bluuebunny/crossref_metadata_2025_split huggingface dataset:
616 Risk Factors and Outcomes in Critically Ill Patients Presenting With Gastrointestinal Bleeding Complicated by Myocardial Ischemia
Authors: Zakarya Mohamed , Krinsley James 
Published: October 2019

INTRODUCTION:
Gastrointestinal Bleeding (GIB) is one of the most common conditions that lead to an admission to the intensive care unit (ICU). The aim of this study is to determine the risk factors, clinical predictors, and prognostic significance of myocardial ischemia associated with GIB.

METHODS:
We reviewed our ICU database and electronic medical record of all patients admitted to the ICU with GIB (including upper or lower GIB) between 10/1/05 and 9/30/18. Data aggregated include demographics, hemoglobin (HGB) and troponin (TROP) values, comorbidities and outcome parameters. Patients were categorized as having myocardial ischemia (“ISCH,” including ST elevation myocardial infarction, non-ST elevation myocardial infarction, or demand ischemia), or no ischemia (“NON”). We compared risk factors and clinical characteristics of both groups and created a multivariable logistic regression model to determine the independent association of ISCH with mortality.

RESULTS:
This investigation includes 403 patients with GIB. 155 of 403 (38.5%) had enzymatic and/or electrocardiographic evidence of ischemia. ISCH were older than NON (78 [66-86] vs. 68 [55-79]; P < 0.0001) with higher rates of cardiac risk factors, including diabetes mellitus (30.3% vs. 20.6%; P = 0.0367), class III or IV cardiac disease (25.8% vs. 5.2%; P < 0.0001), and prior myocardial infarction (20.0% vs. 10.1%; P = 0.0081). ISCH had higher severity of illness: APACHE (acute physiology and chronic health evaluation) III score (62 [50-77] vs. 47 [34-61]; P < 0.0001) and higher rates of mechanical ventilation (18.7% vs. 10.5%; P = 0.029). Minimum HGB values were similar (7.5 [2.0] vs. 7.7 [2.0]; P = 0.2) and maximum TROP were higher (0.21 [0.09-1.90] vs. 0.01 [0.01-0.03]; P < 0.0001). ISCH had longer ICU length of stay (1.7 [1.0-3.2] vs. 1.3 [0.8-2.0] days; P = 0.0001) and higher mortality (20.0% vs. 5.6%; P < 0.0001). Multivariable analysis demonstrated that ISCH was independently associated with higher mortality: Odds ratio (95% confidence interval) 3.23 (1.34-7.78; P = 0.0088).

CONCLUSION:
Myocardial ischemia occurs frequently in critically ill patients admitted to the ICU with GIB and is identified in this investigation as being an independent risk factor for mortality. Recognition of risk factors and comorbidities associated with cardiac disease in the setting of GIB can identify patients who are at increased risk of cardiovascular stress and could aid in targeting more aggressive treatment, potentially improving outcomes.
619 Efficacy of Hemospray in Non-Variceal Upper Gastrointestinal Bleeds: A Systematic Review and Meta-Analysis
Authors: Aziz Muhammad , Weissman Simcha , Mehta Tej I. , Hassan Shafae , Khan Zubair , Fatima Rawish , Alshati Ali , Malik Fahad , Tsirlin Yuriy , Hassan Ammar , Sciarra Michael , Nawras Ali , Rastogi Amit 
Published: October 2019

INTRODUCTION:
Despite various accepted modalities of treatment, gastrointestinal bleeding (GIB) is a major cause of death in the United States. Recently, amongst other hemostatic powders, Hemospray (TC-325) emerged as an effective method in managing patients with non-variceal upper GIB. We conducted this systematic review with meta-analysis to assess the efficacy of Hemospray in patients with non-variceal upper GIB.

METHODS:
A comprehensive literature search of PubMed, Cochrane, and Google Scholar was performed. Our search strategy was restricted to cohort studies and randomized controlled trials (RCTs). Our primary outcomes were clinical and technical success, while our secondary outcomes were aggregate rebleeding, early rebleeding, delayed rebleeding, refractory bleeding, mortality rate, and treatment failure. We used the R package “metafor” (version 2.1-0) and R Studio (version 3.6.0, Boston, Massachusetts) for statistical assessment.

