Brain region-specific roles of brain-derived neurotrophic factor in social stress-induced depressive-like behavior

Brain-derived neurotrophic factor is a key factor in stress adaptation and avoidance of a social stress behavioral response.Recent studies have shown that brain-derived neurotrophic factor expression in stressed mice is brain region–specific,particularly involving the corticolimbic system,including the ventral tegmental area,nucleus accumbens,prefrontal cortex,amygdala,and hippocampus.Determining how brain-derived neurotrophic factor participates in stress processing in different brain regions will deepen our understanding of social stress psychopathology.In this review,we discuss the expression and regulation of brain-derived neurotrophic factor in stress-sensitive brain regions closely related to the pathophysiology of depression.We focused on associated molecular pathways and neural circuits,with special attention to the brain-derived neurotrophic factor–tropomyosin receptor kinase B signaling pathway and the ventral tegmental area–nucleus accumbens dopamine circuit.We determined that stress-induced alterations in brain-derived neurotrophic factor levels are likely related to the nature,severity,and duration of stress,especially in the above-mentioned brain regions of the corticolimbic system.Therefore,BDNF might be a biological indicator regulating stress-related processes in various brain regions.

Contribution of Stress Testing to the Management of Ischemic Heart Disease in Mali

Introduction: Exercise stress testing (on a treadmill or ergometer bicycle) is an important test in cardiology for diagnosing myocardial ischemia. This test in Mali is still in its beginning compared to other countries in the sub-region. The lack of data in Mali prompted this study, which aimed to evaluate the indications of this activity and its diagnostic contribution to cardiology in Mali. Materials and Methods: This was a retrospective, descriptive study. The study was conducted at the “TOUCAM” medical clinic in Kati based on the analysis of stress test reports between January 2016 and August 2022. Result: During the study period, we documented 73 patients who underwent exercise testing on a bicycle ergometer for suspected coronary heart disease. The mean age of our patients was 47.5 ± 13.8 years (14 and 79 years). Males accounted for the majority (78.1%). The sex ratio is 3.5. More than half of our patients were overweight or obese (77.1%). Hypertension and diabetes affected 52.1% and 25.8% of patients, respectively. 20.8% of patients had coronary artery disease. renin-angiotensin-aldosterone system blockers (56.8%) and beta-blockers (51.3%). The main indications were chest pain (63.0%) and ischemia detection (15.1%). A modified STEEP protocol was used. The majority of our patients (71.2%) achieved at least 85% of their maximum theoretical heart rate. The main reason for the termination of the study was fatigue (57.3%). The average duration was 11.3 ± 4.2 minutes. 24.7% thought the stress tests were positive and 17.8% thought they were controversial. Conclusion: This study demonstrates the importance of stress testing in the diagnosis and treatment of ischemic heart disease, especially in settings where we have very limited access to coronary angiography.

Trehalose:A sugar molecule involved in temperature stress management in plants

Trehalose(Tre)is a non-reducing disaccharide found in many species,including bacteria,fungi,invertebrates,yeast,and even plants,where it acts as an osmoprotectant,energy source,or protein/membrane protector.Despite relatively small amounts in plants,Tre concentrations increase following exposure to abiotic stressors.Trehalose-6-phosphate,a precursor of Tre,has regulatory functions in sugar metabolism,crop production,and stress tolerance.Among the various abiotic stresses,temperature extremes(heat or cold stress)are anticipated to impact crop production worldwide due to ongoing climate changes.Applying small amounts of Tre can mitigate negative physiological,metabolic,and molecular responses triggered by temperature stress.Trehalose also interacts with other sugars,osmoprotectants,amino acids,and phytohormones to regulate metabolic reprogramming that underpins temperature stress adaptation.Transformed plants expressing Tre-synthesis genes accumulate Tre and show improved stress tolerance.Genome-wide studies of Tre-encoding genes suggest roles in plant growth,development,and stress tolerance.This review discusses the functions of Tre in mitigating temperature stress—highlighting genetic engineering approaches to modify Tre metabolism,crosstalk,and interactions with other molecules—and in-silico approaches for identifying novel Tre-encoding genes in diverse plant species.We consider how this knowledge can be used to develop temperature-resilient crops essential for sustainable agriculture.

