One fifth of hospitalizations for peptic ulcer-related bleeding are potentially preventable

AIM:To calculate the proportion of potentially preventable hospitalizations due to peptic ulcer disease(PUD),erosive gastritis(EG)or duodenitis(ED).METHODS:Retrospective cohort study using ICD-10codes to identify all patients with upper gastrointestinal hemorrhage secondary to endoscopically proven PUD,EG or ED during the period from March 2007 to October 2010 in three major metropolitan hospitals in Melbourne,Australia.Patients were divided into"high risk"(those who would benefit from gastroprotection)and"not high risk"groups as defined by established guidelines.Mean Rockall score,transfusion requirement,length of stay,rebleeding rates,need for surgery and in-hospital mortality was compared between"high risk"and"not high risk"groups.Within the"high risk"group,those on gastroprotection and those with no gastroprotection were also compared.RESULTS:Five hundred and seven patients were included for analysis of which 174 were classified as high risk.Median values of complete Rockall Score(5vs 4,P=0.002)and length of stay(5 d vs 4 d,P=0.04)were higher in the high risk group but in-hospital mortality was lower(0.6%vs 3.9%,P=0.03).130out of the 174 patients in the high risk group were not taking recommended gastroprotective therapy prior to hospitalization.Past history of PUD(OR=3.7,P=0.006)and clopidogrel use(OR=3.2,P=0.007)significantly predicted prescription of gastroprotective therapy.Using proton pump inhibitor protection rates of 50%-85%from published studies,an estimation of13%to 22%of the total number of the hospitalizations due to PUD or EG/ED related bleeding may have been preventable.CONCLUSION:Up to one fifth of all hospitalizations for bleeding secondary to PUD or EG/ED are potentially preventable.

Investigations for the assessment of adult patients presenting to the emergency department with supraventricular tachycardia

Dear editor,Patients with supraventricular tachycardia(SVT)commonly present to the emergency department(ED).Current guidelines[1,2]do not recommend routine pathology testing and a report on the topic has questioned their role.A systematic review concluded that troponin testing is commonly performed with a high proportion of positive fi ndings,but these results were not associated with major adverse cardiac events.[3]The conclusions of this review were limited by paucity of data and heterogeneity among studies.

A morphometric study of the structures bordering the infra-cochlear corridor-Relevant for endoscopic/microscopic ear surgery

Application of surgical endoscope, used alone or in combination with the surgical microscope, for the operative management of ear and temporal bone conditions may allow improved access and clearance of disease. Preservation of normal structures may also be improved.As the use of this tool is increasing, the need for better understanding of the anatomy of the ear is becoming evident. This is particularly so for endoscopic surgery aiming at removal of lesions involving the infra-cochlear corridor and/or petrous apex.Human temporal bone-derived labyrinth casts(molds), originally made for endolymphatic duct and sac analysis which genuinely represent the membranous labyrinth and its adjacent soft tissues, were morphometrically analyzed in terms of the anatomic relations between structures in and around the infra-cochlear corridor. The distance between the petrous carotid artery(PCA) and the basal turn of the cochlea, the distance between PCA and infra-cochlear vein(ICV)/cochlear aqueduct(CA), and the distance between the lower surface of basal cochlear turn and the point where the carotid artery and jugular vein(JV) meet close to the jugular foramen, were measured to be around 1.3 mm, 6 mm and 8 mm respectively, thus constituting an approximate 6?8 mm2 infra-cochlear corridor. This analysis and further study with larger samples might be helpful for operation via this corridor led to the petrous apex where cholesterol granuloma, cholesteatoma and other lesions are not uncommon.

How should immunomodulators be optimized when used as combination therapy with anti-tumor necrosis factor agents in the management of inflammatory bowel disease?

In the last 15 years the management of inflammatory bowel disease has evolved greatly,largely through the increased use of immunomodulators and,especially,anti-tumor necrosis factor(anti-TNF) biologic agents. Within this time period,confidence in the use of anti-TNFs has increased,whilst,especially in recent years,the efficacy and safety of thiopurines has been questioned. Yet despite recent concerns regarding the risk: benefit profile of thiopurines,combination therapy with an immunomodulator and an anti-TNF has emerged as the recommended treatment strategy for the majority of patients with moderate-severe disease,especially those who are recently diagnosed. Concurrently,therapeutic drug monitoring has emerged as a means of optimizing the dosage of both immunomodulators and antiTNFs. However the recommended therapeutic target levels for both drug classes were largely derived from studies of monotherapy with either agent,or studies underpowered to analyze outcomes in combination therapy patients. It has been assumed that these target levels are applicable to patients on combination therapy also,however there are few data to support this. Similarly,the timing and duration of treatment with immunomodulators when used in combination therapy remains unknown. Recent attention,including post hoc analyses of the pivotal registration trials,has focused on the optimization of anti-TNF agents,when used as either monotherapy or combination therapy. This review will instead focus on how best to optimize immunomodulators when used in combination therapy,including an evaluation of recent data addressing unanswered questions regarding the optimal timing,dosage and duration of immunomodulator therapy in combination therapy patients.

