Use of a clinical pathway in laparoscopic gastrectomy for gastric cancer

AIM: To evaluate the implementation of a clinical pathway and identify clinical factors affecting the clinical pathway for laparoscopic gastrectomy.METHODS: A standardized clinical pathway for gastric cancer(GC) patients was developed in 2001 by the GC surgery team at the Asan Medical Center. We reviewed the collected data of 4800 consecutive patients treated using the clinical pathway following laparoscopic gastrectomy with lymph node dissection for GC involving intracorporeal and extracorporeal anastomosis. The patients were treated between August 2004 and October 2013 in a single institution. To evaluate the rate of completion and risk factors affecting dropout from the clinical pathway, we used a multivariate logistic regression analysis.RESULTS: The overall completion rate of the clinical pathway for laparoscopic gastrectomy was 84.1%(n = 4038). In the comparison between groups of intracorporeal anastomosis and extracorporeal anastomosis patients, the completion rates were 8 3. 8 8 %(n = 1 7 4 0) a n d 8 4. 3 6 %(n = 2 0 7 1), respectively, showing no statistically significant difference. The main reasons for dropping out were postoperative complications(n = 463, 9.7%) and the need for patient observation(n = 299, 6.2%). Among the discharged patients treated using the clinical pathway, the number of patients who were readmitted within 30 d due to postoperative complications was 54(1.1%). In a multivariate analysis, the intraoperative events(OR = 2.558) were the most predictable risk factors for dropping out of the clinical pathway. Additionally, being male(OR = 1.459), advanced age(OR = 1.727), total gastrectomy(OR = 2.444), combined operation(OR = 1.731), and ASA score(OR = 1.889) were significant risk factors affecting the dropout rate from the clinical pathway.CONCLUSION: Laparoscopic gastrectomy appears to be a good indication for the application of a clinical pathway. For successful application, patients with risk factors should be managed carefully.

Application of AI and IoT in Clinical Medicine:Summary and Challenges

The application of artificial intelligence(AI)technology in the medical field has experienced a long history of development.In turn,some long-standing points and challenges in the medical field have also prompted diverse research teams to continue to explore AI in depth.With the development of advanced technologies such as the Internet of Things(IoT),cloud computing,big data,and 5G mobile networks,AI technology has been more widely adopted in the medical field.In addition,the in-depth integration of AI and IoT technology enables the gradual improvement of medical diagnosis and treatment capabilities so as to provide services to the public in a more effective way.In this work,we examine the technical basis of IoT,cloud computing,big data analysis and machine learning involved in clinical medicine,combined with concepts of specific algorithms such as activity recognition,behavior recognition,anomaly detection,assistant decision-making system,to describe the scenario-based applications of remote diagnosis and treatment collaboration,neonatal intensive care unit,cardiology intensive care unit,emergency first aid,venous thromboembolism,monitoring nursing,image-assisted diagnosis,etc.We also systematically summarize the application of AI and IoT in clinical medicine,analyze the main challenges thereof,and comment on the trends and future developments in this field.

Effectiveness of antibiotic prophylaxis for acute esophageal variceal bleeding in patients with band ligation: A large observational study

