Prediction model of stress ulcer after laparoscopic surgery for colorectal cancer established by machine learning algorithm

BACKGROUND Patients with colorectal cancer(CRC)are prone to stress ulcer after laparoscopic surgery.The analysis of risk factors for stress ulcer(SU)in patients with CRC is important to reduce mortality and improve patient prognosis.AIM To identify risk factors for SU after laparoscopic surgery for CRC,and develop a nomogram model to predict the risk of SU in these patients.METHODS The clinical data of 135 patients with CRC who underwent laparoscopic surgery between November 2021 and June 2022 were reviewed retrospectively.They were divided into two categories depending on the presence of SUs:The SU group(n=23)and the non-SU group(n=112).Univariate analysis and multivariate logistic regression analysis were used to screen for factors associated with postoperative SU in patients undergoing laparoscopic surgery,and a risk factor-based nomogram model was built based on these risk factors.By plotting the model's receiver operating characteristic(ROC)curve and calibration curve,a Hosmer-Lemeshow goodness of fit test was performed.RESULTS Among the 135 patients with CRC,23 patients had postoperative SU,with an incidence of 17.04%.The SU group had higher levels of heat shock protein(HSP)70,HSP90,and gastrin(GAS)than the non-SU group.Age,lymph node metastasis,HSP70,HSP90,and GAS levels were statistically different between the two groups,but other indicators were not statistically different.Logistic regression analysis showed that age≥65 years,lymph node metastasis,and increased levels of HSP70,HSP90 and GAS were all risk factors for postoperative SU in patients with CRC(P<0.05).According to these five risk factors,the area under the ROC curve for the nomogram model was 0.988(95%CI:0.971-1.0);the calibration curve demonstrated excellent agreement between predicted and actual probabilities,and the Hosmer-Lemeshow goodness of fit test revealed that the difference was not statistically significant(χ2=0.753,P=0.999),suggesting that the nomogram model had good discrimination,calibration,and stability.CONCLUSION Patients with CRC aged≥65 years,with lymph node metastasis and elevated HSP70,HSP90,GAS levels,are prone to post-laparoscopic surgery SU.Our nomogram model shows good predictive value.

Association of high expression in rat gastric mucosal heat shock protein 70 induced by moxibustion pretreatment with protection against stress injury

AIM:To study the effect of moxibustion on Zusanli or Liangmeng point on gastric mucosa injury in stress-induced ulcer rats and its correlation with the expression of heat shock protein 70 (HSP70). METHODS:Sixty healthy SD rats (30 males,30 females) were divided into control group,injury model group,Zushanli point group,Liangmeng point group. Stress gastric ulcer model was induced by binding cold stress method. Gastric mucosa ulcer injury (UI) index was calculated by Guth method. Gastric mucosa blood flow (GMBF) was recorded with a biological signal analyzer. Protein content and gene expression in gastric mucosal HSP70 were detected by immunohistochemistry (IHC) and reverse transcription polymerase chain reaction (RT-PCR). Thiobarbital method was used to determine malondialdehyde (MDA) content. Gastric mucosal endothelin (ET) and prostaglandin E2 (PGE2) were analyzed by radioimmunoassay. RESULTS:High gastric mucosal UI index,high HSP70 expression,low GMBF and PGF2,elevated MDA and ET were observed in gastric mucosa of rats subjected to cold stress. Moxibustion on Zusanli or Liangmeng point decreased rat gastric mucosal UI index,MDA and ET. Conversely,the expression of HSP70,GMBF,and PGE2 was elevated in gastric mucosa after pretreatment with moxibustion on Zusanli or Liangmeng point. The observed parameters were significantly different between Zusanli and Liangmeng points. CONCLUSION:Pretreatment with moxibustion on Zusanli or Liangmeng point protects gastric mucosa against stress injury. This protection is associated with the higher expression of HSP70 mRNA and protein,leading to release of PGE2 and inhibition of MDA and ET,impairment of gastric mucosal index.