RESULTS:
A total of 19 studies with 747 patients were included for final analysis. Technical success of Hemospray was seen in 96.8% of applications (95% confidence interval (CI) 93%-98%, P < 0.0001, I2 = 44.62%). Clinical success of Hemospray was seen in 92% of applications (95% CI 87%-95%, P < 0.0001, I2 = 44.62%).

CONCLUSION:
To our knowledge, this is the first systematic review and meta-analysis evaluating the efficacy of Hemospray in the management of non-variceal UGIB. The results herein indicate that Hemospray is non-inferior to conventional hemostatic modalities in terms of efficacious cessation of GIB. Hence, Hemospray can be used as an alternative option for the management of upper GIB. Given its ease of use in tandem with its reduced technical expertise for deployment relative to other modalities, Hemospray has the potential to become the new standard therapy for the management of upper GIB. Future research, including RCTs and large cohort studies are needed, to specifically compare Hemospray to other hemostatic powders as well as to other individual, mechanical modalities. Additionally, for the future, larger studies are needed to more accurately comment on the efficacy of Hemospray in upper variceal hemorrhage and lower bleeds, in an attempt to widen its scope of application to all GIB.
620 Enterography May Not Provide Additional Diagnostic Yield After Small Bowel Capsule Endoscopy in Patients With Obscure GI Bleeding
Authors: Barsky Maria , Kwon Alvin Guyun , Yoo Heesoo , Nguyen Nghia , Kalmaz Denise 
Published: October 2019

INTRODUCTION:
Approximately 5% of gastrointestinal bleeding presentations are due to suspected small bowel bleeding or obscure gastrointestinal bleeding (OGIB). Small bowel capsule endoscopy (SBCE) and CT/MR enterography are common modalities used to evaluate the small bowel for possible lesions. The miss rate of SBCE for small bowel tumors has been reported as high as 25%. Due to a concern for possible missed small bowel lesion, CTE/MRE is often performed after SBCE in patients with obscure GI bleeding, however the diagnostic yield of these studies is unknown. The primary aim of this study was to investigate the diagnostic yield of CTE/MRE performed after SBCE in patients with obscure GI bleeding.

METHODS:
A retrospective chart review was performed of patients who underwent both SBCE and CT or MR enterography for evaluation of obscure GI bleeding – both occult and overt. The capsule endoscopy database at a single tertiary academic medical center was reviewed for studies performed from 1/2010-4/2019. Only cases with clinical suspicion of small bowel bleeding were included. Charts were reviewed to determine whether patients had a subsequent CT or MR enterography. Exclusion criteria included more than 6 months between SBCE and enterography, incomplete SBCE and IBD diagnosis. Descriptive statistics were performed.

RESULTS:
A total of n = 11 were included. The indications of the studies were evaluation of anemia and occult blood loss in the setting of unrevealing endoscopies in 72.7% of patients and evaluation of overt bleeding without source on endoscopy for 22.3% of patients. There were five (45.5%) significant small bowel findings on SBCE. There were no small bowel lesions identified by enterography. In the patients with overt bleeding, SBCE identified possible culprit lesions in 66.7% of patients and enterography didn't show any culprit lesions. In patients with occult blood loss, SBCE identified potential culprit lesions in 50% of the patients, while enterography didn't identify any. All patients with a negative SBCE also had a negative enterography study.

CONCLUSION:
These findings suggest that there may be no additional diagnostic yield from enterography performed after SBCE in patients with suspicion of GI bleeding from a small bowel source. SBCE seems to have a high negative predictive value for significant small bowel lesions. Larger studies need to be performed to evaluate the utility of performing enterography after SBCE in the evaluation of suspected small bowel bleeding, both occult and overt.
624 Clinical Outcomes and Endoscopist's Perception of the Use of Hemospray for Gastrointestinal Bleeding: Outcomes From a U.S. Academic Tertiary Care Medical Center
Authors: Weaver Michael , Rood Richard P. , Mullady Daniel , Early Dayna 
Published: October 2019

INTRODUCTION:
Endoscopic management of gastrointestinal bleeding (GIB) has evolved with current standard treatment modalities including epinephrine injection, hemostatic clips, and thermal therapies. A growing body of evidence has demonstrated clinical efficacy of Hemospray in GIB. Recently, the FDA approved Hemospray for treatment of non-variceal GIB in the USA.

