Recognizing and addressing the challenges of gastrointestinal tuberculosis

In this editorial,we comment on the article by Ali et al published in the recent issue of the World Journal of Clinical Cases.This case report shed light on a particularly rare manifestation of this disease-primary gastrointestinal tuberculosis(GTB)presenting as gastric outlet obstruction.GTB presents diagnostic challenges due to its nonspecific symptoms and lack of highly accurate diagnostic algorithms.This editorial synthesizes epidemiological data,risk factors,pathogenesis,clinical presentations,diagnostic methods,and therapies to raise awareness about GTB.GTB constitutes 1%-3%of all tuberculosis cases globally,with 6%-38%of patients also having pulmonary tuberculosis.Pathogenesis involves various modes of Mycobacterium tuberculosis complex entry into the gastrointestinal system,with the terminal ileum and ileocecal valve commonly affected.Clinical presentation varies,often resembling other intra-abdominal pathologies,necessitating a high index of suspicion.Diagnostic tools include a combination of biochemical,microbiological,radiological,and endoscopic assessments.Antitubercular medication remains the cornerstone of treatment,supplemented by surgical intervention in severe cases.Multidisciplinary management involving gastroenterologists,surgeons,pulmonologists,and infectious disease specialists is crucial for optimal outcomes.Despite advancements,timely diagnosis and management challenges persist,underscoring the need for continued research and collaboration in addressing primary GTB.

Arrhythmogenic epilepsy and pacing need: A matter of controversy

There is increasing awareness among the cardiology community regarding ictal bradyarrhythmias as a cause of loss of consciousness. A high degree of suspicion is necessary when diagnosing ictal bradyarrhythmias, and delay in diagnosing this condition may lead to morbidity associated with falls and trauma. Ictal bradyarrhythmias have also been suggested to be associated with sudden unexplained death in epilepsy, although evidence related to this association is limited. There is no guidelinedirected therapy for symptomatic ictal bradyarrhythmias due to a lack of randomized, controlled trials. Cardiac pacemaker therapy is commonly used for these patients; however, currently, there is no universal agreement on the pacing indications for these patients. In this review, we focus on the pathophysiology and clinical presentation of ictal bradyarrhythmias and then discuss the pacing need based on the available literature data.

Effect of pulsed corticosteroids and tocilizumab on hyperinflammation in COVID-19 patients with acute respiratory distress syndrome

Objective:To compare the efficacy of pulsed-dose corticosteroids(≥250 mg methylprednisolone,3 days)and tocilizumab in treating COVID-19-related hyperinflammation.Methods:This prospective observational study included RT-PCR positive COVID-19 patients with acute respiratory distress syndrome,who were admitted to the COVID-19 Adult Intensive Care Unit of Prof Dr.Murat Dilmener Emergency Hospital(Istanbul,Turkey)between December 1,2020 and February 28,2021.Clinical,laboratory and radiological examinations were used to diagnose COVID-19 associated hyperinflammation.Three cohort groups were formed:the pulsed-dose corticosteroids group(250 mg methylprednisolone for 3 days),the tocilizumab group(8 mg/day single dose or 400 mg/day for 2 days),and the combined group(pulsed-dose corticosteroid+tocilizumab).The difference in mortality rates among the groups was compared primarily.The most common cause(s)of death was determined.Furthermore,adverse events(secondary infection,acute kidney injury,arrhythmia,gastrointestinal system bleeding)for 28 days were recorded.Results:A total of 60 patients were included in this study,with 20 patients in each group.There was no statistically significant difference between the 3 groups in mortality rates(55%in the pulsed corticosteroid group,60%in the tocilizumab group,50%in the combined group,χ2=0.404,P=0.817).Infectious causes were found to be the most common cause of mortality in all the three groups,and no difference was found between them(χ2=0.404,P=0.817).There was also no difference in the development of adverse events such as secondary infection,acute kidney injury,arrhythmia,and gastrointestinal bleeding among the groups(P>0.05).Conclusions:Corticosteroids can be used instead of tocilizumab to treat hyperinflammation in COVID-19 patients with acute respiratory distress syndrome.

Goal-directed fluid therapy in gastrointestinal cancer surgery:A prospective randomized study

Objective:To investigate the effects of perioperative goal-directed fluid therapy(GDFT)on intraoperative fluid balance,postoperative morbidity,and mortality.Methods:This is a prospective randomized study,and 90 patients who underwent elective open gastrointestinal cancer surgery between April 2017 and May 2018 were included.Patients were randomized into 2 groups that received liberal fluid therapy(the LFT group,n=45)and goal-directed fluid therapy(the GDFT group,n=45).Patients’Colorectal Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity(CR-POSSUM)physiological score,Charlson Comorbidity Index(CCI),perioperative vasopressor and inotrope use,postoperative AKIN classification,postoperative intensive care unit(ICU)hospitalization,hospital stay,and 30-day mortality were recorded.Results:The volume of crystalloid used perioperatively and the total volume of fluid were significantly lower in the GDFT group compared to the LFT group(P<0.05).CR-POSSUM physiological score and CCI were significantly higher in the GDFT group(P<0.05).Although perioperative vasopressor and inotrope use was significantly higher in the GDFT group(P<0.05),postoperative acute kidney injury development was not affected.Postoperative mortality was determined to be similar in both groups(P>0.05).Conclusion:Although GDFT was demonstrated to be a good alternative method to LFT in open gastrointestinal cancer surgery,and it can prevent perioperative fluid overload,and the postoperative results are comparable in the two groups.

Treatment of laryngopharyngeal reflux disease: A systematic review

BACKGROUNG For a long time,laryngopharyngeal reflux disease(LPRD)has been treated by proton pump inhibitors(PPIs)with an uncertain success rate.AIM To shed light the current therapeutic strategies used for LPRD in order to analysis the rationale in the LPRD treatment.METHODS Three authors conducted a PubMed search to identify papers published between January 1990 and February 2019 about the treatment of LPRD.Clinical prospective or retrospective studies had to explore the impact of medical treatment(s)on the clinical presentation of suspected or confirmed LPRD.The criteria for considering studies for the review were based on the population,intervention,comparison,and outcome framework.RESULTS The search identified 1355 relevant papers,of which 76 studies met the inclusion criteria,accounting for 6457 patients.A total of 64 studies consisted of empirical therapeutic trials and 12 were studies where authors formally identified LPRD with pH-monitoring or multichannel intraluminal impedance-pH monitoring(MII-pH).The main therapeutic scheme consisted of once or twice daily PPIs for a duration ranged from 4 to 24 wk.The most used PPIs were omeprazole,esomeprazole,rabeprazole,lansoprazole and pantoprazole with a success rate ranging from 18%to 87%.Other composite treatments have been prescribed including PPIs,alginate,prokinetics,and H2 Receptor antagonists.CONCLUSION Regarding the development of MII-pH and the identification of LPRD subtypes(acid,nonacid,mixed),future studies are needed to improve the LPRD treatment considering all subtypes of reflux.