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Kondo M, Torisu T, Ihara Y, Kawasaki K, Umeno J, Kawatoko S, Tsuchimoto A, Nakano T, Okabe Y, Kitazono T. Clinical Features of Gastroduodenal Ulcers in Kidney Transplant Patients. Intern Med 2023; 62:3437-3443. [PMID: 37062748 PMCID: PMC10749817 DOI: 10.2169/internalmedicine.1508-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 02/26/2023] [Indexed: 04/18/2023] Open
Abstract
Objective The risk of developing peptic ulcers and gastrointestinal bleeding is high in patients with chronic kidney disease (CKD). Whether or not kidney transplant patients, who are treated with multiple medications, including immunosuppressive drugs, are at an increased risk of developing peptic ulcers is unclear. Methods In this retrospective study, we compared the clinical and endoscopic features of gastroduodenal ulcers between kidney transplant patients and CKD patients. The subjects underwent upper gastrointestinal endoscopy between January 2015 and March 2021. Results Gastroduodenal ulcers were observed more frequently (6.5%) in kidney transplant patients than in CKD patients (2.1%) (p=0.026). Due in part to the lower median age in the kidney transplant ulcer group than in the CKD ulcer group (59 vs. 70 years old, p=0.016), the rates of atrophic gastritis and Helicobacter pylori infection were also lower in the kidney transplant ulcer group than in the CKD ulcer group. Significantly more kidney transplant patients were treated with acid secretion inhibitors than CKD ulcer patients (100% vs. 34.8%, p=0.0005). Peptic ulcers were observed frequently in kidney transplant patients, even though common risk factors for gastroduodenal ulcers other than immunosuppressive drugs were few. All kidney transplant patients were taking immunosuppressive medications, and tacrolimus, mycophenolate mofetil, and methylprednisolone were taken more frequently than others. Conclusion Kidney transplant patients have a high risk of developing gastroduodenal ulcers. All kidney transplant patients take immunosuppressive medications, so there may be an association between immunosuppressive medications and gastroduodenal ulcer development.
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Affiliation(s)
- Masahiro Kondo
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Takehiro Torisu
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yutaro Ihara
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Keisuke Kawasaki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Junji Umeno
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Shinichiro Kawatoko
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
- Department of Anatomic Pathology, Pathological Sciences, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Japan
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Hozman M, Hassouna S, Grochol L, Waldauf P, Hracek T, Pazdiorova BZ, Adamec S, Osmancik P. Previous antithrombotic therapy does not have an impact on the in-hospital mortality of patients with upper gastrointestinal bleeding. Eur Heart J Suppl 2023; 25:E25-E32. [PMID: 37234230 PMCID: PMC10206644 DOI: 10.1093/eurheartjsupp/suad103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
The association between antithrombotics (ATs) and the risk of gastrointestinal bleeding is well known; however, data regarding the influence of ATs on outcomes are scarce. The goals of this study are: (i) to assess the impact of prior AT therapy on in-hospital and 6-month outcomes and (ii) to determine the re-initiation rate of the ATs after a bleeding event. All patients with upper gastrointestinal bleeding (UGB) who underwent urgent gastroscopy in three centres from 1 January 2019 to 31 December 2019 were retrospectively analysed. Propensity score matching (PSM) was used. Among 333 patients [60% males, mean age 69.2 (±17.3) years], 44% were receiving ATs. In multivariate logistic regression, no association between AT treatment and worse in-hospital outcomes was observed. Development of haemorrhagic shock led to worse survival [odds ratio (OR) 4.4, 95% confidence interval (CI) 1.9-10.2, P < 0.001; after PSM: OR 5.3, 95% CI 1.8-15.7, P = 0.003]. During 6-months follow-up, higher age (OR 1.0, 95% CI 1.0-1.1, P = 0.002), higher comorbidity (OR 1.4, 95% CI 1.2-1.7, P < 0.001), a history of cancer (OR 3.6, 95% CI 1.6-8.1, P < 0.001) and a history of liver cirrhosis (OR 2.2, 95% CI 1.0-4.4, P = 0.029) were associated with higher mortality. After a bleeding episode, ATs were adequately re-initiated in 73.8%. Previous AT therapy does not worsen in-hospital outcomes in after UGB. Development of haemorrhagic shock predicted poor prognosis. Higher 6-month mortality was observed in older patients, patients with more comorbidities, with liver cirrhosis and cancer.
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Affiliation(s)
- Marek Hozman
- Cardiocenter, Hospital Karlovy Vary, 360 01 Karlovy Vary, Czech Republic
| | - Sabri Hassouna
- Cardiocenter, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, Ruska 87, 100 00 Prague, Czech Republic
| | - Lukas Grochol
- 2nd Department of Internal Medicine, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady,100 00 Prague, Czech Republic
| | - Petr Waldauf
- Department of Anaesthesia and Intensive Care, 3rd Faculty of Medicine, Charles University and University Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | - Tomas Hracek
- Department of General Surgery, 3rd Faculty of Medicine, Charles University, Faculty Hospital Kralovske Vinohrady, 100 00 Prague, Czech Republic
| | | | - Stanislav Adamec
- Department of Gastroenterology, Hospital Cheb, 350 02 Cheb, Czech Republic
| | - Pavel Osmancik
- Corresponding author. Tel: 00420-721544447, Fax: 00420-267162817,
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Alhalabi MM. Mortality and risk factors associated with peptic ulcer bleeding among adult inpatients of Damascus Hospital, Syria: A cross-sectional study. Medicine (Baltimore) 2023; 102:e33699. [PMID: 37115046 PMCID: PMC10145724 DOI: 10.1097/md.0000000000033699] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/06/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
Peptic ulcer bleeding is associated with significant morbidity and mortality, while monitoring mortality is extremely beneficial to public health, and the latest estimates date back to 2010 for the Syrian population. This study aims to estimate the in-hospital mortality rate and risk factors associated with peptic ulcer bleeding among adult inpatients at Damascus Hospital, Syria. A cross-sectional study with systematic random sampling. Sample size (n) was calculated using the proportional equation: [n = Z2P (1 - P)/d2], with the following hypothesis: Z = 1.96 for the 95% confidence level, P = .253 for mortality in patients hospitalized with complicated peptic ulcers, a margin of error (d) = 0.05, 290 charts were reviewed, and the Chi-square test (χ2 test) was used for categorical variables, and the t test for continuous data. We reported the odds ratio in addition to mean and standard deviation with a 95% confidence. A P value less than .05 was considered statistically significant. Data were analyzed using a statistical package for the social sciences (SPSS). The mortality rate was 3.4%, and the mean age was 61.76 ± 16.02 years. The most frequent comorbidities were hypertension, diabetes mellitus, and ischemic heart disease. The most commonly used medications were NSAIDs, aspirin, and clopidogrel. 74 patients (25.52%) were using aspirin with no documented indication P < .01, odds ratio = 6.541, 95% CI [2.612-11.844]. There were 162 (56%) Smokers. Six patients (2.1%) suffered from recurrent bleeding, and 13 (4.5%) needed surgery. Raising awareness about the risks of using non-steroidal anti-inflammatory drugs may reduce the occurrence of peptic ulcers and, as a result, peptic ulcer complications. Larger, nationwide studies are needed to estimate the real mortality rate in complicated peptic ulcer patients in Syria. There is a lack of some critical data in the patients' charts, which necessitates action to correct.
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Peng D, Zhang M. The effect of aspirin in patients with nonvaricose upper gastrointestinal bleeding and risk factors analysis. Scand J Gastroenterol 2022; 57:149-153. [PMID: 34693854 DOI: 10.1080/00365521.2021.1990396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE This paper aims to explore the effect of aspirin on the in-hospital mortality of patients with NVUGIB. METHODS An observational study retrospectively examined 1514 patients with NVUGIB based on a multi-center database. RESULT Our study reported a mortality rate of 4.8% in patients with NVUGIB, with 163 patients had a history of aspirin. Among 163 patients with an aspirin history, 76 patients (46.6%) continued to take aspirin in the hospital, with an average duration of 0.66 days after bleeding. Subsequent multivariate regression analysis showed heart rate (p <.001, OR = 0.978, 95%CI 0.969-0.987) and albumin (p =.019, OR = 0.658, 95%CI 0.464-0.933) were independent factors for aspirin-therapy after bleeding. Patients who received aspirin after NVUGIB (log-rank = 3.968, p =.046) had better survival than those who did not, but it was not an independent risk factor. The levels of albumin (p < .001, OR = 0.288, 95%CI 0.165-0.505) and INR (p =.013, OR = 1.166, 95%CI 1.033-1.316) and heart rate (p =.005, OR = 1.017, 95%CI 1.005-1.029) were independent factors of in-hospital mortality. CONCLUSIONS The independent risk factors for in-hospital mortality in patients with NVUGIB were albumin and INR and heart rate. The history of aspirin and the aspirin therapy after the bleeding did not affect the in-hospital mortality in patients with NVUGIB.