METHODS:
Consecutive patients treated with Hemospray for management of GIB between 10/2018 and 1/2019 were included in this prospective case series. IRB approval was obtained. Patient demographics, clinical parameters, outcomes, and endoscopist's perceptions on the ease of use of Hemospray were collected. Hemospray was used by an attending as monotherapy, dual therapy with other standard endoscopic techniques, or as a rescue therapy.

RESULTS:
Hemospray was used during 12 cases for GIB. Immediate hemostasis was achieved in 10/12 (83.3%) cases with an average time to hemostasis of 3 minutes and an average of 6.8 sprays used per endoscopy. The mean Blatchford score was 13.7 and the mean Rockall score was 6.3. Hemospray failed in one case of failed band ligation and in one case as rescue therapy for a Forest Class 1a duodenal ulcer. Hemospray was used as a primary modality in 3/12 cases, adjunctive therapy in 3/12 cases, and as rescue therapy in 6/12 cases. Etiologies of GIB included Forest 1a ulcers (n = 3), Forest 1b ulcers (n = 3), MW tear (n = 2), GAVE (n = 1), APC induced rectal ulcer (n = 1), post polypectomy bleed (n = 1) and esophageal variceal bleed (n = 1). No adverse events occurred. Interventional radiology was utilized in 5/12 cases. The 3 day and 7 day rebleeding rates were 0% (0/12) and 25% (3/12) respectively. All-cause mortality was 8% (1/12) at both 7 and 30 days. Hemospray was technically easier to use compared to clips (6/12), epinephrine (4/12), and thermal modalities (5/12) according to the attending endoscopists (Table 1). Difficulties reported during administration of Hemospray included a clogged catheter (n = 2) which required use of a second catheter.

CONCLUSION:
Hemospray is effective in achieving immediate hemostasis in non-variceal GIB with no adverse events in our cohort. Low 3 and 7 day rebleeding rates were below the predicted rebleeding rates. Overall, a majority of attending endoscopists reported that Hemospray was similar or easier to use than conventional methods of hemostasis. Our study is limited by our small patient cohort, but represents real US experience with this recently FDA approved GIB treatment modality.
627 Carvedilol vs. Endoscopic Variceal Ligation in Primary Prevention of First Variceal Hemorrhage Episode: A Systematic Review and Meta-Analysis
Authors: Suchartlikitwong Sakolwan , Vutthikraivit Wasawat , Mingbunjerdsuk Thammasak , Zitun Mohamed , Tikue Alay M. , Nugent Kenneth 
Published: October 2019

INTRODUCTION:
Either a non-selective beta blocker or endoscopic variceal ligation (EVL) is recommended for the primary prevention of a first variceal hemorrhage episode in patients with medium or large sized varices. Carvedilol has been used for this purpose because of its additional alpha-1 antagonist effect and fewer hemodynamic complications. However, data supporting this recommendation are based on two previous randomized controlled trials. More studies have been published since these trials to investigate the benefit of carvedilol. We wanted to compare carvedilol with EVL in patients with esophageal varices to prevent the first variceal hemorrhage episode and to reduce mortality.

METHODS:
We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2019. Included studies were randomized controlled trials that investigated the efficacy of carvedilol compared to EVL to prevent the first variceal bleeding and to reduce mortality. The first variceal bleeding episode was defined as melena and/or hematemesis with endoscopic evidence of bleeding stigmata or recent variceal hemorrhage. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled risk ratio (RR) and 95% confidence intervals.

RESULTS:
Four randomized controlled trials from 2009 to 2018 involving 556 patients (276 patients in the carvedilol group and 280 patients in the EVL group) were included in this meta-analysis. The mean age was 50 years. Compared to EVL, carvedilol did not significantly decrease the first variceal bleeding incidence or 1-year mortality (pooled RR 1.11 (0.56-2.19), P = 0.767, I2 = 53% and 1.22 (0.78-1.91), P = 0.38, I2 = 0%, respectively) (Figures 1 and 2). Serious adverse events that were intolerable and required specific therapy leading to discontinuation of the treatment arm was reported in 4 studies and did not show any significant difference between the carvedilol group and the EVL group (pooled RR 1.14 (0.78-1.68), P = 0.49, I2 = 6.8%) (Figure 3).

