Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review

BACKGROUND: While the effectiveness of upper endoscopy has been established for acute nonvariceal upper gastrointestinal tract hemorrhage, its optimal timing has not been clearly defined. Early endoscopy has been advocated for its ability to achieve prompt diagnosis, risk stratification, and therapeutic hemostasis. OBJECTIVE: To determine whether early vs delayed endoscopy improves patient and economic outcomes for all risk groups with nonvariceal upper gastrointestinal tract hemorrhage. METHODS: A systematic review of 3 computerized databases (MEDLINE, HEALTHSTAR, and Cochrane Database of Systematic Reviews) was performed along with hand searching of published abstracts to identify English-language citations from 1980 to 2000. RESULTS: Twenty-three studies met explicit inclusion criteria. The highest-quality study examining outcomes in low-risk patients found no significant complications at 1-month follow-up for any outpatients managed with early endoscopy. The largest randomized trial of high-risk patients showed no mortality benefit but a significant decrease in transfusion requirements with early endoscopy. Seven of the 8 studies examining the effect of early endoscopy on length of stay as a measure of resource utilization demonstrated a significant reduction compared with that of delayed endoscopy. However, most included studies were found to suffer from 1 or more potentially significant methodologic shortcomings. CONCLUSIONS: The overwhelming majority of existing data suggest that early endoscopy is safe and effective for all risk groups. The clinical and economic outcomes of early endoscopy should be confirmed in additional well-designed randomized controlled trials. Given the strength of the evidence, efforts to develop a more standardized and time-sensitive approach to acute nonvariceal upper gastrointestinal tract hemorrhage should be undertaken.     

Association of cardiac implantable electronic devices with survival in bifascicular block and prolonged PR interval on electrocardiogram

Purpose

Bifascicular block and prolonged PR interval on the electrocardiogram (ECG) have been associated with complete heart block and sudden cardiac death. We sought to determine if cardiac implantable electronic devices (CIED) improve survival in these patients.

Methods

We assessed survival in relation to CIED status among 636 consecutive patients with bifascicular block and prolonged PR interval on the ECG. In survival analyses, CIED was considered as a time-varying covariate.

Results

Average age was 76?±?9 years, and 99% of the patients were men. A total of 167 (26%) underwent CIED (127 pacemaker only) implantation at baseline (n?=?23) or during follow-up (n?=?144). During 5.4?±?3.8 years of follow-up, 83 (13%) patients developed complete or high-degree atrioventricular block and 375 (59%) died. Patients with a CIED had a longer survival compared to those without a CIED in the traditional, static analysis (log-rank p?<?0.0001) but not when CIED was considered as a time-varying covariate (log-rank p?=?0.76). In the multivariable model, patients with a CIED had a 34% lower risk of death (hazard ratio 0.66, 95% confidence interval 0.52–0.83; p?=?0.001) than those without CIED in the traditional analysis but not in the time-varying covariate analysis (hazard ratio 1.05, 95% confidence interval 0.79–1.38; p?=?0.76). Results did not change in the subgroup with a pacemaker only.

Conclusions

Bifascicular block and prolonged PR interval on ECG are associated with a high incidence of complete atrioventricular block and mortality. However, CIED implantation does not have a significant influence on survival when time-varying nature of CIED implantation is considered.

     

Pasteurella multocida Septicemia and Peritonitis in a Patient with Cirrhosis: Case Report and Review of the Literature

A case of Pasteurella multocida septicemia and peritonitis in a patient with cirrhosis is reported and the literature reviewed. Patients with cirrhosis and exposure to domestic animals are at risk for this infection. Initial empiric therapy of spontaneous bacterial peritonitis in such patients should include a penicillin to which this organism is usually susceptible.     

A prospective trial of a new self-expanding plastic stent for malignant esophageal obstruction

OBJECTIVE: We studied a new expandable plastic stent in the palliation of malignant esophageal obstruction. METHODS: Eight patients with malignant esophageal obstruction and dysphagia were studied. An expandable covered plastic stent made of polyester netting and covered with a silicone membrane was inserted and released into the stenosis. Relief of dysphagia and functional status were measured. RESULTS: The stent was successfully inserted in all eight patients. The median dysphagia score dropped from 3 (able to eat liquids only) to 1 (some dysphagia with solid food), and seven of the eight patients had an improvement of at least two grades of dysphagia. Mean survival was 87 days (range 17-226). Stent migration occurred in one patient after 50 days; stent occlusion due to tumor ingrowth was not seen. CONCLUSIONS: A low cost (approximately $400) expandable plastic stent has been developed that is safe and effective in the palliation of malignant esophageal obstruction. Large randomized trials comparing this stent to expandable metal stents are warranted.     