BACKGROUND Esophageal variceal bleeding is a severe complication associated with liver cirrhosis and typically necessitates endoscopic hemostasis.The current standard treatment is endoscopic variceal ligation(EVL),and Western guidelines recom-mend antibiotic prophylaxis following hemostasis.However,given the impro-vements in prognosis for variceal bleeding due to advancements in the management of bleeding and treatments of liver cirrhosis and the global concerns regarding the emergence of multidrug-resistant bacteria,there is a need to reassess the use of routine antibiotic prophylaxis after hemostasis.AIM To evaluate the effectiveness of antibiotic prophylaxis in patients treated for EVL.METHODS We conducted a 13-year observational study using the Tokushukai medical database across 46 hospitals.Patients were divided into the prophylaxis group(received antibiotics on admission or the next day)and the non-prophylaxis group(did not receive antibiotics within one day of admission).The primary outcome was composed of 6-wk mortality,4-wk rebleeding,and 4-wk spontaneous bacterial peritonitis(SBP).The secondary outcomes were each individual result and in-hospital mortality.A logistic regression with inverse probability of treatment weighting was used.A subgroup analysis was conducted based on the Child-Pugh classification to determine its influence on the primary outcome measures,while sensitivity analyses for antibiotic type and duration were also performed.RESULTS Among 980 patients,790 were included(prophylaxis:232,non-prophylaxis:558).Most patients were males under the age of 65 years with a median Child-Pugh score of 8.The composite primary outcomes occurred in 11.2%of patients in the prophylaxis group and 9.5%in the non-prophylaxis group.No significant differences in outcomes were observed between the groups(adjusted odds ratio,1.11;95%confidence interval,0.61-1.99;P=0.74).Individual outcomes such as 6-wk mortality,4-wk rebleeding,4-wk onset of SBP,and in-hospital mortality were not significantly different between the groups.The primary outcome did not differ between the Child-Pugh subgroups.Similar results were observed in the sensitivity analyses.CONCLUSION No significant benefit to antibiotic prophylaxis for esophageal variceal bleeding treated with EVL was detected in this study.Global reassessment of routine antibiotic prophylaxis is imperative.

Leisure-time physical activity and all-cause mortality and cardiovascular disease in adults with type 2 diabetes:Cross-country comparison of cohort studies

Purpose:This study aimed to quantify the dose-response association and the minimal effective dose of leisure-time physical activity(PA)to prevent mortality and cardiovascular disease in adults with type 2 diabetes.Methods:Cross-country comparison of 2 prospective cohort studies including 14,913 and 17,457 population-based adults with type 2 diabetes from the UK and China.Baseline leisure-time PA was self-reported and categorized by metabolic equivalent hours per week(MET-h/week)according to World Health Organization recommendations:none,below recommendation(>0-7.49 MET-h/week);at recommended level(7.5-14.9 MET-h/week);above recommendation(>15 MET-h/week).Mortality and cardiovascular disease data were obtained from national registries.Results:During a median follow-up of 12.4 and 9.7 years,in the UK and China cohorts,repectively,higher levels of leisure-time PA were inversely associated with all-cause(1571 and 2351 events)and cardiovascular mortality(392 and 1060 events),mostly consistent with a linear dose-response relationship.PA below,at,and above recommendations,compared with no activity,yielded all-cause mortality hazard ratios of0.94(95%confidence interval(95%CI):0.79-1.12),0.90(95%CI:0.74-1.10),and 0.85(95%CI:0.70-1.02)in British adults and 0.87(95%CI:0.68-1.10),0.88(95%CI:0.74-1.03),and 0.77(95%CI:0.70-0.85)in Chinese adults.Associations with cardiovascular mortality were more pronounced in British adults(0.80(95%CI:0.58-1.11),0.75(95%CI:0.52-1.09),and 0.69(95%CI:0.48-0.97))but less pronounced in Chinese adults(1.06(95%CI:0.76-1.47),1.01(95%CI:0.80-1.28),and 0.79(95%CI:0.69-0.92)).PA at recommended levels was not associated with lower rates of major adverse cardiovascular events(2345 and 4458 events).Conclusion:Leisure-time PA at the recommended levels was not convincingly associated with lower mortality and had no association with risk of major adverse cardiovascular events in British or Chinese adults with type 2 diabetes.Leisure-time PA above current recommendations may be needed to prevent cardiovascular disease and premature mortality in adults with type 2 diabetes.

Exclusive breastfeeding greater than 50%, success of education in a university hospital in Bogotá: Case-control study

