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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]

ABSTRACT Background and Aims Methods Results Conclusions Severe alcohol‐associated hepatitis (SAH) is associated with high short‐term mortality, and failure of response to corticosteroids is associated with a mortality of ~70%–80% within 6 months. Granulocyte colony‐stimulating factor (G‐CSF) has been studied in steroid non‐responders; however, the data are limited.This is a multicentre retrospective cohort study. The study period was from January 2016 to November 2023. SAH was defined as alcohol‐associated hepatitis (ICD‐10‐CM codes) with serum bilirubin ≥ 5.0 mg/dL and INR ≥ 1.5. Other aetiologies of acute hepatitis and biliary obstruction were excluded. The primary outcome was 90‐day median overall survival in SAH patients treated with G‐CSF compared with standard medical therapy (SMT) or corticosteroids. Propensity score (1:1) matching was performed to control confounding variables.Among 20 132 patients with SAH, 10800 (53.65%) were treated with corticosteroids and 224 (1.11%) G‐CSF. The G‐CSF group was younger (45.5 vs. 48.4) White (79.91% vs. 72.40%); however, there was no age or gender difference between G‐CSF and corticosteroid groups. Whites and patients with more comorbidities received G‐CSF more frequently than SMT or corticosteroids. After propensity score matching, 90‐day overall survival was better in patients who received G‐CSF (88.31% vs. 62.36%, p < 0.01) compared with SMT or corticosteroids (88.31% vs. 74.39%, p < 0.01). Patients on G‐CSF had better 6‐month transplant‐free survival compared with SMT (83.53% vs. 55.36%, p < 0.001) or corticosteroids (82.89% vs. 60.21%, p < 0.001). Gastrointestinal bleeding was less common in G‐CSF group compared with corticosteroids (5.02% vs. 10.50%, p < 0.001).A small minority of patients with severe alcohol‐associated hepatitis receive G‐CSF. G‐CSF improves 90‐day overall survival in patients with severe alcohol‐associated hepatitis and is non‐inferior to corticosteroids. [ABSTRACT FROM AUTHOR]

This article provides information on a rare vascular disease called multifocal lymphangioendotheliomatosis with thrombocytopenia (MLT). MLT is characterized by the presence of multiple vascular lesions and low platelet count. The disease presents as reddish-brown skin papules and can affect various organs, including the gastrointestinal tract. Diagnosis requires a biopsy of the lesions, and treatment options are challenging and controversial. The article discusses two cases of MLT that were treated with Sirolimus, a medication that has shown promise in managing vascular anomalies. This information may be helpful for library patrons researching blood cancers and vascular anomalies. [Extracted from the article]

Background Methods Results Discussion Despite prophylactic platelet transfusions, hypoproliferative thrombocytopenia is associated with bleeding; historical risk factors include hematocrit (HCT) ≤$$ \le $$25%, activated partial thromboplastin time ≥$$ \ge $$30 s, international normalized ratio ≥$$ \ge $$1.2, and platelets≤$$ \le $$5000/μL.We performed a post hoc analysis of bleeding outcomes and risk factors in participants with hematologic malignancy and hypoproliferative thrombocytopenia enrolled in the American Trial to Evaluate Tranexamic Acid Therapy in Thrombocytopenia (A‐TREAT) and randomized to receive either tranexamic acid (TXA) or placebo.World Health Organization (WHO) grade 2+ bleeding occurred in 46% of 330 participants, with no difference between the TXA (44%) and placebo (47%) groups (p = 0.66). Overall, the most common sites of bleeding were oronasal (18%), skin (17%), gastrointestinal (11%), and genitourinary (11%). Among participants of childbearing potential, 28% experienced vaginal bleeding. Platelets ≤5000/μL and HCT < 21% (after adjusting for severe thrombocytopenia) were independently associated with increased bleeding risk (HR 3.78, 95% CI 2.16–6.61; HR 2.67, 95% CI 1.35–5.27, respectively). Allogeneic stem cell transplant was associated with nonsignificant increased risk of bleeding versus chemotherapy alone (HR 1.34, 95% CI 0.94–1.91).The overall rate of WHO grade 2+ bleeding was similar to previous reports, albeit with lower rates of gastrointestinal bleeding. Vaginal bleeding was common in participants of childbearing potential. Platelets ≤5000/μL remained a risk factor for bleeding. Regardless of platelet count, bleeding risk increased with HCT < 21%, suggesting a red blood cell transfusion threshold above 21% should be considered to mitigate bleeding. More investigation is needed on strategies to reduce bleeding in this population. [ABSTRACT FROM AUTHOR]

Key Clinical Message: The occurrence of terlipressin‐induced skin necrosis in cirrhotic patients is a rare but serious adverse event that warrants further investigation. Clinicians should be aware of this potential complication in cirrhotic patients receiving terlipressin therapy and closely monitor for any signs of skin necrosis. Early recognition and prompt intervention are crucial in preventing further complications and improving patient outcomes. Further research is needed to better understand the risk factors associated with terlipressin‐induced skin necrosis and to develop effective preventive strategies. Overall, healthcare providers should exercise caution when prescribing terlipressin to cirrhotic patients, weighing the potential benefits against the risks of this rare but significant adverse event. Terlipressin is commonly used to manage conditions related to portal hypertension, such as hepatorenal syndrome and esophageal variceal bleeding. Despite its therapeutic benefits, terlipressin can rarely lead to severe ischemic complications involving the skin vasculature, known as terlipressin‐induced skin necrosis. We present a 50‐year‐old male with cirrhosis and acute variceal bleeding who developed skin necrosis following terlipressin administration. We performed a comprehensive review of the literature by analyzing 18 case reports/case series comprising 22 cirrhotic patients with terlipressin‐induced skin necrosis. Among these individuals, we found a mean age of 51 years with a male predominance (78%). Further analysis showed that the onset of skin necrosis ranged from 2 to 5 days post‐terlipressin initiation, with bolus administration being predominant (85.7%). The underlying pathophysiological mechanisms of terlipressin‐induced skin ischemia are still elusive but primarily attributed to the vasoconstrictive and thrombogenic effects. Management involves terlipressin discontinuation and supportive care. Physicians should be aware of this potential complication in patients receiving terlipressin and closely observe for any signs of skin rash. [ABSTRACT FROM AUTHOR]

The article investigates the safety of COVID-19 vaccines in the Czech Republic by analyzing adverse events (AEs) reported in connection with different vaccine batches. Data from the State Institute for Drug Control of the Czech Republic was used to compare the findings with a previous study from Denmark. The analysis revealed batch-dependent safety signals, with early vaccine batches associated with higher numbers of AE reports. The study also highlighted differences in AE reporting systems between the Czech Republic and Denmark, suggesting potential underreporting in the Czech system. [Extracted from the article]

