based on the latest literature. It discusses the different types of anticoagulants, their modes of measurement, and the impact they have on laboratory tests. The document also addresses pre-analytical considerations and the neutralization of anticoagulant activity prior to haemostasis testing. [Extracted from the article]

Purpose To analyze the appropriateness of triple-antithrombotic therapy based on the 2020 American College of Cardiology (ACC) consensus statement while evaluating safety outcomes for patients with respect to adverse events. Methods A single-center, retrospective chart review was conducted using electronic medical records from December 18, 2020, to August 31, 2022. The primary endpoint was the rate of appropriateness for triple-antithrombotic therapy in patients discharged from Ochsner LSU Health Shreveport. Appropriateness was a composite endpoint extrapolated from the 2020 ACC consensus statement. For therapy to be defined as appropriate, patients had to have had the correct therapy indication, medications, dosing, and 30-day duration. Secondary safety endpoints included the percentage of patients rehospitalized at 14 and 30 days, the rate of major bleeding events, and the percentage of patients on gastrointestinal prophylaxis while on triple-antithrombotic therapy. Results A total of 93 patients were included in the study, of whom 31 (33%) received appropriate triple-antithrombotic therapy. Prolonged duration of triple-antithrombotic therapy was the most common reason that therapy did not meet the primary endpoint. The readmission rate due to bleeding was 2.2% at 14 days and 6.5% at 30 days. Within 30 days of initiation of triple therapy, 4.3% of patients endured major bleeding as defined by the International Society on Thrombosis and Hemostasis and 2 patients died. Conclusion In this single-center study, triple-antithrombotic therapy appropriately adhered to the 2020 ACC consensus statement for one-third of patients discharged on this therapy. [ABSTRACT FROM AUTHOR]

Background/Aims: The incidence of acute gastrointestinal bleeding (GIB) increases with the utilization of anticoagulant and nonsteroidal anti-inflammatory drugs (NSAIDs). This study aimed to compare the risk of GIB between anticoagulant and NSAIDs combotherapy and anticoagulant monotherapy in real-world practice. Methods: We investigated the relative risk of GIB in individuals newly prescribed anticoagulant and NSAIDs combination therapy and that in individuals newly prescribed anticoagulant monotherapy at three hospitals using “common data model.” Cox proportional hazard models and Kaplan-Meier estimation were employed for risk comparison after propensity score matching. Results: A comprehensive analysis of 2,951 matched pairs showed that patients who received anticoagulant and NSAIDs combousers exhibited a significantly higher risk of GIB than those who received anticoagulant monousers (hazard ratio [HR], 1.66; 95% confidence interval [CI], 1.30 to 2.12; p<0.001). The risk of GIB associated with anticoagulant and NSAIDs combination therapy was also significantly higher than that associated with anticoagulant monotherapy in patients aged >65 years (HR, 1.53; 95% CI, 1.15 to 2.03; p=0.003) and >75 years (HR, 1.89; 95% CI, 1.23 to 2.90; p=0.003). We also found that the risk of GIB was significantly higher in the patients who received anticoagulant and NSAIDs combousers than that in patients who received anticoagulant monousers in both male (p=0.016) and female cohorts (p=0.010). Conclusions: The risk of GIB is significantly higher in patients who receive anticoagulant and NSAIDs combotherapy than that in patients who receive anticoagulant monotherapy. In addition, the risk of GIB associated with anticoagulant and NSAIDs combotherapy was much higher in individuals aged >75 years. Therefore, physicians should be more aware of pay more attention to the risk of GIB when they prescribe anticoagulant and NSAIDs. [ABSTRACT FROM AUTHOR]

Background/Aims: Early studies on direct oral anticoagulants (DOACs) reported a higher risk of gastrointestinal bleeding (GIB) compared with warfarin; however, recent studies have reported a reduced risk. Therefore, this study was designed to evaluate the risk of GIB in users of DOAC and warfarin. Methods: Using a common data model, we investigated the comparative risk of GIB in subjects from eight hospitals who were newly prescribed DOACs or warfarin. We excluded subjects who had a prior history of GIB or had been prescribed both medications. After propensity score matching, we analyzed 3,347 matched pairs of new DOAC and new warfarin users. Results: The risk of GIB in new DOAC users was comparable to that in new warfarin users (hazard ratio [HR], 0.95; 95% confidence interval [CI], 0.65 to 1.40; p=0.808). New DOAC users had a similar risk of GIB to new warfarin users among older patients >65 years (HR, 1.00; 95% CI, 0.69 to 1.52; p=0.997) and in older patients >75 years (HR, 1.21; 95% CI, 0.68 to 2.10; p=0.509). In addition, the risk of GIB was not significantly different between two groups according to sex. We also found that the risk of GIB in DOAC users was 26% lower in edoxaban or apixaban subgroups compared to rivaroxaban or dabigatran subgroups (HR, 0.74; 95% CI, 0.69 to 1.00; p=0.049). Conclusions: In real-world practice, the risk of GIB in new DOAC users is comparable to that in new warfarin users. In DOAC users, the risk of GIB was lower in edoxaban or apixaban subgroups than rivaroxaban or dabigatran subgroups. [ABSTRACT FROM AUTHOR]

Objectives:We aimed to study the impact of gout as a correlative risk factor in the incidence of acute myocardial infarction (AMI) among patients without known MI risk factors. Our study population was obtained from the National Inpatient Sample (NIS) 2011-2018 using the International Classification of Diseases, Ninth and Tenth Revisions. Methods: This study included patients without cardiovascular disease (CVD), and various outcomes were compared among patients with and without gout. Cohorts were weighted using an algorithm provided by the NIS, which allows for national estimates. Our primary endpoint was the odds of developing an MI, and secondary endpoints were adverse hospital events and length of stay. In total, 117,261,842 patients without CVD risk factorswere included in this study, 187,619 (0.16%) of whom had a diagnosis of gout. Results: Patients without CVD risk factors who had gout were older and more likely to be male compared with patients without gout. Among patients without CVD risk factors, the odds of having an AMI were significantly higher in those with gout compared with those without, even after adjusting for chronic nonsteroidal anti-inflammatory drug and oral steroid use. Moreover, patients without CVD risk factors and with gout were more likely to develop acute renal failure, acute thromboembolic event, shock, acute gastrointestinal bleed, and arrhythmia compared with those without gout. Furthermore, patients without CVD risk factors who were admitted with gout had higher mortality compared with those without gout. Conclusions: In our study, we found that patients without risk factors forAMI who had goutwere more likely to develop AMI compared with those without gout. Furthermore, the same patients were more likely to develop other adverse outcomes. Even with proper management, these individuals should be monitored closely for coronary events. [ABSTRACT FROM AUTHOR]

Purpose: Ulcerative colitis (UC) is a serious health problem with increasing morbidity and prevalence worldwide. The pathogenesis of UC is complex, currently believed to be influenced by genetic factors, dysregulation of the host immune system, imbalance in the intestinal microbiota, and environmental factors. Currently, UC is typically managed using aminosalicylates, immunosuppressants, and biologics as adjunctive therapies, with the risk of relapse and development of drug resistance upon discontinuation. Therefore, further research into the pathogenesis of UC and exploration of potential treatment strategies are necessary to improve the quality of life for affected patients. According to previous studies, Lactobacillus paracasei Jlus66 (Jlus66) reduced inflammation and may help prevent or treat UC. Methods: We used dextran sulfate sodium (DSS) to induce a mouse model of UC to assess the effect of Jlus66 on the progression of colitis. During the experiment, we monitored mouse body weight, food and water consumption, as well as rectal bleeding. Hematoxylin-eosin staining was performed to assess intestinal pathological damage. Protein imprinting and immunohistochemical methods were used to evaluate the protein levels of nuclear factor-kappa B (NF-κB), mitogen-activated protein kinase (MAPK), and tight junction (TJ) proteins in intestinal tissues. Fecal microbiota was analyzed based on partial 16S rRNA gene sequencing. Results: Jlus66 supplementation reduced the degree of colon tissue damage, such as colon shortening, fecal occult blood, colon epithelial damage, and weight loss. Supplementation with Jlus66 reduced DSS-induced upregulation of cytokine levels such as TNF-α, IL-1β, and IL-6 (p < 0.05). The NF-κB pathway and MAPK pathway were inhibited, and the expression of TJ proteins (ZO-1, Occludin, and Claudin-3) was upregulated. 16S rRNA sequencing of mouse cecal contents showed that Jlus66 effectively regulated the structure of the intestinal biota. Conclusion: In conclusion, these data indicate that Jlus66 can alter the intestinal biota and slow the progression of UC, providing new insights into potential therapeutic strategies for UC. [ABSTRACT FROM AUTHOR]

The article discusses a 2024 study on the attitudes of patients 65 years and older on the use of routine clinical data in making treatment decisions. Results show participants' interest in such data and in how drugs work for them, and their concerns on confounders like populations' similarity of conditions with them, and on common minor side effects. Also noted are participants' common view that their physicians determine the evidence's applicability to them, and recommend a medication.