Intervention package on stress management: Improving comprehensive well-being among nurses

Objective:The main objective of this study is to investigate the effectiveness of the stress management intervention package in improving stress-related burnout.Materials and Methods:An experimental study was done on 300 nurses selected by a nonprobability convenience sampling technique and a quasi-experimental one-group pre-and posttest research design was utilized.Modified expanded nurses stress scale and self-structured three-point Likert scale on the challenges that nurses may face following stressful life events utilized to collect information.The nurses signed up for six interactive sessions on various stress-coping methods by utilizing a variety of teaching strategies such as lecture cum discussion,video slides,group work,and direct interaction with the experts to explore stress-related issues.Results:Continuous stress affects both the body and the mind,causing psychosomatic symptoms.Data found that 2%to 10%of nurses frequently suffered with physical symptoms such as exhaustion,backache,acidity,headache,shoulder stiffness,and insomnia.Following the intervention,the number of nurses who had these symptoms frequently and sometimes decreased.Previously,10%of nurses experienced emotional symptoms frequently;however,after intervention,this figure was reduced to<2%.The greatest proportion of nurses(18%)reported frequently worrying,while 1.3%expressed frequent worrying after intervention.Maximum(5%)of nurses had a tendency to eat too little or too much;this has been reduced to 0.3%after the intervention.The intervention package on stress management significantly improved nurses’Conclusion:An intervention package for stress management was helpful in lowering physical,emotional,psychological,and behavioral stress-related symptoms among nurses.

Correlation between the rock mass properties and maximum horizontal stress:A case study of overcoring stress measurements

Understanding the mechanical properties of the lithologies is crucial to accurately determine the horizontal stress magnitude.To investigate the correlation between the rock mass properties and maximum horizontal stress,the three-dimensional(3D)stress tensors at 89 measuring points determined using an improved overcoring technique in nine mines in China were adopted,a newly defined characteristic parameter C_(ERP)was proposed as an indicator for evaluating the structural properties of rock masses,and a fuzzy relation matrix was established using the information distribution method.The results indicate that both the vertical stress and horizontal stress exhibit a good linear growth relationship with depth.There is no remarkable correlation between the elastic modulus,Poisson's ratio and depth,and the distribution of data points is scattered and messy.Moreover,there is no obvious relationship between the rock quality designation(RQD)and depth.The maximum horizontal stress σ_(H) is a function of rock properties,showing a certain linear relationship with the C_(ERP)at the same depth.In addition,the overall change trend of σ_(H) determined by the established fuzzy identification method is to increase with the increase of C_(ERP).The fuzzy identification method also demonstrates a relatively detailed local relationship betweenσ_H and C_(ERP),and the predicted curve rises in a fluctuating way,which is in accord well with the measured stress data.

Dip2a regulates stress susceptibility in the basolateral amygdala

Dysregulation of neurotransmitter metabolism in the central nervous system contributes to mood disorders such as depression, anxiety, and post–traumatic stress disorder. Monoamines and amino acids are important types of neurotransmitters. Our previous results have shown that disco-interacting protein 2 homolog A(Dip2a) knockout mice exhibit brain development disorders and abnormal amino acid metabolism in serum. This suggests that DIP2A is involved in the metabolism of amino acid–associated neurotransmitters. Therefore, we performed targeted neurotransmitter metabolomics analysis and found that Dip2a deficiency caused abnormal metabolism of tryptophan and thyroxine in the basolateral amygdala and medial prefrontal cortex. In addition, acute restraint stress induced a decrease in 5-hydroxytryptamine in the basolateral amygdala. Additionally, Dip2a was abundantly expressed in excitatory neurons of the basolateral amygdala, and deletion of Dip2a in these neurons resulted in hopelessness-like behavior in the tail suspension test. Altogether, these findings demonstrate that DIP2A in the basolateral amygdala may be involved in the regulation of stress susceptibility. This provides critical evidence implicating a role of DIP2A in affective disorders.