CONCLUSION:
Our study demonstrated a non-significant difference between carvedilol and EVL to prevent first variceal bleeding or decrease mortality. There was no difference in serious side effects. More randomized controlled trials with larger sample sizes and long term follow up are required to better understand the potential benefit of carvedilol. Our analysis supports the benefit of carvedilol as primary prophylaxis of variceal hemorrhage in cirrhotic patients.
628 Proton Pump Inhibitors or Histamine-2 Receptor Antagonist Co-Therapy Decrease the Risk of Upper Gastrointestinal Bleeding in Patients on Direct Oral Anticoagulation: A Systematic Review and Meta-Analysis
Authors: Suchartlikitwong Sakolwan , Vutthikraivit Wasawat , Mingbunjerdsuk Thammasak , Zitun Mohamed , Laoveeravat Passisd , Shroff Roshan , Carrasco Cinthya , Nugent Kenneth 
Published: October 2019

INTRODUCTION:
Direct oral anticoagulation (DOAC) has gained more universal acceptance for use in patients with venous thrombosis or atrial fibrillation because of its safety profile and the elimination of drug monitoring. However, upper gastrointestinal bleeding (UGIB) is a major complication, especially in those with higher bleeding risk. Recent studies have reported a decreased risk of UGIB in patients using DOAC with proton pump inhibitors (PPI) or histamine-2 receptor (H2RA) but the results are controversial. We aimed to assess the effect of PPI or H2RA co-therapy with DOAC on the risk of UGIB by a systematic review and meta-analysis.

METHODS:
We comprehensively searched the databases of MEDLINE and EMBASE from inception to May 2019. Included studies were cohort (prospective or retrospective) studies that investigated the incidence of UGIB comparing between DOAC with and without PPI or H2RA co-therapy. Upper gastrointestinal bleeding is defined as melena or hematemesis that required hospitalization. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled risk ratio (RR) and 95% confidence intervals.

RESULTS:
Six studies from 2015 to 2018 were included in this meta-analysis and reported a total of 469,593 patients using DOAC. Mean age was more than 70 years. Proton pump inhibitors co-therapy and histamine-2 receptor antagonist co-therapy significantly decreased the incidence of UGIB in DOAC users (pooled RR 0.58 (0.45-0.74), P < 0.001, I2 = 0.0% and 0.63 (0.42-0.96), P = 0.033, I2 = 0.0% respectively) (Figure1 and 2). Three studies reported PPI plus H2RA co-therapy with DOAC decreased the incidence of UGIB but it is not statistically significance (pooled RR 0.71 (0.18-2.74), P = 0.616, I2 = 88.5%) (Figure 3).

CONCLUSION:
Our study demonstrated statistically significant benefit of the combination either PPI or H2RA co-therapy with DOAC to lower the incidence of UGIB. However, the combination of PPI and H2RA did not decrease the risk of bleeding. Randomized controlled trials studies are needed to further evaluate this association.
631 Cyanocrylate for Active Gastric Variceal Bleeding: Clinical Evolution
Authors: Wah-Suárez Martin I. , Cessa-Zanatta José C. , González-González José A. , Maldonado-Garza Héctor J. 
Published: October 2019

INTRODUCTION:
Gastroesophageal variceal hemorrhage is an important complication from portal hypertension. Nearly 20% of this type of bleeding is from gastric varices (GVs), which is considered more profuse and severe compared to esophaeal variceal bleeding. There are many treatment modalities for GVs active bleeding. The use of tissue adhesives like cyanoacrylate is gaining acceptance for the treatment of GVs with a safe profile. The aim of this study is to determine the effectiveness of cyanoacrylate application in active GV bleeding.

METHODS:
We retrospectively reviewed the clinical data of 58 patients who underwent cyanoacrylate application in the setting of active GVs bleeding from January 2016 to July 2018. The outcomes of our study were initial hemostasis, inpatient bleeding, early rebleeding and 6-week mortality. The safety of the procedures was followed as well.

