Gastroenterological Education: Do Digital Data Depositories Make a Difference?

During the three or more years of GI Fellowship, trainees acquire a large percentage of the specialized medical knowledge that they will carry throughout their careers. It is thus important to foster a commitment to continuous learning and practices during fellowship intended to extend beyond training. Since relying solely on traditional textbooks is no longer adequate, numerous valuable resources exist as supplementary aids for learning and studying. Nevertheless, lacking a practical structure to navigate the sheer volume of these resources can be overwhelming. The sources of knowledge in gastroenterology during the digital age include published guidelines, eBooks, podcasts, board examination preparation, mobile applications, and engagement with social media. This article seeks to offer trainees and early career gastroenterologists' guidance for effectively utilizing diverse digital tools for ongoing and lifelong education.

Outcomes of bile duct resection with or without liver resection in management of Klatskin tumor: A 15-year U.S. National Data Review

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Background: Surgical resection can provide an increase in survival for incurable patients with cholangiocarcinoma (CCA); Since outcomes improve significantly with more aggressive intervention liver resection (LR) should be pursued together with common bile duct resection (CBDR). We aimed to analyze the trends of surgical management of hilar CCA also known as Klatskin tumor (KT) across 15 years in the U.S. Methods: We extracted two cohorts of hospitalizations from Nationwide Inpatient Sample (NIS) 2005-2019yy using ICD-9 and ICD-10 diagnosis and procedure codes for KT, CBDR and LR. First group of patients with KT had CBDR performed alone and the second group of KT patients received CBDR and LR during the same hospitalization. We compared mortality, performed socio-demographic analysis stratified by patient and hospital information and used length of stay (LOS) and mean charges (MC) as additional outcomes. Results: We extracted a total of 3,095 hospitalizations with KT that underwent CBDR alone or CBDR with LR. There was a transition in proportion of CBDR alone versus CBDR with LR across years, which we attribute to the change in coding from ICD-9 to ICD- 10, with the combined coding year 2015 demonstrating equalization of proportion of performed procedures prior to the flip in 2016. Since ICD-10 procedure coding was more specific for CBDR and LR, we as a result of this conclude that ICD-10 coding years 2016 and onward are more accurate and the latest trends demonstrate the increasing performance of only CBDR in KT patients rather than CBDR with LR (75% vs. 25% in 2019). Analysis of socio-demographics is presented in the Table. More than 2/3 of the patients were above age 60. Proportionally CBDR alone was more likely to be covered by public insurance than CBDR with LR (Public: 63.7% vs. 57.1%; Private: 34% vs. 40%). Even though it is a more invasive intervention, CBDR with LR had slightly less mean overall charges (MC=$223,903 for CBDR vs. $212,072 for CBDR with LR (P=0.5574)) and similar hospital resource utilization (LOS= 14 days for CBDR vs.14.7 days for CBDR with LR) compared to CBDR alone. Most of the procedures (>94%) were performed in teaching hospitals. Inpatient mortality was 5.5% for CBDR alone vs. 8.7 % for CBDR with LR. Conclusions: Our analysis demonstrated that for KT proportionally, CBDR performance is more prevalent than CBDR with LR in the latest years 2016-2019. Considering the comparable cost and hospital resource utilization with intent to cure, more aggressive surgical management should be pursued. Inpatient mortality was higher for more aggressive surgical management 5.5% for CBDR alone vs. 8.7% for CBDR with LR. Insurance type may play a role in the procedure choice. [Table: see text]

Therapeutic Anticoagulation with Heparin in Noncritically Ill Patients with Covid-19

BACKGROUND

Thrombosis and inflammation may contribute to the risk of death and complications among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation may improve outcomes in noncritically ill patients who are hospitalized with Covid-19.

METHODS

In this open-label, adaptive, multiplatform, controlled trial, we randomly assigned patients who were hospitalized with Covid-19 and who were not critically ill (which was defined as an absence of critical care-level organ support at enrollment) to receive pragmatically defined regimens of either therapeutic-dose anticoagulation with heparin or usual-care pharmacologic thromboprophylaxis. The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge. This outcome was evaluated with the use of a Bayesian statistical model for all patients and according to the baseline d-dimer level.