Cardiovascular diseases are the leading cause of death globally, making the use of oral anticoagulants for prevention increasingly important. Historically, warfarin has played a significant role in this context. In recent years, introduction of new oral anticoagulants, such as rivaroxaban, apixaban, dabigatran, and edoxaban, has been seen. This study evaluates the risk associated with the use of oral anticoagulants by analyzing spontaneous adverse drug reactions reported to the Portuguese Pharmacovigilance System from 2012 to 2021. The study includes 951 adverse drug reactions reports, with the majority (n = 770; 80.97%) classified as serious. Of the 770 serious adverse drug reactions reports, the most commonly reported seriousness criterion was "Clinically Important" (n = 350; 45.45%). In terms of demographics, there was a higher reporting rate among the elderly population, with a greater prevalence of females. The System Organ Class group with the highest number of adverse drug reactions was "Gastrointestinal disorders," with the most commonly reported Preferred Term being "Gastrointestinal hemorrhage," and dabigatran was the most frequently reported drug. In summary, oral anticoagulants have adverse drug reactions that require continuous monitoring. Accurate identification and monitorization of adverse drug reactions is an important starting point to improve drug safety in population. [ABSTRACT FROM AUTHOR]

The article in the British Journal of Haematology offers guidelines for healthcare professionals in the UK regarding the measurement of non-coumarin anticoagulants and their effects on laboratory assays. It includes a comprehensive table of licensed anticoagulants, their measurement methods, and potential laboratory tests. The document stresses the importance of monitoring direct oral anticoagulants (DOACs) in specific situations, such as renal impairment or suspected overdose, and discusses the challenges and variability in monitoring unfractionated heparin (UFH) therapy. The text provides detailed information on monitoring various anti-coagulant therapies, highlighting the significance of using specific assays for accurate monitoring and addressing potential adverse events associated with these medications. [Extracted from the article]

Peptic ulcer disease is an important cause of upper gastrointestinal bleeding. Current guidelines recommend endoscopic treatment for ulcers with active bleeding or non‐bleeding visible vessels, but the optimal management of ulcers with adherent clots is unclear. We performed a systematic review of the efficacy of endoscopic versus medical management of peptic ulcers with adherent clots. A systematic literature search was performed through September 2022 (MEDLINE, Embase, and CENTRAL). Randomized controlled trials (RCTs) comparing the effect of endoscopic versus medical management alone for peptic ulcers with adherent clots on the outcome of recurrent bleeding were incuded. A random‐effects meta‐analysis was performed to estimate the overall treatment effect. We included seven RCTs reporting on the endoscopic versus medical management of peptic ulcers with adherent clots. The pooled cohort comprised 268 patients with a mean age of 62.8 years and a mean follow up of 20 days. There was a significant reduction in the risk of recurrent bleeding with endoscopic hemostatic treatment for peptic ulcers with adherent clots, compared with medical management alone (risk ratio [RR] = 0.40, 95% confidence interval [CI] 0.16–0.95, 268 participants). However, there was no difference in mortality (RR = 0.90, 95% CI 0.23–3.59, 52 participants) or need for ulcer surgery (RR = 0.48, 95% CI 0.10–2.28, 52 participants) between endoscopic and medical management groups. In summary, there was evidence for a reduction in recurrent bleeding from peptic ulcers with adherent clots treated with endoscopic hemostatic techniques compared with medical management alone but no difference in rates of mortality or need for surgery. [ABSTRACT FROM AUTHOR]

Introduction: Patients on nonvitamin K antagonist (NVKA) are usually taking other drugs. Potential interaction may increase the gastrointestinal (GI) bleeding risk associated with NVKA. Methods: Observational cohort study using Medicare data from 2017 to 2020. Participants receiving a NVKA were included. A concomitant overlapping period while on NVKA was assessed for nonsteroidal anti‐inflammatory drugs (NSAIDS), selective serotonin reuptake inhibitors (SSRI), antiplatelets, glucocorticoids, aspirin and proton pump inhibitors (PPI). A logistic regression predicting either any bleeding or GI bleeding was conducted estimating the odds ratio (OR) and 95% confidence interval (CI). Results: A total of 102 531 people on NVKA with mean age 77 years (SD = 9.8) and 55% females (N = 56 671) were included. Previous history of GI bleeding occurred in 2 908 (2.8%) participants, concomitant exposure to PPI occurred in 38 713 (38%), SSRI in 16 487 (16%), clopidogrel in 15 795 (15.4%), NSAIDs in 13 715 (13.4%) and glucocorticoids in 13 715 (13.4%). Risk for any bleeding was shown for clopidogrel (OR: 1.37, 95% CI: 1.30, 1.44), prasugrel/ticagrelor (OR: 1.36, 95% CI: 1.18, 1.58), glucocorticoids (OR: 1.26, 95% CI: 1.19, 1.34), and SSRIs (OR: 1.13, 95% CI: 1.07, 1.19). GI bleeding risk was shown for clopidogrel (OR: 1.44, 95% CI: 1.34, 1.55), prasugrel/ticagrelor (OR: 1.47, 95% CI: 1.20, 1.79), SSRIs (OR: 1.09, 95% CI: 1.01, 1.17) and glucocorticoids (OR: 1.33, 95% CI: 1.23, 1.44). PPI use was correlated with both NSAID (r = 0.07, p ≤ 0.0001) and SSRI use (r = 0.09, p ≤ 0.0001). Conclusion: NVKA concomitantly taken with antiplatelets, glucocorticoids, and SSRIs showed an increased risk for any bleeding and GI bleeding. [ABSTRACT FROM AUTHOR]

This document provides a comprehensive overview of iron deficiency, its diagnosis, and management. It highlights the global prevalence of iron deficiency, with a particular focus on its impact on women. The document explains the classifications and diagnosis of iron deficiency, as well as the causes and investigation of the condition. It also discusses various treatment options, including oral and intravenous iron supplementation, and emphasizes the importance of monitoring response to therapy. The document includes helpful tables outlining recommended serum ferritin levels, the likelihood of different causes of iron deficiency, and the elemental iron content of different oral iron formulations. It also provides information on intravenous iron formulations and their recommended dosages. This resource is a valuable tool for individuals researching iron deficiency and its treatment options. [Extracted from the article]