BACKGROUND Maintenance rates of exclusive breastfeeding(EBF)worldwide are low,thus,one of the objectives of the summary of policies on breastfeeding(BF)in world nutrition goals for 2025 are that at least 50%of infants under six months of age receive EBF that year.The Objective of this study is to document the rates of EBF in children born in San Ignacio University Hospital(HUSI)and identify factors associated with maintenance.AIM To document the percentages of EBF in those that were born at HUSI and identify factors associated to their maintenance.METHODS This is a study of cases and controls in an analytic,retrospective cohort that took children born alive between January 2016 and January 2019 at HUSI located in the city of Bogotá,Colombia.RESULTS Receiving information about BF at HUSI was able to maintain EBF up until 4 mo(OR=1.65;95%CI:1.02-2.66).The presence of gynecologic and obstetric comorbidities(OR=0.32;95%CI:0.12-0.83),having mastitis(OR=0.56;95%CI:0.33-0.94),and receiving information from mass media(OR=0.52;95%CI:0.31-0.84)are factors associated with not maintaining EBF.CONCLUSION Receiving education at a Women-and Child-Friendly Institution was the only significant factor to achieve EBF until 4 mo,with a frequency greater than the one reported in the country,which matches multiple studies where counseling and individualized support on BF achieve this purpose.Knowledge about BF and early detection of obstetric/gynecologic complications must be strengthened among the healthcare staff in charge of mothers during post-partum.Additionally,strategies must be promoted to continue BF such as creating milk banks with the objective of increasing BF rates even when mothers return to work.

Hypoxia-related bioinformatic signatures associated with prognosis and tumor microenvironment of pancreatic cancer:Current status,concerns,and future perspectives

Pancreatic cancer(PC),a highly lethal tumor with nearly identical incidence and mortality rates,has become the sixth leading cause of cancer-related deaths.Hypoxia is an important malignant factor in PC,as it regulates angiogenesis,metabolic reprogramming,tumor progression,and metastasis.Disrupting the hypoxic microenvironment can enhance the efficacy of antitumor therapy and improve the prognosis of patients with PC.With the advent of bioinformatics,hypoxia-related PC models have emerged in recent years.They provide a reference for estimating the prognosis and immune microenvironment of patients with PC and identify potential biomarkers for targeting hypoxic microenvironment.However,these findings based on bioinformatic analysis may not be completely reliable without further experimental evidence and clinical cohort validation.The application of these models and biomarkers in clinical practice to predict survival time and develop anti hypoxic therapeutic strategies for patients with PC remains in its infancy.In this editorial,we review the current status of hypoxia-related prognostic models in PC,analyze their similarities and differences,discuss several existing challenges,and provide potential solutions and directions for further studies.This editorial will facilitate the optimization,validation,and determination of the molecular mechanisms of related models.

Elevated cardiovascular risk and acute events in hospitalized colon cancer survivors:A decade-apart study of two nationwide cohorts

BACKGROUND Over the years,strides in colon cancer detection and treatment have boosted survival rates;yet,post-colon cancer survival entails cardiovascular disease(CVD)risks.Research on CVD risks and acute cardiovascular events in colorectal cancer survivors has been limited.AIM To compare the CVD risk and adverse cardiovascular outcomes in current colon cancer survivors compared to a decade ago.METHODS We analyzed 2007 and 2017 hospitalization data from the National Inpatient Sample,studying two colon cancer survivor groups for CVD risk factors,mortality rates,and major adverse events like pulmonary embolism,arrhythmia,cardiac arrest,and stroke,adjusting for confounders via multivariable regression analysis.RESULTS Of total colon cancer survivors hospitalized in 2007(n=177542)and 2017(n=178325),the 2017 cohort often consisted of younger(76 vs 77 years),male,African-American,and Hispanic patients admitted non-electively vs the 2007 cohort.Furthermore,the 2017 cohort had higher rates of smoking,alcohol abuse,drug abuse,coagulopathy,liver disease,weight loss,and renal failure.Patients in the 2017 cohort also had higher rates of cardiovascular comorbidities,including hypertension,hyperlipidemia,diabetes,obesity,peripheral vascular disease,congestive heart failure,and at least one traditional CVD(P<0.001)vs the 2007 cohort.On adjusted multivariable analysis,the 2017 cohort had a significantly higher risk of pulmonary embolism(PE)(OR:1.47,95%CI:1.37-1.48),arrhythmia(OR:1.41,95%CI:1.38-1.43),atrial fibrillation/flutter(OR:1.61,95%CI:1.58-1.64),cardiac arrest including ventricular tachyarrhythmia(OR:1.63,95%CI:1.46-1.82),and stroke(OR:1.28,95%CI:1.22-1.34)with comparable all-cause mortality and fewer routine discharges(48.4%vs 55.0%)(P<0.001)vs the 2007 cohort.CONCLUSION Colon cancer survivors hospitalized 10 years apart in the United States showed an increased CVD risk with an increased risk of acute cardiovascular events(stroke 28%,PE 47%,arrhythmia 41%,and cardiac arrest 63%).It is vital to regularly screen colon cancer survivors with concomitant CVD risk factors to curtail long-term cardiovascular complications.