RESULTS

The trial was stopped when prespecified criteria for the superiority of therapeutic-dose anticoagulation were met. Among 2219 patients in the final analysis, the probability that therapeutic-dose anticoagulation increased organ support-free days as compared with usual-care thromboprophylaxis was 98.6% (adjusted odds ratio, 1.27; 95% credible interval, 1.03 to 1.58). The adjusted absolute between-group difference in survival until hospital discharge without organ support favoring therapeutic-dose anticoagulation was 4.0 percentage points (95% credible interval, 0.5 to 7.2). The final probability of the superiority of therapeutic-dose anticoagulation over usual-care thromboprophylaxis was 97.3% in the high d-dimer cohort, 92.9% in the low d-dimer cohort, and 97.3% in the unknown d-dimer cohort. Major bleeding occurred in 1.9% of the patients receiving therapeutic-dose anticoagulation and in 0.9% of those receiving thromboprophylaxis.

CONCLUSIONS

In noncritically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin increased the probability of survival to hospital discharge with reduced use of cardiovascular or respiratory organ support as compared with usual-care thromboprophylaxis. (ATTACC, ACTIV-4a, and REMAP-CAP ClinicalTrials.gov numbers, NCT04372589, NCT04505774, NCT04359277, and NCT02735707.).

Therapeutic Anticoagulation with Heparin in Critically Ill Patients with Covid-19

BACKGROUND

Thrombosis and inflammation may contribute to morbidity and mortality among patients with coronavirus disease 2019 (Covid-19). We hypothesized that therapeutic-dose anticoagulation would improve outcomes in critically ill patients with Covid-19.

METHODS

In an open-label, adaptive, multiplatform, randomized clinical trial, critically ill patients with severe Covid-19 were randomly assigned to a pragmatically defined regimen of either therapeutic-dose anticoagulation with heparin or pharmacologic thromboprophylaxis in accordance with local usual care. The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death (assigned a value of -1) and the number of days free of cardiovascular or respiratory organ support up to day 21 among patients who survived to hospital discharge.

RESULTS

The trial was stopped when the prespecified criterion for futility was met for therapeutic-dose anticoagulation. Data on the primary outcome were available for 1098 patients (534 assigned to therapeutic-dose anticoagulation and 564 assigned to usual-care thromboprophylaxis). The median value for organ support-free days was 1 (interquartile range, -1 to 16) among the patients assigned to therapeutic-dose anticoagulation and was 4 (interquartile range, -1 to 16) among the patients assigned to usual-care thromboprophylaxis (adjusted proportional odds ratio, 0.83; 95% credible interval, 0.67 to 1.03; posterior probability of futility [defined as an odds ratio <1.2], 99.9%). The percentage of patients who survived to hospital discharge was similar in the two groups (62.7% and 64.5%, respectively; adjusted odds ratio, 0.84; 95% credible interval, 0.64 to 1.11). Major bleeding occurred in 3.8% of the patients assigned to therapeutic-dose anticoagulation and in 2.3% of those assigned to usual-care pharmacologic thromboprophylaxis.

CONCLUSIONS

In critically ill patients with Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin did not result in a greater probability of survival to hospital discharge or a greater number of days free of cardiovascular or respiratory organ support than did usual-care pharmacologic thromboprophylaxis. (REMAP-CAP, ACTIV-4a, and ATTACC ClinicalTrials.gov numbers, NCT02735707, NCT04505774, NCT04359277, and NCT04372589.).

DYSFUNCTION OF VARIOUS ORGAN SYSTEMS INDUCED BY SEPSIS WITH UNDERLYING SEVERE MYELOMIC DISEASES AND PROSTATE CANCER (CASE REPORT)