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Affiliation(s)
- Ding Peng
- Department of Gastroenterology, Xuanwu Hospital Capital Medical University, Beijing, China
| | - Mei Zhang
- Department of Gastroenterology, Xuanwu Hospital Capital Medical University, Beijing, China
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Jeon HJ, Moon HS, Kwon IS, Kang SH, Sung JK, Jeong HY. Which scoring system should be used for non-variceal upper gastrointestinal bleeding? Old or new? J Gastroenterol Hepatol 2021; 36:2819-2827. [PMID: 34031928 DOI: 10.1111/jgh.15555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/01/2021] [Accepted: 05/19/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIM Several scoring systems for predicting outcomes in patients with non-variceal upper gastrointestinal bleeding (NVUGIB) have recently been devised, but not sufficiently validated. We compared the predictive accuracy of several scoring systems and assessed the usefulness of new scoring systems. METHODS The medical records of 1048 patients with NVUGIB were reviewed to collect demographic, clinical, laboratory, and endoscopic data. The areas under the receiver operating characteristic curve (AUROCs) were calculated for the ABC, new Japanese scoring system, Progetto Nazionale Emorrhagia Digestiva (PNED), and other scores to compare their predictive accuracy for 30-day mortality, therapeutic intervention, rebleeding, and prolonged hospital stay (≥ 10 days). Outcome predictors were identified by multivariate analysis. RESULTS The ABC, new Japanese scoring system, and PNED scores best predicted 30-day mortality (AUROC 0.907), need for therapeutic intervention (AUROC 0.707), and rebleeding (AUROC 0.874), respectively (all P < 0.001). The ABC and PNED scores were similarly better at predicting prolonged hospital stay (ABC AUROC: 0.765; PNED AUROC: 0.790; both P < 0.001). Thirty-day mortality was related to sex, systolic blood pressure (SBP), syncope, estimated glomerular filtration rate (eGFR), albumin, heart failure, disseminated malignancy, chronic obstructive pulmonary disease (COPD), and liver cirrhosis. Sex, age, SBP, hematemesis, blood urea nitrogen, and eGFR independently predicted the need for therapeutic intervention. Sex, SBP, pulse, albumin level, heart failure, disseminated malignancy, and COPD predicted rebleeding. CONCLUSION The outcomes of patients with NVUGIB were better predicted by newly developed than by old scoring systems.
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Affiliation(s)
- Hong Jae Jeon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Hee Seok Moon
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - In Sun Kwon
- Clinical Trials Center, Chungnam National University Hospital, Daejeon, South Korea
| | - Sun Hyung Kang
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Jae Kyu Sung
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
| | - Hyun Yong Jeong
- Division of Gastroenterology, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, South Korea
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Abstract
Purpose of review Peptic ulcer disease (PUD) is a recognized complication of non-steroidal anti-inflammatory drugs (NSAIDs). Stress ulcers are a concern for intensive care unit (ICU) patients; PUD is also an issue for patients taking anticoagulation. Helicobacter pylori test and treat is an option for patients starting NSAID therapy, and proton pump inhibitors (PPIs) may reduce PUD in NSAID patients and other high-risk groups. Recent findings There are a large number of trials that demonstrate that Helicobacter pylori eradication reduces PUD in NSAID patients. PPI is also effective at reducing PUD in this group and is also effective in ICU patients and those on anticoagulants. The effect is too modest for PPI to be recommended in everyone, and more research is needed as to which groups would benefit the most. Increasing age, past history of PUD, and comorbidity are the most important risk factors. Summary H. pylori test and treat should be offered to older patients starting NSAIDS, while PPIs should be prescribed to patients that are at high risk of developing PUD and at risk of dying from PUD complications.
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Role of Helicobacter pylori in Upper Gastrointestinal Bleeding Among Ischemic Stroke Hospitalizations: A Nationwide Study of Outcomes. GASTROINTESTINAL DISORDERS 2019. [DOI: 10.3390/gidisord1030029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Helicobacter pylori (H. pylori) is a well-recognized risk factor for upper gastrointestinal bleeding (UGIB). The exposure to tissue plasminogen activator (tPA), anti-platelets, and anticoagulants increases the risk of UGIB in acute ischemic stroke (AIS) patients, the risk stratification of H. pylori infection is not known. In this retrospective cross-sectional study, we aimed to evaluate the relationship between H. pylori and GIB in patients hospitalized with AIS. Methods: In the nationwide data, hospitalization for AIS was identified by primary diagnosis using International Classification of Diseases, clinical modification (ICD-9-CM) codes. Subgroup of patients with GIB and H. pylori were identified in AIS cohort. A stepwise multivariable logistic regression model was fitted to evaluate the outcome of upper GIB and role of H. Pylori in UGIB. Results: Overall 4,224,924 AIS hospitalizations were identified, out of which 18,629 (0.44%) had UGIB and 3122 (0.07%) had H. pylori. The prevalence of H. pylori-induced UGIB among UGIB in AIS was 3.05%. The prevalence of UGIB was markedly elevated among the H. pylori infection group (18.23% vs. 0.43%; p < 0.0001) compared to the non-H. pylori group. In multivariable regression analysis, H. pylori was associated with markedly elevated odds of UGIB (aOR:27.75; 95%CI: 21.07–36.55; p < 0.0001). Conclusion: H. pylori infection had increased risk-adjusted occurrence of UGIB amongst the AIS hospitalized patients. H. pylori testing may improve risk stratification for UGIB and lower the health care cost burden in stroke hospitalization.
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Causada-Calo N, Germini F, Yuan Y, Eikelboom JW, Moayyedi P. Proton-pump inhibitors for the prevention of upper gastrointestinal bleeding in adults receiving antithrombotic therapy. Hippokratia 2019. [DOI: 10.1002/14651858.cd013415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Natalia Causada-Calo
- St. Michael's Hospital; Department of Medicine, Division of Gastroenterology; 30 Bond St. Therapeutic Endoscopy Unit, 16th floor, Cardinal Carter North Toronto ON Canada M5B 1W8
| | - Federico Germini
- McMaster University; Department of Health Research Methods, Evidence, and Impact; Hamilton ON Canada
| | - Yuhong Yuan
- McMaster University; Department of Medicine, Division of Gastroenterology; 1280 Main Street West Room HSC 3N51 Hamilton ON Canada L8S 4K1
| | - John W Eikelboom
- McMaster Clinic; Thrombosis Service; HHS - General Hospital 237 Barton Street East Hamilton ON Canada L8L 2X2
| | - Paul Moayyedi
- McMaster University; Department of Medicine, Division of Gastroenterology; 1280 Main Street West Room HSC 3N51 Hamilton ON Canada L8S 4K1
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Characteristics and outcomes of gastroduodenal ulcer bleeding: a single-centre experience in Lithuania. GASTROENTEROLOGY REVIEW 2018; 12:277-285. [PMID: 29358997 PMCID: PMC5771452 DOI: 10.5114/pg.2017.72103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 10/29/2016] [Indexed: 11/29/2022]
Abstract
Introduction Despite the optimal use of combined endoscopic haemostasis and pharmacologic control of acid secretion in the stomach, mortality in patients with peptic ulcer bleeding (PUB) has remained constant. Recent data has shown that the majority of patients with PUB die of non-bleeding-related causes. Aim To provide an overview of our experience of PUB management, with emphasis on the effect of age, gender, comorbidities, and drug use on the characteristics and outcomes of gastroduodenal ulcer bleeding. Material and methods We retrospectively reviewed the medical records of all patients admitted with the primary diagnosis of acute, chronic or unspecified gastric and/or duodenal ulcer with haemorrhage during 2008–2012. Results Two hundred and nineteen patients were identified. 46.6% of patients were ≥ 65 years old (elderly) and 53.4% were < 65 years old (young). The young patients were more likely to have duodenal ulcers and liver failure at admission. Previous use of medications was more regularly observed in gastric ulcer patients than in duodenal ulcer patients. Rebleeding occurred in 43 (19.6%) patients and death in 5 (2.3%) patients. Increased risk of mortality in our patients was associated with age ≥ 65 years (RR = 2.21; 95% CI: 1.90–2.56; p = 0.021). Conclusions Management of peptic ulcer bleeding should aim at reducing the risk of multiorgan failure and cardiopulmonary death instead of focusing merely on successful haemostasis.
