Post-polypectomy bleeding after colonoscopy on uninterrupted aspirin/non steroideal antiflammatory drugs: Systematic review and meta-analysis

Background and aimThe aim of this systematic review and meta-analysis was to assess the risk of post-polypectomy bleeding (PPB) in patients that underwent colorectal polypectomy and exposed to ASA/NSAIDs.MethodsRelevant publications were identified in MEDLINE/EMBASE for the period 1950–2016. Studies with specified ASA/NSAIDs exposure and bleeding rate were included. Study quality was ascertained according to Newcastle-Ottawa Scale. Forest plot was based on fixed or random effect models in relation to the heterogeneity.Results11 studies (4 prospective and 7 retrospective) including 9307 patients were included in the analyses. Overall, 344 patients (OR 1.8; 95% CI 1.2–2.7; p-value 0.001, I² 52%) experienced rectal bleeding after procedure. While the rate of immediate PPB on aspirin and/or NSAIDs was not increased (OR 1.1; CI 95% 0.6–2.1; d.f. = 1, p = 0.64, I² 0%), the risk of delayed PPB was augmented (OR 1.7; 95% CI 1.2–2.2; d.f. = 8, p = 0.127, I² 36%).ConclusionsASA/NSAIDs are not a risk factor for immediate PPB but the chance of delayed is increased.     

Efectos adversos inmunomediados gastrointestinales y hepáticos inducidos por los inhibidores del punto de control inmunitario: estudio descriptivo observacional

IntroductionImmune checkpoint inhibitors (ICIs) are effective agents against several malignancies. However, they are associated with gastrointestinal and liver immune-related adverse events (GI-IrAEs and LI-IrAEs), which can lead to their temporary or permanent discontinuation.AimThe aim of this study was to evaluate the efficacy and gastrointestinal and liver toxicity of ICIs in oncological treatments in actual clinical practice.Material and methodsPatients with advanced cancer who received at least 1 ICI dose between May 2015 and September 2018 were retrospectively assessed.Results132 patients with non-small cell lung cancer (65.15%, n = 86); melanoma (22.7%, n = 30); renal carcinoma (9.09%, n = 12); and other tumours (3%, n = 4) were included. The treatments administered were nivolumab (n = 82), pembrolizumab (n = 28), atezolizumab (n = 13), durvalumab (n = 2), ipilimumab (n = 1) and the antiCTLA-4/PD-1 combination (n = 6). In total, 51 patients (38.6%) developed IrAEs, 17 (12.9%) of which experienced GI-IrAEs. Of these, 8 (47%) needed steroids and 1 patient required surgery due to intestinal perforation. Grade I Li-IrAEs were observed in 4 patients (3.03%): 2 (50%) required corticosteroids and 1 patient had to discontinue treatment. Four patients (66.6%) who received combination therapy experienced GI-IrAEs. IrAE incidence were not associated with age, gender or drug response.ConclusionsGI-IrAEs are one of the most common adverse events in patients receiving ICIs. A multidisciplinary approach and a greater understanding of these events could help to reduce morbidity and therapy discontinuation.     

A comprehensive evaluation of the gastrointestinal tract in iron-deficiency anemia with predefined hemoglobin below 9 mg/dL: A prospective cohort study

BackgroundAnemia is defined as hemoglobin below the cutoff of normal in studies examining the gastrointestinal (GI) tract in iron-deficiency anemia (IDA). Although the risk of GI cancer (GIC) increases as hemoglobin decreases, guidelines do not usually recommend hemoglobin thresholds for IDA investigation.MethodsTo elucidate whether underlying GI disorders explain the different hemoglobin values and clinical outcomes observed initially in IDA patients referred for GI workup, we prospectively investigated the diagnostic yield of a thorough GI examination in consecutive IDA adults with predefined hemoglobin <9 g/dL and no extraintestinal bleeding.Results4552 patients were enrolled over 10 years. 96% of 4038 GI lesions were consistent with occult bleeding disorders and 4% with non-bleeding disorders. Predominant bleeding disorders included upper GI ulcerative/erosive lesions (51%), GIC (15%), and angiodysplasias (12%). Diffuse angiodysplasias (45% of angiodysplasias) and GIC showed the lowest hemoglobin values (6.3 [1.5] and 6.4 [1.3] g/dL, respectively). While the spread (diffuse vs. localized) and number (<3 vs. ≥3) of angiodysplasias correlated with the degree of anemia, hemoglobin values were lower in GIC with vs. without ulcerated/friable lesions (6.0 [1.1] vs. 7.0 [1.2] g/dL, P < 0.001).ConclusionNot only GIC but also diffuse angiodysplasias caused the most severe anemia in IDA with predefined hemoglobin values <9 g/dL.     