With the recent development of interventional endoscopic ultrasound (EUS), EUS‐guided vascular interventions have seen increased clinical and research focus. This modality can be used to diagnose portal hypertension and treat portal hypertension‐related gastrointestinal varices and refractory gastrointestinal hemorrhage, including pseudoaneurysm. The vascular embolic materials used for treatment include tissue adhesives (cyanoacrylates), sclerosants, thrombin, and vascular embolic coils, all of which are associated with favorable results. The feasibility of EUS‐guided procedures, including portal vein stenting and portosystemic shunt formation conventionally performed percutaneously and transvenously, has also been demonstrated, albeit in animal studies. As EUS‐guided vascular intervention is a technique that may receive significant attention in the future, we provide a thorough review of the current evidence for its use. [ABSTRACT FROM AUTHOR]

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]

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]

The first article discusses a rare oesophageal lesion called oesophageal submucosal gland duct adenoma (ESGDA). It is typically diagnosed in males aged 50-80 and can cause abdominal pain. Less than 20 cases have been reported, with some cases also involving other types of cancer. The article emphasizes the importance of considering ESGDA in the differential diagnosis of oesophageal submucosal lesions and highlights the need for complete endoscopic mucosal resection.The second article focuses on colonoscopy in octogenarians and older patients for colorectal cancer (CRC) detection. The study evaluates the effectiveness and safety of a contemporary bowel preparation method called 1L polyethylene glycol plus ascorbic acid (1L PEG+ASC) in this population. The results show that 1L PEG+ASC was highly effective and had a good safety profile, with over half of the patients achieving high-quality colon cleansing. [Extracted from the article]

This document includes summaries of three articles from the Journal of Gastroenterology & Hepatology. The first article discusses the safety, efficacy, and tolerability of an ultra-low volume bowel preparation called NER1006. The study found that NER1006 was a safe and effective option for bowel preparation, with high scores on the Boston Bowel Preparation Scale and positive quality indicators for colonoscopy. The second article focuses on the recurrence of gastroesophageal reflux disease (GERD) symptoms after cessation of vonoprazan therapy. The study found that the presence of a hiatal hernia was a significant predictor for symptomatic recurrence of GERD. The third article discusses the establishment of a tertiary faecal microbiota transplant (FMT) service and its outcomes. The study found that FMT was effective in treating recurrent Clostridium difficile infection (CDI) and had a high rate of primary response and cure. [Extracted from the article]

Key Clinical Message: Cystic artery pseudoaneurysm is a rare phenomenon associated with cholecystitis. We describe the successful management of angioembolisation and cholecystectomy. Cystic artery pseudoaneurysm (CAP) is a rare but clinically significant condition with various etiological factors. Cholecystitis is a prominent cause, often leading to inflammation‐induced arterial wall erosion and pseudoaneurysm formation. CAP can present with a range of symptoms, including hemobilia, upper GI bleeding, and jaundice. Despite its rarity, CAP warrants attention in emergency care due to its potential for life‐threatening arterial bleeding. Timely diagnosis is crucial, with imaging techniques playing a key role. Depending on the clinical context, management options include endovascular embolization and surgical intervention. Due to the limited cases, standard protocols remain elusive. A 64‐year‐old woman presented with abdominal pain, anorexia, and weight loss, prompting an evaluation for possible gallbladder cancer. She experienced sudden abdominal pain and upper gastrointestinal bleeding (hematemesis). Laboratory findings revealed leukocytosis, anemia, and abnormal liver function tests. Imaging showed gallbladder wall thickening, luminal contraction, and a pseudoaneurysm in the cystic artery. The patient underwent angioembolization followed by cholecystectomy, confirming acute cholecystitis and CAP with thrombosis. This case underscores the importance of early recognition and appropriate management in CAP, particularly when accompanied by acute cholecystitis. [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.

Gastrointestinal tumors, the second leading cause of human mortality, are characterized by their association with inflammation. Currently, progress in the early diagnosis and effective treatment of gastrointestinal tumors is limited. Recent whole‐genome analyses have underscored their profound heterogeneity and extensive genetic and epigenetic reprogramming. Epigenetic reprogramming pertains to dynamic and hereditable alterations in epigenetic patterns, devoid of concurrent modifications in the underlying DNA sequence. Common epigenetic modifications encompass DNA methylation, histone modifications, noncoding RNA, RNA modifications, and chromatin remodeling. These modifications possess the potential to invoke or suppress a multitude of genes associated with cancer, thereby governing the establishment of chromatin configurations characterized by diverse levels of accessibility. This intricate interplay assumes a pivotal and indispensable role in governing the commencement and advancement of gastrointestinal cancer. This article focuses on the impact of epigenetic reprogramming in the initiation and progression of gastric cancer, esophageal cancer, and colorectal cancer, as well as other uncommon gastrointestinal tumors. We elucidate the epigenetic landscape of gastrointestinal tumors, encompassing DNA methylation, histone modifications, chromatin remodeling, and their interrelationships. Besides, this review summarizes the potential diagnostic, therapeutic, and prognostic targets in epigenetic reprogramming, with the aim of assisting clinical treatment strategies. [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]

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 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]

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]

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]

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]

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]

Introduction: Both atrial fibrillation (AF) and amyloidosis increase stroke risk. We evaluated the best anticoagulation strategy in AF patients with coexistent amyloidosis. Methods: Consecutive AF patients with concomitant amyloidosis were divided into two groups based on the postablation stroke‐prophylaxis approach; group 1: left atrial appendage occlusion (LAAO) in eligible patients and group 2: oral anticoagulation (OAC). Group 1 patients were further divided into Gr. 1A: LAAO + half‐does NOAC (HD‐NOAC) for 6 months followed by aspirin 81 mg/day and Gr. 1B: LAAO + HD‐NOAC. In group 1 patients, with complete occlusion at the 45‐day transesophageal echocardiogram, patients were switched to aspirin, 81 mg/day at 6 months. In case of leak, or dense "smoke" in the left atrium (LA) or enlarged LA, they were placed on long‐term half‐dose (HD) NOAC. Group 2 patients remained on full‐dose NOAC during the whole study period. Results: A total of 92 patients were included in the analysis; group 1: 56 and group 2: 36. After the 45‐day TEE, 31 patients from group 1 remained on baby‐aspirin and 25 on HD NOAC. At 1‐year follow‐up, four stroke, one TIA and six device‐thrombus were reported in group 1A, compared to none in patients in group 1B (5/31 vs. 0/25, p =.03). No bleeding events were reported in group 1, whereas group 2 had five bleeding events (one subdural hematoma, one retinal hemorrhage, and four GI bleedings). Additionally, one stroke was reported in group 2 that happened during brief discontinuation of OAC. Conclusion: In patients with coexistent AF and amyloidosis, half‐dose NOAC following LAAO was observed to be the safest stroke‐prophylaxis strategy. [ABSTRACT FROM AUTHOR]