• Direct oral anticoagulants (DOACs) are widely used for cancer-associated venous thromboembolism. • It is unclear whether DOACs are safe for gastrointestinal (GI) cancer in the real-world setting. • Upper GI cancer, but not lower GI cancer, was associated with a higher risk for major bleeding. • Unresected upper GI cancer may have a higher risk for major bleeding than non-GI cancer. Direct oral anticoagulants (DOACs) have become widely used for cancer-associated venous thromboembolism (VTE). However, DOAC-associated bleeding complications remain challenging, especially in patients with gastrointestinal (GI) cancer. This study aimed to compare the bleeding outcomes between patients with upper or lower GI cancers and those without GI cancer. Using the COMMAND VTE Registry-2 database, which is a multicenter registry enrolling 5197 consecutive acute symptomatic VTE patients among 31 centers in Japan between January 2015 and August 2020, we identified 1149 active cancer patients with DOACs (upper GI cancer: N = 88; lower GI cancer: N = 114; non-GI cancer: N = 947). The primary outcome was major bleeding during anticoagulation therapy, which was evaluated in the competing risk regression model. The upper GI cancer group had a lower mean body weight, and most often had anemia. The cumulative 5-year incidence of major bleeding was higher in the upper GI cancer group (upper GI cancer: 22.4 %, lower GI cancer: 15.4 %, and non-GI cancer: 11.6 %, P = 0.015). The most frequent major bleeding site in the upper GI cancer group was the upper GI (53 %), followed by the lower GI (24 %). After adjusting for the confounders, the excess risk in upper GI cancer relative to non-GI cancer remained significant for major bleeding (adjusted subhazard ratio, 2.25; 95 %CI, 1.31–3.87, P = 0.003), but that in lower GI cancer was insignificant. Upper GI cancer, but not lower GI cancer, as compared to non-GI cancer was associated with a higher risk for major bleeding during anticoagulation therapy with DOACs. Clinical Trial Registration: URL: http://www.umin.ac.jp/ctr/index.htm Unique identifier: UMIN000044816. CI, confidence interval [Display omitted] [ABSTRACT FROM AUTHOR]

Objectives: Upper gastrointestinal bleeding (GIB) in patients has been well-characterized in liver cirrhosis but studies on lower GIB are limited. The clinical characteristics, management and outcomes in patients with and without liver cirrhosis was compared to determine the overall features of GIB in patients with liver cirrhosis compared with non-cirrhotics. Methods: A retrospective study on cirrhotics hospitalized for GIB 2010–2021, matched with control group of non-cirrhotics (1:4) for upper vs. lower GIB. Patients with overt bleeding leading to hospitalization were included. Results: Overall, 396 patients had cirrhosis, 267 (67%) men, median age 62, alcoholic etiology 177/396 (45%), median MELD 12 (range 6–32). Overall 102 cirrhotics had GIB, matched with 391 non-cirrhotics. Overall 87 (85%) cirrhotic patients had upper and 15% lower GIB. Compared to non-cirrhotics, the cause of GIB was more commonly acute variceal bleeding (AVB) (42% vs. 1%), hemorrhoids 40% vs. 6% (p = 0.002), less commonly gastric ulcer 13% vs. 31% (p < 0.001), duodenal ulcer 9% vs. 29% (p < 0.001), 5% of cirrhotics used NSAIDs vs. 26% of controls (p < 0.001). Rebleeding occurred in 14% of cirrhotics vs. 3% in controls (p < 0.001). Only one cirrhotic patient (1%) died from GIB vs. 0.8% of controls within 45 days. Overall mortality 45 days after hospitalization was 10% in cirrhotics vs. 5% in controls (p < 0.001) Conclusions: Bleeding from gastric and duodenal ulcers were less common in cirrhotics than in controls. Bleeding from hemorrhoids was more common in cirrhotics. Mortality due to GIB was low in both groups but overall mortality was significantly higher in cirrhotics. [ABSTRACT FROM AUTHOR]

Background: There is a discrepancy in the surgical and endoscopic literature for managing duodenal perforations. Although often managed conservatively, surgical repair is the standard treatment for duodenal perforations. This contrasts with the gastroenterology literature, which now recommends endoscopic repair of duodenal perforations, which are more frequently iatrogenic from the growing field of advanced endoscopic procedures. This study aims to provide a scoping review to summarize the current literature content and quality on endoscopic repair of duodenal perforations. Methods: The protocol for performing this scoping review was outlined by the Joanna Briggs Institute. All studies that reported primary outcomes of patients who had undergone endoscopic repair of duodenal perforations before February 2022, regardless of perforation etiology or repair type were reviewed, with studies after 1999 meeting inclusion criteria. The study excluded articles that did not report clinical outcomes of endoscopic repair, articles that did not describe where in the gastrointestinal tract the endoscopic repair occurred, pediatric patients, and animal studies. Results: 7606 abstracts were screened, with 474 full articles reviewed and 152 studies met inclusion criteria. 560 patients had duodenal perforations repaired endoscopically, with a technical success rate of 90.4% and a survival rate of 86.7%. Most of these perforations (74.5%) were iatrogenic from endoscopic procedures or surgery. Only one randomized control trial (RCT) was found, and 53% of studies were case reports. Conclusion: These results suggest that endoscopic repair could emerge as a viable first-line treatment for duodenal perforation and highlight the need for more high-quality research in this topic. [ABSTRACT FROM AUTHOR]

Background: The sleeve gastrectomy (SG) has become the most common bariatric procedure worldwide. However, insufficient weight loss or weight recidivism is frequent, which may require effective and safe revisional procedures. Objective: To determine the technical feasibility and safety of a minimally invasive, duodeno-ileal side-to-side anastomosis using a Sutureless Neodymium Anastomosis Procedure (SNAP) for patients with weight recidivism or inadequate weight loss following SG. Methods: This is a prospective, single-arm, open-label pilot study that enrolled patients with obesity to assist in weight reduction following an SG performed > 12 months prior. For the SNAP, self-assembling magnets were deployed into the ileum (laparoscopically) and duodenum (per-oral endoscopy). Magnets were coupled under laparoscopic and fluoroscopic guidance to create a compression anastomosis. The primary endpoints were technical feasibility, weight loss, and rate of serious adverse events (SAEs). Results: Successful duodeno-ileal diversions were created with SNAP in 27 participants (mean age: 50.6 ± 9.1, mean BMI: 38.1 ± 4.6 kg/m2) with no device-related serious adverse events. Upper endoscopy at 3 months confirmed patent, healthy anastomoses in all patients. At 9 months, patients (n = 24) experienced 11.9 ± 6.2%, 14.5 ± 10.8%, and 17.0 ± 13.9% TBWL at 3, 6, and 9 months, respectively. There were no device-related SAEs. Conclusion: The SNAP is technically feasible and relatively safe, with all patients presenting widely patent anastomosis at 3 months. Patients experienced a progressive, clinically meaningful weight loss. Further studies are needed to confirm our findings. [ABSTRACT FROM AUTHOR]

This article explores the use of transesophageal echocardiography (TEE) during advanced cardiac life support (ACLS) to enhance the effectiveness of cardiopulmonary resuscitation (CPR). TEE allows for continuous monitoring and improved imaging during CPR, potentially optimizing chest compression quality. However, there is limited evidence on the impact of TEE on patient outcomes. A recent study suggests that avoiding aortic valve compression during CPR may improve the likelihood of achieving and sustaining return of spontaneous circulation (ROSC). Further research is needed to determine long-term outcomes and potential biases in evaluating TEE findings. The article proposes that incorporating TEE as a surrogate for chest compression performance could be beneficial, but more rigorous studies are necessary to demonstrate its effectiveness in improving survival and neurological outcomes. The text also briefly touches on the management of aneurysmal subarachnoid hemorrhage, highlighting the variability in thresholds and triggers for fluid loading and blood transfusions. [Extracted from the article]