Are the specific and nonspecific ANA staining patterns of Behçet's Disease patients important?

BackgroundThe autoinflammatory character of Behçet's Disease has led researchers to investigate the role of autoantibodies. However, no significant positive result has been reported for autoantibody tests for the disease.AimsTo investigate the specific and nonspecific staining patterns of Behçet's Disease (BD) patients.Methods140 patients (87 females, 53 males) with an average of 41.9 ± 3 years who were being followed up for Behçet's Disease, and a control group consisting of a total of 736 (464 females, 272 males) healthy volunteers made up of blood donors without any disease whose average age was 50.2 ± 4 years were included in the study. Peripheral venous blood was collected from the patients and the sera were separated. Patient sera were studied by indirect immunofluorescence antibody test (IFA) at a dilution of 1/40 and 1/100.ResultsA total of 140 (87 females, 53 males) Behçet's Disease patients and 736 (464 females, 272 males) healthy controls were examined. The rate of ANA positivity was 11.6% in the control group and 10.7% in the Behçet's Disease group. In general, no difference was detected between the patients and the healthy controls in terms of autoantibody positivity (p > 0.05). However, when examined in terms of patterns, the low detection of DFS70 and the observation of centriole staining type patterns in Behçet's Disease patients was noteworthy (p < 0.05).ConclusionAutoantibody tests, which hold an important place in classic autoimmune diseases, are not necessary for Behçet's patients, but they should be examined in terms of nonspecific patterns.     

Effects of body mass index or dosage on gastrointestinal disorders associated with extended-release metformin in type 2 diabetes: Sub-analysis of a Phase IV open-label trial in Chinese patients

AimTo determine whether gastrointestinal (GI) tolerability of metformin monotherapy varies according to baseline BMI or at doses >1500 mg/day in patients newly diagnosed with type 2 diabetes.MethodsWe performed a sub-analysis of the safety population from a prospective, multicenter, Phase IV open-label study in which 371 Chinese patients with type 2 diabetes received extended-release metformin monotherapy for 16 weeks. The incidence, severity and duration of GI adverse events (AEs) were compared between normal-weight (BMI < 25 kg/m², n = 155) and overweight/obese (BMI ≥ 25 kg/m², n = 216) patients. The primary objective was to determine whether baseline BMI affect the incidence, severity and duration of GI AEs, using Fisher's exact test and Student's t-test. Secondary objectives were to compare these factors according to final metformin dose (≤1500 mg/day versus 2000 mg/day).ResultsThe proportion of patients who reported ≥1 GI AE did not differ significantly between BMI groups (25.2% of the normal-weight group versus 21.3% of the overweight/obese group; p = 0.3840). Patients who reported GI AEs in the two BMI groups experienced similar GI AE severity (p = 0.5410), mean duration (p = 0.3572) and duration distribution (p = 0.1347). There was no significant difference in GI AE severity and duration between metformin dosage groups (≤1500 mg/day versus 2000 mg/day).ConclusionsNewly-diagnosed Chinese type 2 diabetes patients of normal weight are no more likely than overweight/obese patients to suffer from increased incidence rates, severity or duration of GI AEs when treated with first-line extended-release metformin monotherapy. Doses of 2000 mg/day did not increase the severity or duration of GI AEs.     