Systematic review and meta-analysis of colon cleansing preparations in patients with inflammatory bowel disease

AIM To performed a systematic review and meta-analysis to determine any possible differences in terms of effectiveness, safety and tolerability between existing colon-cleansing products in patients with inflammatory bowel disease.METHODS Systematic searches were performed( January 1980-September 2016) using MEDLINE, EMBASE, Scopus, CENTRAL and ISI Web of knowledge for randomized trials assessing preparations with or without adjuvants, given in split and non-split dosing, and in high(> 3 L) or low-volume(2 L or less) regimens. Bowel cleansing quality was the primary outcome. Secondary outcomes included patient willingness-torepeat the procedure and side effects/complications.RESULTS Out of 439 citations, 4 trials fulfilled our inclusion criteria(n = 449 patients). One trial assessed the impact of adding simethicone to polyethylene glycol(PEG) 4 L with no effect on bowel cleansing quality, but a better tolerance. Another trial compared senna to castor oil, again without any differences in term of bowel cleansing. Two trials compared the efficacy of PEG high-volume vs PEG low-volume associated to an adjuvant in split-dose regimens: PEG low-dose efficacy was not different to PEG high-dose; OR = 0.84(0.37-1.92). A higher proportion of patients were willing to repeat low-volume preparations vs high-volume; OR = 5.11(1.31-20.0). CONCLUSION In inflammatory bowel disease population, PEG lowvolume regimen seems not inferior to PEG high-volume to clean the colon, and yields improved willingness-torepeat. Further additional research is urgently required to compare contemporary products in this population.

Effects of Incretin-based Therapies on Weight-related Indicators among Patients with Type 2 Diabetes: A Network Meta-analysis

Objective To evaluate the effects of incretin-based therapies on body weight as the primary outcome,as well as on body mass index(BMI)and waist circumference(WC)as secondary outcomes.Methods Databases including Medline,Embase,the Cochrane Library,and clinicaltrials.gov(www.clinicaltrials.gov)were searched for randomized controlled trials(RCTs).Standard pairwise meta-analysis and network meta-analysis(NMA)were both carried out.The risk of bias(ROB)tool recommended by the Cochrane handbook was used to assess the quality of studies.Subgroup analysis,sensitivity analysis,meta-regression,and quality evaluation based on the Grading of Recommendations Assessment,Development,and Evaluation(GRADE)were also performed.Results A total of 292 trials were included in this study.Compared with placebo,dipeptidyl-peptidase IV inhibitors(DPP-4 Is)increased weight slightly by 0.31 kg[95%confidence interval(CI):0.05,0.58]and had negligible effects on BMI and WC.Compared with placebo,glucagon-like peptide-1 receptor agonists(GLP-1 RAs)lowered weight,BMI,and WC by-1.34 kg(95%CI:-1.60,-1.09),-1.10 kg/m2(95%CI:-1.42,-0.78),and-1.28 cm(95%CI:-1.69,-0.86),respectively.Conclusion GLP-1 RAs were more effective than DPP-4 Is in lowering the three indicators.Overall,the effects of GLP-1 RAs on weight,BMI,and WC were favorable.