Food,fibre,bile acids and the pelvic floor: An integrated low risk low cost approach to managing irritable bowel syndrome

Patients presenting with abdominal pain and diarrhea are often labelled as suffering from irritable bowel syndrome,and medications may be used often without success. Advances in the understanding of the causes of the symptoms(including pelvic floor weakness and incontinence,bile salt malabsorption and food intolerance) mean that effective,safe and well tolerated treatments are now available.

Risk stratification for coronary artery disease in multi-ethnic populations:Are there broader considerations for cost efficiency?

Coronary artery disease(CAD) screening and diagnosis are core cardiac specialty services.From symptoms,autopsy correlations supported reductions in coronary blood flow and dynamic epicardial and microcirculatory coronaries artery disease as etiologies.While angina remains a clinical diagnosis,most cases require correlation with a diagnostic modality.At the onset of the evidence building process much research,now factored into guidelines were conducted among population and demographics that were homogenous and often prior to newer technologies being available.Today we see a more diverse multi-ethnic population whose characteristics and risks may not consistently match the populations from which guideline evidence is derived.While it would seem veryunlikely that for the majority,scientific arguments against guidelines would differ,however from a translational perspective,there will be populations who differ and importantly there are cost-efficacy questions,e.g.,the most suitable first-line tests or what parameters equate to an adequate test.This article reviews non-invasive diagnosis of CAD within the context of multi-ethnic patient populations.

Systemic inflammatory response following acute myocardial infarction

在 infarcted 心的尖锐 cardiomyocyte 坏死产生联系损坏的分子的模式，激活表明，并且被触发强烈煽动性的回答的补充和像使用费的 receptor/interleukin-1。Inflammasomes 也认出危险信号并且调停跟随尖锐心肌的梗塞(AMI ) 的无菌的煽动性的反应。煽动性的反应服务修理心，但是过多的发炎导致不利左室的改变和心失败。除了局部炎症，深刻全身的发炎反应与 AMI 在病人被记录了，它包括传播煽动性的 cytokines， chemokines 和房间的举起外部白血球和血小板的粘附分子，和激活。过多的煽动性的反应能被一个 deregulated 免疫系统引起。AMI 也与骨头髓激活和怒气 monocytopoiesis 被联系，它在发炎的地点支撑单核白血球的连续供应。积累的证据证明了那全身的发炎加重动脉粥样硬化，为全身的发炎的标记是不利临床的结果的预言者(例如死亡，周期性的心肌的梗塞，和心失败) 在有 AMI 的病人。

How to perform gastrointestinal ultrasound: anatomy and normal findings

Gastrointestinal ultrasound is a practical, safe, cheap and reproducible diagnostic tool in inflammatorybowel disease gaining global prominence amongst clinicians. Understanding the embryological processes of the intestinal tract assists in the interpretation of abnormal sonographic findings. In general terms, the examination principally comprises interrogation of the colon, mesentery and small intestine using both lowfrequency and high-frequency probes. Interpretation of findings on GIUS includes assessment of bowel wall thickness, symmetry of this thickness, evidence of transmural changes, assessment of vascularity using Doppler imaging and assessment of other specific features including lymph nodes, mesentery and luminal motility. In addition to B-mode imaging, transperineal ultrasonography, elastography and contrast-enhanced ultrasonography are useful adjuncts. This supplement expands upon these features in more depth.

重型颅脑损伤的早期治疗(英文)

Severe traumatic brain injury remains a major health-care problem worldwide. Although major progress has been made in understanding of the pathophysiology of this injury,this has not yet led to substantial improvements in outcome. In this report,we address present knowledge and its limitations,research innovations,and clinical implications. Improved outcomes for patients with severe traumat- ic brain injury could result from progress in pharmacological and other treatments,neural repair and regeneration,optimisation of surgical indications and techniques,and combination and individually targeted treatments. Expanded classification of traumatic brain injury and in- novations in research design will underpin these advances. We are optimistic that further gains in outcome for patients with severe traumat- ic brain injury will be achieved in the next decade.