Background First-line over-the-scope (OTS) clip treatment has shown higher efficacy than standard endoscopic therapy in acute nonvariceal upper gastrointestinal bleeding (NVUGIB) from different causes. We compared OTS clips with through-the-scope (TTS) clips as first-line mechanical treatment in the specific setting of peptic ulcer bleeding. Methods We conducted an international, multicenter randomized controlled trial on consecutive patients with suspected NVUGIB. Patients with Forrest Ia–IIb gastroduodenal peptic ulcer were randomized 1:1 to OTS clip or TTS clip treatment. The primary outcome was the rate of 30-day rebleeding after successful initial hemostasis. Secondary outcomes included the rates of successful initial hemostasis and overall clinical success, defined as the composite of successful initial hemostasis and no evidence of 30-day rebleeding. Results 251 patients were screened and 112 patients were randomized to OTS (n = 61) or TTS (n = 51) clip treatment. The 30-day rebleeding rates were 1.6% (1/61) and 3.9% (2/51) in patients treated with OTS clips and TTS clips, respectively (Kaplan–Meier log-rank, P = 0.46). Successful initial hemostasis rates were 98.4% (60/61) in the OTS clip group and 78.4% (40/51) in the TTS clip group (P = 0.001). Overall clinical success rates were 96.7% (59/61) with OTS clips and 74.5% (38/51) with TTS clips (P = 0.001). Conclusions Low rates of 30-day rebleeding were observed after first-line endoscopic treatment of acute peptic ulcer bleeding with either OTS or TTS clips. However, OTS clips showed higher efficacy than TTS clips in achieving successful initial hemostasis and overall clinical success. [ABSTRACT FROM AUTHOR]

This prospective study describes the occurrence, morphology and localisation of type 1 abomasal ulcers (AU1) in various diseases of buffaloes and cattle. The carcasses were examined to confirm the cause of death. The abomasa were examined for AU1 and their characteristics. The AU1 were categorised into four subtypes, 1a, 1b, 1c and 1d, as per standard procedure. Traumatic reticuloperitonitis/pericarditis, reticular diaphragmatic hernia, intestinal obstruction, peritonitis, bronchopneumonia and theileriosis were the common causes for AU1. The overall prevalence of AU1 was 62.9%, which did not differ significantly with species and age. The prevalence of acute ulcers (1a and 1b) was significantly higher than that of chronic ulcers (1c and 1d). Most AU1 were located in the caudal third of abomasal body on parietal surface along the greater curvature. Most of the 1a ulcers were located in the pylorus, while 1b, 1c and 1d were located in the abomasal body. The overall prevalence of AU1 was lower (P<0.05) in the fundus than in other anatomical regions of the abomasum. Type 1b ulcers were more numerous than other subtypes. It was concluded that AU1 may be an important cause of slow recovery/poor prognosis under clinical situations and hence, the therapy protocol for such cases should include treatment for probable gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Summary This study aimed to evaluate the efficacy and safety of duodenal–jejunal bypass liner (DJBL) for obesity and type 2 diabetes mellitus. A comprehensive search of electronic databases was conducted up to September 15, 2022. Thirty studies involving 1751 patients were included. At 12 months post‐implantation, the reduction in body mass index (BMI) was 4.8 kg/m2 (95% CI 4.1, 5.5), with an excess weight loss of 41.3% (95% CI 33.4%,49.2%) and a total weight loss of 13.1% (95% CI 10.1%, 16.0%). Significant decrease was observed in HbA1c and fasting glucose, with a standardized mean difference of − 0.72 (95% CI − 0.95, − 0.48) and − 0.62 (95% CI − 0.82, − 0.42), respectively. However, these improvements in weight loss and glycemic control were only partially sustained after explantation. In situ, DJBL significantly improves blood pressure and lipid levels. The pooled early removal rate was 19%, and the incidence of severe adverse events was 17%, including device migration (6%), gastrointestinal hemorrhage (4%), device obstruction (4%), and hepatic abscess (2%). DJBL offers significant improvement in weight loss and glycemic control, as well as cardiovascular parameters while in situ. Further studies are warranted to better understand the long‐term efficacy and safety of DJBL. The benefits of DJBL need to be carefully weighed against the risks in clinical decision‐making. [ABSTRACT FROM AUTHOR]

Cases and studies of protruding early gastric cancer (EGC) combined with spontaneous bleeding are relatively rare. The current study present a female patient aged 70 to 75 years old with hemorrhagic shock caused by spontaneous bleeding from EGC type 0-Isp, which was successfully cured by rapid emergency endoscopic submucosal dissection (ESD). [ABSTRACT FROM AUTHOR]

Background: Portal hypertensive enteropathy (PHE) is a small-bowel lesion observed in patients with portal hypertension. The clinical significance of endoscopic findings in PHE remains unclear. We aimed to clarify the clinical significance and predictive factors of capsule endoscopic findings in patients with PHE based on long-term outcomes. Methods: This retrospective study enrolled 55 patients with PHE (33 males and 22 females; median age, 64 years; range, 23–87) followed for > 3 years using capsule endoscopy (CE) between February 2009 and May 2023. We evaluated the clinical factors affecting PHE exacerbations and the effects of PHE exacerbations on gastrointestinal bleeding by comparing exacerbated and unchanged PHE groups. Results: Overall, 3 (5%) patients showed improvement, 33 (60%) remained unchanged, and 19 (35%) showed exacerbation on follow-up CE. In the exacerbated group, the rates of worsened fibrosis-4 index, exacerbated esophageal varices, and exacerbated portal hypertensive gastropathy were significantly higher than those in the unchanged group (21%, 32%, and 42% vs. 3%, 6%, and 12%, respectively; P < 0.05), and the rate of splenectomy was significantly lower in the exacerbated group than in the unchanged group (5% vs. 39%, respectively; P < 0.01). In multivariate analysis, exacerbation of esophageal varices and absence of splenectomy were significantly associated with PHE exacerbation. The rate of gastrointestinal bleeding after follow-up CE was significantly high in the exacerbated group (log-rank, P = 0.037). Conclusions: Exacerbation of esophageal varices and splenectomy were significantly associated with exacerbation of PHE. Exacerbated PHE requires specific attention to prevent gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Background: Echinocandins belong to the fourth generation of antifungals, and there are no systematic studies on their risk in coagulation dysfunction; this study will predict the risk of coagulation dysfunction of echinocandins using the US Food and Drug Administration Adverse Event Reporting System (FAERS) database. Method: Data from January 2004 to March 2024 were obtained from FAERS. We examined the clinical characteristics of the coagulation dysfunction events and conducted disproportionality analysis by using reporting odds ratios (ROR) to compare echinocandins with the full database. Results: There were 313 reports of coagulation dysfunction related to echinocandins as the primary suspect (PS) drug. The median time to incident for coagulation dysfunction was 3 (interquartile range [IQR] 1–9) days. Compared to triazoles and polyenes, echinocandins have a stronger signal (ROR 3.18, 95%CI 2.81–3.51, p < 0.01) of coagulation dysfunction. Compared to caspofungin and micafungin, anidulafungin has a stronger signal (ROR 6.84, 95%CI 4.83–9.70, p < 0.01). The strongest signal corresponding to disseminated intravascular coagulation (DIC), platelet count decreased, thrombocytopenia, gastrointestinal haemorrhage, cerebral haemorrhage, pulmonary haemorrhage and thrombotic thrombocytopenic purpura (TTP) is micafungin (ROR 27.19, 95%CI 18.49–39.98), micafungin (ROR 3.50, 95%CI 2.36–5.19), anidulafungin (ROR 9.75, 95%CI 5.22–18.19), micafungin (ROR 3.17, 95%CI 2.02–4.97), micafungin (ROR 4.95, 95%CI 2.81–8.72), caspofungin (ROR 20.76, 95%CI 11.77–36.59), micafungin (ROR 20.43, 95%CI 8.49–49.14), respectively. Conclusions: For coagulation dysfunction, we found stronger signals for echinocandins than triazoles and polyenes, and stronger signals for anidulafungin than micafungin and caspofungin. Coagulation parameters should be closely monitored while using the respective drugs. Highlights: Real world data were used to predict the risk of coagulopathy for three classes of drugs: echinocandins, triazoles, and polyenes. Real-world data were used to compare the risk of coagulopathy between caspofungin, micafungin, and anidulafungin. Different causes of coagulation dysfunction were analyzed by subgroups. [ABSTRACT FROM AUTHOR]