Dynamic functional and ultrastructural changes of gastric parietal cells induced by water immersion-restraint stress in rats

AIM： To investigate the dynamic functional and ultrastructural changes of gastric parietal cells induced by water immersion-restraint stress （WRS） in rats.METHODS： WRS model of Sprague-Dawley （SD） rats was established. Fifty-six male SD rats were randomly divided into control group, stress group and post-stress group. The stress group was divided into 1, 2 and 4 h stress subgroups. The post-stress group was divided into 24, 48 and 72 h subgroups. The pH value of gastric juice, ulcer index （UI） of gastric mucosa and H^＋, K^＋- ATPase activity of gastric parietal cells were measured. Ultrastructural change of parietal cells was observed under transmission electron microscope （TEM）.RESULTS： The pH value of gastric juice decreased time-dependently in stress group and increased in post-stress group. The H^＋, K^＋-ATPase activity of gastric parietal cells and the UI of gastric mucosa increased time-dependently in stress group and decreased in poststress group. Compared to control group, the pH value decreased remarkably （P = 0.0001）, the UI and H^＋, K^＋- ATPase activity increased significantly （P = 0.0001, P = 0.0174） in 4 h stress subgroup. UI was positively related with stress time （r = 0.9876, P 〈 0.01） but negatively with pH value （r = -0.8724, P 〈 0.05）. The parietal cells became active in stress group, especially in 4 h stress subgroup, in which plenty of intracellular canalicular and mitochondria were observed under TEM. In post-stress group, the parietal cells recovered to resting state.CONCOUSION： The acid secretion of parietal cells is consistent with their ultrastructural changes during the development and healing of stress ulcer induced by WRS and the degree of gastric mucosal lesions, suggesting gastric acid play an important role in the development of stress ulcer and is closely related with the recovery of gastric mucosal lesions induced by WRS.

Effect of pre-moxibustion on apoptosis and proliferation of gastric mucosa cells

AIM： TO observe the effects of pre-moxibustion on apoptosis and proliferation of gastric mucosal cell in rats with stress-induced ulcer, and to analyze the relationship between those effects and the expression of heat-shock protein 70 （HSP70）. METHODS： Sixty healthy Sprague Dawley rats were randomly assigned into four groups, namely group A, B, C and D. The animal model of stress ulcer was established by water immersion and restraint stress. The rats in group A, B, and D served as the restraint, model, and non-acupoint controls, respectively, while those in group C received moxibustion at Zusanli and Uangmen points. Immunohistochemical methodology was used to detect the expression of HSP70, apoptosis index （AI, × 10^-6/μm^2） and proliferation index （PCNA-LI, × 10^-6/μm^2）. The mucosal expression of transforming growth factor α （TGF-α） was detected by radioimmunoassay. RESULTS： IVloxibustion at Zusanli and Liangmen points significantly decreased the gastric injury and the apoptosis of gastric mucosal cells, while markedly increased the mucosal expression of TGF-α and HSP70 as well as the proliferation of gastric mucosal cells. Compared with group A, ulcer index （UI） （26.8 ± 9.8 vs 12.0 ± 5.9, P 〈 0.01）, AI （9.6 ± 4.2 vs 4.4 ± 2.6, P 〈 0.05） and expression of HSP70 （9.6 ± 4.2 vs 4.4 ± 2.6, P 〈 0.05） were significantly increased, but the content of TGF-α （104.7 ± 51.2 pg/mL vs 254.0 ± 86.9 pg/mL, P 〈 0.01） and PCNA-LI （6.9 ± 4.7 vs 14.9 ± 4.6, P 〈 0.05） were significantly decreased in group B. However, ulcer index values （UI） and AI were obviously lower in group C compared to groups B and D （14.1 ± 5.4 vs 26.8 ± 9.8 and 26.2 ± 7.7, P 〈 0.01, 3.0 ± 1.6 vs 9.6 ± 4.2 and 8.2 ± 5.2, P 〈0.05, respectively）, but content of TGF-α （237.0 ± 72.6 pg/mL vs 104.7 ± 51.2 pg/mL and 154.1 ± 61.3 pg/mL, P 〈0.01） and expression of HSP70 （0.13 ± 0.03 vs 0.08 ± 0.06 and 0.06 ± 0.04, P 〈 0.05） were higher in group C. Furthermore, the PCNA-LI was significantly higher in group C than in group B （21.6 ± 4.1 vs 6.9 ± 4.7, P 〈 0.01）. CONCLUSION： Moxibustion at Zusanli and Liangmen points has a protective effect on rats gastric mucosa in stress-induced gastric ulcer, which is closely related to its actions in promoting synthesis of TGF-α and proliferation of gastric mucosal cells, suppressing gastric mucosal cell apoptosis, and up-regulating HSP70 expression.