Staged liver resection for colorectal metastases:a valuable strategy or a waste of time?

BACKGROUND:The use of staged liver resections for colorectal metastases has been increasing in recent times.The aim of this study was to determine the practices and outcomes of those surgeons attending the Australia and New Zealand Hepatic, Pancreatic and Biliary Association(ANZHPBA)meeting in 2008 who perform staged resections. METHODS:A questionnaire was sent to all members of the ANZHPBA and the international faculty who were invited to attend the annual meeting held in Coolum,Queensland, Australia in October 2008. RESULTS:There were 30 responses from 7 centres across the UK,Germany and Australia.Twenty-eight patients completed treatment.The study population was predominantly male (n=20,67%),with an average age of 59.4 years.All patients had bilobar disease.A right-sided first resection was planned in 39%of cases.Seventeen percent of patients underwent portal vein embolization prior to first resection.A second operation was performed at an average of 2.8 months from the first resection.Overall,50%(n=14)of patients eventually achieved a complete(R0)staged procedure.Twelve complications after the first resection were seen in 32%patients(n=9).Twenty- three patients underwent a second liver resection.Twenty-five complications after the second resection were present in 57% (n=13). CONCLUSIONS:Two-stage liver resections are beneficial if both stages are completed and an R0 resection is achieved. While there is increased morbidity and mortality,we believe that staged liver resection for colorectal metastases is a valuable strategy in selected cases.

知证卫生决策工具之九--系统评价结果的适用性评价

卫生体系的差异往往使得在某种环境下适用的卫生政策或规划不适用于其他情况,或这种差异使相同的卫生政策或规划在不同环境下起作用的方式不同,甚至使其效果大相径庭。因此,决策者及其支持者所面临的最大挑战是需弄清支持某一决策的研究证据是否适用于他们所处的环境。系统评价通过总结各种背景下的研究证据而使这一问题迎刃而解。但许多系统评价并未对描述原始研究的实施背景。本文建议用下面几个问题来指导决策者评价系统评价结果在特定环境下的适用性:①系统评价纳入研究的实施背景是否相同或研究结果是否能在不同环境下或不同时期内保持一致性?②有可能明显改变决策的可接受性和可行性的现实条件和制约因素是否存在重要差异?③在卫生系统制度方面是否存在重要差异从而意味着某种决策不能以同样的方式起作用?④基线情况是否存在重要差异以至于产生不同的绝对效应,尽管相对效应是一致的?⑤从决策、实施、监测及评估中还能得到哪些启示?尽管有理由推断某决策在某特定环境下的作用可能不同,但我们几乎总是可以从对各种可能的决策方案及其实施、监测、评估方法的系统评价中获得一些启示。

Lobar lung transplantation from deceased donors: A systematic review

AIM To systematically review reports on deceased-donor-lobar lung transplantation(dd LLTx) and uniformly describe sizematching using the donor-to-recipient predicted-total lung-capacity(pT LC) ratio. METHODS We set out to systematically review reports on ddL LTx and uniformly describe size matching using the donorto-recipient pT LC ratio and to summarize reported oneyear survival data of ddL LTx and conventional-LTx. We searched in Pub Med, CINAHL via EBSCO, Cochrane Database of Systematic Reviews via Wiley(CDSR),Database of Abstracts of Reviews of Effects via Wiley(DARE), Cochrane Central Register of Controlled Trials via Wiley(CENTRAL), Scopus(which includes EMBASE abstracts), and Web of Science for original reports on ddL LTx. RESULTS Nine observational cohort studies reporting on 301 ddL LTx met our inclusion criteria for systematic review of size matching, and eight for describing one-year-survival. The dd LLTx-group was often characterized by high acuity;however there was heterogeneity in transplant indications and pre-operative characteristics between studies. Data to calculate the pT LC ratio was available for 242 ddL LTx(80%). The mean pT LCratio before lobar resection was1.25 ± 0.3 and the transplanted pT LCratio after lobar resection was 0.76 ± 0.2. One-year survival in the ddL LTxgroup ranged from 50%-100%, compared to 72%-88%in the conventional-LTx group. In the largest study ddL LTx(n = 138) was associated with a lower one-year-survival compared to conventional-LTx(n = 539)(65.1% vs84.1%, P < 0.001). CONCLUSION Further investigations of optimal donor-to-recipient size matching parameters for ddL LTx could improve outcomes of this important surgical option.