Simple Summary: Both a real-world meta-analysis and our multicenter retrospective analysis suggest that omitting esophagogastroduodenoscopy (EGD) in specific hepatocellular carcinoma (HCC) patients is a safe and cost-effective strategy for those undergoing atezolizumab with bevacizumab (A+B), without leading to an elevated risk of bleeding complications. In our study, conducted in Canadian centers during the early access period of A+B, 30% of patients did not undergo pre-treatment EGD. This clinical decision was often based on the absence of cirrhosis, significant thrombocytopenia, or a low likelihood of portal hypertension, as assessed by their physicians. Despite the absence of standardized guidelines and the use of an individualized approach to EGD screening, patients did not experience negative treatment outcomes or worse survival. Our data also indicated that bleeding complications associated with A+B treatment are predominantly non-GI in nature. There may be several reasons not to use EGD routinely in this setting, which include a balance between patient risks and healthcare resources. EGD is an invasive procedure that requires sedation and carries a small risk of complications, along with potential discomfort and anxiety. The limited availability of expert endoscopists' time could also lead to significant delays in initiating effective therapy in the advanced HCC setting where A+B has been shown to prolong life. The IMbrave150 trial established atezolizumab with bevacizumab (A+B) as standard care for hepatocellular carcinoma (HCC), recommending an esophagogastroduodenoscopy (EGD) within 6 months of treatment initiation to prevent bleeding from esophagogastric varices. The necessity of mandatory EGD for all patients remains unclear. We retrospectively analyzed 112 HCC patients treated with A+B at five Canadian cancer centers from 1 July 2020 to 31 August 2022. A+B was the first-line therapy for 90% of patients, with median overall survival at 20.3 months and progression-free survival at 9.6 months. There was no survival difference between patients with bleeding and those without. Before A+B, 71% (n = 79) of patients underwent an EGD within 6 months, revealing varices in 41% (n = 32) and requiring intervention in 19% (n = 15). The overall bleeding rate was 15% (n = 17), with GI-specific bleeding occurring in 5% (n = 17). In the EGD group, GI-specific bleeding was 6% (n = 5) while in the non-EGD group, it was 3% (n = 1). Non-GI bleeding was observed in 10% (n = 11) of patients. Outcomes for HCC patients treated with A+B in Canada were comparable to IMbrave150. There was no increase in GI bleeding in patients without pre-treatment EGD, possibly supporting a selective EGD approach. [ABSTRACT FROM AUTHOR]

Background: Concomitant use of clopidogrel and proton pump inhibitor (PPI) is common, but PPI may reduce the antiplatelet effects of clopidogrel in patients undergoing percutaneous coronary intervention (PCI). We evaluated the impact of PPI use on clinical outcomes in post-PCI patients, by incorporating P2Y12 reaction unit (PRU) and CYP2C19 genotyping results. Methods: From a multicenter registry of patients who underwent PCI with drug-eluting stent implantation and received clopidogrel-based dual antiplatelet therapy (DAPT), patients who were prescribed a PPI at the time of PCI (PPI users) were compared to those who were not (non-users). The primary outcome included all-cause death, myocardial infarction, stent thrombosis, or cerebrovascular accident at 12 months. Major bleeding (Bleeding Academic Research Consortium [BARC] types 3–5) and gastrointestinal (GI) bleeding (BARC types 3–5) were important secondary outcomes. The adjusted outcomes were compared using a 1:1 propensity-score (PS) matching and competing risk analysis. Results: Of 13,160 patients, 2,235 (17.0%) were prescribed PPI, with an average age of 65.4 years. PPI users had higher on-treatment PRU levels than non-users. After PS matching, the primary outcome occurred in 51 patients who were PPI users (cumulative incidence, 4.7%) and 41 patients who were non-users (cumulative incidence, 3.7%; log-rank p = 0.27). In carriers of both CYP2C19 loss-of-function alleles, PPI use was linked to an increased risk of the primary outcome (hazard ratio, 3.22; 95% confidence interval, 1.18–8.78). The incidence of major bleeding and GI bleeding (BARC types 3–5) was comparable between PPI users and non-users in the PS-matched cohort. Conclusions: In post-PCI patients receiving clopidogrel-based DAPT, PPI use was not linked to an increased risk of adverse cardiac and cerebrovascular events, but there was a small but significant increase in on-treatment PRU. Future research using a more individualized approach would further elucidate these interactions and guide evidence-based clinical practices. [ABSTRACT FROM AUTHOR]

Background: Heterotopic gastric mucosa (HGM) can be located in various parts of the gastrointestinal tract. As a rare anomaly in the small intestine, it can become complicated by intussusception, obstruction, gastrointestinal bleeding, and even peritonitis, leading to death. Case presentation: This case report focuses on a 12-year-old Middle Eastern boy who presented with hematochezia and abdominal pain for a couple of days. A tagged Red blood cell (RBC) scan and Technetium scan revealed gastrointestinal bleeding at the lower abdomen, highly suggestive of the diagnosis of Meckel's diverticulum. Subsequently, exploratory laparotomy revealed contiguous and scattered mucosal lesions with multiple polyps of various sizes in the terminal ileum. Meckel's diverticulum was absent, and the patient was treated with resection and primary anastomosis. The resected tissue revealed extensive ectopic gastric mucosa and polypoid tissues. The patient recovered uneventfully and was discharged four days after the surgery. The symptoms did not recur within six months after his surgery. Conclusion: Our case demonstrated that despite the rarity of multiple polypoid gastric heterotopias in the terminal ileum, it should be considered as one of the differential diagnoses of gastrointestinal tract bleeding. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusion The impact of chronic oral anticoagulant (OACs) use on long‐term post‐discharge outcomes after coronavirus disease 2019 (COVID‐19) hospitalisation remains unclear. Herein, we compared clinical outcomes up to 2‐years after COVID‐19 hospitalisation between patients on vitamin K antagonists (VKAs), direct‐acting OACs (DOACs) and no OAC therapy.Data from TriNetX, a global federated health research network, were used. Adult patients on VKAs, DOACs or no OAC therapy at diagnosis of COVID‐19 between 20 January 2020 and 31 December 2021, who were hospitalised for COVID‐19, were included. The primary outcomes were all‐cause mortality, ischaemic stroke/transient ischaemic attack (TIA)/systemic embolism (SE) and the composite of intracranial haemorrhage (ICH)/gastrointestinal bleeding, at 2 years after COVID‐19 hospitalisation.We included 110,834 patients with COVID‐19. Following propensity score matching (PSM), we identified a decreased mortality risk in DOAC‐treated patients compared to the no OAC cohort (RR .808, 95% CI .751–.870). A higher risk of ischaemic stroke/TIA/SE was observed in VKA users compared to DOAC users (RR 1.100, 95% CI 1.020–1.220) and in VKA users compared to patients not taking OAC (RR 1.400, 95% CI 1.140–1.720). VKA use was associated with a greater risk of ICH/gastrointestinal bleeding than DOAC users (RR 1.198, 95% CI 1.066–1.347), while DOAC users had a lower risk compared to no OAC‐treated patients (RR .840, 95% CI .754–.936).COVID‐19 patients taking prior DOACs were associated with lower long‐term mortality risk and ICH/gastrointestinal bleeding than patients not taking OAC. Compared to patients on DOACs, VKA users were associated with higher risks of mortality, ischaemic stroke/TIA/SE and ICH/gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Background Methods Results Conclusions Pre‐left ventricular assist device (LVAD) pectoralis muscle assessment, an estimate of sarcopenia, has been associated with postoperative mortality and gastrointestinal bleeding, though its association with inflammation, endotoxemia, length‐of‐stay (LOS), and readmissions remains underexplored.This was a single‐center cohort study of LVAD patients implanted 1/2015–10/2018. Preoperative pectoralis muscle area was measured on chest computed tomography (CT), adjusted for height squared to derive pectoralis muscle area index (PMI). Those with PMI in the lowest quintile were defined as low‐PMI cohort; all others constituted the reference cohort. Biomarkers of inflammation (interleukin‐6, adiponectin, tumor necrosis factor‐α [TNFα]) and endotoxemia (soluble (s)CD14) were measured in a subset of patients.Of the 254 LVAD patients, 95 had a preoperative chest CT (median days pre‐LVAD: 7 [IQR 3–13]), of whom 19 (20.0%) were in the low‐PMI cohort and the remainder were in the reference cohort. Compared with the reference cohort, the low‐PMI cohort had higher levels of sCD14 (2594 vs. 1850 ng/mL; p = 0.04) and TNFα (2.9 vs. 1.9 pg/mL; p = 0.03). In adjusted analyses, the low‐PMI cohort had longer LOS (incidence rate ratio 1.56 [95% confidence interval 1.16–2.10], p = 0.004) and higher risk of 90‐day and 1‐year readmissions (subhazard ratio 5.48 [1.88–16.0], p = 0.002; hazard ratio 1.73 [1.02–2.94]; p = 0.04, respectively).Pre‐LVAD PMI is associated with inflammation, endotoxemia, and increased LOS and readmissions. [ABSTRACT FROM AUTHOR]