This document is a guideline from the British Society for Haematology on the treatment of cancer-associated venous thrombosis (CAT) in adults. It emphasizes the importance of considering factors such as bleeding risk, tumor site, oral medication suitability, drug interactions, and patient preferences when deciding on the most appropriate treatment. The guideline also provides recommendations for thromboprophylaxis in hospitalized patients, surgical patients, and ambulatory cancer outpatients. It highlights the high risk of VTE in patients with pancreatic cancer and multiple myeloma and discusses specific thromboprophylaxis strategies for these populations. The document also discusses the management of catheter-related thrombosis and the use of inferior vena cava filters. Thrombocytopenia, a condition characterized by low platelet count, is discussed, and it is suggested that anticoagulation should be continued in thrombocytopenic patients during the first 4-6 weeks after thrombosis. The document also discusses the treatment of recurrent VTE (venous thromboembolism) in cancer patients and suggests that supratherapeutic doses of LMWH (low molecular weight heparin) may be effective in reducing the risk of further recurrence. [Extracted from the article]

Ceftazidime/avibactam (CAZ/AVI) is a combination of a well‐known third‐generation, broad‐spectrum cephalosporin with a new beta‐lactamase inhibitor that has been approved for the treatment of various infectious diseases (especially multidrug‐resistant Gram‐negative bacterial infections) by the Food and Drug Administration (FDA). The current study extensively assessed CAZ/AVI‐related adverse events (AEs) in the real world through data mining of the FDA Adverse Event Reporting System (FAERS) database to better understand toxicities. The signals of CAZ/AVI‐related AEs were quantified using disproportionality analyses, including the reporting odds ratio, the proportional reporting ratio, the Bayesian confidence propagation neural network, and the multi‐item gamma Poisson shrinker algorithms. Out of 10,114,815 records retrieved from the FAERS database, 628 cases were identified, where CAZ/AVI was implicated as the primary suspect drug. A total of 61 preferred terms with significant disproportionality that simultaneously met the criteria of all four algorithms were retained. Several unexpected safety signals may also occur, including melena, hypernatremia, depressed level of consciousness, brain edema, petechiae, delirium, and shock hemorrhagic. The median onset time for AEs associated with CAZ/AVI was 4 days, with most cases occurring within 3 days after CAZ/AVI initiation. [ABSTRACT FROM AUTHOR]

Introduction: Gastrointestinal (GI) bleeding events (BEs) in von Willebrand disease (VWD) are difficult to diagnose and often recurrent. Limited data from clinical trials has led to lack of consensus on treatment options. Aim: Describe current treatments and outcomes for GI BEs in people with VWD. Methods: This retrospective, observational, multicentre chart review study was conducted from January 2018 through December 2019 and included patients with inherited VWD with ≥1 GI BE in the preceding 5 years. Baseline characteristics, number and aetiology of BEs, associated GI‐specific morbidities/lesions, treatment and outcomes were analysed descriptively. Results: Sixty bleeds were reported in 20 patients with type 1 (20%), type 2 (50%) and type 3 (30%) VWD. During the 5‐year study period, 31 (52%) BEs had one identified or suspected cause; multiple causes were reported in 11 (18%). Most GI BEs (72%) were treated with a combination of von Willebrand factor (VWF), antifibrinolytics and/or other haemostatic or non‐haemostatic treatments. Time to resolution did not differ by VWF treatment use; however, BEs treated with non‐VWF treatments tended to resolve later. In patients with GI‐specific morbidities/lesions, 84% resolved with first‐line treatment; time to resolution tended to be longer than in patients without such morbidities/lesions. Thirteen BEs occurred in patients receiving prophylaxis and 47 in patients receiving on‐demand treatment; 18 BEs resulted in a switch to prophylaxis after bleed resolution. Conclusions: This study confirms the unmet need for the management of recurrent GI BEs in people with VWD and the need for prospective data, especially on prophylaxis. [ABSTRACT FROM AUTHOR]

Background: Upper gastrointestinal (GI) bleeding is a common medical emergency. This study aimed to develop models to predict critically ill patients with upper GI bleeding in‐hospital and 30‐day survival, identify the correlation factor and infer the causality. Methods: A total of 2898 patients with upper GI bleeding were included from the Medical Information Mart for Intensive Care‐IV and eICU‐Collaborative Research Database, respectively. To identify the most critical factors contributing to the prognostic model, we used SHAP (SHapley Additive exPlanations) for machine learning interpretability. We performed causal inference using inverse probability weighting for survival‐associated prognostic factors. Results: The optimal model using the light GBM (gradient boosting algorithm) algorithm achieved an AUC of.93 for in‐hospital survival,.81 for 30‐day survival in internal testing and.87 for in‐hospital survival in external testing. Important factors for in‐hospital survival, according to SHAP, were SOFA (Sequential organ failure assessment score), GCS (Glasgow coma scale) motor score and length of stay in ICU (Intensive critical care). In contrast, essential factors for 30‐day survival were SOFA, length of stay in ICU, total bilirubin and GCS verbal score. Our model showed improved performance compared to SOFA alone. Conclusions: Our interpretable machine learning model for predicting in‐hospital and 30‐day mortality in critically ill patients with upper gastrointestinal bleeding showed excellent accuracy and high generalizability. This model can assist clinicians in managing these patients to improve the discrimination of high‐risk patients. [ABSTRACT FROM AUTHOR]

Background: Gastrointestinal bleeding (GIB) in patients with continuous flow left ventricular assist devices (CF‐LVADs) is often related to GI angiodysplasia (GIAD). We previously reported data on VEGF inhibition with IV bevacizumab in the treatment of LVAD‐associated GIAD bleeding, and now present follow‐up data on patients treated with IV bevacizumab and/or low‐dose oral pazopanib. Methods: All consecutive adult patients with LVAD‐associated GIB from GIAD treated with bevacizumab or pazopanib, from July 20, 2017 to June 22, 2022, were included in the analysis. Data on hospitalizations, GI endoscopic procedures, and blood transfusions were obtained from first admission for GIB up to a median of 35.7 months following treatment initiation (range 1.3–59.8 months). Results: Eleven patients (91% male, mean 69.5 ± 8.9 years) were included. Eight patients (73%) received IV bevacizumab, two patients (18%) received oral pazopanib, and one patient (9%) received bevacizumab followed by pazopanib therapy. We observed a significantly decreased number of annualized hospitalizations for GIB (median difference − 2.87, p = 0.002), blood transfusions (median difference − 20.9, p = 0.01), and endoscopies (median difference − 6.95, p = 0.007) in patients pre‐ and post‐anti‐angiogenic therapy (bevacizumab and/or pazopanib). Similarly, a significant improvement in these clinical outcomes was noted in the bevacizumab group with decreased annualized hospitalizations (median difference − 2.75, p = 0.014), blood transfusions (median difference − 24.5, p = 0.047), and number of endoscopies (median differences −6.88, p = 0.006). Conclusion: Anti‐angiogenic therapy with IV bevacizumab and/or low‐dose oral pazopanib appears to provide benefits in patients with LVAD‐associated GIB with reduced hospitalizations, blood transfusions, and need for GI endoscopic procedures. [ABSTRACT FROM AUTHOR]