Acquired sensorineural hearing loss,oxidative stress,and microRNAs

Hearing loss is the third leading cause of human disability.Age-related hearing loss,one type of acquired sensorineural hearing loss,is largely responsible for this escalating global health burden.Noise-induced,ototoxic,and idiopathic sudden sensorineural are other less common types of acquired hearing loss.The etiology of these conditions is complex and multi-fa ctorial involving an interplay of genetic and environmental factors.Oxidative stress has recently been proposed as a likely linking cause in most types of acquired sensorineural hearing loss.Short non-coding RNA sequences known as microRNAs(miRNAs)have increasingly been shown to play a role in cellular hypoxia and oxidative stress responses including promoting an apoptotic response.Sensory hair cell death is a central histopathological finding in sensorineural hearing loss.As these cells do not regenerate in humans,it underlies the irreversibility of human age-related hearing loss.Ovid EMBASE,Ovid MEDLINE,Web of Science Core Collection,and ClinicalTrials.gov databases over the period August 1,2018 to July 31,2023 were searched with"hearing loss,""hypoxamiRs,""hypoxia,""microRNAs,""ischemia,"and"oxidative stress"text words for English language primary study publications or registered clinical trials.Registe red clinical trials known to the senior author we re also assessed.A total of 222studies were thus identified.After excluding duplicates,editorials,retra ctions,secondary research studies,and non-English language articles,39 primary studies and clinical trials underwent full-text screening.This resulted in 11 animal,in vitro,and/or human subject journal articles and 8 registered clinical trial database entries which form the basis of this narrative review.MiRNAs miR-34a and miR-29b levels increase with age in mice.These miRNAs were demonstrated in human neuroblastoma and murine cochlear cell lines to target Sirtuin 1/peroxisome proliferato r-activated receptor gamma coactivator-1-alpha(SIRT1/P GC-1α),SIRT1p53,and SIRT1/hypoxia-inducible factor 1-alpha signaling pathways resulting in increased apoptosis.Furthermore,hypoxia and oxidative stress had a similar adve rse apoptotic effect,which was inhibited by resve ratrol and a myocardial inhibitorassociated transcript,a miR-29b competing endogenous mRNA.Gentamicin reduced miR-182-5p levels and increased cochlear oxidative stress and cell death in mice-an effect that was corrected by inner ear stem cell-derived exosomes.There is ongoing work seeking to determine if these findings can be effectively translated to humans.

Imperative for long-term management and surveillance in Kawasaki disease

Kawasaki disease(KD)is a significant pediatric vasculitis known for its potential to cause severe coronary artery complications.Despite the effectiveness of initial treatments,such as intravenous immunoglobulin,KD patients can experience long-term cardiovascular issues,as evidenced by a recent case report of an adult who suffered a ST-segment elevation myocardial infarction due to previous KD in the World Journal of Clinical Cases.This editorial emphasizes the critical need for long-term management and regular surveillance to prevent such complications.By drawing on recent research and case studies,we advocate for a structured approach to follow-up care that includes routine cardiac evaluations and preventive measures.

Enhancing perianal disease management with integrated physical and psychological approaches

This article provides a comprehensive analysis of the study by Hou et al,focusing on the complex interplay between psychological and physical factors in the postoperative recovery(POR)of patients with perianal diseases.The study sheds light on how illness perception,anxiety,and depression significantly influence recovery outcomes.Hou et al developed a predictive model that demonstrated high accuracy in identifying patients at risk of poor recovery.The article explores the critical role of pre-operative psychological assessment,highlighting the need for mental health support and personalized recovery plans in enhancing POR quality.A multidisciplinary approach,integrating mental health professionals with surgeons,anesthesiologists,and other specialists,is emphasized to ensure comprehensive care for patients.The study’s findings serve as a call to integrate psychological care into surgical practice to optimize outcomes for patients with perianal diseases.

Endoplasmic reticulum stress and autophagy in cerebral ischemia/reperfusion injury:PERK as a potential target for intervention

Several studies have shown that activation of unfolded protein response and endoplasmic reticulum(ER)stress plays a crucial role in severe cerebral ischemia/reperfusion injury.Autophagy occurs within hours after cerebral ischemia,but the relationship between ER stress and autophagy remains unclear.In this study,we established experimental models using oxygen-glucose deprivation/reoxygenation in PC12 cells and primary neurons to simulate cerebral ischemia/reperfusion injury.We found that prolongation of oxygen-glucose deprivation activated the ER stress pathway protein kinase-like endoplasmic reticulum kinase(PERK)/eukaryotic translation initiation factor 2 subunit alpha(e IF2α)-activating transcription factor 4(ATF4)-C/EBP homologous protein(CHOP),increased neuronal apoptosis,and induced autophagy.Furthermore,inhibition of ER stress using inhibitors or by si RNA knockdown of the PERK gene significantly attenuated excessive autophagy and neuronal apoptosis,indicating an interaction between autophagy and ER stress and suggesting PERK as an essential target for regulating autophagy.Blocking autophagy with chloroquine exacerbated ER stress-induced apoptosis,indicating that normal levels of autophagy play a protective role in neuronal injury following cerebral ischemia/reperfusion injury.Findings from this study indicate that cerebral ischemia/reperfusion injury can trigger neuronal ER stress and promote autophagy,and suggest that PERK is a possible target for inhibiting excessive autophagy in cerebral ischemia/reperfusion injury.