Background Patients with chronic kidney disease (CKD) and atrial fibrillation (AF) on oral anticoagulants (OACs) are at high risk of bleeding. Determinants of major bleeding risk in OAC users with AF and CKD are not well established and available bleeding score systems do not perform well in CKD. This study aims to present risk factors associated with major bleeding in a Swedish cohort of OAC-treated patients with CKD G3–5D. Methods We conducted a Swedish register-based cohort study including patients with AF and CKD G3–5D on warfarin or direct OACs (DOACs) between 2009 and 2018. Data were collected from high-quality registers including the Swedish Renal Registry and Auricula, a register for AF and OACs. Risk factors for major bleeding were investigated with Cox regression analysis. Results Of 2453 included patients, 59% were on warfarin (time in therapeutic range 67%) and 41% on DOACs. Major bleeding rates were 8.9/100 patient-years. Factors associated with increased bleeding risk were glomerular filtration rate category, G5/5D versus G3 {hazard ratio [HR] 1.92 [95% confidence interval (CI) 1.43–2.56]}, previous gastrointestinal bleeding [HR 1.77 (95% CI 1.39–2.25)], previous other bleeding [HR 1.33 (95% CI 1.09–1.62)], congestive heart failure [HR 1.36 (95% CI 1.11–1.68)], male sex [HR 1.28 (95% CI 1.03–1.60)] and vascular disease [HR 1.35 (95% CI 1.01–1.79)]. Conclusion Patients with AF and G3–5D on OACs are at a high risk of bleeding. Previous major bleeding and kidney failure are strongly associated with major bleeding. The present study also shows an association between OAC-associated bleeding and male sex, congestive heart failure and vascular disease. Knowledge about determinants of bleeding in advanced CKD is essential when deciding on when to anticoagulate or not. [ABSTRACT FROM AUTHOR]

Background: The effectiveness of aspirin for the primary prevention of cerebro-cardiovascular diseases in Koreans remains unclear. Therefore, we evaluated the preventive effects of low-dose aspirin (equal or less than 100 mg) on cerebro-cardiovascular events. Method: We conducted a retrospective cohort study using the National Sample Cohort dataset. From the 1,106,580 individuals eligible in 2004, we selected 200 individuals (47% male and 22.5% aged 65 or older) who consistently received low-dose aspirin from 2004 to 2013 for inclusion in the aspirin cohort. Participants for the control cohort, who did not use aspirin, were selected through propensity score matching based on variables. Result: We compared the incidences of endpoints (acute myocardial infarction, cerebral infarction, gastrointestinal hemorrhage, and cerebral hemorrhage) between the aspirin group and the non-aspirin group over the 9-year follow-up period. There was no significant difference in the incidence rates of acute myocardial infarction, cerebral infarction, gastrointestinal hemorrhage, or cerebral hemorrhage between the aspirin and non-aspirin groups. Low-dose aspirin for primary prevention in Koreans did not reduce myocardial or cerebral infarctions and did not increase the risk of gastrointestinal or cerebral hemorrhage. Conclusion: Therefore, we suggest that aspirin for primary prevention should be used cautiously and tailored to the individual's baseline cardiovascular risk. [ABSTRACT FROM AUTHOR]

Summary: There are limited data on the optimal choice of anticoagulation in multiple myeloma (MM) patients receiving immunomodulatory drugs (IMiDs). We conducted a propensity score‐matched cohort study using the TriNetX database to compare the efficacy and safety of factor Xa inhibitors and warfarin in this patient population. Compared to warfarin, factor Xa inhibitors had a similar risk of deep vein thrombosis (hazard ratio [HR]: 1.11 [95% CI: 0.50–2.46]) or pulmonary embolism (HR: 1.08 [95% CI: 0.59–2.00]). There were no differences in the risk of gastrointestinal or intracranial bleeding. Factor Xa inhibitor‐treated patients had lower all‐cause mortality (HR: 0.56 [95% CI: 0.36–0.86]) compared with warfarin. These data suggest that factor Xa inhibitors had similar safety and efficacy compared with warfarin for MM patients on IMiDs. [ABSTRACT FROM AUTHOR]

Background: Treatment with atezolizumab and bevacizumab has become standard of care for advanced unresectable hepatocellular carcinoma (HCC) but carries an increased gastrointestinal bleeding risk. Therefore, patients are often required to undergo esophagogastroduodenoscopy (EGD) to rule out esophageal varices (EV) prior to initiating therapy, which can delay care and lead to unnecessary procedural risks and health care costs. In 2019, the EVendo score was created and validated as a noninvasive tool to accurately screen out patients who were at low risk for having EV that required treatment. We sought to validate whether the EVendo score could be used to accurately predict the presence of EV and varices needing treatment (VNT) in patients with HCC. Methods: This was a retrospective multicenter cohort study of patients with HCC from 9/2004 to 12/2021. We included patients who underwent EGDs within 1 year after their HCC diagnosis. We collected clinical parameters needed to calculate an EVendo score at the time of EGD and compared the EVendo model prediction to the gold standard endoscopic report in predicting presence of VNT. Results: 112 with HCC were recruited to this study, with 117 qualifying EGDs. VNT occurred in 39 (33.3%) patients. The EVendo score had a sensitivity of 97.4% and a negative predictive value of 96.9%, supporting the validity in applying EVendo in predicting VNT in HCC. Conclusion: In this study, we validated the use of the EVendo score in ruling out VNT in patients with HCC. The application of the EVendo score could safely defer about 30% of EGDs for EV screening in HCC patients. Although additional validation cohorts are needed, this suggests that EVendo score can potentially be applied in patients with HCC to avoid unnecessary EGDs, which can ultimately mitigate healthcare costs and delays in initiating HCC treatment with atezolizumab and bevacizumab. [ABSTRACT FROM AUTHOR]

Background: Sleeve gastrectomy (SG) increased in popularity after 2010 but recent data suggest it has concerning rates of gastroesophageal reflux and need for conversions. This study aims to evaluate recent trends in the utilization of bariatric procedures, associated complications, and conversions using an administrative claims database in the United States. Methods: We included adults who had bariatric procedures from 2000 to 2020 with continuous enrollment for at least 6 months in the MarketScan Commercial Claims and Encounters database. Index bariatric procedures and subsequent revisions or conversions were identified using CPT codes. Baseline comorbidities and postoperative complications were identified with ICD-9-CM and ICD-10 codes. Cumulative incidences of complications were estimated at 30-days, 6-months, and 1-year and compared with stabilized inverse probability of treatment weighted Kaplan–Meier analysis. Results: We identified 349,411 bariatric procedures and 5521 conversions or revisions. The sampled SG volume appeared to begin declining in 2018 while Roux-en-Y gastric bypass (RYGB) remained steady. Compared to RYGB, SG was associated with lower 1-year incidence [aHR, (95% CIs)] for 30-days readmission [0.65, (0.64–0.68)], dehydration [0.75, (0.73–0.78)], nausea or vomiting [0.70, (0.69–0.72)], dysphagia [0.55, (0.53–0.57)], and gastrointestinal hemorrhage [0.43, (0.40–0.46)]. Compared to RYGB, SG was associated with higher 1-year incidence [aHR, (95% CIs)] of esophagogastroduodenoscopy [1.13, (1.11–1.15)], heartburn [1.38, (1.28–1.49)], gastritis [4.28, (4.14–4.44)], portal vein thrombosis [3.93, (2.82–5.48)], and hernias of all types [1.36, (1.34–1.39)]. There were more conversions from SG to RYGB than re-sleeving procedures. SG had a significantly lower 1-year incidence of other non-revisional surgical interventions when compared to RYGB. Conclusions: The overall volume of bariatric procedures within the claims database appeared to be declining over the last 10 years. The decreasing proportion of SG and the increasing proportion of RYGB suggest the specific complications of SG may be driving this trend. Clearly, RYGB should remain an important tool in the bariatric surgeon's armamentarium. [ABSTRACT FROM AUTHOR]

Background and Aim: Effective clinical event classification is essential for clinical research and quality improvement. The validation of artificial intelligence (AI) models like Generative Pre‐trained Transformer 4 (GPT‐4) for this task and comparison with conventional methods remains unexplored. Methods: We evaluated the performance of the GPT‐4 model for classifying gastrointestinal (GI) bleeding episodes from 200 medical discharge summaries and compared the results with human review and an International Classification of Diseases (ICD) code‐based system. The analysis included accuracy, sensitivity, and specificity evaluation, using ground truth determined by physician reviewers. Results: GPT‐4 exhibited an accuracy of 94.4% in identifying GI bleeding occurrences, outperforming ICD codes (accuracy 63.5%, P < 0.001). GPT‐4's accuracy was either slightly lower or statistically similar to individual human reviewers (Reviewer 1: 98.5%, P < 0.001; Reviewer 2: 90.8%, P = 0.170). For location classification, GPT‐4 achieved accuracies of 81.7% and 83.5% for confirmed and probable GI bleeding locations, respectively, with figures that were either slightly lower or comparable with those of human reviewers. GPT‐4 was highly efficient, analyzing the dataset in 12.7 min at a cost of 21.2 USD, whereas human reviewers required 8–9 h each. Conclusion: Our study indicates GPT‐4 offers a reliable, cost‐efficient, and faster alternative to current clinical event classification methods, outperforming the conventional ICD coding system and performing comparably to individual expert human reviewers. Its implementation could facilitate more accurate and granular clinical research and quality audits. Future research should explore scalability, prompt and model tuning, and ethical implications of high‐performance AI models in clinical data processing. [ABSTRACT FROM AUTHOR]