Incidence of venous thromboembolism and the role of D-dimer as predictive marker in patients with advanced gastric cancer receiving chemotherapy:A prospective study

To investigated the incidence and risk factors of venous thromboembolism (VTE) in patients with advanced gastric cancer (AGC) receiving chemotherapy. METHODSAll consecutive chemotherapy-naïve patients with AGC who would receive palliative chemotherapy between November 2009 and April 2012 in our hospital were recruited. Their pretreatment clinical and laboratory variables, including D-dimer, were recorded. The frequency of VTE development and survival rates during each chemotherapy cycle and regularly thereafter were assessed. RESULTSA total of 241 patients enrolled between November 2009 and April 2012 were analyzed. During a median follow-up duration of 10.8 mo (95%CI: 9.9-11.7), 27 patients developed VTE and the incidence of VTE was 17.5% (95%CI: 10.5-24.0, 12.0 events/100 person-years). The 6-mo and 1-year cumulative incidences were 7.8% (95%CI: 4.2%-11.4%) and 12.4% (95%CI: 7.3-17.2), respectively. Thirteen (48.1%) patients were symptomatic and the other 14 (51.9%) patients were asymptomatic. In multivariate analysis, pretreatment D-dimer level was the only marginally significant risk factor associated with VTE development (hazard ratio = 1.32; 95%CI: 1.00-1.75, P = 0.051). CONCLUSIONThe incidence of VTE is relatively high in patients with AGC receiving chemotherapy, and pretreatment D-dimer level might be a biomarker for risk stratification of VTE.

Operative vs non-operative management of displaced proximal humeral fractures in the elderly: A systematic review and meta-analysis of randomized controlled trials

AIM: To perform a systematic review and meta-analysis comparing operative vs non-operative treatment of displaced proximal humerus fractures in elderly patients.METHODS: A systematic literature search was performed using EMBASE and MEDLINE through the OVID interface,CINAHL,the Cochrane Central Register of Controlled Trials(CENTRAL),Proquest,Web of Science,SAE digital library,and Transportation Research Board's TRID database.Searches of conference proceedings were also conducted.All available randomized controlled trials comparing operative vs non-operative management of displaced three- and four-part proximal humerus fractures in elderly patients were included.The primary outcomes measures included physical function,pain,health related quality of life,mortality,and the re-operation rate.RESULTS: Six randomized controlled trials(n = 287) were included.There was no statistically significant difference in function(MD = 1.72,95%CI:-2.90-6.34,P = 0.47),as measured by the Constant score,between the operative and the non-operative treatment groups.There was no statistically significance difference insecondary outcomes of health related quality of life(standardized MD = 0.27,95%CI:-0.05-0.59,P = 0.09),and mortality(relative risk 1.29,95%CI: 0.50-3.35,P = 0.60).Operative treatment had a statistically significant higher re-operation rate(relative risk 4.09,95%CI: 1.50-11.15,P = 0.006),and statistically significant decreased pain(MD = 1.26,95%CI: 0.02-2.49,P = 0.05).CONCLUSION: There is moderate quality evidence to suggest that there is no difference in functional outcomes between the two treatments.Further high quality randomized controlled trials are required to determine if certain subgroup populations benefit from surgical management.

Saddle pulmonary embolism is not a sign of high-risk deterioration in non-high-risk patients: A propensity score-matched study

BACKGROUND: There is controversy regarding whether saddle main pulmonary artery(MPA) embolism represents a high risk of deterioration in non-high-risk acute pulmonary embolism(PE) patients. This study aims to address this issue by conducting a propensity score matching(PSM) study.METHODS: A total of 727 non-high-risk acute PE patients were retrospectively evaluated. We evaluated the Bova score and risk stratification to examine the risk of deterioration. Deterioration defined as any adverse event within 30 days after admission. Computed tomographic pulmonary angiography was used to identify the embolism type. All patients were matched into four subgroups by PSM according to age, sex, Bova score, and risk stratification:(1) MPA and non-MPA embolism;(2) non-saddle MPA and non-MPA embolism;(3) saddle MPA and non-saddle MPA embolism;(4) saddle MPA and non-MPA embolism. Correlations were analyzed using Cox regression analysis, and deterioration risk was compared between subgroups using Kaplan-Meier analysis.RESULTS: Cox regression analysis revealed that MPA embolism was correlated with deterioration, regardless of whether saddle MPA embolism was included or excluded. Saddle MPA embolism was not correlated with deterioration, regardless of comparison with non-saddle MPA embolism or non-MPA embolism. Patients with MPA and non-saddle MPA embolism presented a high risk for deterioration(logrank test=5.23 and 4.70, P=0.022 and 0.030, respetively), while patients with saddle MPA embolism were not at a high risk of deterioration(log-rank test=1.20 and 3.17, P=0.729 and 0.077, respetively).CONCLUSIONS: Saddle MPA embolism is not indicative of a high risk of deterioration in nonhigh-risk acute PE patients.