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Outcomes of patients hospitalized with peptic ulcer disease diagnosed in acute upper endoscopy. Eur J Gastroenterol Hepatol 2017; 29:1251-1257. [PMID: 28857894 DOI: 10.1097/meg.0000000000000951] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from bleeding ulcers has remained unchanged. The aims of the current study were to evaluate the significance of PUD among patients admitted for acute upper endoscopy and to evaluate the survival of PUD patients. PATIENTS AND METHODS In this prospective, observational cohort study, data on 1580 acute upper endoscopy cases during 2012-2014 were collected. A total of 649 patients were included with written informed consent. Data on patients' characteristics, living habits, comorbidities, drug use, endoscopy and short-term and long-term survival were collected. RESULTS Of all patients admitted for endoscopy, 147/649 (23%) had PUD with the main symptom of melena. Of these PUD patients, 35% had major stigmata of bleeding (Forrest Ia-IIb) in endoscopy. Patients with major stigmata had significantly more often renal insufficiency, lower level of blood pressure with tachycardia and lower level of haemoglobin, platelets and ratio of thromboplastin time. No differences in drug use, Charlson comorbidity class, BMI, smoking or alcohol use were found. Of the PUD patients, 31% were Helicobacter pylori positive. The 30-day mortality was 0.7% (95% confidence interval: 0.01-4.7), 1-year mortality was 12.9% (8.4-19.5) and the 2-year mortality was 19.4% (13.8-26.8), with no difference according to major or minor stigmata of bleeding. Comorbidity (Charlson>1) was associated with decreased survival (P=0.029) and obesity (BMI≥30) was associated with better survival (P=0.023). CONCLUSION PUD is still the most common cause for acute upper endoscopy with very low short-term mortality. Comorbidity, but not the stigmata of bleeding, was associated with decreased long-term survival.
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Redeen S. The Trend of Tranexamic Use in Upper Gastrointestinal Bleeding Ulcers. Gastroenterology Res 2017; 10:159-165. [PMID: 28725302 PMCID: PMC5505280 DOI: 10.14740/gr836w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/12/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Bleeding ulcer is a common condition, especially among the elderly population. Tranexamic acid (TXA) has been successfully used for many bleeding conditions. Its use in patients with bleeding ulcer is inclusive yet. The aim of this study was to provide an overview of the prescription of TXA. METHODS This retrospective cohort study was performed as a review of medical records at the Surgery Department, University Hospital in Linkoping. Patients with complete esophagogastroduodenoscopy and ulcer disease were included and divided on the basis of treatment with TXA or not. Differences between the groups were statistically analyzed. RESULTS The main part of the prescription of TXA, 65%, occurred during 2010 and 2011, and 35% between 2012 and 2013 (P < 0.05). In the group treated with TXA, 84% needed blood transfusion, compared to 64% in the control group (P = 0.039). Of the patients treated with TXA, 18% were re-bleeding compared to 14% of the controls (P = 0.594). Median value for days at hospital was 5 in the tranexamic group and 3 in the control group (P = 0.005). CONCLUSION The prescription of TXA has declined between 2010 and 2013. TXA was more often prescribed to patients with more severe gastrointestinal (GI) bleeding ulcer disease. Further investigation is needed to conclude the significance of tranexamic acid in patients with GI bleeding ulcer disease.
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Affiliation(s)
- Stefan Redeen
- Department of Surgery and Department of Clinical and Experimental Medicine, Linkoping University, Linkoping, Sweden.
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12
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Elwood PC, Morgan G, Galante J, Chia JWK, Dolwani S, Graziano JM, Kelson M, Lanas A, Longley M, Phillips CJ, Pickering J, Roberts SE, Soon SS, Steward W, Morris D, Weightman AL. Systematic Review and Meta-Analysis of Randomised Trials to Ascertain Fatal Gastrointestinal Bleeding Events Attributable to Preventive Low-Dose Aspirin: No Evidence of Increased Risk. PLoS One 2016; 11:e0166166. [PMID: 27846246 PMCID: PMC5113022 DOI: 10.1371/journal.pone.0166166] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 10/19/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Aspirin has been shown to lower the incidence and the mortality of vascular disease and cancer but its wider adoption appears to be seriously impeded by concerns about gastrointestinal (GI) bleeding. Unlike heart attacks, stroke and cancer, GI bleeding is an acute event, usually followed by complete recovery. We propose therefore that a more appropriate evaluation of the risk-benefit balance would be based on fatal adverse events, rather than on the incidence of bleeding. We therefore present a literature search and meta-analysis to ascertain fatal events attributable to low-dose aspirin. METHODS In a systematic literature review we identified reports of randomised controlled trials of aspirin in which both total GI bleeding events and bleeds that led to death had been reported. Principal investigators of studies in which fatal events had not been adequately described were contacted via email and asked for further details. A meta-analyses was then performed to estimate the risk of fatal gastrointestinal bleeding attributable to low-dose aspirin. RESULTS Eleven randomised trials were identified in the literature search. In these the relative risk (RR) of 'major' incident GI bleeding in subjects who had been randomised to low-dose aspirin was 1.55 (95% CI 1.33, 1.83), and the risk of a bleed attributable to aspirin being fatal was 0.45 (95% CI 0.25, 0.80). In all the subjects randomised to aspirin, compared with those randomised not to receive aspirin, there was no significant increase in the risk of a fatal bleed (RR 0.77; 95% CI 0.41, 1.43). CONCLUSIONS The majority of the adverse events caused by aspirin are GI bleeds, and there appears to be no valid evidence that the overall frequency of fatal GI bleeds is increased by aspirin. The substantive risk for prophylactic aspirin is therefore cerebral haemorrhage which can be fatal or severely disabling, with an estimated risk of one death and one disabling stroke for every 1,000 people taking aspirin for ten years. These adverse effects of aspirin should be weighed against the reductions in vascular disease and cancer.