INTRODUCTION: There is substantial variability in patient outcomes for gastrointestinal bleeding (GIB) across hospitals. This study aimed to identify hospital factors associated with GIB outcomes. METHODS: This was a retrospective cohort study of Medicare fee-for-service beneficiaries hospitalized for GIB from 2016 to 2018. These data were merged with the American Hospital Association Annual Survey data to incorporate hospital characteristics. We used generalized linear mixed-effect models to estimate the effect of hospital-level characteristics on patient outcomes after adjusting for patient risk factors including anticoagulant and antiplatelet use, recent GIB, and comorbidities. The primary outcome was 30-day mortality, and secondary outcomes included length of stay and a composite outcome of 30-day readmission or mortality. RESULTS: Factors associated with improved GIB 30-day mortality included large hospital size (defined as beds >400, odds ratio [OR] 0.93, 95% confidence interval [CI] 0.90-0.97), greater case volume (OR 0.97, 95% CI 0.96-0.98), increased resident and nurse staffing (OR 0.88, 95% CI 0.83-0.94), and blood donor center designation (OR 0.93, 95% CI 0.88-0.99). Patients treated at a hospital with multiple advanced capabilities, such as availability of advanced endoscopy, advanced intensive care unit (ICU) capabilities (both a medical-surgical ICU and cardiac ICU), blood donor center, and liver transplant center, had a 22% reduction in 30-day mortality risk, compared with those hospitalized in a hospital with none of these services (OR 0.78, 95% CI 0.68-0.91). However, length of stay increased with additional services. DISCUSSION: Patients hospitalized for GIB at hospitals with multiple advanced specialized capabilities have lower mortality but longer lengths of stay. Further research should examine the processes of care linked to these services that contribute to improved mortality in GIB. [ABSTRACT FROM AUTHOR]

Apixaban, rivaroxaban, and warfarin have shown benefit for preventing major ischemic events—albeit with increased bleeding risk—among patients in the general population with atrial fibrillation (AF). However, data are scarce in patients with cirrhosis and AF. This study compared the effectiveness and safety of apixaban versus rivaroxaban and versus warfarin in patients with cirrhosis and AF. Visual Abstract. Comparative Effectiveness and Safety of Apixaban, Rivaroxaban, and Warfarin in Patients With Cirrhosis and Atrial Fibrillation: A Nationwide Cohort Study Apixaban, rivaroxaban, and warfarin have shown benefit for preventing major ischemic events—albeit with increased bleeding risk—among patients in the general population with atrial fibrillation (AF). However, data are scarce in patients with cirrhosis and AF. This study compared the effectiveness and safety of apixaban versus rivaroxaban and versus warfarin in patients with cirrhosis and AF. Background: Apixaban, rivaroxaban, and warfarin have shown benefit for preventing major ischemic events, albeit with increased bleeding risk, among patients in the general population with atrial fibrillation (AF). However, data are scarce in patients with cirrhosis and AF. Objective: To compare the effectiveness and safety of apixaban versus rivaroxaban and versus warfarin in patients with cirrhosis and AF. Design: Population-based cohort study. Setting: Two U.S. claims data sets (Medicare and Optum's de-identified Clinformatics Data Mart Database [2013 to 2022]). Participants: 1:1 propensity score (PS)–matched patients with cirrhosis and nonvalvular AF initiating use of apixaban, rivaroxaban, or warfarin. Measurements: Primary outcomes included ischemic stroke or systemic embolism and major hemorrhage (intracranial hemorrhage or major gastrointestinal bleeding). Database-specific and pooled PS-matched rate differences (RDs) per 1000 person-years (PY) and Cox proportional hazard ratios (HRs) with 95% CIs were estimated, controlling for 104 preexposure covariates. Results: Rivaroxaban initiators had significantly higher rates of major hemorrhagic events than apixaban initiators (RD, 33.1 per 1000 PY [95% CI, 12.9 to 53.2 per 1000 PY]; HR, 1.47 [CI, 1.11 to 1.94]) but no significant differences in rates of ischemic events or death. Consistently higher rates of major hemorrhage were found with rivaroxaban across subgroup and sensitivity analyses. Warfarin initiators also had significantly higher rates of major hemorrhage than apixaban initiators (RD, 26.1 per 1000 PY [CI, 6.8 to 45.3 per 1000 PY]; HR, 1.38 [CI, 1.03 to 1.84]), particularly hemorrhagic stroke (RD, 9.7 per 1000 PY [CI, 2.2 to 17.2 per 1000 PY]; HR, 2.85 [CI, 1.24 to 6.59]). Limitation: Nonrandomized treatment selection. Conclusion: Among patients with cirrhosis and nonvalvular AF, initiators of rivaroxaban versus apixaban had significantly higher rates of major hemorrhage and similar rates of ischemic events and death. Initiation of warfarin versus apixaban also contributed to significantly higher rates of major hemorrhagic events, including hemorrhagic stroke. Primary Funding Source: National Institutes of Health. [ABSTRACT FROM AUTHOR]

The Canadian Association of Radiologists (CAR) Gastrointestinal Expert Panel consists of radiologists, a gastroenterologist, a general surgeon, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 20 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for one or more of these clinical/diagnostic scenarios. Recommendations from 58 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) for guidelines framework were used to develop 85 recommendation statements specific to the adult population across the 20 scenarios. This guideline presents the methods of development and the referral recommendations for dysphagia/dyspepsia, acute nonlocalized abdominal pain, chronic abdominal pain, inflammatory bowel disease, acute gastrointestinal bleeding, chronic gastrointestinal bleeding/anemia, abnormal liver biopsy, pancreatitis, anorectal diseases, diarrhea, fecal incontinence, and foreign body ingestion. [ABSTRACT FROM AUTHOR]

Background: CT angiography (CTA), a minimally invasive diagnostic technique, has become popular for looking into acute gastrointestinal hemorrhages. This study aimed to evaluate the validity of Computed tomography angiography (CTA) for diagnosis of the cause of acute GIB and its influence on treatment. Methods: This study was carried out in Radiodiagnosis Department, Faculty of Medicine, Zagazig University on 24 cases with acute GIB during the period from June 2023 to December 2023 on 24 patients who were acute GIB. Age > 18 years. Both male and female were included as a comprehensive sample. Results: The most frequent diagnoses detected by CT-angiography among patients were esophageal gastric varices which was detected among (75%) of the patients, while the least frequent diagnoses detected was pancreatic arteriovenous malformations in 25% of patients. There was no significant difference between bleeding type and age or gender (P>0.05). sensitivity of CT angiography in diagnoses bleeding compared to endoscopy is (92.3%), positive predictive value (PPV) is (63.2%), negative predictive value (NPV) is (80.0%), accuracy of Ct angiography in diagnoses bleeding compared to endoscopy is (66.7%). Conclusions: CT angiography is a valid, noninvasive method that is conveniently accessible. CT angiography has a high sensitivity in identifying the source of current bleeding. The results of CT angiography are useful in guiding the best course of treatment (directed endoscopic intervention, angiographic embolization, or surgery), as well as in determining when these treatments should be carried out [ABSTRACT FROM AUTHOR]

Background: Small bowel capsule endoscopy (SBCE) and device‐assisted enteroscopy (DAE) have an established role in the investigation and management of small bowel pathology. Previous studies have reported on the yield of SBCE (60%) and DAE (57%), but none have been in an Australian setting. Aims: To determine the yield of SBCE and any DAE performed as a direct consequence of SBCE in an Australian referral centre. Methods: A single‐centre retrospective study was conducted at a tertiary hospital in Australia, enrolling consecutive patients between 1 January 2009 and 31 December 2021 undergoing SBCE. Data were collected with respect to demographics, procedural factors and findings, as well as findings and interventions of any DAE procedures performed after the SBCE. Results: 1214 SBCEs were performed, with a median age of 66 years old (60.8% men). The predominant indications were anaemia (n = 853, 70.2%) and overt gastrointestinal bleeding (n = 320, 26.4%). Of the complete small bowel studies (1132/1214, 93.2%), abnormal findings were detected in 588 cases (51.9%), most commonly angioectasias (266/588, 45.2%), erosions (106/588, 18.0%) and ulcers (97/588, 8.6%). 165 patients underwent a DAE (117 antegrade, 48 retrograde). Antegrade DAE had a higher yield than retrograde DAE (77.8% vs 54.2%; P = 0.002) and a higher rate of intervention (69.2% vs 37.5%; P < 0.001). Conclusion: In this largest single‐centre cohort of patients undergoing SBCE to date, there is a similar yield of abnormal findings compared to existing literature. DAE, especially with an antegrade approach, had high diagnostic and therapeutic yield when pursued after a positive SBCE study. [ABSTRACT FROM AUTHOR]