Association of visceral obesity and early colorectal neoplasia

AIM:To examine whether visceral adipose tissue(VAT)serves as a risk factor for colorectal adenoma-early colorectal cancer(CRC)sequence.METHODS:A retrospective case-control study was conducted with 153 patients with stageⅠCRC,age/sex-matched 554 patients with colorectal adenoma and557 normal controls.All subjects underwent various laboratory tests,abdominal fat computed tomography(CT),and colonoscopy.VAT was defined as an intraabdominal adipose tissue area measured by CT scan.Adipose tissue area was measured at the level of the umbilicus from CT scan.We used the lowest quartile of VAT and subcutaneous adipose tissue area as a reference group.RESULTS:The body mass index(BMI),total cholesterol,fasting glucose and VAT areas were significantly different among normal,adenoma and CRC groups.The VAT area was 120.6±49.0 cm2in normal controls,130.6±58.4 cm2in adenoma group and 117.6±51.6cm2in CRC group(P=0.002).In univariate analysis,increased BMI was a risk factor for CRC compared to control(P=0.025).However,VAT area was not a risk factor for CRC compared to control.In multivariate analysis that adjusted for smoking,alcohol consumption and subcutaneous adipose tissue area,VAT area was inversely related to CRC,compared to the adenoma(OR=0.53,95%CI:0.31-0.92,highest quartile vs lowest quartile).CONCLUSION:Our study shows that visceral obesity is not a risk factor for early CRC.Visceral obesity might influence the normal-adenoma sequence but not the adenoma-early carcinoma sequence.

Efficacy of fermented milk and whey proteins in Helicobacter pylori eradication:A review

Helicobacter pylori (H. pylori) eradication is considered a necessary step in the management of peptic ulcer disease, chronic gastritis, gastric adenocarcinoma and mucosa associated lymphoid tissue lymphoma. Standard triple therapy eradication regimens are inconvenient and achieve unpredictable and often poor results. Eradication rates are decreasing over time with increase in antibiotic resistance. Fermented milk and several of its component whey proteins have emerged as candidates for complementary therapy. In this context the current review seeks to summarize the current evidence available on their role in H. pylori eradication. Pertinent narrative/systematic reviews, clinical trials and laboratory studies on individual components including fermented milk, yogurt, whey proteins, lactoferrin, &#x003b1;-lactalbumin (&#x003b1;-LA), glycomacropeptide and immunoglobulin were comprehensively searched and retrieved from Medline, Embase, Scopus, Cochrane Controlled Trials Register and abstracts/proceedings of conferences up to May 2013. A preponderance of the evidence available on fermented milk-based probiotic preparations and bovine lactoferrin suggests a beneficial effect in Helicobacter eradication. Evidence for &#x003b1;-LA and immunoglobulins is promising while that for glycomacropeptide is preliminary and requires substantiation. The magnitude of the potential benefit documented so far is small and the precise clinical settings are ill defined. This restricts the potential use of this group as a complementary therapy in a nutraceutical setting hinging on better patient acceptability/compliance. Further work is necessary to identify the optimal substrate, fermentation process, dose and the ideal clinical setting (prevention/treatment, first line therapy/recurrence, symptomatic/asymptomatic, gastritis/ulcer diseases etc.). The potential of this group in high antibiotic resistance or treatment failure settings presents interesting possibilities and deserves further exploration.