MicroRNAs as potential biomarkers for diagnosis of post-traumatic stress disorder

Post-traumatic stress disorder is a mental disorder caused by exposure to severe traumatic life events.Currently,there are no validated biomarkers or laboratory tests that can distinguish between trauma survivors with and without post-traumatic stress disorder.In addition,the heterogeneity of clinical presentations of post-traumatic stress disorder and the overlap of symptoms with other conditions can lead to misdiagnosis and inappropriate treatment.Evidence suggests that this condition is a multisystem disorder that affects many biological systems,raising the possibility that peripheral markers of disease may be used to diagnose post-traumatic stress disorder.We performed a PubMed search for microRNAs(miRNAs)in post-traumatic stress disorder(PTSD)that could serve as diagnostic biomarkers and found 18 original research articles on studies performed with human patients and published January 2012 to December 2023.These included four studies with whole blood,seven with peripheral blood mononuclear cells,four with plasma extracellular vesicles/exosomes,and one with serum exosomes.One of these studies had also used whole plasma.Two studies were excluded as they did not involve microRNA biomarkers.Most of the studies had collected samples from adult male Veterans who had returned from deployment and been exposed to combat,and only two were from recently traumatized adult subjects.In measuring miRNA expression levels,many of the studies had used microarray miRNA analysis,miRNA Seq analysis,or NanoString panels.Only six studies had used real time polymerase chain reaction assay to determine/validate miRNA expression in PTSD subjects compared to controls.The miRNAs that were found/validated in these studies may be considered as potential candidate biomarkers for PTSD and include miR-3130-5p in whole blood;miR-193a-5p,-7113-5p,-125a,-181c,and-671-5p in peripheral blood mononuclear cells;miR-10b-5p,-203a-3p,-4488,-502-3p,-874-3p,-5100,and-7641 in plasma extracellular vesicles/exosomes;and miR-18a-3p and-7-1-5p in blood plasma.Several important limitations identified in the studies need to be taken into account in future studies.Further studies are warranted with war veterans and recently traumatized children,adolescents,and adults having PTSD and use of animal models subjected to various stressors and the effects of suppressing or overexpressing specific microRNAs.

Hydrogen sulfide reduces oxidative stress in Huntington's disease via Nrf2

The pathophysiology of Huntington's disease involves high levels of the neurotoxin quinolinic acid. Quinolinic acid accumulation results in oxidative stress, which leads to neurotoxicity. However, the molecular and cellular mechanisms by which quinolinic acid contributes to Huntington's disease pathology remain unknown. In this study, we established in vitro and in vivo models of Huntington's disease by administering quinolinic acid to the PC12 neuronal cell line and the striatum of mice, respectively. We observed a decrease in the levels of hydrogen sulfide in both PC12 cells and mouse serum, which was accompanied by down-regulation of cystathionine β-synthase, an enzyme responsible for hydrogen sulfide production. However, treatment with NaHS(a hydrogen sulfide donor) increased hydrogen sulfide levels in the neurons and in mouse serum, as well as cystathionine β-synthase expression in the neurons and the mouse striatum, while also improving oxidative imbalance and mitochondrial dysfunction in PC12 cells and the mouse striatum. These beneficial effects correlated with upregulation of nuclear factor erythroid 2-related factor 2 expression. Finally, treatment with the nuclear factor erythroid 2-related factor 2inhibitor ML385 reversed the beneficial impact of exogenous hydrogen sulfide on quinolinic acid-induced oxidative stress. Taken together, our findings show that hydrogen sulfide reduces oxidative stress in Huntington's disease by activating nuclear factor erythroid 2-related factor 2,suggesting that hydrogen sulfide is a novel neuroprotective drug candidate for treating patients with Huntington's disease.