RATIONALE: Critically ill adults can develop stress-related mucosal damage from gastrointestinal hypoperfusion and reperfusion injury, predisposing them to clinically important stress-related upper gastrointestinal bleeding (UGIB). OBJECTIVES: The objective of this guideline was to develop evidence-based recommendations for the prevention of UGIB in adults in the ICU. DESIGN: A multiprofessional panel of 18 international experts from dietetics, critical care medicine, nursing, and pharmacy, and two methodologists developed evidence-based recommendations in alignment with the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. Conflict-of-interest policies were strictly followed during all phases of guideline development including task force selection and voting. METHODS: The panel members identified and formulated 13 Population, Intervention, Comparison, and Outcome questions. We conducted a systematic review for each question to identify the best available evidence, statistically analyzed the evidence, and then assessed the certainty of the evidence using the GRADE approach. We used the evidence-to-decision framework to formulate the recommendations. Good practice statements were included to provide additional guidance. RESULTS: The panel generated nine conditional recommendations and made four good practice statements. Factors that likely increase the risk for clinically important stress-related UGIB in critically ill adults include coagulopathy, shock, and chronic liver disease. There is no firm evidence for mechanical ventilation alone being a risk factor. Enteral nutrition probably reduces UGIB risk. All critically ill adults with factors that likely increase the risk for stress-related UGIB should receive either proton pump inhibitors or histamine-2 receptor antagonists, at low dosage regimens, to prevent UGIB. Prophylaxis should be discontinued when critical illness is no longer evident or the risk factor(s) is no longer present despite ongoing critical illness. Discontinuation of stress ulcer prophylaxis before transfer out of the ICU is necessary to prevent inappropriate prescribing. CONCLUSIONS: The guideline panel achieved consensus regarding the recommendations for the prevention of stress-related UGIB. These recommendations are intended for consideration along with the patient's existing clinical status. [ABSTRACT FROM AUTHOR]

This article provides a summary of a guideline developed by the Society of Critical Care Medicine and the American Society of Health-System Pharmacists on the prevention of stress-related gastrointestinal bleeding in critically ill adults. The guideline offers evidence-based recommendations on the use of stress ulcer prophylaxis (SUP) in the ICU. The recommendations include administering enteral nutrition, providing SUP to patients with risk factors for gastrointestinal bleeding, and using proton pump inhibitors or histamine-2 receptor antagonists as first-line agents for SUP. The article also discusses the results of a meta-analysis on SUP in critically ill patients, which found that proton pump inhibitors were associated with a reduced risk of upper gastrointestinal bleeding compared to histamine-2 receptor antagonists, but there may be an increased risk of mortality. Sucralfate was found to be associated with a lower risk of pneumonia compared to proton pump inhibitors and histamine-2 receptor antagonists. However, there is no evidence supporting the concurrent use of sucralfate and acid suppressants for SUP. The article includes information about the authors and their affiliations, as well as disclosures of potential conflicts of interest. [Extracted from the article]

Key Clinical Message: Upper gastrointestinal bleeding due to primary aortoesophageal fistula is a rare clinical condition burdened with high mortality rate. However, the outcomes are closely related to the level of clinical awareness, the complementary and multidisciplinary approach during the diagnostic workup, and the selected treatment option. We present an atypical case of an aneurysm of the thoracoabdominal aorta complicated with primary aortoesophageal fistula (AEF). A 55‐year‐old male with no previous diseases, presented with prolonged and intense back pain and upper gastrointestinal bleeding. The gastroscopy detected an unusual culprit lesion in the distal esophagus resembling an esophageal wall defect, and the computed tomography revealed an aneurysm of the thoracoabdominal aorta, remarkable surrounding hematoma, and active contrast extravasation. Despite the urgent surgical repair, a lethal outcome occurred. AEF patients require high clinical awareness and complementary multidisciplinary approach in order to provide a rapid diagnosis and optimal treatment. [ABSTRACT FROM AUTHOR]

Purpose Transjugular intrahepatic portosystemic shunt (TIPS) is an established intervention for symptomatic portal hypertension, with many patients experiencing hepatic encephalopathy (HE) as an undesirable side effect. For medically refractory HE, TIPS reduction can decrease the burden of neurotoxic metabolites. This study aimed to evaluate the efficacy of TIPS reduction for the treatment of medically refractory post-TIPS HE. Methods A retrospective search using an institutional database yielded 45 patients who underwent TIPS reduction between 2011 and 2021. Four patients were excluded due to lack of post-TIPS HE, and 41 patients in total were included. The primary endpoint was improvement of HE after TIPS reduction as measured by the West Haven scores. Secondary endpoints included postreduction recurrence of ascites or gastrointestinal bleeding, procedural complications, and 30-day mortality. Results TIPS reduction was performed in all 41 patients with a 30-day mortality rate of 9.8%. No deaths were attributable to the procedure itself. Twenty-seven patients (65.9%) had improvement in HE and 10 patients (24.4%) proceeded to TIPS occlusion due to refractory HE. The average pre- and postreduction West Haven grades were 2.9 ± 0.5 and 1.9 ± 1.2 (p < 0.001), respectively. One patient (2.4%) had spontaneous TIPS thrombosis after reduction and developed arterial gastrointestinal bleeding, 15 patients (36.6%) experienced recurrent ascites, and there were no cases of variceal hemorrhage. Conclusion In this population, TIPS reduction improved medically refractory HE in 65.9% of patients with a 36.6% risk of recurrent ascites, no cases of variceal hemorrhage, and 9.8% 30-day mortality. [ABSTRACT FROM AUTHOR]

Background Pan-intestinal capsule endoscopy (PCE) evaluates the small bowel and colon noninvasively. This study evaluated diagnostic accuracy and safety of PCE vs. colonoscopy as first-line examination in suspected mid–lower gastrointestinal bleeding (MLGIB). Methods In this prospective, single-center, single-blinded cohort study, consecutive patients with suspected MLGIB underwent PCE followed by same-day colonoscopy. Diagnostic accuracy for potentially hemorrhagic lesions (PHLs; combined diagnosis by PCE + colonoscopy) and incidence of adverse events were assessed. Results 100 patients were included (median age 70 [range 18–92] years; 65% female). PHLs were diagnosed in 46 patients, including small-bowel and/or colon angioectasias in 32. PCE correctly identified 54 individuals without PHLs, and 95.7% (44/46) of those with PHLs vs. 50.0% (23/46) for colonoscopy (P<0.01). PHLs were detected by PCE alone in 65.2% (30/46), both examinations in 28.3% (13/46), and colonoscopy alone in 6.5% (3/46). PHLs were diagnosed at the ileocolonic region in 28% of patients, with PCE diagnosing 25/28 cases (89.3%) and colonoscopy diagnosing 23/28 (82.1%; P=0.13). Interventional procedures were performed at colonoscopy in 13/81 patients with iron-deficiency anemia (16.0%) vs. 6/19 patients with overt bleeding (31.6%; P<0.01). No significant adverse events occurred with PCE vs. 2% with colonoscopy. Conclusions In patients with MLGIB, PCE avoided further invasive procedures in >50% of patients. PCE was safe and more effective than colonoscopy in identifying PHL both in the small bowel and colon. These results support the potential use of PCE as first-line examination in patients with suspected MLGIB. [ABSTRACT FROM AUTHOR]

Background: Proton pump inhibitors (PPIs) are the most commonly prescribed drugs for preventing upper gastrointestinal bleeding in critically ill patients. However, concerns have arisen about the possible harms of using PPIs, including potentially increased risk of pneumonia, Clostridioides difficile infection, and more seriously, an increased risk of death in the most severely ill patients. Triggered by the REVISE trial, which is a forthcoming large randomized trial comparing pantoprazole to placebo in invasively mechanically ventilated patients, we will conduct this systematic review to evaluate the efficacy and safety of PPIs versus no prophylaxis for critically ill patients. Methods: We will systematically search randomized trials that compared gastrointestinal bleeding prophylaxis with PPIs versus placebo or no prophylaxis in adults in the intensive care unit (ICU). Pairs of reviewers will independently screen the literature, and for those eligible trials, extract data and assess risk of bias. We will perform meta‐analyses using a random‐effects model, and calculate relative risks for dichotomous outcomes and mean differences for continuous outcomes, and the associated 95% confidence intervals. We will conduct subgroup analysis to explore whether the impact of PPIs on mortality differs in more and less severely ill patients. We will assess certainty of evidence using the GRADE approach. Discussion: This systematic review will provide the most up‐to‐date evidence regarding the merits and limitations of stress ulcer prophylaxis with PPIs in critically ill patients in contemporary practice. [ABSTRACT FROM AUTHOR]