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Affiliation(s)
- Peter C. Elwood
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | - Gareth Morgan
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Hywel Dda University Health Board, Llanelli, United Kingdom
| | - Julieta Galante
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
| | - John W. K. Chia
- Division of Medical Oncology, National Cancer Centre, Singapore, Singapore
| | - Sunil Dolwani
- Institute of Cancer & Genetics Cardiff University, Cardiff, United Kingdom
| | | | - Mark Kelson
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | - Angel Lanas
- University Clinic Hospital, University of Zaragoza, IIS Aragón, CIBEReshd, Zaragoza, Spain
| | - Marcus Longley
- Welsh Institute for Health and Social Care, University of South Wales, Cardiff, United Kingdom
| | - Ceri J. Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, United Kingdom
| | - Janet Pickering
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
| | | | - Swee S. Soon
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
| | - Will Steward
- Department of Cancer Studies, University of Leicester, Leicester, United Kingdom
| | - Delyth Morris
- University Library Services, Cardiff University, Cardiff, United Kingdom
| | - Alison L. Weightman
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, United Kingdom
- Specialist Unit for Review Evidence (SURE), Cardiff University, Cardiff, United Kingdom
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Scarpignato C, Gatta L, Zullo A, Blandizzi C. Effective and safe proton pump inhibitor therapy in acid-related diseases - A position paper addressing benefits and potential harms of acid suppression. BMC Med 2016; 14:179. [PMID: 27825371 PMCID: PMC5101793 DOI: 10.1186/s12916-016-0718-z] [Citation(s) in RCA: 242] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2016] [Accepted: 10/14/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The introduction of proton pump inhibitors (PPIs) into clinical practice has revolutionized the management of acid-related diseases. Studies in primary care and emergency settings suggest that PPIs are frequently prescribed for inappropriate indications or for indications where their use offers little benefit. Inappropriate PPI use is a matter of great concern, especially in the elderly, who are often affected by multiple comorbidities and are taking multiple medications, and are thus at an increased risk of long-term PPI-related adverse outcomes as well as drug-to-drug interactions. Herein, we aim to review the current literature on PPI use and develop a position paper addressing the benefits and potential harms of acid suppression with the purpose of providing evidence-based guidelines on the appropriate use of these medications. METHODS The topics, identified by a Scientific Committee, were assigned to experts selected by three Italian Scientific Societies, who independently performed a systematic search of the relevant literature using Medline/PubMed, Embase, and the Cochrane databases. Search outputs were distilled, paying more attention to systematic reviews and meta-analyses (where available) representing the best evidence. The draft prepared on each topic was circulated amongst all the members of the Scientific Committee. Each expert then provided her/his input to the writing, suggesting changes and the inclusion of new material and/or additional relevant references. The global recommendations were then thoroughly discussed in a specific meeting, refined with regard to both content and wording, and approved to obtain a summary of current evidence. RESULTS Twenty-five years after their introduction into clinical practice, PPIs remain the mainstay of the treatment of acid-related diseases, where their use in gastroesophageal reflux disease, eosinophilic esophagitis, Helicobacter pylori infection, peptic ulcer disease and bleeding as well as, and Zollinger-Ellison syndrome is appropriate. Prevention of gastroduodenal mucosal lesions (and symptoms) in patients taking non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapies and carrying gastrointestinal risk factors also represents an appropriate indication. On the contrary, steroid use does not need any gastroprotection, unless combined with NSAID therapy. In dyspeptic patients with persisting symptoms, despite successful H. pylori eradication, short-term PPI treatment could be attempted. Finally, addition of PPIs to pancreatic enzyme replacement therapy in patients with refractory steatorrhea may be worthwhile. CONCLUSIONS Overall, PPIs are irreplaceable drugs in the management of acid-related diseases. However, PPI treatment, as any kind of drug therapy, is not without risk of adverse effects. The overall benefits of therapy and improvement in quality of life significantly outweigh potential harms in most patients, but those without clear clinical indication are only exposed to the risks of PPI prescription. Adhering with evidence-based guidelines represents the only rational approach to effective and safe PPI therapy. Please see related Commentary: doi: 10.1186/s12916-016-0724-1 .
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Affiliation(s)
- Carmelo Scarpignato
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy.
| | - Luigi Gatta
- Clinical Pharmacology & Digestive Pathophysiology Unit, Department of Clinical & Experimental Medicine, University of Parma, Maggiore University Hospital, Cattani Pavillon, I-43125, Parma, Italy
- Gastroenterology & Endoscopy Unit, Versilia Hospital, Azienda USL Toscana Nord Ovest, Lido di Camaiore, Italy
| | - Angelo Zullo
- Division of Gastroenterology & Digestive Endoscopy, Nuovo Regina Elena Hospital, Rome, Italy
| | - Corrado Blandizzi
- Division of Pharmacology, Department of Clinical & Experimental Medicine, University of Pisa, Pisa, Italy
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Malmi H, Kautiainen H, Virta LJ, Färkkilä MA. Increased short- and long-term mortality in 8146 hospitalised peptic ulcer patients. Aliment Pharmacol Ther 2016; 44:234-45. [PMID: 27240732 DOI: 10.1111/apt.13682] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 11/09/2015] [Accepted: 05/09/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Incidence and complications of peptic ulcer disease (PUD) have declined, but mortality from peptic ulcer bleeding has remained unchanged. The few recent studies on mortality associated with both uncomplicated and complicated patients with peptic ulcer disease provide contradictory results. AIMS To evaluate short- and long-term mortality, and the main causes of death in peptic ulcer disease. METHODS In this retrospective epidemiologic cohort study, register data on 8146 adult patients hospitalised with peptic ulcer disease during 2000-2008 were collected in the capital region of Finland. All were followed in the National Cause of Death Register until the end of 2009. The data were linked with the nationwide Drug Purchase Register of the Finnish Social Insurance Institution. RESULTS Mean follow-up time was 4.9 years. Overall mortality was substantially increased, standardised mortality ratio 2.53 (95% CI: 2.44-2.63); 3.7% died within 30 days, and 11.8% within 1 year. At 6 months, the survival of patients with perforated or bleeding ulcer was lower compared to those with uncomplicated ulcer; hazard ratios were 2.06 (1.68-2.04) and 1.32 (1.11-1.58), respectively. For perforated duodenal ulcers, both the short- and long-term survival was significantly impaired in women. The main causes of mortality at 1 year were malignancies and cardiovascular diseases. Previous use of statins was associated with significant reduction in all-cause mortality. CONCLUSIONS One-year mortality in patients hospitalised with peptic ulcer disease remained high with no change. This peptic ulcer disease cohort had a clearly decreased survival rate up to 10 years, especially among women with a perforated duodenal ulcer, most likely explained by poorer survival due to underlying comorbidity.
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Affiliation(s)
- H Malmi
- Gastrointestinal Surgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - H Kautiainen
- Department of General Practice and Primary Health Care, Helsinki University Hospital, University of Helsinki, Helsinki, Finland.,Department of General Practice and Primary Health Care, University of Eastern Finland, Kuopio, Finland
| | - L J Virta
- Research Department, The Social Insurance Institution of Finland, Turku, Finland
| | - M A Färkkilä
- Helsinki University Clinic of Gastroenterology, University of Helsinki, Helsinki, Finland
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15
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Souk KM, Tamim HM, Abu Daya HA, Rockey DC, Barada KA. Aspirin use for primary prophylaxis: Adverse outcomes in non-variceal upper gastrointestinal bleeding. World J Gastrointest Surg 2016; 8:501-507. [PMID: 27462392 PMCID: PMC4942750 DOI: 10.4240/wjgs.v8.i7.501] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/15/2016] [Accepted: 05/11/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare outcomes of patients with non-variceal upper gastrointestinal bleeding (NVUGIB) taking aspirin for primary prophylaxis to those not taking it.
METHODS: Patients not known to have any vascular disease (coronary artery or cerebrovascular disease) who were admitted to the American University of Beirut Medical Center between 1993 and 2010 with NVUGIB were included. The frequencies of in-hospital mortality, re-bleeding, severe bleeding, need for surgery or embolization, and of a composite outcome defined as the occurrence of any of the 4 bleeding related adverse outcomes were compared between patients receiving aspirin and those on no antithrombotics. We also compared frequency of in hospital complications and length of hospital stay between the two groups.
RESULTS: Of 357 eligible patients, 94 were on aspirin and 263 patients were on no antithrombotics (control group). Patients in the aspirin group were older, the mean age was 58 years in controls and 67 years in the aspirin group (P < 0.001). Patients in the aspirin group had significantly more co-morbidities, including diabetes mellitus and hypertension [25 (27%) vs 31 (112%) and 44 (47%) vs 74 (28%) respectively, (P = 0.001)], as well as dyslipidemia [21 (22%) vs 16 (6%), P < 0.0001). Smoking was more frequent in the aspirin group [34 (41%) vs 60 (27%), P = 0.02)]. The frequencies of endoscopic therapy and surgery were similar in both groups. Patients who were on aspirin had lower in-hospital mortality rates (2.1% vs 13.7%, P = 0.002), shorter hospital stay (4.9 d vs 7 d, P = 0.01), and fewer composite outcomes (10.6% vs 24%, P = 0.01). The frequencies of in-hospital complications and re-bleeding were similar in the two groups.
CONCLUSION: Patients who present with NVUGIB while receiving aspirin for primary prophylaxis had fewer adverse outcomes. Thus aspirin may have a protective effect beyond its cardiovascular benefits.