Potentiality of STOPP/START criteria used in primary care to effectively change inappropriate prescribing in elderly patients

PurposeTo analyse the potentiality of STOPP/START criteria for changing inappropriate prescribing (IP) in elderly polypharmacy patients, and their usefulness as perceived by general practitioners (GPs).Subjects and methodsThis was a cross-sectional study with 100 patients aged ≥ 65 years on four medications or more, from 20 GP lists across three health centres. The study variables included: age, sex, comorbidity, medications, IP (STOPP/START criteria), and GP adherence to recommendations, reasons for not adhering and perception of the toolkit's usefulness. Data were collected from electronic medical records and interviews with GPs.ResultsPatients (mean age 77 ± 5.7 years, 64% women) were prescribed a mean of 12.3 drugs/person, 8.7 for chronic conditions. We identified 92 instances of IP in 58 patients (95%CI 48–68%): 55 STOPP criteria in 42 patients (most involving acetylsalicylic acid 20%, NSAIDs 18% or benzodiazepines 16%) and 37 START in 31 patients. For all GPs, ≥ 1 instance of IP was detected, only two accepting all the recommendations. GPs adhered to 43/92 recommendations (46.7%, 95%CI 36.3–57.1%): 22/55 STOPP (40%, 95%CI 27–53%) and 21/37 START (56.8%, 95%CI 39.5-74.1%). Key reasons for not adhering were not being the prescribing physician (42%) and not seeing benefits (44%). While 95% trusted the recommendations, only 65% thought them feasible.ConclusionsDetecting IP using STOPP/START criteria is no guarantee of improving prescribing to the same extent, since GPs accept < 50% of recommendations. While GPs generally appreciate the relevance of the tool and claim to trust it, many believe applying it is not feasible in practice, time being the main barrier cited.     

Comparison of urgent and early endoscopy for acute non-variceal upper gastrointestinal bleeding in high-risk patients

ObjectiveData regarding early (within 24 h) and urgent endoscopy (within 12 h) in non-variceal upper gastrointestinal bleeding (NV-UGIB) revealed conflicting results. This study aimed to investigate the impact of endoscopy timing on the outcomes of high-risk patients with NV-UGIB.Patients and methodsFrom February 2020 to February 2021, consecutive high-risk (Glasgow–Blatchford score ≥12) adults admitted to the emergency department with NV-UGIB were analyzed retrospectively. The primary composite outcome was 30-day mortality from any cause, inpatient rebleeding, need for endoscopic re-intervention, need for surgery or angiographic embolization.Results240 patients were enrolled: 152 (63%) patients underwent urgent endoscopy (<12 h) and 88 (37%) patients underwent early endoscopy (12–24 h). One or more components of the composite outcome were observed in 53 (22.1%) patients: 30 (12.5%) had 30-day mortality, rebleeding occurred in 27 (11.3%), 7 (2.9%) underwent endoscopic re-intervention, and 5 (2.1%) required surgery or angiographic embolization. The composite outcome was similar between the groups. Multivariate analysis showed only hemodynamic instability on admission (OR: 3.05, p = 0.006), and the previous history of cancer (OR: 2.42, p = 0.029) were significant in predicting composite outcome. In terms of secondary outcomes, the endoscopic intervention was higher in the urgent endoscopy group (p = 0.006), whereas the number of transfused erythrocyte suspensions and the length of hospital stay was higher in the early endoscopy group (p = 0.002 and p = 0.040, respectively).ConclusionsUrgent endoscopy leads to a significant reduction in the length of hospitalization and the number of transfused erythrocyte suspensions in NV-UGIB, which can contribute to patient satisfaction, reduce healthcare expenditure, and improve hospital bed availability. The composite outcome and its sub-outcomes were the same among both groups.     