Introduction: Despite heightened risk of venous thromboembolism (VTE) in hospitalized patients with inflammatory bowel disease (IBD), pharmacologic prophylaxis remains underutilized, particularly in those presenting with hematochezia. Although placement of retrievable inferior vena cava filters (rIVCF) may be considered in those with contraindications to anticoagulation and VTE risk, current recommendations from clinical guidelines are incongruent, leading to wide variation in practice. Case Presentation: This report highlights a case of rIVCF used in the management of recurrent VTEs in a patient hospitalized for persistent gastrointestinal bleeding. Conclusion: Our case demonstrates the need for a lower threshold for initiating VTE prophylaxis in patients with active IBD, even when hematochezia is the presenting symptom. A small group of patients with recurrent VTE and clear contraindications to anticoagulation may require IVCFs, necessitating close follow-up and monitoring for filter complications. [ABSTRACT FROM AUTHOR]

Importance: Severe pulmonary infections, including COVID-19, community-acquired pneumonia, influenza, and Pneumocystis pneumonia, are a leading cause of death among adults worldwide. Pulmonary infections in critically ill patients may cause septic shock, acute respiratory distress syndrome, or both, which are associated with mortality rates ranging between 30% and 50%. Observations: Corticosteroids mitigate the immune response to infection and improve outcomes for patients with several types of severe pulmonary infections. Low-dose corticosteroids, defined as less than or equal to 400 mg hydrocortisone equivalent daily, can reduce mortality of patients with severe COVID-19, community-acquired pneumonia, and Pneumocystis pneumonia. A randomized clinical trial of 6425 patients hospitalized with COVID-19 who required supplemental oxygen or noninvasive or invasive mechanical ventilation reported that dexamethasone 6 mg daily for 10 days decreased 28-day mortality (23% vs 26%). A meta-analysis that included 7 randomized clinical trials of 1689 patients treated in the intensive care unit for severe bacterial community-acquired pneumonia reported that hydrocortisone equivalent less than or equal to 400 mg daily for 8 days or fewer was associated with lower 30-day mortality compared with placebo (10% vs 16%). In a meta-analysis of 6 randomized clinical trials, low-dose corticosteroids were associated with lower mortality rates compared with placebo for patients with HIV and moderate to severe Pneumocystis pneumonia (13% vs 25%). In a predefined subgroup analysis of a trial of low-dose steroid treatment for septic shock, patients with community-acquired pneumonia randomized to 7 days of intravenous hydrocortisone 50 mg every 6 hours and fludrocortisone 50 μg daily had decreased mortality compared with the placebo group (39% vs 51%). For patients with acute respiratory distress syndrome caused by various conditions, low-dose corticosteroids were associated with decreased in-hospital mortality (34% vs 45%) according to a meta-analysis of 8 studies that included 1091 patients. Adverse effects of low-dose corticosteroids may include hyperglycemia, gastrointestinal bleeding, neuropsychiatric disorders, muscle weakness, hypernatremia, and secondary infections. Conclusions and Relevance: Treatment with low-dose corticosteroids is associated with decreased mortality for patients with severe COVID-19 infection, severe community-acquired bacterial pneumonia, and moderate to severe Pneumocystis pneumonia (for patients with HIV). Low-dose corticosteroids may also benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both. This Review discusses whether treatment with low-dose corticosteroids may benefit critically ill patients with respiratory infections who have septic shock, acute respiratory distress syndrome, or both. [ABSTRACT FROM AUTHOR]

Aims: Our aims were to describe the clinical characteristics, adverse clinical events, healthcare resource utilization (HCRU) and costs of patients with major bleeding during direct Factor Xa inhibitor (FXai) use. Methods: This is a retrospective cohort study that included secondary data from computerized health records of seven Spanish Autonomous Communities. Patients with a first major bleeding during treatment with a direct FXai were analyzed during a 3-year period. Results: Of 8972 patients taking a direct FXai, 470 (5.24%) had major bleeding (mean age (SD) 77.93 (9.71) years, 61.06% women). The most frequent indications for using FXais were atrial fibrillation (78.09%) and venous thromboembolism (17.66%). Among those with major bleeding, 88.94% presented with gastrointestinal bleeding, 6.81% intracranial bleeding, 2.13% trauma-related bleeding and 4.26% other major bleeding. Prothrombin complex concentrates were used in 63.19%, followed by transfusion of blood products (20.21%) and Factor VIIa (7.66%). In total, 4.26% of patients died in the hospital due to the first major bleeding. At the study end (after 3-year follow-up), 28.94% of the patients had died, 12.34% had a myocardial infarction and 9.15% an ischemic stroke. At year 3, overall bleeding cost was EUR 5,816,930.5, of which 79.74% accounted for in-hospital costs to treat the bleeding episode. Conclusions: Despite the use of replacement agents being high, major events were common, with a 29% mortality at the end of the follow up, and HCRU and costs were high, evidencing the need for new reversal treatment strategies. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study is to assess the efficacy, short- and long-term cardiovascular and non-cardiovascular mortalities and postoperative morbidities of surgical pulmonary embolectomy (SPE) for patients with massive or submassive pulmonary embolism. Methods: A comprehensive literature review was performed to identify articles reporting SPE for pulmonary embolism. The outcomes included in-hospital and long-term mortality in addition to postoperative morbidities. The random effect inverse variance method was used. Cumulative meta-analysis, leave-one-out sensitivity analysis, subgroup analysis and meta-regression were performed. Results: Among the 1949 searched studies in our systematic literature search, 78 studies met our inclusion criteria, including 6859 cases. The mean age ranged from 42 to 65 years. The percentage of males ranged from 25.6% to 86.7%. The median rate of preoperative cardiac arrest was 27.6%. The percentage of contraindications to preoperative systemic thrombolysis was 30.4%. The preoperative systemic thrombolysis use was 11.5%. The in-hospital mortality was estimated to be 21.96% (95% CI: 19.21–24.98); in-hospital mortality from direct cardiovascular causes was estimated to be 16.05% (95% CI: 12.95–19.73). With a weighted median follow-up of 3.05 years, the late cardiovascular and non-cardiovascular mortality incidence rates were 0.39 and 0.90 per person-year, respectively. The incidence of pulmonary bleeding, gastrointestinal bleeding, surgical site bleeding, non-surgical site bleeding and wound complications was 0.62%, 4.70%, 4.84%, 5.80% and 7.2%, respectively. Cumulative meta-analysis showed a decline in hospital mortality for SPE from 42.86% in 1965 to 20.56% in 2024. Meta-regression revealed that the publication year and male sex were associated with lower in-hospital mortality, while preoperative cardiac arrest, the need for inotropes or vasopressors and preoperative mechanical ventilation were associated with higher in-hospital mortality. Conclusions: This study demonstrates acceptable perioperative mortality rates and late cardiovascular and non-cardiovascular mortality in patients who undergo SPE for massive or submassive pulmonary embolism. [ABSTRACT FROM AUTHOR]

Summary: Background: Acute non‐variceal upper gastrointestinal bleeding (UGIB) is challenging in patients at high risk of re‐bleeding in whom standard endoscopic treatment (ST) has limited effectiveness. Over‐the‐scope clips (OTSC) have shown promise in these patients although their precise role remains uncertain. Aims: To confirm the role of OTSC in patients with UGIB at high risk of re‐bleeding. Methods: We systematically searched CENTRAL, MEDLINE and Embase from January 1st, 1970 to April 24, 2024 for randomised controlled trials (RCTs) comparing OTSC and ST in acute non‐variceal UGIB with high re‐bleeding risk. The GRADE framework assessed evidence certainty, while trial sequential analysis (TSA) controlled random errors and evaluated conclusion validity. Results: We analysed four RCTs (319 patients); pooled risk ratio (RR) for clinical success at initial endoscopy favoured OTSC (RR = 1.30, 95% CI = 1.08–1.56, p = 0.006, I2 = 58%, moderate certainty of evidence). TSA showed the desired sample size was 410 and the cumulative Z curve crossing the trial sequential monitoring boundary. The pooled RR for re‐bleeding within 30 days favoured OTSC (RR = 0.53, 95% CI = 0.30–0.94, p = 0.03, I2 = 0%, moderate certainty of evidence). There was no significant difference in 30‐day mortality, or length of hospital or ICU stay. Conclusions: Moderate certainty evidence supports OTSC as a superior initial treatment for acute non‐variceal UGIB with high re‐bleeding risk. Further large‐scale studies are needed to confirm OTSCs' role by exploring other prognostic outcomes and assessing cost‐effectiveness and potential complications. [ABSTRACT FROM AUTHOR]