Patients on antithrombotic therapy (ATT) have the highest risk of ongoing bleeding and mortality. Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a novel hemostatic agent for the ...treatment of upper gastrointestinal bleeding (UGIB). Initial reports on its use appear promising in terms of initial hemostasis and rebleeding rates. It is unknown whether this also pertains to patients on ATT. The aim of the current study therefore was to evaluate the efficacy of Hemospray in the treatment of UGIB in patients taking ATTs. A total of 16 unselected consecutive patients with UGIB who were treated with Hemospray were analyzed (eight taking ATT for various indications and eight not on ATT). Initial hemostasis was achieved after Hemospray application in 5 /8 patients on ATT (63 %) and in all eight patients not on therapy (P = 0.20). Rebleeding rates were similar in both groups. These preliminary data on the use of Hemospray in the management of UGIB are promising in both patients with and without ATT; however, caution should be exercised for its use in patients on ATT with spurting arterial bleeding.
A recent international guideline recommends surveillance of premalignant gastric lesions for patients at risk of progression to gastric cancer. The aim of this study was to identify the role of the ...distribution and severity of premalignant lesions in risk categorization.
Patients with a previous diagnosis of atrophic gastritis, intestinal metaplasia, or low grade dysplasia were invited for surveillance endoscopy with non-targeted biopsy sampling. Biopsy specimens were evaluated by pathologists (four general and one expert) using the Sydney and the operative link for gastric intestinal metaplasia (OLGIM) systems, and scores were compared using kappa statistics.
140 patients were included. In 37 % (95 % confidence interval CI 29 % - 45 %) the severity of premalignant lesions was less than at baseline, while 6 % (95 %CI 2 % - 10 %) showed progression to more severe lesions. Intestinal metaplasia in the corpus was most likely to progress to more than one location (57 %; 95 %CI 36 % - 76 %). The proportion of patients with multilocated premalignant lesions increased from 24 % at baseline to 31 % at surveillance (P = 0.014). Intestinal metaplasia was the premalignant lesion most frequently identified in subsequent endoscopies. Intestinal metaplasia regressed in 27 % compared with 44 % for atrophic gastritis and 100 % for low grade dysplasia. Interobserver agreement was excellent for intestinal metaplasia (k = 0.81), moderate for dysplasia (k = 0.42), and poor for atrophic gastritis (k < 0).
Premalignant gastric lesions found in the corpus have the highest risk of progression, especially intestinal metaplasia, which has excellent interobserver agreement. This supports the importance of intestinal metaplasia as marker for follow-up in patients with premalignant gastric lesions.
Summary
Background
Helicobacter pylori prevalence in Western countries has been declining simultaneously with increases in childhood asthma and allergic diseases; prior studies have linked these ...phenomena.
Aims
To examine the association between H. pylori colonisation in children and risk of asthma and related conditions at school age. We secondly examined additional effects of maternal H. pylori status by pairing with children's status.
Methods
This study was embedded in a multi‐ethnic population‐based cohort in Rotterdam, The Netherlands. We measured anti‐H. pylori and anti‐CagA antibodies in serum of children obtained at age 6 years, and of their mothers obtained during midpregnancy. Asthma or related conditions were reported for children at age 6 years. We used multivariate logistic regression analyses among 3797 subjects.
Results
In children, the H. pylori positivity rate was 8.7%, and 29.2% of these were CagA‐positive. A child's colonisation with a CagA‐negative‐H. pylori strain was associated with an increased risk of asthma (Odds ratio 2.11; 95% CI 1.23–3.60), but this differed for European (3.64; 1.97–6.73) and non‐European (0.52; 0.14–1.89) children. When taking into account maternal H. pylori status, only H. pylori‐positive children with an H. pylori‐negative mother had increased risk of asthma (2.42; 1.11–5.27), accounting for 3.4% of the asthma risk.
Conclusions
Colonisation of a European child with a CagA‐negative‐H. pylori strain at age 6 was associated with an increased prevalence of asthma, but there was no association for non‐European children. The underlying mechanisms for the observed risk differences require further research.
The use of self-expandable metal stents (SEMS) has occasionally been described for the treatment of uncontrollable esophageal variceal bleeding (EVB) as a bridge to an alternative treatment option ...(i. e. transjugular intrahepatic portosystemic shunt TIPS). It is currently not known whether SEMS placement is appropriate for more than temporary hemostasis. This case series report describes five patients in whom EVB could not be controlled with variceal band ligation and who were not suitable to undergo a TIPS procedure at the time of bleeding. SEMS were placed in these patients with the intent of definitive treatment. Successful initial hemostasis was achieved in all five patients, and sustained hemostasis occurred in four. Stents were removed from two patients after > 14 days and remained in situ until death in three other patients (range 6 - 214 days). No complications related to this longer duration were observed. In one case, TIPS could be performed at a later stage. SEMS could be a definitive treatment for uncontrollable esophageal bleeding in patients with a limited life expectancy or those unsuitable for TIPS at the time of bleeding.