Vedolizumab for ulcerative colitis: Real world outcomes from a multicenter observational cohort of Australia and Oxford

BACKGROUND Vedolizumab(VDZ),a humanised monoclonal antibody that selectively inhibits alpha4-beta7 integrins is approved for use in adult moderate to severe ulcerative colitis(UC)patients.AIM To assess the efficacy and safety of VDZ in the real-world management of UC in a large multicenter cohort involving two countries and to identify predictors of achieving remission.METHODS A retrospective review of Australian and Oxford,United Kingdom data for UC patients.Clinical response at 3 mo,endoscopic remission at 6 mo and clinical remission at 3,6 and 12 mo were assessed.Cox regression models and Kaplan Meier curves were performed to assess the time to remission,time to failure and the covariates influencing them.Safety outcomes were recorded.RESULTS Three hundred and three UC patients from 14 centres in Australia and United Kingdom,[60%n=182,anti-TNF naïve]were included.The clinical response was 79%at 3 mo with more Australian patients achieving clinical response compared to Oxford(83%vs 70%P=0.01).Clinical remission for all patients was 56%,62%and 60%at 3,6 and 12 mo respectively.Anti-TNF naive patients were more likely to achieve remission than exposed patients at all the time points(3 mo 66%vs 40%P<0.001,6 mo 73%vs 46%P<0.001,12 mo 66%vs 51%P=0.03).More Australian patients achieved endoscopic remission at 6 mo compared to Oxford(69%vs 43%P=0.01).On multi-variate analysis,anti-TNF naïve patients were 1.8(95%CI:1.3-2.3)times more likely to achieve remission than anti-TNF exposed(P<0.001).32 patients(11%)had colectomy by 12 mo.CONCLUSION VDZ was safe and effective with 60%of UC patients achieving clinical remission at 12 mo and prior anti-TNF exposure influenced this outcome.

Tranexamic acid for major trauma patients in Ireland

BACKGROUND:The Clinical Randomisation of an Anti-fibrinolytic in Significant Hemorrhage-2(CRASH-2)is the largest randomized control trial(RCT)examining circulatory resuscitation for trauma patients to date and concluded a statistically significant reduction in all-cause mortality in patients administered tranexamic acid(TXA)within 3 hours of injury.Since the publication of CRASH-2,significant geographical variance in the use of TXA for trauma patients exists.This study aims to assess TXA use for major trauma patients with hemorrhagic shock in Ireland after the publication of CRASH-2.METHODS:A retrospective cohort study was conducted using data derived from the Trauma Audit and Research Network(TARN).All injured patients in Ireland between January 2013 and December 2018 who had evidence of hemorrhagic shock on presentation(as defined by systolic blood pressure[SBP]<100 mmHg[1 mmHg=0.133 kPa]and administration of blood products)were eligible for inclusion.Death at hospital discharge was the primary outcome.RESULTS:During the study period,a total of 234 patients met the inclusion criteria.Among injured patients presenting with hemorrhagic shock,133(56.8%;95%confidence interval[CI]50.2%–63.3%)received TXA.Of patients that received TXA,a higher proportion of patients presented with shock index>1(70.68%vs.57.43%)and higher Injury Severity Score(ISS>25;49.62%vs.23.76%).Administration of TXA was not associated with mortality at hospital discharge(odds ratio[OR]0.86,95%CI 0.31–2.38).CONCLUSIONS:Among injured Irish patients presenting with hemorrhagic shock,TXA was administered to 56.8%of patients.Patients administered with TXA were on average more severely injured.However,a mortality benefit could not be demonstrated.

Time spent outdoors and myopia:establishing an evidence base

Myopia is a highly prevalent refractive error in Asia(1).Although mild myopia does not have serious ocular ramifications,pathological myopia is associated with the development of various ocular pathologies that can lead to irreversible visual loss or blindness(2).The prevalence of visual impairment attributable to pathologic myopia is 0.2-1.4% in Asian populations(3).Over the past few generations,the prevalence of myopia has increased significantly(4).In urbanized areas of East

Spectrum of imaging and characteristics for liver tumors treated with irreversible electroporation