Cost effectiveness analysis of population-based serology screening and ^(13)C-Urea breath test for Helicobacter pylori to prevent gastric cancer:A markov model

AIM:To compare the costs and effectiveness of no screening and no eradication therapy, the population- based Helicobacter pylori (H pylori) serology screening with eradication therapy and 13C-Urea breath test (UBT) with eradication therapy. METHODS:A Markov model simulation was carried out in all 237 900 Chinese males with age between 35 and 44 from the perspective of the public healthcare provider in Singapore. The main outcome measures were the costs, number of gastric cancer cases prevented, life years saved, and quality-adjusted life years (QALYs) gained from screening age to death. The uncertainty surrounding the cost-effectiveness ratio was addressed by one-way sensitivity analyses. RESULTS:Compared to no screening, the incremental cost-effectiveness ratio (ICER) was $16 166 per life year saved or $13 571 per QALY gained for the serology screening, and $38 792 per life year saved and $32 525 per QALY gained for the UBT. The ICER was $477 079 per life year saved or $390 337 per QALY gained for the UBT compared to the serology screening. The cost- effectiveness of serology screening over the UBT was robust to most parameters in the model. CONCLUSION:The population-based serologyscreening for H pylori was more cost-effective than the UBT in prevention of gastric cancer in Singapore Chinese males.

Multidisciplinary management of acute mesenteric ischemia:Surgery and endovascular intervention

Acute mesenteric ischemia(AMI)is a rare cause of the“acute abdomen”,characterized by impaired blood flow to the intestine.The principle of treatment is restoration of perfusion to ischemic bowel and resection of any necrotic intestine.Surgery and endovascular intervention are two complementary approaches to mesenteric ischemia.Endovascular intervention is not an alternative to the surgical approach,but it has the potential to improve the prognosis of patients with AMI when judiciously combined with a surgical approach.Due to the need for emergent treatment of patients with acute mesenteric ischemia,the treatment strategy needs to be modified for each facility.This review aims to highlight cutting-edge studies and provide reasonable treatment strategies for patients with acute mesenteric ischemia based on available evidence.

Impact of gastroesophageal reflux control through tailored proton pump inhibition therapy or fundoplication in patients with Barrett's esophagus

AIM To determine the impact of upwards titration of proton pump inhibition(PPI) on acid reflux, symptom scores and histology, compared to clinically successful fundoplication.METHODS Two cohorts of long-segment Barrett's esophagus(BE) patients were studied. In group 1(n = 24), increasing doses of PPI were administered in 8-wk intervals until acid reflux normalization. At each assessment, ambulatory 24 h p H recording, endoscopy with biopsies and symptom scoring(by a gastroesophageal reflux disease health related quality of life questionnaire, GERD/HRLQ) were performed. Group 2(n = 30) consisted of patients with a previous fundoplication. RESULTS In group 1, acid reflux normalized in 23 of 24 patients, resulting in improved GERD/HRQL scores(P = 0.001), which were most pronounced after the starting dose of PPI(P < 0.001). PPI treatment reached the same level of GERD/HRQL scores as after a clinically successful fundoplication(P = 0.5). Normalization of acid reflux in both groups was associated with reduction in papillary length, basal cell layer thickness, intercellular space dilatation, and acute and chronic inflammation of squamous epithelium. CONCLUSION This study shows that acid reflux and symptom scores co-vary throughout PPI increments in long-segment BE patients, especially after the first dose of PPI, reaching the same level as after a successful fundoplication. Minor changes were found among GERD markers at the morphological level.

Effects of natural mineral-rich water consumption on the expression of sirtuin 1 and angiogenic factors in the erectile tissue of rats with fructose-induced metabolic syndrome

Consuming a high-fructose diet induces metabolic syndrome （MS）-Iike features, including endothelial dysfunction. Erectile dysfunction is an early manifestation of endothelial dysfunction and systemic vascular disease. Because mineral deficiency intensifies the deleterious effects of fructose consumption and mineral ingestion is protective against MS, we aimed to characterize the effects of 8weeks of natural mineral-rich water consumption on the structural organization and expression of vascular growth factors and receptors on the corpus cavernosum （CC） in 10% fructose-fed Sprague-Dawley rats （FRUCT）. Differences were not observed in the organization of the CC either on the expression of vascular endothelial growth factor （VEGF） or the components of the angiopoietins/Tie2 system. However, opposing expression patterns were observed for VEGF receptors （an increase and a decrease for VEGFR1 and VEGFR2, respectively） in FRUCT animals, with these patterns being strengthened by mineral-rich water ingestion. Mineral-rich water ingestion （FRUCTMIN） increased the proportion of smooth muscle cells compared with FRUCT rats and induced an upregulatory tendency of sirtuin I expression compared with the control and FRUCT groups. Western blot results were consistent with the dual immunofluorescence evaluation. Plasma oxidized low-density lipoprotein and plasma testosterone levels were similar among the experimental groups, although a tendency for an increase in the former was observed in the FRUCTMIN group. The mineral-rich water-treated rats presented changes similar to those observed in rats treated with MS-protective polyphenol-rich beverages or subjected to energy restriction, which led us to hypothesize that the effects of mineral-rich water consumption may be more vast than those directly observed in this study.