A 65-year-old male patient, unconscious, was admitted into the clinic by the Ambulance. From the patient's medical history it was revealed that several hours before the admission in the clinic the following symptoms were present: shortness of breath, fever, hypotonia, consciousness inhibition, because of which emergency brigade was called and was brought by the Emergency Brigade. The history is loaded by chronic pathologies: myeloma disease, prostate cancer, ciliary arrhythmia, heart failure; received several courses of polichemotherapy, last ten days has been treated for pneumonia with antibiotics of ceftriaxone group in outpatient setting. It is also noteworthy that for the last three months dysfunction of musculoskeletal system with muscle weakness, restricted motion has been present. Clinically there was present dysfunction syndrome of several organs: disorder of function of several organs that required emergency intervention, recovery chance was very low, correlation with morbidity in PIRO was high. By investigation it is known, that as SIRS aggravates, and turns into septic shock, lethal index increases, especially when the underlying severe diseases are present. On basis of certain data we can conclude that the severity of the disease may have some compatibility with results, although it is alteration of further clinical status of initial stage that has the closest compatibility with results. Sepsis toward MODS experiences progress with lethal results. Mortality rate in the patients with acute respiratory deficiency increases from 50% to 80%. In most patients with sepsis syndrome, who have 3 or more organs damaged, lethality is more than 90%. In this certain case organ systems that are mostly involved in the process during the sepsis, are respiratory, blood, renal and cardiovascular systems, were all involved , in the mentioned case a reasonable symptomatic and pathognomic treatment and the appropriate measures led to the recovery of the above mentioned patient. Sepsis syndrome is developed when the balance between the substances that contribute to the inflammation and anti-inflammatory substances is violated. By the mentioned case there is sepsis - induced polyorganic insufficiency with underlying severe somatic pathological condition, with violation of hemodynamics. Clinically the insufficiency of all the organic systems developed at the background of cardio-respiratory-cerebral insufficiency, with functional insufficiency of all the organ systems and violation of buffer system. With reasonable pathognomic and symptomatic treatment eradication of vicious circle was possible. The patient was discharged from the clinic with positive clinic-laboratory recovery. The condition is stable. Neurological status -contact, adequate, with high capacity to work, and with an achievement of 2 year remission.

[CLINICAL EVALUATION OF THE NEW ANTISEPTIC MESHES]

Improving the results of hernia treatment and prevention of complications became a goal of our research which included two parts - experimental and clinical. Histomorphological and bacteriological researches showed that the best result out of the 3 control groups was received in case of covering implant "Coladerm"+ with chlorhexidine. Based on the experiment results working process continued in clinics in order to test and introduce new "coladerm"+ chlorhexidine covered poliprophilene meshes into practice. For clinical illustration there were 60 patients introduced to the research who had hernioplasty procedures by different nets: I group - standard meshes+"coladerm"+chlorhexidine, 35 patients; II group - standard meshes +"coladerm", 15 patients; III group - standard meshes, 10 patients. Assessment of the wound and echo-control was done post-surgery on the 8th, 30th and 90th days. This clinical research based on the experimental results once again showed the best anti-microbe features of new antiseptic polymeric biocomposite meshes (standard meshes+"coladerm"+chlorhexidine); timely termination of regeneration and reparation processes without any post-surgery suppurative complications. We hope that new antiseptic polymeric biocomposite meshes presented by us will be successfully used in surgical practice of hernia treatment based on and supported by expermental-clinical research.

[HERNIOPLASTIC MORFOLOGICAL FEATURES (EXPERIMENTAL STADY)]

Despite many years of experience in the field of hernia surgical treatment there still exist many unsolved problems such as a safe and non infected closure of defects of abdominal cavity wall. The aim of the study was to improve the result of treatment of abdominal wall hernias with the use of new antiseptic polymer, bio-composite protective mesh membrane covered with coladerm+chlorhexidine. Experimental study involved 21 rabbits. Meshes were fixed on anterior abdominal wall according to the following schewe: Option I: mesh size 10-20mm was put into both the groin area of the rabbits. Option II: A light standart mesh grid size 10-20mm covered with coladerm was placed on both sides of abdominal wall of the rabbits. Option III: A light mesh, covered with oladerm+Chlorhexidine was placed in to the abdominal wall of the rabbits. Removal dates of taking the animals from experiments were 14th, 30th, 45th, 90th and 180th days for further histomorpological and bacteriological research. The best result from these options was when implants we covered with coladerm+Chlorhexidine, which was shown on follow up period. In third control group experessed strong connective tissue formatting stromis picture,wich is the main task of modern hernia plastic. It is expected that new bio-composite meshes, covered with coladerm+Chlorhexidine, may be succesfuly used in clinical practice, which will reduce infectious complications of meshes and problems associated with them.