Background and Aim
At the same time that Helicobacter pylori prevalence is declining in Western countries, immigrants from developing countries with high H. pylori prevalence have settled in Western ...urban areas. Actual epidemiological data on H. pylori in a migrant community may help in realizing a more selective approach to assess H. pylori‐related diseases. We aimed to define H. pylori prevalence as well as risk groups for H. pylori in a cohort of young women living in a multi‐ethnic European city.
Methods
We measured Immunoglobulin G (IgG) anti‐H. pylori and CagA‐antibodies in serum of pregnant women included in a population‐based prospective cohort study, the Generation R study. Information on demographics and socioeconomic status was collected by questionnaires. Chi‐square and logistic regression were used.
Results
In total, 3146 (46%) of the 6837 tested women (mean age 29.7 ± 5.3) were H. pylori‐positive and 1110 (35%) of them were CagA‐positive. The H. pylori prevalence in Dutch women was 24%, which was significantly lower than in non‐Dutch women (64%; P < 0.001). In particular, H. pylori positivity was found in 92% of Moroccan (odds ratio 19.2; 95% confidence interval 11.8–32.0), 80% of Cape Verdean (7.6; 5.0–11.5), 81% of Turkish (9.0; 6.7–12.1), 60% of Dutch Antillean (3.3; 2.3–4.7), and 58% of Surinamese women (3.0; 2.3–3.8). Among H. pylori‐positive Dutch subjects, 19% were CagA‐positive compared with 40% of the non‐Dutch subjects (P < 0.001).
Conclusions
Despite a general trend of declining prevalence in Western countries, H. pylori remains highly prevalent in migrant communities, which may constitute target groups for screening and eradication to prevent H. pylori‐related diseases.
Background:
The International Consortium for Health Outcomes Measurement has selected the self-administered comorbidity questionnaire (SCQ) to adjust case-mix when comparing outcomes of inflammatory ...bowel disease (IBD) treatment between healthcare providers. However, the SCQ has not been validated for use in IBD patients.
Objectives:
We assessed the validity of the SCQ for measuring comorbidities in IBD patients.
Design:
Cohort study.
Methods:
We assessed the criterion validity of the SCQ for IBD patients by comparing patient-reported and clinician-reported comorbidities (as noted in the electronic health record) of the 13 diseases of the SCQ using Cohen’s kappa. Construct validity was assessed using the Spearman correlation coefficient between the SCQ and the Charlson Comorbidity Index (CCI), clinician-reported SCQ, quality of life, IBD-related healthcare and productivity costs, prevalence of disability, and IBD disease activity. We assessed responsiveness by correlating changes in the SCQ with changes in healthcare costs, productivity costs, quality of life, and disease activity after 15 months.
Results:
We included 613 patients. At least fair agreement (κ > 0.20) was found for most comorbidities, but the agreement was slight (κ < 0.20) for stomach disease κ = 0.19, 95% CI (−0.03; 0.41), blood disease κ = 0.02, 95% CI (−0.06; 0.11), and back pain κ = 0.18, 95% CI (0.11; 0.25). Correlations were found between the SCQ and the clinician-reported SCQ ρ = 0.60, 95% CI (0.55; 0.66), CCI ρ = 0.39, 95% CI (0.31; 0.45), the prevalence of disability ρ = 0.23, 95% CI (0.15; 0.32), and quality of life ρ = −0.30, 95% CI (−0.37; −0.22), but not between the SCQ and healthcare or productivity costs or disease activity (|ρ| ⩽ 0.2). A change in the SCQ after 15 months was not correlated with a change in any of the outcomes.
Conclusion:
The SCQ is a valid tool for measuring comorbidity in IBD patients, but face and content validity should be improved before being used to correct case-mix differences.
Background & Aims A new generation of oral anticoagulants (nOAC), which includes thrombin and factor Xa inhibitors, has been shown to be effective, but little is known about whether these drugs ...increase patients’ risk for gastrointestinal bleeding (GIB). Patients who require OAC therapy frequently have significant comorbidities and may also take aspirin and/or thienopyridines. We performed a systematic review and meta-analysis of the risk of GIB and clinically relevant bleeding in patients taking nOAC. Methods We queried MEDLINE, EMbase, and the Cochrane library (through July 2012) without language restrictions. We analyzed data from 43 randomized controlled trials (151,578 patients) that compared nOAC (regardless of indication) with standard care for risk of bleeding (19 trials on GIB). Odds ratios (ORs) were estimated using a random-effects model. Heterogeneity was assessed with the Cochran Q test and the Higgins I2 test. Results The overall OR for GIB among patients taking nOAC was 1.45 (95% confidence interval CI, 1.07−1.97), but there was substantial heterogeneity among studies (I2 , 61%). Subgroup analyses showed that the OR for atrial fibrillation was 1.21 (95% CI, 0.91−1.61), for thromboprophylaxis after orthopedic surgery the OR was 0.78 (95% CI, 0.31−1.96), for treatment of venous thrombosis the OR was 1.59 (95% CI, 1.03−2.44), and for acute coronary syndrome the OR was 5.21 (95% CI, 2.58−10.53). Among the drugs studied, the OR for apixaban was 1.23 (95% CI, 0.56−2.73), the OR for dabigatran was 1.58 (95% CI, 1.29−1.93), the OR for edoxaban was 0.31 (95% CI, 0.01−7.69), and the OR for rivaroxaban was 1.48 (95% CI, 1.21−1.82). The overall OR for clinically relevant bleeding in patients taking nOAC was 1.16 (95% CI, 1.00−1.34), with similar trends among subgroups. Conclusions Studies on treatment of venous thrombosis or acute coronary syndrome have shown that patients treated with nOAC have an increased risk of GIB, compared with those who receive standard care. Better reporting of GIB events in future trials could allow stratification of patients for therapy with gastroprotective agents.