Background and Aim: This study investigates the effectiveness of bedside ultrasonography in predicting blood transfusion requirements in patients with upper gastrointestinal bleeding (UGIB). It focuses on evaluating the inferior vena cava (IVC) diameter, IVC collapsibility index (CI), and stroke volume (SV) as ultrasonographic measures. Methods: A hundred adult patients enrolled in this prospective clinical study. The patients were divided into two groups (group 1: only saline administered group, group 2: saline and blood administered group). IVC diameter, IVC CI, and SV were measured at the time of admission and after treatment. Results: At the initial admission, group 1 exhibited an IVC CI of 20.4% and an SV of 65.0 mL, whereas group 2 displayed an IVC CI of 26.6% and an SV of 58.0 mL. Upon analyzing the relationship between the Glasgow–Blatchford score (GBS) and SV, we identified a significant negative correlation (r = −0.7350; P < 0.001). Similarly, a weak negative correlation was observed between the Rockall score (RS) and SV (r = −0.4718; P < 0.001). It is worth noting that patients with UGIB require blood transfusion if their SV falls below 62.5 mL, with an area under the curve (AUC) of 89.1% and a 95% confidence interval (CI) ranging from 82.8% to 95.4%. Conclusion: IVC CI and SV can be used as parameters to predict the need for blood transfusion in the ED in patients with UGIB. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Our report details a rare case of gastrointestinal bleeding in an adult male from Meckel's diverticulum. Diagnostic tests were negative except for technetium‐99m pertechnetate scintigraphy with SPECT/CT, highlighting importance of diverse modalities. [ABSTRACT FROM AUTHOR]

Background: Klippel‐Trenaunay‐Weber syndrome (KTWS) is a rare disease with a wide range of manifestations. KTWS is characterized by a clinical triad of varicosities of the extremities, cutaneous vascular malformations, and hypertrophy of soft tissues and long bones. The diagnosis is made clinically supplemented with magnetic resonance imaging and computed tomography. Aim: Hereby we aim to highlight the significance of the possible life‐threatening first‐time presentations associated with the GI system in previously undiagnosed KTWS patients. Patient: We report the case of a 47‐year‐old male with KTWS, who presented with various symptoms such as rectorrhagia since childhood, digestive problems and abnormal lateral vascular malformations of the left buttock which extended all the way to the leg, vascular malformations of the left fourth and fifth toes as well as soft tissue swelling of the left foot. There was no evidence of other clinical presentations. The patient was hospitalized with severe rectorrhagia and a hemoglobin level of 3/9. Physical examination revealed a blood pressure of 85/55 and pulse rate of 115. Ruptured aneurysm of the superior mesenteric artery was found on angiography and subsequently treated with embolization. Dermatologic evaluation showed pitting edema of the left leg and foot and multiple vascular lesions. Thus a diagnosis of KTWS was established. Pulsed dye laser therapy and compression bandage was performed for the patient. The patient's follow‐up was done 3 months after discharge for which the patient was again consulted by a dermatologist and gastroenterologist. Lymphedema of the left leg had improved to a great extend so treatment with compression bandage was continued. Colonoscopy was repeated for the patient to evaluate and control possible active sources of bleeding, due to potential life‐threating complications. Results: According to previous findings, there have been few case reports of KTWS presenting with gastrointestinal manifestations, fewer of which have covered acute life‐threatening bleedings associated with this system. [ABSTRACT FROM AUTHOR]

Background: Warfarin is considered the primary oral anticoagulant for patients with atrial fibrillation and end-stage renal disease (ESRD) requiring dialysis. Although warfarin can offer significant stroke prevention in this population, the accompanying major bleeding risks make warfarin nearly prohibitive. Apixaban was shown to be superior to warfarin in preventing stroke or systemic embolism, with a lower risk of bleeding and mortality in a large, randomized trial of individuals with mostly normal renal function but none with ESRD. Methods: We systematically reviewed evidence comparing apixaban versus warfarin for atrial fibrillation in this population, and evaluated outcomes of stroke or systemic embolism, and major bleeding using random- effects models. The main safety outcome was major bleeding, and the main effectiveness outcome was stroke or systemic embolism. Results: We found five observational studies of 10036 patients (2638 receiving apixaban, and 7398 receiving warfarin) meeting inclusion criteria. Pooled analysis demonstrated a significant reduction in major bleeding with apixaban as compared to warfarin (odds ratio [OR] 0.51, 95% confidence interval [CI] 0.42--0.61; p < .0001). Apixaban was also associated with a reduction in intracranial bleeding (OR 0.58, 95% CI 0.37--0.92; p = .02) and in gastrointestinal bleeding (OR 0.61, 95% CI 0.51--0.73; p < .0001). Furthermore, apixaban was associated with a reduction in stroke/systemic embolism (OR 0.64, 95% CI 0.50--0.82; p < .0001). Conclusion: Apixaban was associated with superior outcomes and reduced adverse events compared to warfarin in observational studies of patients with atrial fibrillation on dialysis. Randomized controlled studies are needed to confirm these findings. [ABSTRACT FROM AUTHOR]

The article discusses Blue rubber bleb nevus syndrome (BRBNS), a rare venous malformation syndrome primarily affecting the skin and gastrointestinal tract. Sirolimus, an immunosuppressant, has shown promise in treating BRBNS by reducing lesion size, pain, and bleeding episodes. The study presents five pediatric cases where sirolimus treatment resulted in positive outcomes. Further research is needed to standardize the use of sirolimus in treating BRBNS. [Extracted from the article]