Adherence to hypoglycaemic medication among people with type 2 diabetes in primary care

AimsTo assess levels and correlates of adherence to hypoglycaemic medication among patients offered organised general practice diabetes care.Methods60 patients prescribed oral hypoglycaemic medication were recruited to a two-month prospective study. Prescribed doses taken and days on which the prescribed number of doses was taken were measured by MEMS (Medication Event Monitoring System).ResultsOverall 99.1% of prescribed doses were taken (median, IQR: 96.8–100%), this was inversely correlated with daily dose frequency (Spearman's rho = 0.37, p = 0.004). Only 4 patients (6.7%) took less than 90% of prescribed doses. The prescribed dose was taken on 96.4% of days (median, IQR: 89.1–98.2%), this was correlated with age (rho = 0.26, p = 0.047) and inversely correlated with HbA_1c levels (rho = ?0.29, p = 0.02) and daily dose frequency (rho = ?0.33, p = 0.009). Adherence to metformin was less than to other hypoglycaemic medication (Z = ?3.48, p = 0.0005).ConclusionsA dispensing practice with a well-run diabetes service can support high rates of adherence to hypoglycaemic medication. Before changing medication, low adherence might be considered as a possible cause of progressive hyperglycaemia, particularly among patients prescribed metformin more than once a day. Selective monitoring with MEMS may have a clinical as well as a research role in such people.     

Éducation thérapeutique en prévention primaire cardiovasculaire : intérêt prolongé à 4 ans

BackgroundOur patient therapeutic education program yields improvements in health after one year. But what can we see after 4 years, when the patient alone is responsible for following the program?Patients and methodsTwo hundred and ninety-one patients participated in the first part of our study and were followed during one year. Four years into the ongoing study, we reviewed the progress of the first 200 patients. We compared the already published Risk Factors and Eating Habits scores between the beginning of the study (T0), one year later (T1) and after 4 years (T4).ResultsThe Risk Factor score at T0 is 9.5 ± 7.8, moving to 7 ± 7.5 at T1, and then to 6.8 ± 7.8 at T4 (P < 0.001 between T0 and T1 and T0 and T4). Endurance physical activities saw the greatest improvement: 0.79 ± 5 at T0, −1.07 ± 4.5 at T1 and −1.61 ± 4.5 at T4 (P < 0.001 between T0 and T1 and T0 and T4). The Eating Habits score went from −18.2 ± 7.3 to −22.2 ± 6.4 and then to −23.5 ± 6.4 (P < 0.001 between T0 and T1 and T0 and T4). The best results were obtained through increased consumption of whole grains, green vegetables and fish.ConclusionThe positive results of the progress of risk factors and eating habits, noted after one year, are even greater four years after the end of the therapeutic education program.     

Association and relative importance of multiple risk factor control on cardiovascular disease,end-stage renal disease and mortality in people with type 2 diabetes: A population-based retrospective cohort study

AimsTo evaluate the risk of cardiovascular disease (CVD), end-stage renal disease (ESRD), and mortality, when implementing a multifactorial optimal control approach in primary care in the United Kingdom (UK), in individuals with newly diagnosed type 2 diabetes.Materials and methodsA retrospective cohort of 53 942 patients were stratified into 1 of the 8 groups according to whether glycated haemoglobin (HbA1c), blood pressure (BP) and total cholesterol (TC) target values were achieved or not from baseline to the date of last follow-up. Those with single or combinations of risk factor control targets achieved, were compared to those who achieved no targets in any of the risk factor. Hazard ratios from the Cox proportional hazards models were estimated against patients who achieved no targets.ResultsOf 53 942 patients with newly diagnosed type 2 diabetes, 28%, 55%, and 68% were at target levels for HbA1c <48 mmol/mol (<6.5%), BP < 140/85 mm Hg, and TC < 5 mmol/L respectively, 36%, 40%, and 12% were at target levels for any one, two, or all three risk factors respectively. Being at HbA1c, BP, and TC targets was associated with an overall 47%, 25%, 42%, 55% and 42% reduction in the risk of ischemic heart disease, cerebrovascular disease, ESRD, cardiovascular-mortality, and all-cause-mortality respectively. Among all subgroups, the risk reduction of study outcome events was greater in the subgroups of patients with microalbuminuria, males, smokers, and patients with BMI ≥ 30 kg/m².ConclusionsOptimal levels of HbA1c, BP, and TC occurring together in patients with newly diagnosed type 2 diabetes are uncommon. Achieving multiple risk factor control targets could substantially reduce the risk of CVD, ESRD and mortality.