Gastroesophageal variceal bleeding in patients with cirrhosis is associated with significant morbidity and mortality, as well as a high rebleeding risk. Limited data are available on the role of ...transjugular intrahepatic portosystemic shunt (TIPS) with covered stents in patients receiving standard endoscopic, vasoactive, and antibiotic treatment. In this multicenter randomized trial, long‐term endoscopic variceal ligation (EVL) or glue injection + β‐blocker treatment was compared with TIPS placement in 72 patients with a first or second episode of gastric and/or esophageal variceal bleeding, after hemodynamic stabilization upon endoscopic, vasoactive, and antibiotic treatment. Randomization was stratified according to Child‐Pugh score. Kaplan‐Meier (event‐free) survival estimates were used for the endpoints rebleeding, death, treatment failure, and hepatic encephalopathy. During a median follow‐up of 23 months, 10 (29%) of 35 patients in the endoscopy + β‐blocker group, as compared to 0 of 37 (0%) patients in the TIPS group, developed variceal rebleeding (P = 0.001). Mortality (TIPS 32% vs. endoscopy 26%; P = 0.418) and treatment failure (TIPS 38% vs. endoscopy 34%; P = 0.685) did not differ between groups. Early hepatic encephalopathy (within 1 year) was significantly more frequent in the TIPS group (35% vs. 14%; P = 0.035), but during long‐term follow‐up this difference diminished (38% vs. 23%; P = 0.121). Conclusions: In unselected patients with cirrhosis, who underwent successful endoscopic hemostasis for variceal bleeding, covered TIPS was superior to EVL + β‐blocker for reduction of variceal rebleeding, but did not improve survival. TIPS was associated with higher rates of early hepatic encephalopathy. (Hepatology 2016;63:581–589)
Acute lower gastrointestinal bleeding (LGIB) is diverse in origin and can be substantial, requiring urgent hemostasis. Hemospray is a promising novel hemostatic agent for upper gastrointestinal ...bleeding (UGIB). It has been claimed in a small series that the use of Hemospray is also feasible in LGIB. We aimed to expand our knowledge of the application of Hemospray for the treatment of LGIB in a wider range of conditions to further define the optimal patient population for this new therapeutic modality. We analyzed the outcomes of nine unselected consecutive patients with active LGIB treated with Hemospray in two major hospitals in Europe. Initial hemostasis was achieved after Hemospray application in all patients. Rebleeding occurred in two patients (22%) who were on acetyl salicylic acid and presented with spurting bleeds. These preliminary data show that Hemospray can be effective in the management of LGIB, but suggest cautious use for patients on antithrombotic therapy and spurting bleeds.
Background: The prevalence of Helicobacter pylori in Western populations has steadily decreased. This has been suggested as one of the factors involved in the recent increase of asthma and allergy. ...Some studies have reported a negative association between H. pylori and asthma and allergy, but data are inconsistent and there are a few studies in children.
Aim: We investigated whether the prevalence of H. pylori was associated with asthma symptoms, allergic rhinitis, and atopic dermatitis in childhood.
Methods: We determined IgG anti‐H. pylori and CagA antibodies in serum of Dutch children, who took part in the PIAMA birth cohort study. Serum was collected from 545 children, aged 7–9 years (Dutch ethnicity 91.5%). Symptoms of asthma and atopy were assessed by yearly questionnaires. Chi‐square tests and logistic regression were used.
Results: We found 9%H. pylori and 0.9% CagA seropositivity. Twelve (5.9%) children with reported wheezing ever were H. pylori positive, compared to 37 (10.9%) of the non‐wheezers (p = .05). No significant differences in H. pylori prevalence were found between children with or without allergic rhinitis (8.5% vs 9.5%), atopic dermatitis (8.7% vs 9.2%), and physician‐diagnosed asthma (7.1% vs 9.4%). Multivariate analysis showed no significant associations between H. pylori seropositivity and wheezing (OR 0.52; 95% CI 0.25–1.06), allergic rhinitis (OR 0.96; 95% CI 0.51–1.81), atopic dermatitis (OR 1.05; 95% CI 0.56–1.98) or physician‐diagnosed asthma (OR 0.87; 95% CI 0.37–2.08).
Conclusion: We found a borderline significantly lower H. pylori seropositivity in children with wheezing compared to non‐wheezers, but no association between H. pylori serum‐antibody status and allergic rhinitis, atopic dermatitis, or asthma.
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