Conceptual and perceptual similarity between encoding and retrieval contexts and recognition memory context effects in older and younger adults

We examined the hypothesis that older adults' deficits in contextual memory result from difficulties in contending with partial encoding-to-retrieval changes in the context. We measured effects of contextual change and constancy on recognition memory for words, in older and younger adults. We assessed the ability to adjust to partial contextual changes by manipulating encoding-retrieval context similarity: identical, new and unrelated, conceptually similar, or perceptually similar. For both older and younger adults, identical and conceptually similar contexts benefited recognition of target words, whereas perceptually similar contexts did not. Older adults did not make more false alarms. In contrast, older adults' direct recognition of contextual stimuli was at chance. These results indicate that retrieval processes, rather than encoding or rigidity in the use of contextual cues, are implicated in older adults' difficulties in memory for contextual information.     

Patient perspectives on de‐simplifying their single‐tablet co‐formulated antiretroviral therapy for societal cost savings

Objectives

The incremental costs of expanding antiretroviral (ARV) drug treatment to all HIV‐infected patients are substantial, so cost‐saving initiatives are important. Our objectives were to determine the acceptability and financial impact of de‐simplifying (i.e. switching) more expensive single‐tablet formulations (STFs) to less expensive generic‐based multi‐tablet components. We determined physician and patient perceptions and acceptance of STF de‐simplification within the context of a publicly funded ARV budget.

Methods

Programme costs were calculated for patients on ARVs followed at the Southern Alberta Clinic, Canada during 2016 (Cdn$). We focused on patients receiving Triumeq® and determined the savings if patients de‐simplified to eligible generic co‐formulations. We surveyed all prescribing physicians and a convenience sample of patients taking Triumeq® to see if, for budgetary purposes, they felt that de‐simplification would be acceptable.

Results

Of 1780 patients receiving ARVs, 62% (n = 1038) were on STF; 58% (n = 607) of patients on STF were on Triumeq®. The total annual cost of ARVs was $26 222 760. The cost for Triumeq® was $8 292 600. If every patient on Triumeq® switched to generic abacavir/lamivudine and Tivicay® (dolutegravir), total costs would decrease by $4 325 040. All physicians (n = 13) felt that de‐simplifying could be safely achieved. Forty‐eight per cent of 221 patients surveyed were agreeable to de‐simplifying for altruistic reasons, 27% said no, and 25% said maybe.

Conclusions

De‐simplifying Triumeq® generates large cost savings. Additional savings could be achieved by de‐simplifying other STFs. Both physicians and patients agreed that selective de‐simplification was acceptable; however, it may not be acceptable to every patient. Monitoring the medical and cost impacts of de‐simplification strategies seems warranted.

     

部分脱乙酰甲壳质生物套管小间隙桥接修复周围神经损伤:免疫组织化学观察

目的:神经断端保留小间隙的静脉桥接模拟神经外膜形成神经再生室,为周围神经再生创造了良好的生理环境,从而保证神经束的良好对合。实验采用部分脱乙酰甲壳质作为套管材料,用小间隙桥接方法修复坐骨神经损伤,观察套管内的神经再生情况,并与传统外膜缝合法进行比较。方法:实验于2001-01/2002-10在北京大学人民医院创伤骨科实验室完成。①主要材料:实验所用中空圆柱形套管为北京大学人民医院与中国纺织科学院共同发明的一种部分脱乙酰甲壳质生物套管(专利号:01136314.2)。实验中所用套管尺寸为:管长4 mm,壁厚0.1 mm,内径1.5 mm。②实验动物:健康成年雄性SD大鼠20只,随机分成2大组,每组10只,每一大组全部10只动物的左腿坐骨神经为一组,右腿坐骨神经为另一组,每组10根坐骨神经。另取5只同样大鼠双侧坐骨神经未做处理作为正常对照组。③实验方法:外膜原位缝合组:切断坐骨神经,显微镜下神经外膜原位缝合;生物套管小间隙原位桥接组:切断坐骨神经,显微镜下小间隙套管桥接;断端旋转180°外膜缝合组:切断坐骨神经,显微镜下远端旋转180°后,神经外膜缝合;断端旋转180°生物套管小间隙桥接组:切断坐骨神经,显微镜下远端旋转180°后,小间隙套管桥接。④实验评估:术后第7,14,21,28,42天取坐骨神经,进行免疫组织化学染色及观察。结果:再生神经延套管中央走行,7 d时已有部分纤维通过2 mm间隙,14 d时有髓纤维数量明显多于近端。21 d后,套管组与原位外膜组新生有髓神经纤维数相近。再生纤维胞核数量较多,髓鞘纤细。套管结构完整。结论:此种部分脱乙酰甲壳质生物套管内的再生神经连续、整齐,髓鞘完整,其神经再生情况好于传统外膜缝合法。