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16
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Liang CC, Chou CY, Chang CT, Wang IK, Huang CC. Upper gastrointestinal bleeding as a risk factor for dialysis and all-cause mortality: a cohort study of chronic kidney disease patients in Taiwan. BMJ Open 2016; 6:e010439. [PMID: 27150184 PMCID: PMC4861130 DOI: 10.1136/bmjopen-2015-010439] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE Impaired renal function is associated with higher risk of upper gastrointestinal bleeding (UGIB) in patients with chronic kidney disease and not on dialysis (CKD-ND). It is unclear if UGIB increases risk of chronic dialysis. The aim of the study was to investigate risk of chronic dialysis in CKD-ND patients with UGIB. SETTING All CKD-ND stage 3-5 patients of a CKD programme in one hospital between 2003 and 2009 were enrolled and prospectively followed until September 2012. PRIMARY AND SECONDARY OUTCOME MEASURES Chronic dialysis (dialysis for more than 3 months) started and all-cause mortality. The risk of chronic dialysis was analysed using Cox proportional hazard regression with adjustments for age, gender and renal function, followed by competing-risks analysis. RESULTS We analysed 3126 CKD-ND patients with a mean age of 65±14 years for 2.8 years. Of 3126 patients, 387 (12.4%) patients developed UGIB, 989 (31.6%) patients started chronic dialysis and 197 (6.3%) patients died. UGIB increased all-cause mortality (adjusted HR (aHR): 1.51, 95% CI 1.07 to 2.13) and the risk of chronic dialysis (aHR; 1.29, 95% CI 1.11 to 1.50). The subdistribution HR (SHR) of UGIB for chronic dialysis (competing event: all-cause mortality) was 1.37 (95% CI 1.15 to 1.64) in competing-risks analysis with adjustments for age, renal function, gender, diabetes, haemoglobin, albumin and urine protein/creatinine ratio. CONCLUSIONS UGIB is associated with increased risk of chronic dialysis and all-cause mortality in patients with CKD-ND stages 3-5. This association is independent of age, gender, basal renal function, haemoglobin, albumin and urine protein levels.
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Affiliation(s)
- Chih-Chia Liang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
- Graduate Program of Translational Medicine, China Medical University, Taichung, Taiwan
- Institute of Biomedical Sciences, Academia Sinica, Taipei, Taiwan
| | - Che-Yi Chou
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiz-Tzung Chang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - I-Kuan Wang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiu-Ching Huang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
- Graduate Program of Translational Medicine, China Medical University, Taichung, Taiwan
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Subramaniam K, Spilsbury K, Ayonrinde OT, Latchmiah F, Mukhtar SA, Semmens JB, Leahy MF, Olynyk JK. Red blood cell transfusion is associated with further bleeding and fresh-frozen plasma with mortality in nonvariceal upper gastrointestinal bleeding. Transfusion 2015; 56:816-26. [PMID: 26718025 DOI: 10.1111/trf.13446] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 10/23/2015] [Accepted: 11/06/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Blood products are commonly transfused for patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). While concerns exist about further bleeding and mortality in subsets of patients receiving red blood cell (RBC) transfusion, the impact of non-RBC blood products has not previously been systematically investigated. The aim of the study was to investigate the associations between blood products transfusion, further bleeding, and mortality after acute NVUGIB. STUDY DESIGN AND METHODS A retrospective cohort study examined further bleeding and 30-day and 1-year mortality in adult patients who underwent gastroscopy for suspected acute NVUGIB between 2008 and 2010 in three tertiary hospitals in Western Australia. Survival analysis was performed. RESULTS A total of 2228 adults (63% male) with 2360 hospital admissions for NVUGIB met the inclusion criteria. Median age at presentation was 70 years (range, 19-99 years). Thirty-day mortality was 4.9% and 1-year mortality was 13.9%. Transfusion of 4 or more units of RBCs was associated with greater than 10 times the odds of further bleeding in patients with a hemoglobin level of more than 90 g/L (odds ratio, 11.9; 95% confidence interval [CI], 3.1-45.7; p ≤ 0.001), but was not associated with mortality. Administration of 5 or more units of fresh-frozen plasma (FFP) was associated with increased 30-day (hazard ratio, 2.8; 95% CI, 1.3-5.9; p = 0.008) and 1-year (hazard ratio, 2.6; 95% CI, 1.3-5.0; p = 0.005) mortality after adjusting for coagulopathy, comorbidity, Rockall score, and other covariates. CONCLUSION In this large, multicenter study of NVUGIB, RBC transfusion was associated with further bleeding but not mortality, while FFP transfusion was associated with increased mortality in a subset of patients.
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Affiliation(s)
- Kavitha Subramaniam
- Gastroenterology and Hepatology Unit, The Canberra Hospital.,Australian National University Medical School, Canberra, ACT, Australia
| | | | - Oyekoya T Ayonrinde
- Centre for Population Health Research.,Department of Gastroenterology, Fremantle Hospital.,School of Medicine and Pharmacology (Fremantle Hospital Campus), The University of Western Australia, Fremantle, WA, Australia.,Department of Gastroenterology and Hepatology, Fiona Stanley Hospital
| | - Faye Latchmiah
- Department of Gastroenterology, Fremantle Hospital.,Department of Gastroenterology and Hepatology, Fiona Stanley Hospital
| | | | | | - Michael F Leahy
- School of Medicine and Pharmacology (Fremantle Hospital Campus), The University of Western Australia, Fremantle, WA, Australia.,Department of Haematology, Royal Perth Hospital, Perth, WA, Australia
| | - John K Olynyk
- Department of Gastroenterology, Fremantle Hospital.,Department of Gastroenterology and Hepatology, Fiona Stanley Hospital.,Curtin Health Innovation Research Institute and School of Biomedical Sciences, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia.,School of Veterinary and Life Sciences, Murdoch University, Murdoch, WA, Australia
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18
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Nagasue T, Nakamura S, Kochi S, Kurahara K, Yaita H, Kawasaki K, Fuchigami T. Time trends of the impact of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs on peptic ulcer bleeding in Japanese patients. Digestion 2015; 91:37-41. [PMID: 25632915 DOI: 10.1159/000368810] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are the main causes of peptic ulcers. The purpose of the present study was to elucidate the time trends of the impact of H. pylori infection and use of NSAIDs and/or antithrombotic agents on peptic ulcer bleeding (PUB) in Japanese patients. METHODS We retrospectively reviewed 719 patients who had received endoscopic hemostasis for PUB between 2002 and 2013. Subjects were divided into either the first-half group (2002-2007, n = 363) or the second-half group (2008-2013, n = 356). The clinical characteristics of the patients, including the prevalence of H. pylori infection and use of NSAIDs and antithrombotic agents, were compared between the two groups. RESULTS Compared to the first-half group, patients in the second-half group were characterized by older age (proportion of the patients above 60 years old, 63.9 vs. 76.7%, p = 0.0002), less frequent H. pylori infection (71.6 vs. 57.9%, p < 0.001) and more frequent NSAID intake (39.9 vs. 48.6%, p = 0.02). No significant difference was observed regarding the use of antithrombotic agents between the two groups (18.6 vs. 23.3%, p = 0.13). The prevalence of H. pylori infection and proportion of patients above 60 years old were significantly different between the two groups in a multivariate analysis. CONCLUSION The main cause of PUB has clearly shifted from H. pylori infection to the use of NSAIDs over the last decade.