Risk factors and prognostic value of acute severe lower gastrointestinal bleeding in Crohn’s disease

BACKGROUND Acute severe lower gastrointestinal bleeding(LGIB)is an uncommon but challenging complication of Crohn’s disease(CD).AIM To identify the predictors of acute severe LGIB and to evaluate the impact of acute severe LGIB on the subsequent clinical course in CD patients.METHODS A retrospective inception cohort study was conducted in 75 CD patients with acute severe LGIB and 1359 CD patients without acute severe LGIB who were diagnosed between February 1991 and November 2019 at Asan Medical Center,a tertiary university hospital in Korea.Multivariable analysis with Cox proportional hazard regression was performed to identify the risk factors for acute severe LGIB.A matched analysis using 72 patients with bleeding and 267 matched patients without within the cohort was also conducted to investigate whether acute severe LGIB is a predictor of clinical outcomes of CD.RESULTS Multivariable Cox regression analysis revealed that early use of thiopurines[hazard ratio(HR):0.23,95%confidence interval(CI):0.12-0.48;P<0.001]and female sex(HR:0.51,95%CI:0.27-0.94;P=0.031)were significantly associated with a lower risk of acute severe LGIB.The cumulative risks of behavioral progression and intestinal resection were not significantly different between the two matched groups(P=0.139 and P=0.769,respectively).The hospitalization rate was higher in the bleeding group than in the matched non-bleeding group(22.1/100 vs 13.2/100 patient-years;P=0.012).However,if hospitalizations due to bleeding episodes were excluded from the analysis,the hospitalization rate was not significantly different between the bleeding group and the matched nonbleeding group(14.5/100 vs 13.2/100 patient-years;P=0.631).CONCLUSION Early use of thiopurines may reduce the risk of acute severe LGIB.History of acute severe LGIB may not have a significant prognostic value in patients with CD.

Ischemic colitis after enema administration: Incidence, timing, and clinical features

BACKGROUND Enema administration is a common procedure in the emergency department(ED). However, several published case reports on enema-related ischemic colitis(IC) have raised the concerns regarding the safety of enema agents. Nevertheless, information on its true incidence and characteristics are still lacking.AIM To investigate the incidence, timing, and risk factors of IC in patients receiving enema.METHODS We consecutively collected the data of all adult patients receiving various enema administrations in the ED from January 2010 to December 2018 and identified patients confirmed with IC following enema. Of 8320 patients receiving glycerin enema, 19 diagnosed of IC were compared with an age-matched control group without IC.RESULTS The incidence of IC was 0.23% among 8320 patients receiving glycerin enema;however, there was no occurrence of IC among those who used other enema agents. The mean age ± standard deviation(SD) of patients with glycerin enemarelated IC was 70.2 ± 11.7. The mean time interval ± SD from glycerin enema administration to IC occurrence was 5.5 h ± 3.9 h(range 1-15 h). Of the 19 glycerin enema-related IC cases, 15(79.0%) were diagnosed within 8 h. The independent risk factors for glycerin-related IC were the constipation score [Odds ratio(OR), 2.0;95% confidence interval(CI): 1.1-3.5, P = 0.017] and leukocytosis(OR, 4.5;95%CI: 1.4-14.7, P = 0.012).CONCLUSION The incidence of glycerin enema-related IC was 0.23% and occurred mostly in the elderly in the early period following enema administration. Glycerin enemarelated IC was associated with the constipation score and leukocytosis.