Hematology is a clinical specialty with strong roots in the laboratory; accordingly, the lab can help solve perplexing clinical problems. This review highlights clinical‐pathological conundrums addressed during my 35‐year hematology career at McMaster University. Heyde syndrome is the association between aortic stenosis and bleeding gastrointestinal (GI) angiodysplasia where the bleeding is usually cured by aortic valve replacement; the chance reading of a neonatal study showing reversible deficiency of high‐molecular‐weight (HMW) multimers of von Willebrand factor (vWF) following surgical correction of congenital heart disease provided the key insight that a subtle deficiency of HMW multimers of vWF explains Heyde syndrome. The unusual immunobiology of heparin‐induced thrombocytopenia (HIT)—a highly prothrombotic, antibody‐mediated, anti‐platelet factor 4 (PF4) disorder featuring rapid appearance and then disappearance (seroreversion) of the pathological heparin‐dependent platelet‐activating antibodies—permitted identification of key clinical features that informed development of a scoring system (4Ts) to aid in HIT diagnosis. Atypical clinical presentations of HIT prompted identification of heparin‐independent anti‐PF4 antibodies, now recognized as the explanation for vaccine‐induced immune thrombotic thrombocytopenia (VITT), as well as VITT‐like disorders triggered by adenovirus infection. Another unusual feature of HIT is its strong association with limb ischemia, including limb necrosis secondary to deep‐vein/microvascular thrombosis (venous limb gangrene). The remarkable observation that supratherapeutic warfarin anticoagulation predisposes to HIT‐ and cancer‐associated venous limb gangrene provided insight into disturbed procoagulant/anticoagulant balance; these concepts are relevant to microvascular thrombosis in critical illness (symmetrical peripheral gangrene), including a pathophysiological role for proximate "shock liver" (impaired hepatic synthesis of natural anticoagulants). [ABSTRACT FROM AUTHOR]

Summary: Background: Acute upper gastrointestinal bleeding (UGIB) is a common emergency requiring hospital‐based care. Advances in care across pre‐endoscopic, endoscopic and post‐endoscopic phases have led to improvements in clinical outcomes. Aims: To provide a detailed, evidence‐based update on major aspects of care across pre‐endoscopic, endoscopic and post‐endoscopic phases. Methods: We performed a structured bibliographic database search for each topic. If a recent high‐quality meta‐analysis was not available, we performed a meta‐analysis with random effects methods and odds ratios with 95% confidence intervals. Results: Pre‐endoscopic management of UGIB includes risk stratification, a restrictive red blood cell transfusion policy unless the patient has cardiovascular disease, and pharmacologic therapy with erythromycin and a proton pump inhibitor. Patients with cirrhosis should be treated with prophylactic antibiotics and vasoactive medications. Tranexamic acid should not be used. Endoscopic management of UGIB depends on the aetiology. For peptic ulcer disease (PUD) with high‐risk stigmata, endoscopic therapy, including over‐the‐scope clips (OTSCs) and TC‐325 powder spray, should be performed. For variceal bleeding, treatment should be customised by severity and anatomic location. Post‐endoscopic management includes early enteral feeding for all UGIB patients. For high‐risk PUD, PPI should be continued for 72 h, and rebleeding should initially be evaluated with a repeat endoscopy. For variceal bleeding, high‐risk patients or those with further bleeding, a transjugular intrahepatic portosystemic shunt can be considered. Conclusions: Management of acute UGIB should include treatment plans for pre‐endoscopic, endoscopic and post‐endoscopic phases of care, and customise treatment decisions based on aetiology and severity of bleeding. [ABSTRACT FROM AUTHOR]

Background: Dogs with congenital intrahepatic portosystemic shunt (IHPSS) are predisposed to gastrointestinal inflammation, ulceration, and bleeding, unlike dogs with congenital extrahepatic portosystemic shunt (EHPSS). Limited information is available about hematologic differences between dogs with IHPSS and dogs with EHPSS. Objective: Compare hemogram variables between dogs with IHPSS and EHPSS. We hypothesized that hematologic variables would differ between the 2 populations, with a higher frequency and severity of anemia and microcytosis in dogs with IHPSS. Animals: Twenty‐six client‐owned dogs with IHPSS and 35 client‐owned dogs with EHPSS. Methods: Retrospective cross‐sectional study. Dogs were included if a CBC was performed before shunt attenuation. Contingency analysis was performed to determine if the frequency of clinical signs and of hematologic variables below the reference range differed between groups. Hematologic and selected biochemical variables were compared between groups using an analysis of covariance with age as a covariate. Results: Gastrointestinal clinical signs (IHPSS, 81% vs EHPSS, 34%; P =.01), anemia (31% vs 6%; P =.01), microcytosis (77% vs 29%; P =.002), and hypochromia (77% vs 49%; P =.03) were more common in dogs with IHPSS than in dogs with EHPSS. Dogs with IHPSS had lower packed cell volume (34% vs 41%, P =.04), hemoglobin concentration (11.5 g/dL vs 13.7 g/dL, P =.03), mean corpuscular volume (57 fL vs 65 fL; P =.001), and mean corpuscular hemoglobin concentration (32 g/dL vs 33 g/dL; P =.04) than dogs with EHPSS. Conclusions and Clinical Importance: Dogs with IHPSS had a higher frequency of anemia, microcytosis, and hypochromia and exhibited more gastrointestinal clinical signs. [ABSTRACT FROM AUTHOR]

Summary: Background: Proton pump inhibitors (PPI) are frequently used in patients with cirrhosis. Aims: This study aimed to determine whether PPI use is associated with the prognosis of cirrhotic patients. Methods: We conducted a multicentre retrospective cohort study involving 1485 patients who had experienced hepatic encephalopathy (HE) from 7 referral centres in Korea. The primary outcome was overall survival and secondary outcomes included the development of cirrhotic complications, including recurrent HE, spontaneous bacterial peritonitis (SBP), hepatorenal syndrome (HRS), and gastrointestinal bleeding. Patients treated with PPI with a mean defined daily dose (mDDD) ≥0.5 (high‐dose PPI group) were compared to those treated with PPI of an mDDD < 0.5 (No or low‐dose PPI group) for each outcome. Results: Among 1485 patients (median age, 61 years; male, 61%), 232 were assigned to the high‐dose PPI group. High‐dose PPI use was independently associated with a higher risk of death (adjusted HR [aHR] = 1.71, 95% confidence interval [CI] = 1.38–2.11, p < 0.001). This result was reproducible after propensity score‐matching (PSM) (aHR = 1.90, 95% CI = 1.49–2.44, p < 0.001). High‐dose PPI use was an independent risk factor of recurrent HE (before PSM: aHR = 2.04, 95% CI = 1.66–2.51, p < 0.001; after PSM: aHR = 2.16, 95% CI = 1.70–2.74, p < 0.001), SBP (before PSM: aHR = 1.87, 95% CI = 1.43–2.43, p < 0.001; after PSM: aHR = 1.76, 95% CI = 1.31–2.36, p = 0.002), HRS (before PSM: aHR = 1.48, 95% CI = 1.02–2.15, p = 0.04; after PSM: aHR = 1.47, 95% CI = 0.95–2.28, p = 0.09), and gastrointestinal bleeding (before PSM: aHR = 1.46, 95% CI = 1.12–1.90, p = 0.006; after PSM: aHR = 1.74, 95% CI = 1.28–2.37, p < 0.001). Conclusions: The use of high‐dose PPI was independently associated with increased risks of mortality and cirrhotic complications. [ABSTRACT FROM AUTHOR]