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Affiliation(s)
- Tomohiro Nagasue
- Division of Gastroenterology, Matsuyama Red Cross Hospital, Matsuyama, Japan
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19
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Wehbeh A, Tamim HM, Abu Daya H, Abou Mrad R, Badreddine RJ, Eloubeidi MA, Rockey DC, Barada K. Aspirin Has a Protective Effect Against Adverse Outcomes in Patients with Nonvariceal Upper Gastrointestinal Bleeding. Dig Dis Sci 2015; 60:2077-87. [PMID: 25732717 DOI: 10.1007/s10620-015-3604-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 02/18/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE To determine the effect of aspirin and anticoagulants on clinical outcomes and cause of in-hospital death in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). METHODS Patients were identified from a tertiary center database that included all patients with UGIB. Clinical outcomes including (1) in-hospital mortality, (2) severe bleeding, (3) rebleeding, (4) in-hospital complications, and (5) length of hospital stay were examined in patients taking (a) aspirin only, (b) anticoagulants only, and (c) no antithrombotics. RESULTS Of 717 patients with NVUGIB, 56 % (402) were taking at least one antithrombotic agent. Seventy-eight (11 %) patients died in hospital, and 310 (43 %) had severe bleeding (BP < 90 mmHg, HR > 120 b/min, Hb < 7 g/dL on presentation, or transfusion of >3 units). On multivariate analysis, being on aspirin was protective against in-hospital mortality [OR 0.26 (0.13-0.53)], rebleeding [OR 0.31 (0.17-0.59)], and predictive of a shorter hospital stay (coefficient = -4.2 days; 95 % CI -8.7, 0.3). Similarly, being on nonaspirin antiplatelets was protective against in-hospital mortality (P = 0.03). However, being on anticoagulants was predictive of in-hospital complications [OR 2.0 (1.20-3.35)] and severe bleeding [OR 1.69 (1.02-2.82)]. Compared to those not taking any antithrombotics, patients who bled on aspirin were less likely to die in hospital of uncontrolled gastrointestinal bleeding (3.6 vs 0 %, P ≤ 0.01) and systemic cancer (4.9 vs 0 %, P ≤ 0.002), but equally likely to die of cardiovascular/thromboembolic disease, sepsis, and multiorgan failure. CONCLUSION Patients who present with NVUGIB on aspirin had reduced in-hospital mortality and fewer adverse outcomes, while those on anticoagulants had increased in-hospital complications.
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Affiliation(s)
- Antonios Wehbeh
- Division of Gastroenterology and Hepatology, American University of Beirut Medical Center, Riad El Solh, Beirut, 1107 2020, Lebanon,
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20
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Holland-Bill L, Christiansen CF, Gammelager H, Mortensen RN, Pedersen L, Sørensen HT. Chronic liver disease and 90-day mortality in 21,359 patients following peptic ulcer bleeding--a Nationwide Cohort Study. Aliment Pharmacol Ther 2015; 41:564-72. [PMID: 25588862 DOI: 10.1111/apt.13073] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 09/15/2014] [Accepted: 12/19/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND Bleeding is a serious and frequent complication of peptic ulcer disease. Hepatic dysfunction can cause coagulopathy and increases the risk of peptic ulcer bleeding. However, whether chronic liver disease increases mortality after peptic ulcer bleeding remains unclear. AIM To examine the prognostic impact of chronic liver disease on mortality after peptic ulcer bleeding. METHODS We used population-based medical registries to conduct a cohort study of all Danish residents hospitalised with incident peptic ulcer bleeding from 2004 through 2011. We identified patients diagnosed with liver cirrhosis or non-cirrhotic chronic liver disease before their admission for peptic ulcer bleeding. We then computed 90-day mortality after peptic ulcer bleeding based on the Kaplan-Meier method (1 - survival function) and used a Cox regression model to estimate mortality rate ratios (MRRs), controlling for potential confounders. RESULTS We identified 21,359 patients hospitalised with peptic ulcer bleeding. Among these, 653 (3.1%) had a previous diagnosis of liver cirrhosis and 474 (2.2%) had a history of non-cirrhotic chronic liver disease. Patients with liver cirrhosis and non-cirrhotic chronic liver disease had a cumulative 90-day mortality of 25.3% and 20.7%, respectively, compared to 18.3% among patients without chronic liver disease. Liver cirrhosis was associated with an adjusted 90-day MRR of 2.38 (95% CI: 2.02-2.80), compared to 1.49 (95% CI: 1.22-1.83) among patients with non-cirrhotic chronic liver disease. CONCLUSION Patients with chronic liver disease, particularly liver cirrhosis, are at increased risk of death within 90 days after hospitalisation for peptic ulcer bleeding compared to patients without chronic liver disease.
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Affiliation(s)
- L Holland-Bill
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; California Pacific Medical Center Research Institute, California Pacific Medical Center, San Francisco, CA, USA
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MacFarlane BV, Bergin JK, Reeves P, Matthews A. Australian pharmacies prevent potential adverse reactions in patients taking warfarin requesting over-the-counter analgesia. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2014; 23:167-72. [DOI: 10.1111/ijpp.12152] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 09/09/2014] [Indexed: 11/26/2022]
Abstract
Abstract
Objective
The objective of this article was to assess if Australian pharmacy staff prevent potential adverse reactions in warfarin patients requesting over-the-counter (OTC) analgesia.
Methods
Mystery shoppers entered 170 pharmacies across Australia to request OTC analgesia for a hypothetical patient with a wrist injury who currently takes warfarin following a heart valve replacement. The request was made to the first pharmacist or non-pharmacist staff member to approach the mystery shopper. The interaction was audio-taped and assessed by a pharmacist. The OTC analgesic recommended was assessed for the potential to cause an adverse bleeding event. The quality of advice given with the OTC analgesic was assessed against determined criteria. Results were compared with scenarios of similar request type where the hypothetical patient was not taking warfarin.
Key findings
Mystery shoppers enquiring about taking OTC analgesics concomitantly with warfarin had access to the pharmacist in 97.0% of cases. All 170 pharmacies recommended OTC analgesics that were less likely to cause adverse events when taken with warfarin. The advice given and the communication between pharmacy staff and mystery shoppers were of high quality.
Conclusion
Australian pharmacies support the quality use of medicines by patients taking warfarin by providing expeditious access to the pharmacist, appropriate recommendations of OTC analgesics, high standards of quality of advice and they communicate in a way to ensure ease of understanding by the consumer. The protocols used by pharmacy staff help prevent potentially serious adverse drug events.
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Affiliation(s)
| | - Jenny K Bergin
- The Australian College of Pharmacy, Canberra, ACT, Australia
| | - Peter Reeves
- The Australian College of Pharmacy, Canberra, ACT, Australia
| | - Andrew Matthews
- Pharmacy Transformation Group, The Pharmacy Guild of Australia, Canberra, ACT, Australia
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Liang CC, Wang SM, Kuo HL, Chang CT, Liu JH, Lin HH, Wang IK, Yang YF, Lu YJ, Chou CY, Huang CC. Upper gastrointestinal bleeding in patients with CKD. Clin J Am Soc Nephrol 2014; 9:1354-9. [PMID: 24903385 DOI: 10.2215/cjn.09260913] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND OBJECTIVES Patients with CKD receiving maintenance dialysis are at risk for upper gastrointestinal bleeding. However, the risk of upper gastrointestinal bleeding in patients with early CKD who are not receiving dialysis is unknown. The hypothesis was that their risk of upper gastrointestinal bleeding is negatively linked to renal function. To test this hypothesis, the association between eGFR and risk of upper gastrointestinal bleeding in patients with stages 3-5 CKD who were not receiving dialysis was analyzed. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with stages 3-5 CKD in the CKD program from 2003 to 2009 were enrolled and prospectively followed until December of 2012 to monitor the development of upper gastrointestinal bleeding. The risk of upper gastrointestinal bleeding was analyzed using competing-risks regression with time-varying covariates. RESULTS In total, 2968 patients with stages 3-5 CKD who were not receiving dialysis were followed for a median of 1.9 years. The incidence of upper gastrointestinal bleeding per 100 patient-years was 3.7 (95% confidence interval, 3.5 to 3.9) in patients with stage 3 CKD, 5.0 (95% confidence interval, 4.8 to 5.3) in patients with stage 4 CKD, and 13.9 (95% confidence interval, 13.1 to 14.8) in patients with stage 5 CKD. Higher eGFR was associated with a lower risk of upper gastrointestinal bleeding (P=0.03), with a subdistribution hazard ratio of 0.93 (95% confidence interval, 0.87 to 0.99) for every 5 ml/min per 1.73 m(2) higher eGFR. A history of upper gastrointestinal bleeding (P<0.001) and lower serum albumin (P=0.004) were independently associated with higher upper gastrointestinal bleeding risk. CONCLUSIONS In patients with CKD who are not receiving dialysis, lower renal function is associated with higher risk for upper gastrointestinal bleeding. The risk is higher in patients with previous upper gastrointestinal bleeding history and low serum albumin.