Therapeutic irreversible electroporation (IRE) is a relatively new technique for targeted tumor ablation. Needle electrodes are placed into or around the targeted region to deliver a series of brief electric pulses that disrupt cell membrane integrity, killing cells in a non-thermal manner that does not affect the extracellular matrix or sensitive structures such as major vasculature and bile ducts;making IRE an advantageous technique, especially for tumors that are unresectable or ineligible for thermal ablation. Here, we present on the imaging findings from IRE liver tumor treatments from ultrasound, computed tomography, magnetic resonance, and positron emission tomography. Imaging aids planning and implementing treatments by visualizing the targeted volume and guiding electrode placement. Immediate changes to the affected IRE region may be observed to verify complete ablation of the tumor with margin during the procedure, and permits follow-up evaluation of clinical outcome. In particular, we present tumor treatments in regions adjacent to sensitive structures that contraindicate thermal therapies.

Evaluating mechanism and severity of injuries among trauma patients admitted to Sina Hospital,the National Trauma Registry of Iran

Purpose:Injuries are one of the leading causes of death and lead to a high social and financial burden.Injury patterns can vary significantly among different age groups and body regions.This study aimed to evaluate the relationship between mechanism of injury,patient comorbidities and severity of injuries.Methods:The study included trauma patients from July 2016 to June 2018,who were admitted to Sina Hospital,Tehran,Iran.The inclusion criteria were all injured patients who had at least one of the following:hospital length of stay more than 24 h,death in hospital,and transfer from the intensive care unit of another hospital.Data collection was performed using the National Trauma Registry of Iran minimum dataset.Results:The most common injury mechanism was road traffic injuries(49.0%),followed by falls(25.5%).The mean age of those who fell was significantly higher in comparison with other mechanisms(p<0.001).Severe extremity injuries occurred more often in the fall group than in the vehicle collision group(69.0%vs.43.5%,p<0.001).Moreover,cases of severe multiple trauma were higher amongst vehicle collisions than injuries caused by falls(27.8%vs.12.9%,p=0.003).Conclusion:Comparing falls with motor vehicle collisions,patients who fell were older and sustained more extremity injuries.Patients injured by motor vehicle collision were more likely to have sustained multiple trauma than those presenting with falls.Recognition of the relationship between mechanisms and consequences of injuries may lead to more effective interventions.

Anaphylaxis to Skin Prick Testing in a 29-Year-Old Woman

Introduction: Skin prick testing (SPT) is a common test to diagnose IgE sensitization and the rate of adverse reactions is very low. Case Presentation: 29-year-old woman with anaphylactic reaction to routine SPT with 11 allergens (aero and food). Discussion: Allergy profile included multiple food and inhalant allergies, polysensitization, prior episode of anaphylaxis to mushrooms, active eczema and active hay fever but not active asthma. Conclusion: Anaphylaxis to SPT, although a rare event, is unpredictable necessitating availability of appropriate personnel and adequate resuscitation facilities for all testing.

Pooled Plasmid Sequencing Reveals the Relationship Between Mobile Genetic Elements and Antimicrobial Resistance Genes in Clinically Isolated Klebsiella pneumoniae

Plasmids remain important microbial components mediating the horizontal gene transfer(HGT)and dissemination of antimicrobial resistance.To systematically explore the relationship between mobile genetic elements(MGEs)and antimicrobial resistance genes(ARGs),a novel strategy using single-molecule real-time(SMRT)sequencing was developed.This approach was applied to pooled conjugative plasmids from clinically isolated multidrug-resistant(MDR)Klebsiella pneumoniae from a tertiary referral hospital over a 9-month period.The conjugative plasmid pool was obtained from transconjugants that acquired antimicrobial resistance after plasmid conjugation with 53 clinical isolates.The plasmid pool was then subjected to SMRT sequencing,and 82 assembled plasmid fragments were obtained.In total,124 ARGs(responsible for resistance to b-lactam,fluoroquinolone,and aminoglycoside,among others)and 317 MGEs[including transposons(Tns),insertion sequences(ISs),and integrons]were derived from these fragments.Most of these ARGs were linked to MGEs,allowing for the establishment of a relationship network between MGEs and/or ARGs that can be used to describe the dissemination of resistance by mobile elements.Key elements involved in resistance transposition were identified,including IS26,Tn3,IS903 B,ISEcp1,and ISKpn19.As the most predominant IS in the network,a typical IS26-mediated multi-copy composite transposition event was illustrated by tracing its flanking 8-bp target site duplications(TSDs).The landscape of the pooled plasmid sequences highlights the diversity and complexity of the relationship between MGEs and ARGs,underpinning the clinical value of dominant HGT profiles.