Background: Acute lower gastrointestinal bleeding (LGIB) is a common reason for hospital admission. However, the majority resolve spontaneously and only a minority require inpatient intervention. We aimed to describe the epidemiology and aetiology of acute LGIB admissions in our institution. We also aimed to validate the Oakland Score, which can identify patients at low risk of adverse outcome from LGIB, in our population and determine the proportion who could have safely avoided admission. Methods: Using the prospective, validated Otago Clinical Audit database (DIVA), we searched for adult patients admitted to Dunedin Hospital with a primary diagnosis of LGIB between January 2013 and December 2020. We retrieved data to calculate the Oakland Score and details of inpatient treatment from the electronic patient record. We excluded patients admitted electively, admissions related to inflammatory bowel disease, and those with upper gastrointestinal bleeding. Results: We identified 761 patients of which 501 met inclusion criteria (56% male, median age 76 years, 82% NZ European). Overall, 72% were managed with observation or diagnostic endoscopy, 32% received blood products, and 7% required haemostatic intervention to control bleeding. The area under the receiver operating characteristic curve for the Oakland Score was 0.85 (95% CI, 0.81–0.89). A cut‐off score of ≤10 predicted a 95% probability of safely avoiding admission. This equates to saving 30 bed‐days annually. Conclusion: The majority of patients admitted with LGIB are managed conservatively. The Oakland Score could be used as a stratification tool to safely reduce the admission rate. [ABSTRACT FROM AUTHOR]

Background and Aim: Cohort studies have linked metabolic syndrome (MetS) to gastrointestinal (GI) cancer risk. We aimed to evaluate the associations between MetS, its components, and combinations of MetS components with eight GI cancers risk. Methods: We conducted a systematic search of prospective cohort studies and performed a meta‐analysis. Subgroup analyses regarding diagnostic criteria, sex, cancer sites, histological subtypes, ethnic groups, and studies adjusted for alcohol consumption were carried out. Mendelian randomization (MR) was employed to evaluate the causality between 17 MetS‐related traits and eight GI cancers among Europeans and Asians separately. Results: Meta‐analyses of 31 prospective studies indicated that MetS was significantly associated with an increased risk of colorectal cancer (CRC) (RR [95% CI] = 1.13 [1.12–1.15]), esophageal cancer (EC) (RR [95% CI] = 1.17 [1.03–1.32]), gallbladder cancer (GBC) (RR [95% CI] = 1.37[1.10–1.71]), liver cancer (LC) (RR [95% CI] = 1.46 [1.29–1.64]), and pancreatic cancer (PaC) (RR [95% CI] = 1.25 [1.20–1.30]), but not gastric cancer (GC) (RR [95% CI] = 1.11 [0.96–1.28]). Regarding the associations between MetS components and GI cancers risk, the following associations showed statistical significance: obesity‐CRC/LC/EC/, hypertriglyceridemia‐LC/PaC, reduced high‐density lipoprotein (HDL)‐CRC/LC/GC/PaC, hyperglycemia‐CRC/LC/PaC, and hypertension‐CRC/LC/EC/PaC. Sex‐specific associations were observed between individual MetS components on GI cancers risk. Among the top three common combinations in both sexes, obesity + HTN + hyperglycemia had the strongest association with CRC risk (RR [95% CI] = 1.54 [1.49–1.61] for males and 1.27 [1.21–1.33] for females). MR analyses revealed causality in 16 exposure–outcome pairs: waist‐to‐hip ratio/BMI/HbA1c‐CRC; BMI/childhood obesity/waist circumference/T2DM/glucose‐EC; BMI/waist circumference/cholesterol‐LC; cholesterol/childhood obesity/waist circumference/HbA1c‐PaC; and HbA1c‐GBC. These results were robust against sensitivity analyses. Conclusions: Since MetS is reversible, lifestyle changes or medical interventions targeting MetS patients might be potential prevention strategies for GI cancers. [ABSTRACT FROM AUTHOR]

This article discusses the risk of early death (ED) in patients with acute promyelocytic leukemia (APL). The study found that the mortality rate was significantly higher in high-risk and very high-risk patients compared to low-risk patients. The analysis did not reveal any differences in bone marrow morphology or cytometric markers between ED and non-ED patients, suggesting that these factors may not play a role in determining the risk of early mortality. The study also evaluated the effectiveness of the ED risk score in patients treated with the ATO+ATRA regimen and found no premature deaths in this group. The article concludes that the ED risk score is effective in predicting early mortality and emphasizes the importance of timely diagnosis and treatment in improving outcomes for APL patients. [Extracted from the article]

Objective: This study was undertaken to determine the excess risk of antithrombotic‐related bleeding due to cerebral small vessel disease (SVD) burden. Methods: In this observational, prospective cohort study, patients with cerebrovascular or cardiovascular diseases taking oral antithrombotic agents were enrolled from 52 hospitals across Japan between 2016 and 2019. Baseline multimodal magnetic resonance imaging acquired under prespecified conditions was assessed by a central diagnostic radiology committee to calculate total SVD score. The primary outcome was major bleeding. Secondary outcomes included bleeding at each site and ischemic events. Results: Of the analyzed 5,250 patients (1,736 women; median age = 73 years, 9,933 patient‐years of follow‐up), antiplatelets and anticoagulants were administered at baseline in 3,948 and 1,565, respectively. Median SVD score was 2 (interquartile range = 1–3). Incidence rate of major bleeding was 0.39 (per 100 patinet‐years) in score 0, 0.56 in score 1, 0.91 in score 2, 1.35 in score 3, and 2.24 in score 4 (adjusted hazard ratio [aHR] for score 4 vs 0 = 5.47, 95% confidence interval [CI] = 2.26–13.23), that of intracranial hemorrhage was 0.11, 0.33, 0.58, 0.99, and 1.06, respectively (aHR = 9.29, 95% CI = 1.99–43.35), and that of ischemic event was 1.82, 2.27, 3.04, 3.91, and 4.07, respectively (aHR = 1.76, 95% CI = 1.08–2.86). In addition, extracranial major bleeding (aHR = 3.43, 95% CI = 1.13–10.38) and gastrointestinal bleeding (aHR = 2.54, 95% CI = 1.02–6.35) significantly increased in SVD score 4 compared to score 0. Interpretation: Total SVD score was predictive for intracranial hemorrhage and probably for extracranial bleeding, suggesting the broader clinical relevance of cerebral SVD as a marker for safe implementation of antithrombotic therapy. ANN NEUROL 2024;95:774–787 [ABSTRACT FROM AUTHOR]