Lower limb stress fractures in sport:Optimising their management and outcome

Stress fractures in sport are becoming increasing more common,comprising up to 10%of all of sporting injuries.Around 90%of such injuries are located in the lower limb.This articles aims to define the optimal management of lower limb stress fractures in the athlete,with a view to maximise return rates and minimise return times to sport.Treatment planning of this condition is specific to the location of the injury.However,there remains a clear division of stress fractures by"high"and"low"risk."Low risk"stress fractures are those with a low probability of fracture propagation,delayed union,or non-union,and so can be managed reliably with rest and exercise limitation.These include stress fractures of the PosteroMedial Tibial Diaphysis,Metatarsal Shafts,Distal Fibula,Medial Femoral Neck,Femoral Shaft and Calcaneus."High risk"stress fractures,in contrast,have increased rates of fracture propagation,displacement,delayed and non-union,and so require immediate cessation of activity,with orthopaedic referral,to assess the need for surgical intervention.These include stress fractures of the Anterior Tibial Diaphysis,Fifth Metatarsal Base,Medial Malleolus,Lateral Femoral Neck,Tarsal Navicular and Great Toe Sesamoids.In order to establish the optimal methods for managing these injuries,we present and review the current evidence which guides the treatment of stress fractures in athletes.From this,we note an increased role for surgical management of certain high risk stress fractures to improve return times and rates to sport.Following this,key recommendations are provided for the management of the common stress fracture types seen in the athlete.Five case reports are also presented to illustrate the application of sportfocussed lower limb stress fracture treatment in the clinical setting.

Clinical benefits of rational-emotive stress management therapy for job burnout and dysfunctional distress of special education teachers

It has been observed that managing job burnout and dysfunctional distress constitute part of the major challenges among special educators,and that empirical data on the management of burnout and dysfunctional distress associated with the job of special education teachers are lacking in the literature.The current article discusses the clinical benefits of a rational-emotive stressmanagement therapy program in reducing the level of job burnout symptoms and dysfunctional distress in special education teachers,using evidence from a 2018 clinical trial study that reported the efficacy of this intervention.Results show the clinical benefits and implications of conducting a rational-emotive stress management intervention,and recommendations are made for future research.

Heat stress management in underground mines

Heat management must be maintained within the mine working environment to minimize stress on equipment and personnel. The issue is a growing concern as mines continue to expand in size, depth and infrastructure. Heat management is a concern as it relates to both heat sensitive equipment and more importantly the health and safety of the workers found within the mine. Proper application of engineering protocols and work practice controls will have a direct impact on the health and safety of workers and increased productivity. Using continuous monitoring stations placed in strategic locations throughout the mine to capture the environmental conditions, various strategies can be used in the planning and prevention of potential hazard exposure. Economic analysis is used to select the most feasible strategy for heat stress control. This paper presents a step by step methodology that may be considered by ventilation specialists to effectively implement a heat management control system. A case study based on a detailed heat management assessment conducted for a potash mine in Saskatchewan, Canada is presented.

Broken heart: A matter of the endoplasmic reticulum stress bad management?

Cardiovascular diseases are the number one cause of morbidity and mortality in the United States and worldwide.The induction of the endoplasmic reticulum(ER)stress,a result of a disruption in the ER homeostasis,was found to be highly associated with cardiovascular diseases such as hypertension,diabetes,ischemic heart diseases and heart failure.This review will discuss the latest literature on the different aspects of the involvement of the ER stress in cardiovascular complications and the potential of targeting the ER stress pathways as a new therapeutic approach for cardiovascular complications.

Acute respiratory distress syndrome after liver transplantation: etiology, prevention and management

