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.

Clinical features of acute esophageal mucosal lesions and reflux esophagitis Los Angeles classification grade D: A retrospective study

BACKGROUND Acute esophageal mucosal lesions(AEMLs)are an underrecognized and largely unexplored disease.Endoscopic findings are similar,and a higher percentage of AEML could be misdiagnosed as reflux esophagitis Los Angeles classification grade D(RE-D).These diseases could have different pathologies and require different treatments.AIM To compare AEML and RE-D to confirm that the two diseases are different from each other and to clarify the clinical features of AEML.METHODS We selected emergency endoscopic cases of upper gastrointestinal bleeding with circumferential esophageal mucosal injury and classified them into AEML and RE-D groups according to the mucosal injury’s shape on the oral side.We examined patient background,blood sampling data,comorbidities at onset,endoscopic characteristics,and outcomes in each group.RESULTS Among the emergency cases,the AEML and RE-D groups had 105(3.1%)and 48(1.4%)cases,respectively.Multiple variables exhibited significantly different results,indicating that these two diseases are distinct.The clinical features of AEML consisted of more comorbidities[risk ratio(RR):3.10;95%confidence interval(CI):1.68–5.71;P<0.001]and less endoscopic hemostasis compared with RE-D(RR:0.25;95%CI:0.10–0.63;P<0.001).Mortality during hospitalization was higher in the AEML group(RR:3.43;95%CI:0.82–14.40;P=0.094),and stenosis developed only in the AEML group.CONCLUSION AEML and RE-D were clearly distinct diseases with different clinical features.AEML may be more common than assumed,and the potential for its presence should be taken into account in cases of upper gastrointestinal bleeding with comorbidities.

Effectiveness of early colonoscopy in patients with colonic diverticular hemorrhage:A single-center retrospective cohort study

BACKGROUND Current guidelines recommend colonoscopy within 24 h for acute lower gastrointestinal bleeding;however,the evidence in support for colonic diverticular hemorrhage(CDH)indications remains insufficient.AIM To investigate the effectiveness of early colonoscopy on the length of hospital stay for CDH patients.METHODS We conducted a single-center retrospective cohort study.Patients who underwent colonoscopy within 24 h of presentation(early group)were compared with those who underwent colonoscopy beyond 24 h of presentation(elective group).The primary outcome was the length of hospital stay,and secondary outcomes were the identification of stigmata of recent hemorrhage(SRH),rebleeding,red blood cell transfusion more than 4 units,and interventional radiology and abdominal surgery after colonoscopy.RESULTS We identified 574 CDH cases.Patients were divided into the early(n=328)and elective(n=226)groups.After propensity score matching,191 pairs were generated.The length of hospital stay did not significantly differ between the two groups(early group vs elective group;median,7 vs 8 d;P=0.10).The early group had a significantly high identification of SRH(risk difference,11.6%;95%CI:2.7 to 20.3;P=0.02).No significant differences were found in the rebleeding(risk difference,4.7%;95%CI:-4.1 to 13.5;P=0.35),red blood cell transfusion more than 4 units(risk difference,1.6%;95%CI:-7.5 to 10.6;P=0.82),and interventional radiology and abdominal surgery rate after colonoscopy(risk difference,0.5%;95%CI:-2.2 to 3.2;P=1.00).CONCLUSION Early colonoscopy within 24 h,on arrival for CDH,could not improve the length of hospital stay.

Impact of COVID-19 infection rates on admissions for ambulatory care sensitive conditions:nationwide difference-in difference design in Japan

Objectives SARS-CoV-2 infection(COVID-19)has affected tertiary medical institutions and primary care.Admission for ambulatory care sensitive conditions(ACSCs)is an important indicator of primary care quality.However,no nationwide study,especially in Asia,has examined the association between admissions for ACSCs and local surges in COVID-19.This study aimed to examine how the number of admissions for ACSCs has changed in Japan between the areas with higher and lower rates of COVID-19 infection.Design This was a retrospective two-stage cross-sectional study.We employed a difference-in difference design to compare the number of hospital admissions for ACSCs between the areas with higher and lower rates of COVID-19 infection in Japan.Setting The study used a nationwide database in Japan.Participants All patients were aged 20 years and above and were admitted due to ACSCs during the study period between March and September 2019(before the pandemic)and between March and September 2020(during the pandemic).Results The total number of ACSC admissions was 464560(276530 in 2019 and 188030 in 2020).The change in the number of admissions for ACSCs per 100000 was not statistically significant between the areas with higher and lower rates of COVID-19 infection:7.50(95%CI−87.02 to 102.01).In addition,in acute,chronic and preventable ACSCs,the number of admissions per 100000 individuals did not change significantly.Conclusion Although admissions for ACSCs decreased during the COVID-19 pandemic,there was no significant change between the areas with higher and lower rates of COVID-19 infection.This implies that the COVID-19 pandemic affected the areas with higher infection rates and the areas with lower rates.