RESULTS:
A total of 75 procedures of cyanoacrylate injection were performed in 58 patients over a period of 3 years (January 2016-July 2018). Thirty-seven male patients (63.7%) with a mean age of 55.9 ± 13.8 years old were included. The mean duration of follow-up was 122 ± 2 days (range 1 to 719 days). From the total of patients enrolled, 32 (55.1%) and 11 (18.9%) were Child Pugh B and C, respectively. The main symptoms in these patients were hematemesis in 29 (50.0%), melena in 7 (12.0%), or both in 19 (32.7%). In the 58 patients evaluated, the different types of GVs were registered; many patients had more than one type of GVs according to Sarin´s classification. GV prevalence in our patients was GOV2 (43.1%), IGV1 (41.3%), GOV1 (22.4%) and IGV2 (10.3%). The success of the index endoscopic hemostatic procedure was 96.5%. A second endoscopy was performed in 58.6% of patients within 24 hours to assure complete blood vessel occlusion and no residual bleeding; a second cyanoacrylate injection was needed in 12% patients (20.6%). The inpatient and early rebleeding was 18.9% and 17.2%, respectively. The overall mortality was 18.9%. Adverse events were not detected in the current study.

CONCLUSION:
Cyanoacrylate injection is an effective therapeutic and safe option in acute GVs bleeding. We suggest an aggressive approach therapy in patients with active GVs bleeding, since it portends a higher incidence of recurrence; a second-look endoscopy, the use of endoscopic ultrasound and a thorough evaluation of rebleeding should be considered.
633 The Role of CHA2DS2-VASc Score vs. Anticoagulation for Predicting Morbidity and Mortality for Ischemic Bowel Disease Secondary to Atrial Fibrillation
Authors: Dasu Neethi R. , Khalid Yaser , McMahon Donald , Randle Troy 
Published: October 2019

INTRODUCTION:
Atrial fibrillation is a common disorder with potentially multiple adverse outcomes, one such being ischemic bowel disease. The aims of this study are: to evaluate the role of CHA2DS2-VASc score as a predictor of higher mortality in patients who have atrial fibrillation and ischemic bowel disease, i.e., if a higher CHA2DS2-VASc score is associated with higher mortality; to evaluate whether being on anticoagulation is associated with a lower mortality for such patients in this population.

METHODS:
This retrospective study reviewed patients admitted to three community hospitals over a 3 year period with the primary diagnoses of atrial fibrillation and ischemic bowel disease. The subject cohort was gathered with ICD 10 codes. Baseline characteristics such as age, sex, CHA2DS2-VASc Score, mean Cr, and subjects use of anticoagulation were analyzed. Hazard ratios, P-values, Confidence Intervals, and a Cox proportional hazards model for the baseline characteristics were calculated. Kaplan-Meier curves were calculated and then plotted together for subjects on anticoagulation versus those not on anticoagulation. The area under the receiver operating characteristic (ROC) curve was employed to assess the predictive power of CHA2DS2-VASc score for mortality development among ischemic bowel disease patients with atrial fibrillation.

RESULTS:
Sixty-five patients were included. The majority of the patients were older than >75 (63%), female (69%), and had established HTN (68%). The mean CHA2DS2-VASc score was 4.25 with P-value <0.009. Utilizing the cox proportional-hazards model, the hazard ratios for females, patients with diabetes mellitus, and CHA2DS2-VASc score were statistically significant with P-value < 0.05 and hazard ratios with confidence intervals that did not include 1. The area under the curve of ROC was 0.67, indicating a fair-to-poor marker with regards to the predictive power of CHA2DS2-VASc score for mortality development in this patient population. When examining mortality in patients based on whether or not patients were on anticoagulation, the hazard ratio was 0.36 (CI 0.089) with P < 0.05. The Kaplan-Meier curves demonstrate longer survival and less mortality for patients with atrial fibrillation on anticoagulation.

CONCLUSION:
The predictive power of the CHA2DS2-VASc score was relatively low. The CHA2DS2-VASc score had a statistically significant hazard ratio, a score >4 had increased mortality. Patients on anticoagulation had less mortality than patients not on anticoagulation.