Objective: To study the etiology, prevention andmanagement of acute respiratory distress syndrome(ARDS) after liver transplantation.Methods: The clinical data of 104 patients with end-stage liver diseases who had had liver transplanta-tions were retrospectively reviewed.Results: Seventeen patients (16.3%, 17/104) alto-gether were diagnosed as having ARDS after livertransplantation. Ten of them developed ARDS within24 hours, of whom 1 died during the operation, and7 developed ARDS 3 or 4 days after they were extu-bated and when methylprednisolone was tapered.Fourteen of the 17 ARDS patients (14/17) werefound to have overloaded crystalloid infusion, mas-sive transfusion of blood or blood products such asplasma, platelets, in addition to a prolonged surgicaltime secondary to serious bleeding during the dis-eased liver removal without evidence of active infec-tion. One was found to have serious systemic infec-tion and operatively disseminated intravascular coag-ulation. Four of the recipients developed ARDS sud-denly when intravenous cyclosporine was given on the3rd day after operation. One patient of the 4 had allof the aforementioned conditions. Two patients suf-fered from gastric aspiration. Five (30%, 5/17) ofthem survived ARDS with the combined treatmentconsisting of positive end-expiratory pressure me-chanicai ventilation suctioning as much edema fluidor sputum as possible, administration of diuretics,bolus of corticosteroids, and culture-based antibiot-ics. Hemeodialysis was indicated for patients with ol-iguric renal failure.Conclusions: ARDS is a serious multifactoral compli-cation after liver transplantation with a high mortali-ty and fatality. The most likely cause is fluid over-load from crystalloid liquid infusion or massive trans-fusion. The other predisposing or contributing fac-tors include sepsis, Ⅳ use of cyclosporine, fast ta-pering of corticosteroids, and gastric aspiration.Other factors such as transfusion-related acute lunginjury (TRALI), and reperfusion syndrome of thenewly implanted liver may also contribute. Thoughthe treatment should primarily be supportive in na-ture, it is helpful to understand the predisposing andcontributing factors and to aid in prevention, man-agement and treatment.

Human Factors/Ergonomics (HFE) in Leadership and Management: Organizational Interventions to Reduce Stress in Healthcare Delivery

Clinician Burnout is a personal and public health issue. Most occupational stressors contributing to clinician burnout are systemic. The combination of organizational interventions along with individual interventions is necessary to make significant lasting difference in reducing burnout, improving clinician and patient satisfaction and reducing latent error in healthcare delivery. Application of Human Factors/Ergonomics (HFE) science in healthcare leadership and management is a gap in current training for leaders. HFE uses concepts from organizational, educational and cognitive science, systems science and industrial engineering. HFE application is especially necessary in a fast changing highly stressful healthcare environment which impacts the wellbeing of clinicians and the safety of patients under care. Practical suggestions for working with various healthcare leadership styles and organizational dynamics, while aligning wellness efforts with institutional mission are discussed. Concrete examples of decreasing extraneous mental load on clinicians to preserve their brainpower to achieve quality patient care are illustrated. Organizational interventions in combination with individual interventions to reduce and manage burnout have enormous potential to improve clinician wellbeing and satisfaction in taking care of patients, reduce costs, risk of error and create the safe working environment needed to sustainably give high quality care to patients.

Salinity Stress in Wheat:Effects,Mechanisms and Management Strategies

Salinity stress is a major threat to global food production and its intensity is continuously increasing because of anthropogenic activities.Wheat is a staple food and a source of carbohydrates and calories for the majority of people across the globe.However,wheat productivity is adversely affected by salt stress,which is associated with a reduction in germination,growth,altered reproductive behavior and enzymatic activity,disrupted photosynthesis,hormonal imbalance,oxidative stress,and yield reductions.Thus,a better understanding of wheat(plant)behavior to salinity stress has essential implications to devise counter and alleviation measures to cope with salt stress.Different approaches including the selection of suitable cultivars,conventional breeding,and molecular techniques can be used for facing salt stress tolerance.However,these techniques are tedious,costly,and labor-intensive.Management practices are still helpful to improve the wheat performance under salinity stress.Use of arbuscular mycorrhizal fungi,plant growth-promoting rhizobacteria,and exogenous application of phytohormones,seed priming,and nutrient management are important tools to improve wheat performance under salinity stress.In this paper,we discussed the effect of salinity stress on the wheat crop,possible mechanisms to deal with salinity stress,and management options to improve wheat performance under salinity conditions.

Stress gastric ulcer after cardiac surgery: Pathogenesis risk factors and medical management

Stress ulcer lesions of upper gastrointestinal tract are well recognized in patients undergoing open cardiac surgery. Gastrointestinal bleeding following cardiac surgery is infrequent with significant morbidity and mortality. The pathogenesis of mucosal lesions and subsequent haemorrhage is complex and multifactorial. The diagnosis as well as the treatment of this complication remains a challenge for surgeons. Identifying the source of bleeding can be difficult. Despite of the successful control of haemorrhage using various combinations of endoscopic and pharmacological therapies, the mortality rate remains unchanged. Benefit of routine stress ulcer prophylaxis remains controversial.