Clinical and cost impact of intravenous proton pump inhibitor use in non-ICU patients

AIM:To assess the appropriateness of the indication and route of administration of proton-pump-inhibitors (PPIs) and their associated cost impact. METHODS:Data collection was performed prospec-tively during a 6-mo period on 340 patients who re-ceived omeprazole intravenously during their hospital stay in non-intensive care floors. Updated guidelines were used to assess the appropriateness of the indication and route of administration. RESULTS:Complete data collection was available for 286 patients which were used to assess intravenous (IV) PPIs utilization. Around 88% of patients were receiving PPIs for claimed stress ulcer prophylaxis (SUP) indication; of which,only 17% met the guideline criteria for SUP indication,14% met the criteria for non-steroidal-anti-inflammatory drugs-induced ulcer prophylaxis,while the remaining 69% were identifi ed as having an unjustified indication for PPI use. Theinitiation of IV PPIs was appropriate in 55% of pa-tients. Half of these patients were candidates for switching to the oral dosage form during their hos-pitalization,while only 36.7% of these patients were actually switched. The inappropriate initiation of PPIs via the IV route was more likely to take place on the medical floor than the surgical floor (53% vs 36%,P = 0.003). The cost analysis associated with the appro-priateness of the indication for PPI use as well as the route of administration of PPI revealed a possible saving of up to $17 732.5 and $14 571,respectively. CONCLUSION:This study highlights the over-utili-zation of IV PPIs in non-intensive care unit patients. Restriction of IV PPI use for justified indications and route of administration is recommended.

Curling ulcer in the setting of severe sunburn: A case report

BACKGROUND While sunburns are very common,especially in pediatrics,curling ulcers secondary to sunburns are a very rare entity that has not been noted in the literature in over fifty years.This case is the first addition to the literature since the originally documented case.CASE SUMMARY A previously healthy 17 year old male presents to the emergency room with lethargy,shortness of breath on exertion,dark stools and nausea.His fatigue started to become significantly worse four days prior to admission.Approximately two weeks prior to admission,the patient was on a beach vacation with his family at which time he suffered severe sunburns.He had developed crampy epigastric abdominal pain,which was followed by dark,loose stools.On exam,he is non-toxic appearing,but with pallor and peeling skin on his face and chest with epigastric tenderness.Infectious stool studies were all negative including Helicobacter pylori.He denies use of any non-steroidal anti-inflammatory drugs and also denies alcohol or recreational drug use.While admitted he is found to be significantly anemic with his hemoglobin as low as 6.3 requiring two units of packed red blood cells.Endoscopy revealed several severe and deep ulcerations in the antrum and body of the stomach indicative of stress or curling ulcers.CONCLUSION While the incidence of stress ulcers is not known,it is most common with severe acute illness,most commonly presenting as upper gastrointestinal(GI)bleeding.It is essential to be aware of the risk of curling ulcers secondary to severe sunburns as patients with stress ulcer GI bleeding have increased morbidity and mortality compared to those who do not have GI bleed.