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Affiliation(s)
- Chih-Chia Liang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - Su-Ming Wang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - Huey-Liang Kuo
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiz-Tzung Chang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - Jiung-Hsiun Liu
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - Hsin-Hung Lin
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - I-Kuan Wang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - Ya-Fei Yang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - Yueh-Ju Lu
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and
| | - Che-Yi Chou
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiu-Ching Huang
- Kidney Institute and Division of Nephrology, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan; and College of Medicine, China Medical University, Taichung, Taiwan
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Abu Daya H, Eloubeidi M, Tamim H, Halawi H, Malli AH, Rockey DC, Barada K. Opposing effects of aspirin and anticoagulants on morbidity and mortality in patients with upper gastrointestinal bleeding. J Dig Dis 2014; 15:283-92. [PMID: 24593260 DOI: 10.1111/1751-2980.12140] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE We aimed to determine the effect of antithrombotics on in-hospital mortality and morbidity in patients with peptic ulcer disease-related upper gastrointestinal bleeding (PUD-related UGIB). METHODS The study cohort was retrospectively selected from a tertiary center database of patients with PUD-related UGIB, defined as bleeding due to gastric or duodenal ulcers, or erosive duodenitis, gastritis or esophagitis. Outcomes were compared among patient groups based on their antithrombotic medications before admission. Patients on no antithrombotics served as controls. The composite adverse outcomes, in-hospital mortality, rebleeding and/or need for surgery were measured. Severe bleeding and in-hospital complications were also recorded. RESULTS Of 398 patients with PUD-related UGIB, 44.5% were on aspirin or anticoagulants only. The composite adverse outcome was most common in patients taking anticoagulants only (40.5%), intermediate in controls (23.1%) and least in those taking aspirin only (12.1%). On multivariate analysis, patients taking aspirin alone had a significantly lower risk of adverse outcome events (odds ratio [OR] 0.4, 95% CI 0.2-0.8) and a shorter length of hospital stay (regression coefficient = -3.4, 95% CI [-6.6, -0.6]). In contrast, taking anticoagulants was associated with a greater risk of adverse outcome events (OR 2.3, 95% CI 1.0-5.3), severe bleeding (OR 2.6, 95% CI 1.2-5.8) and in-hospital complications (OR 2.9, 95% CI 1.3-6.6). CONCLUSIONS Patients with PUB-related UGIB while taking aspirin had fewer adverse outcomes compared with those taking anticoagulants. Aspirin may have beneficial effects in this population.
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Affiliation(s)
- Hussein Abu Daya
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA; Division of Gastroenterology and Hepatology, American University of Beirut Medical Center, Beirut, Lebanon
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Wang Q, Ljung R, Lagergren J, Lu Y. Prognosis of concomitant users of clopidogrel and proton-pump inhibitors in a high-risk population for upper gastrointestinal bleeding. BMC Pharmacol Toxicol 2014; 15:22. [PMID: 24731755 PMCID: PMC4002561 DOI: 10.1186/2050-6511-15-22] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 03/25/2014] [Indexed: 12/19/2022] Open
Abstract
Background It is unclear whether concomitant use of clopidogrel and proton-pump inhibitors (PPIs) increases the risk of recurrence of cardiovascular disease or death in patients at high risk of upper gastrointestinal (GI) bleeding. Methods Based on the Swedish Patient Register, a cohort of cardiovascular disease (including acute myocardial infarction, stroke and angina, from 2006 to 2008) was selected from a population with any diagnosis of upper GI bleeding. Data on drug prescription was retrieved from the Prescribed Drug Register. Patients entered into the cohort after their first discharge for cardiovascular disease and were followed up to death, recurrence of cardiovascular disease, or 90 days. A Cox regression model was conducted and hazard ratios (HRs) with 95% confidence intervals (CIs) were estimated to evaluate the risks among users of different drug prescriptions. Results Patients who were current users of only PPIs (HR 2.02, 95% CI 1.19-3.44), only clopidogrel (HR 1.14, 95% CI 0.53-2.45) and nonusers of both (HR 2.36, 95% CI 1.39-4.00) were at a higher risk of death compared with patients with a concomitant use. Results were similar among 1779 patients who had any history of upper GI bleeding (HR 2.05, 95% CI 1.18-3.54; HR 1.25, 95% CI 0.57-2.72; HR 2.30, 95% CI 1.33-3.98, respectively). Conclusion Among patients at high risk of upper GI bleeding, those with a concomitant use of PPIs and clopidogrel were at a decreased risk of mortality, and possibly also a decreased risk of recurrence of cardiovascular disease.
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Affiliation(s)
| | | | | | - Yunxia Lu
- Department of Molecular Medicine and Surgery, Karolinska Institutet, SE-171 76 Stockholm, Sweden.
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Malmi H, Kautiainen H, Virta LJ, Färkkilä N, Koskenpato J, Färkkilä MA. Incidence and complications of peptic ulcer disease requiring hospitalisation have markedly decreased in Finland. Aliment Pharmacol Ther 2014; 39:496-506. [PMID: 24461085 DOI: 10.1111/apt.12620] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 04/08/2013] [Accepted: 12/24/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND The characteristics of peptic ulcer disease (PUD) are changing. AIM To evaluate time trends in the incidence of PUD and its complications in hospitalised patients at the beginning of the 21st century, drug therapies in out-patient care as a risk factor for recurrent PUD, and medication used by PUD patients compared with the background population. METHODS In this retrospective epidemiologic cohort study, data from the years 2000-2008 came from The Hospital District of Helsinki and Uusimaa, and the Finnish Care Register. All hospitalised adult patients with PUD in the capital region of Finland were included. The data were linked with nationwide Prescription Register of the Finnish Social Insurance Institution allowing detailed individual medicine purchase data. RESULTS A total of 9951 peptic ulcers were detected among 8146 individual patients during the study period. The mean annual incidence of all peptic ulcers decreased from 121/100,000 (95% CI: 117-125) in 2000-2002, to 79 (95% CI: 76-82) in 2006-2008 [Incidence rate ratio = 0.62 (95% CI: 0.58-0.64), P < 0.001 after age and sex adjustment]. Decrease in incidence was seen in all age groups and in both sexes. The overall rate of severe complications of PUD was reduced. One-year cumulative incidence of recurrent ulcers was 13%. Use of several drugs was associated with increased risk for recurrence. The purchases of various drugs were more common among PUD patients compared with background population. CONCLUSIONS Both the incidence and complication rates have markedly decreased during the study period. Recurrent peptic ulcer disease was associated with polypharmacy.
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Affiliation(s)
- H Malmi
- Department of Gastrointestinal Surgery, Helsinki University Central Hospital, Helsinki, Finland
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Liang CC, Muo CH, Wang IK, Chang CT, Chou CY, Liu JH, Yen TH, Huang CC, Chung CJ. Peptic ulcer disease risk in chronic kidney disease: ten-year incidence, ulcer location, and ulcerogenic effect of medications. PLoS One 2014; 9:e87952. [PMID: 24498412 PMCID: PMC3912161 DOI: 10.1371/journal.pone.0087952] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2013] [Accepted: 01/03/2014] [Indexed: 12/30/2022] Open
Abstract
Objectives We aimed at determining peptic ulcer disease (PUD) incidence among chronic kidney disease (CKD) patients during 1998–2008, compared to patients without CKD, and at examining associations between CKD and PUD. Methods Data for 1998–2008 were extracted from the National Health Insurance Research Database in Taiwan. The annual PUD incidence (cases per thousand persons per year) was calculated separately for patients with and without CKD. Characteristics of patients with newly diagnosed PUD (n = 16322) were compared to those of a control group without PUD (n = 32644). The 2 groups were matched for age, sex, and index year. Odds ratios (OR) and 95% confidence intervals (CI) were estimated by logistic regression. Results Over the 10-year period, the PUD incidence was ∼10–12 times higher in CKD patients than in those without CKD. Its incidence in elderly CKD patients increased rapidly over time. For CKD patients, most PUD events (>95%) were managed during hospitalization. Peptic ulcer risk, adjusted for all potential confounders, was much higher in CKD patients undergoing hemodialysis (adjusted OR, 9.74; 95% CI, 7.11–13.31). Maintenance hemodialysis patients were 2 times more likely to have gastric ulcers than duodenal ulcers, while CKD patients not on dialysis had similar risks for both. There were no significant interactions between medications and CKD status on the peptic ulcer risk. Unlike CKD patients on nonsteroidal anti-inflammatory drugs and clopidogrel, those on aspirin did not have a higher peptic ulcer risk (adjusted OR, 0.88; 95% CI, 0.44–1.77). Conclusions CKD patients have a substantially increased PUD risk, and the majority of CKD patients with PUD require hospital management. Further, peptic ulcer risk is affected by hemodialysis therapy, patient status (inpatient vs. outpatient), and ulcerogenic medications.