Objectives: Although several studies have shown the usefulness of artificial intelligence to identify abnormalities in small‐bowel capsule endoscopy (SBCE) images, few studies have proven its actual clinical usefulness. Thus, the aim of this study was to examine whether meaningful findings could be obtained when negative SBCE videos were reanalyzed with a deep convolutional neural network (CNN) model. Methods: Clinical data of patients who received SBCE for suspected small‐bowel bleeding at two academic hospitals between February 2018 and July 2020 were retrospectively collected. All SBCE videos read as negative were reanalyzed with the CNN algorithm developed in our previous study. Meaningful findings such as angioectasias and ulcers were finally decided after reviewing CNN‐selected images by two gastroenterologists. Results: Among 202 SBCE videos, 103 (51.0%) were read as negative by humans. Meaningful findings were detected in 63 (61.2%) of these 103 videos after reanalyzing them with the CNN model. There were 79 red spots or angioectasias in 40 videos and 66 erosions or ulcers in 35 videos. After reanalysis, the diagnosis was changed for 10 (10.3%) patients who had initially negative SBCE results. During a mean follow‐up of 16.5 months, rebleeding occurred in 19 (18.4%) patients. The rebleeding rate was 23.6% (13/55) for patients with meaningful findings and 16.1% (5/31) for patients without meaningful findings (P = 0.411). Conclusion: Our CNN algorithm detected meaningful findings in negative SBCE videos that were missed by humans. The use of deep CNN for SBCE image reading is expected to compensate for human error. [ABSTRACT FROM AUTHOR]

Key Clinical Message: Duodenal GISTs are rare and challenging tumors. Acute life‐threatening upper GI bleeding is a possible presentation of duodenal GISTs. Surgery is the standard treatment for localized duodenal GISTs. Imatinib is an effective adjuvant therapy for duodenal GISTs. GIST is the most common mesenchymal neoplasm of the gastrointestinal tract, accounting for 1%–2% of gastrointestinal tumors. They originate from the interstitial cells of Cajal and are rare in patients younger than 30 years. The stomach is the most common site, followed by the small intestine and colon. GISTs are caused by a gain‐of‐function mutation in the proto‐oncogene receptor tyrosine kinase, with activating mutations in KIT being the most common. Most GISTs are asymptomatic. Even if gastrointestinal bleeding is the most common complication life‐threatening hemorrhage is extremely uncommon. We present a case of a 31‐year‐old male patient presented with massive active hematemesis and melena with hemorrhagic shock. The patient presented with massive hematemesis and melena of 1 h duration. Endoscopy showed pulsating active bleeding from the third part of the duodenum which was difficult to manage via endoscopy. Histopathologic evaluation showed spindle cell type GIST. Intraoperatively, there was a nodular mass with active bleeding on the third part of the duodenum. Duodenectomy with end‐to‐end anastomosis was done. Discharged with no postoperative complication and was put on imatinib. There are considerable challenges that arise in the diagnosis and treatment of duodenal gastrointestinal stromal tumors (GISTs) when they present with life‐threatening upper gastrointestinal hemorrhage. In order to achieve the best possible outcomes for patients, it is crucial to have a comprehensive understanding of the clinical presentation, diagnostic methods, and treatment approaches. [ABSTRACT FROM AUTHOR]

Background and Aim: The presence of blood in the stomach has been thought to affect the performance of diagnostic tests used in detecting Helicobacter pylori (H. pylori) in the stomach. This study evaluates the effect of upper gastrointestinal bleeding on the efficacy of a rapid urease test (RUT) and compares the results with the pathologic method. Methods: In this descriptive study, 100 patients presented with upper gastrointestinal bleeding, confirmed from endoscopy, referred to Shahid Rahimi Hospital in Khorramabad were enrolled. Antral biopsy was performed in all the patients and the samples were extracted for histopathology and RUT. A questionnaire was used to collect rapid urease test outcomes and associated parameters (antibiotic, bismuth, and proton pump inhibitors), histology and demographic data. Histopathology was used as the gold standard for diagnosis of H. pylori. Results: Of the 52 patients who were reported positive for H. pylori in pathology, 36 had RUT‐positive H. pylori, sensitivity 69.2%, and of 48 patients whose pathology was negative, 25 had negative RUT, specificity 52.1%. Of 59 RUT, 36 had positive pathology, positive predictive value was 61% and from 41 with negative RUT, 25 had negative pathology, negative predictive value was 61%. The prevalence of H. pylori infection was significantly associated with the age of 50 years and above, p = 0.042, and previous history of bleeding, p = 0.019. Conclusion: Gastrointestinal bleeding can reduce the sensitivity of RUT. The negative results of these tests in acute upper gastrointestinal bleeding should therefore be interpreted carefully. [ABSTRACT FROM AUTHOR]

Aims: We aimed to elucidate the association between malnutrition and the occurrence of bleeding events in patients with heart failure. Methods and results: We evaluated the nutritional status of patients with heart failure [n = 2044, median (inter‐quartile range) age 69.0 (59.0–78.0) years, 1209 (59.1%) males] using the Geriatric Nutritional Risk Index (GNRI). The primary endpoint was a composite of bleeding events such as haemorrhagic stroke or gastrointestinal bleeding. According to the survival classification and regression tree analysis, the accurate cut‐off point of GNRI for predicting the primary endpoint was 106.2. We divided the patients into two groups based on GNRI levels: high GNRI group (GNRI ≥ 106.2, n = 606, 29.6%) and low GNRI group (GNRI < 106.2, n = 1438, 70.4%). We compared the patients' characteristics and prognosis between the two groups. The low GNRI group was older [72.0 (63.0–79.0) vs. 63.0 (53.0–73.0) years, P < 0.001] and had a lower prevalence of male sex (56.9% vs. 64.5%, P = 0.001). There were no differences in the use of antiplatelet agents and anticoagulants between the two groups. Levels of B‐type natriuretic peptide were higher [321.1 (123.3–667.4) vs. 111.6 (42.6–235.4) pg/mL, P < 0.001] and levels of haemoglobin were lower [12.4 (10.8–13.7) vs. 14.2 (12.9–15.4) g/dL, P < 0.001] in the low GNRI group. The Kaplan–Meier analysis demonstrated that bleeding event rates were higher in the low GNRI group (log‐rank P < 0.001). The multivariable Cox proportional hazard analysis revealed that low GNRI (hazard ratio 1.952, 95% confidence interval 1.002–3.805, P = 0.049) was associated with bleeding events. Conclusions: Heart failure patients with poor nutritional status, determined by GNRI under 106.2, experienced high bleeding event rates. Comprehensive management is required to avoid bleeding event in those populations. [ABSTRACT FROM AUTHOR]