Evaluation of the Appropriateness of Gastrointestinal Prophylaxis in the Critically III

The aim of this study was to determine the utilization of SRMD （stress related mucosal disease） prophylaxis in the ICU （intensive care unit） of a large teaching institution based on duration and defined adverse effects. Patients were reviewed for appropriateness of SRMD prophylactic therapy based on the presence of two independent risk factors （coagulopathy and mechanical ventilation greater than 48 hours） versus presence of any one risk factor from a list developed by the study investigator. Data was collected into spreadsheets and outcomes were analyzed using descriptive statistics. When evaluating patients based on the presence of any risk factor, 84 percent of patients had at least one risk factor present, while 16 percent did not have any. In patients who received famotidine, there was one occtLrrence of Clostridium difficile and 6 cases of electrolyte abnormalities. In patients who received a PPI, there was one documented case of HAP, two cases of ventilator-associated pneumonia, three cases of Clostridium difficile, and 14 patients who developed electrolyte abnormalities. Data does not show an association between acid suppression therapy and incidence of nosocomial infections. The number of patients whose therapy exceeded the appropriate stop-date compared with the number of patients in which SRMD prophylaxis was discontinued when risk factors diminished was greater when evaluating patients based upon the two independent risk factors.

The therapeutic effect of high-dose esomeprazole on stress ulcer bleeding in trauma patients

Purpose： To compare the therapeutic effects of different doses of intravenous esomeprazole on treating trauma patients with stress ulcer bleeding. Methods： A total of 102 trauma patients with stress ulcer bleeding were randomly divided into 2 groups： 52 patients were assigned to the high-dose group who received 80 mg intravenous esomeprazole, and then 8 mg/h continuous infusion for 3 days; 50 patients were assigned to the conventional dose group who received 40 mg intravenous esomeprazole sodium once every 12 h for 72 h. Results： Compared with the conventional dose group, the total efficiency of the high-dose group and conventional dose group was 98.08% and 86.00%, respectively （p 〈 0.05）, the hemostatic time was 22.10 h ± 5.18 h and 28.27 h ± 5.96 h, respectively （p 〈 0.05）. Conclusion： Both doses of intravenous esomeprazole have good hemostatic effects on stress ulcer bleeding in trauma patients. The high-dose esomeprazole is better for hemostasis.

Effect and Mechanism of Moxibustion on Acupoints Zusanli （ST 36） and Liangmen （ST 21） in the Prevention and Treatment of Stress Ulcer

Objective： To observe the effect of moxibustion on acupoints Zusanli （ST 36） and Liangmen （ST 31） on cell proliferation and cell apoptosis of gastric mucosa in rats with stress ulcer, investigatethe mechanism of moxibustion in promoting the repair of gastric mucosal injury at cellular and molecular levels, Methods： Sixty healthy Sprague-Dawley rats were randomly divided into four groups： the restraint control group, model group, moxibustion on acupoints group and moxibustion on non-acupoints group. Water immersion and restraint stress （WRS） was used to copy the stress ulcer model of rats, radio-immunoassay was used to detect the content of transforming growth factor （TGF-α）, and S-P immunohistochemical assay was adopted to determine the HSP70 expression, the proliferating cell nuclear antigen （PCNA） and cell apoptosis index in gastric mucosa. Results： For the WRS-induced gastric ulcer model of rat, the gastric mucosal injury （gastric ulcer index, UI） was increased, the content of TGF-α was decreased, PCNA was also decreased, HSP70 expression and cell apoptosis index were all increased （P〈0.01）, Moxibustion on acupoints Zusanli （ST 36） and Liangmen （ST 31） could decrease UI, increase the content of TGF-α, promote the expression of PCNA and HSP70, decrease cell apoptosis index in gastric mucosa, with significant differences when compared with the model group and control group （P〈0.01）. Conclusions： Moxibustion on acupoints Zusanli （ST 36） and Liangmen （ST 31） had protective effect on the gastric mucosa of stress ulcer, its mechanism may be promoting the TGF-α synthesis, stimulating cell proliferation in gastric mucosa and inhibiting cell apoptosis in gastric mucosa, and this process is related to the moxibustion-induced HSP70 expression.