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Affiliation(s)
- Chih-Chia Liang
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chih-Hsin Muo
- Department of Public Health, China Medical University, Taichung, Taiwan
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan
| | - I-Kuan Wang
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chiz-Tzung Chang
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Che-Yi Chou
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Jiung-Hsiun Liu
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Tzung-Hai Yen
- Department of Nephrology, Chang Gung Memorial Hospital, Taipei, Taiwan
- College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chiu-Ching Huang
- Division of Nephrology and Kidney Institute, China Medical University Hospital, Taichung, Taiwan
- Department of Medicine, College of Medicine, China Medical University, Taichung, Taiwan
| | - Chi-Jung Chung
- Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
- Department of Health Risk Management, College of Public Health, China Medical University, Taichung, Taiwan
- * E-mail:
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Improving quality of care in peptic ulcer bleeding: nationwide cohort study of 13,498 consecutive patients in the Danish Clinical Register of Emergency Surgery. Am J Gastroenterol 2013; 108:1449-57. [PMID: 23732464 DOI: 10.1038/ajg.2013.162] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2012] [Accepted: 04/23/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The treatment of peptic ulcer bleeding (PUB) is complex, and mortality remains high. We present results from a nationwide initiative to monitor and improve the quality of care (QOC) in PUB. METHODS All Danish hospitals treating PUB patients between 2004 and 2011 prospectively registered demographic, clinical, and prognostic data. QOC was evaluated using eight process and outcome indicators, including time to initial endoscopy, hemostasis obtainment, proportion undergoing surgery, rebleeding risks, and 30-day mortality. RESULTS A total of 13,498 PUB patients (median age 74 years) were included, of which one-quarter were in-hospital bleeders. Preadmission use of anticoagulants, multiple coexisting diseases, and the American Society of Anesthesiologists scores increased between 2004 and 2011. Considerable improvements were observed for most QOC indicators over time. Endoscopic treatment was successful with primary hemostasis achieved in more patients (94% in 2010-2011 vs. 89% in 2004-2006, relative risk (RR) 1.06 (95% confidence intervals 1.04-1.08)), endoscopy delay for hemodynamically unstable patients decreased during this period (43% vs. 34% had endoscopy within 6 h, RR 1.33 (1.10-1.61)), and fewer patients underwent open surgery (4% vs. 6%, RR 0.72 (0.59-0.87)). After controlling for time changes in prognostic factors, rebleeding rates improved (13% vs. 18%, adjusted RR 0.77 (0.66-0.91)). Crude 30-day mortality was unchanged (11% vs. 11%), whereas adjusted mortality decreased nonsignificantly over time (adjusted RR 0.89 (0.78-1.00)). CONCLUSIONS QOC in PUB has improved substantially in Denmark, but the 30-day mortality remains high. Future initiatives to improve outcomes may include earlier endoscopy, having fully trained endoscopists on call, and increased focus on managing coexisting disease.
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Effect of comorbidity on mortality in patients with peptic ulcer bleeding: systematic review and meta-analysis. Am J Gastroenterol 2013; 108:331-45; quiz 346. [PMID: 23381016 DOI: 10.1038/ajg.2012.451] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES By systematic review and meta-analysis, we sought to assess the impact of comorbidity on short-term mortality in patients with peptic ulcer bleeding (PUB). METHODS We conducted systematic searches in PubMed and Embase (January 1989-January 2010). Relative risks (RRs) were pooled across selected studies and an analysis of diagnostic test accuracy was performed to validate the results further. RESULTS Of 1,572 identified studies, 16 were eligible for inclusion. Only three had a low risk of bias and the overall quality of evidence was low. The risk of death (30-day or in-hospital mortality) was significantly greater in PUB patients with comorbidity than in those without (RR: 4.44; 95% confidence interval (CI): 2.45-8.04). The pooled sensitivity for comorbidity predicting death in patients with PUB was 0.86 (95% CI: 0.66-0.95) and the pooled specificity was 0.53 (95% CI: 0.40-0.65). PUB patients with three or more comorbidities had a greater risk of dying than those with one or two (RR: 3.46; 95% CI: 1.34-8.89). All individual comorbidities that we assessed significantly increased the risk of death associated with PUB. However, RRs were higher for hepatic, renal, and malignant disease (range: 4.04-6.33; no significant heterogeneity) than for cardiovascular and respiratory disease and diabetes (2.39, 2.45, and 1.63, respectively; no significant heterogeneity). CONCLUSIONS Underlying comorbidity is consistently associated with increased mortality in patients with PUB. The number and type of comorbidities in patients with PUB should be carefully evaluated and factored into initial management strategies.
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Why do mortality rates for nonvariceal upper gastrointestinal bleeding differ around the world? A systematic review of cohort studies. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2012; 26:537-43. [PMID: 22891179 DOI: 10.1155/2012/862905] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Discrepancies exist in reported mortality rates of nonvariceal upper gastrointestinal bleeding (NVUGIB). OBJECTIVE To perform a systematic review assessing possible reasons for these disparate findings and to more reliably compare them. METHODS The MEDLINE, EMBASE and ISI Web of Knowledge databases were searched for studies reporting mortality rates in NVUGIB involving adults and published in English. To ensure robust and contemporary estimates, studies spanning 1996 to January 2011 that included more than 1000 patients were selected. RESULTS Eighteen of 3077 studies were selected. Ten studies used administrative databases and the remaining eight used registries. The mortality rates reported in these studies ranged from 1.1% in Japan to 11% in Denmark. There were variations in reported mortality rates among countries and also within countries. Reasons for these disparities included a spectrum of quality in reporting as well as heterogeneous definitions of case ascertainment, differing patient populations with regard to severity of presentation and associated comorbidities, varying durations of follow-up and different health care system-related practices. CONCLUSIONS Wide differences in reported NVUGIB mortality rates are attributable to differences in adopted methodologies and populations studied. More uniform standards in reporting are needed; only then can true observed variations enable a better understanding of causes of death and pave the way to improved patient outcomes.
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Zullo A, Hassan C, Oliveti D, Chiriatti A, Chiuri DAE, Marotti G, Morelli L, Morini S. Helicobacter pylori management in non-steroidal anti-inflammatory drug therapy patients in primary care. Intern Emerg Med 2012; 7:331-5. [PMID: 21451987 DOI: 10.1007/s11739-011-0578-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2011] [Accepted: 03/17/2011] [Indexed: 12/27/2022]
Abstract
Non-steroidal anti-inflammatory drugs (NSAIDs) may cause gastroduodenal ulcers and its complications. Helicobacter pylori infection is recognized as an additional risk factor for ulcer development, its eradication in NSAIDs users being recommended. In this cross-sectional study, during a 1-week period, consecutive patients who were routinely visiting in 58 primary care clinics were enrolled. A questionnaire was used to collect clinical data on the patients who were chronically taking NSAIDs. Patients with age >65 years, a personal history of peptic ulcer, concomitant therapy with steroids, anti-coagulants, multiple NSAIDs, or relevant co-morbidities were considered at high risk for NSAIDs gastroduodenal complications. Data on H. pylori infection management were collected. Overall, H. pylori was searched for in 140 (16.1%) out of 869 patients receiving chronic NSAID therapy, and it was eventually cured in 43 (72.9%) of the infected cases. In detail, H. pylori status was not investigated in 670 (77.1%) of those patients at high risk of NSAID-related gastroduodenal lesions, including 516 patients ≥65 years old, and 154 younger, but with at least 1 adjunctive risk factor. In addition, 234 (35%) of these high-risk patients were not receiving any gastric mucosa protection. Our data find that H. pylori infection is investigated in fewer than one of every five NSAID-user patients in primary care. The low alertness towards such an infection in these patients suggests a need for prompt implementation of current guidelines.
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Affiliation(s)
- Angelo Zullo
- Gastroenterology and Digestive Endoscopy, Nuovo Regina Margherita Hospital, Via E. Morosini, 30, 00153 Rome, Italy.
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