Characterization of Potential Pathogenic Bacteria Isolated in High-Risk Infectious Services at the University Hospital Center of Suru-Léréin Benin

Healthcare-associated infections (HCAIs) remain a major public health concern. The aim of this study was to characterize potential pathogenic bacteria isolated in high-risk infectious services at the University Hospital Center of Suru-Léré in Benin. A cross-sectional, descriptive study was carried out on 215 samples with 8 air samples, 20 hand samples and 187 samples of medical-technical material. Genes for resistance to β-lactam antibiotics (blaTEM, blaSHV, blaCTX-M and blaOXA-1) were sought. The data were processed and analyzed using EPI Info version 3.5.4 software. A total of 10 bacterial species were identified. Of the 319 bacterial strains identified, Staphylococcus saprophyticus, Staphylococcus aureus and Enterococcus faecalis were predominant at 20.06%, 17.87% and 11.28% respectively. Antibiotic susceptibility showed that the majority of bacterial strains were multidrug-resistant. Of the 4 resistance genes sought, only the blaTEM and blaSHV genes were found. The poor microbiological quality observed in high-risk infectious services could be a risk factor for healthcare-associated infections. It is therefore useful to implement preventive measures in order to prevent or reduce the risk of healthcare-associated infections.

Risk Factors for Surgical Site Infections in Patients Operated at the University Clinic of Traumatology-Orthopedics and Restorative Surgery of the National Hospital and University Center Hubert Koutoukou Maga in Cotonou

Background: Operative site infections (ISO) are typically nosocomial. According to the WHO the incidence of ISO varies from 0.5% to 15% and exceeds 25% in developing countries. They result from the combined action of several factors and represent a concern for public health. To study the contributing factors of surgical site infections in patients operated at the University Clinic of Orthopedic Traumatology of CNHU-HKM of Cotonou. Method: This was an analytical cross-sectional study that involved 35 operated patients and ten nurses. Were included in our study: 1) All patients, without distinction of sex or age, having been operated on in the university clinic of orthopedic traumatology, during the survey period;2) Patients hospitalized for post-operative care during the survey period;3) The nursing staff on duty during our study period. The usual statistical measures were used according to the type of variables: means, standard deviations, percentages. Data analysis first involved calculating percentages for the qualitative variables and means followed by their standard deviations for the quantitative variables. Next, the Pearson Chi-square test was used to test the association between the dependent variable and the independent variables of interest. The significance level is set at p Results: The prevalence of surgical site infections was 28.58%. The main factors contributing to the occurrence of SSIs that were found were the patient’s level of education (p = 0.003) and the reuse of bandages used for dressing (p = 0.004). Other potential factors such as the economic status of the patient, the poor quality of technical dressings, and the preoperative stay were also highlighted. Conclusion: Surgical site infections remain a global concern. Risk factors were found on both the patient and nurse sides. It is urgent to address these various factors to minimize the occurrence of surgical site infections.

Characterization of Four University Hospitals Wastewater in Cotonou, Benin

Introduction: Because of the specificity of their care activities, hospital wastewater contains various contaminants such as germs, disinfectants, metals, pharmaceuticals and chemical reagents, potentially infectious or toxic, which can be harmful to living organisms, or create ecological damage. This study aimed to analyze the quality of wastewaters produced by university hospitals of Cotonou in Benin. Methods: We conduct an analytical cross-sectional study including 30 wastewater samples from selected hospitals. An analysis of variance was performed at the significance level of 0.05. Results: Microbiological analysis showed the presence of germs such as total coliform types, faecal coliforms, fecal streptococcus, staphylococcus, yeasts and Clostridium perfringens in hospital wastewater samples. There was a significant difference (p < 0.05) in the microbial loads of various germs, except staphylococcus, between hospitals. With regard to the physicochemical parameters, only the conductivity complied with the standards for the discharge of wastewater into the environment. A significant difference was noted between hospitals, for the electrical conductivity of wastewater (p < 0.05). The average levels of metals detected in the wastewaters were in line with Benin’s standards. There was no difference between the average concentrations of metals except for copper (p < 0.05). Conclusion: The wastewater produced by the university hospitals of Cotonou is of poor quality and therefore requires adequate prior treatment before discharge into the environment.

Impact of concomitant use of proton pump inhibitors and clopidogrel or ticagrelor on clinical outcomes in patients with acute coronary syndrome

Background There is great debate on the possible adverse interaction between proton pump inhibitors （PPIs） and clopidogrel. In ad- dition, whether the use of PPIs affects the clinical efficacy of ticagrelor remains less known. We aimed to determine the impact of concomi- tant administration of PPIs and clopidogrel or ticagrelor on clinical outcomes in patients with acute coronary syndrome （ACS） after percuta- neous coronary intervention （PCI）. Methods We retrospectively analyzed data fi＇om a ＂real world＂, international, multi-center registry between 2003 and 2014 （n = 15,401） and assessed the impact of concomitant administration of PPIs and clopidogrel or ticagrelor on 1-year composite primary endpoint （all-cause death, re-infarction, or severe bleeding） in patients with ACS after PCI. Results Of 9429 patients in the final cohort, 54.8% （n = 5165） was prescribed a PPI at discharge. Patients receiving a PPI were older, more often female, and were more likely to have comorbidities. No association was observed between PPI use and the primary endpoint for patients receiving clopidogrel （ad- justed HR： 1.036; 95% CI： 0.903-1.189） or ticagrelor （adjusted HR： 2.320; 95% CI： 0.875-45.151） （Pinteraction = 0.2004）. Similarly, use of a PPI was not associated with increased risk of all-cause death, re-infarction, or a decreased risk of severe bleeding for patients treated with either clopidogrel or ticagrelor. Conclusions In patients with ACS following PCI, concomitant use of PPIs was not associated with in- creased risk of adverse outcomes in patients receiving either clopidogrel or ticagrelor. Our findings indicate it is reasonable to use a PPI in combination with clopidogrel or ticagrelor, especially in patients with a higher risk of gastrointestinal bleeding.

PD-L1 expression and its effect on clinical outcomes of EGFRmutant NSCLC patients treated with EGFR-TKIs

Objective:Epidermal growth factor receptor(EGFR)activation was reported to upregulate programmed death-ligand 1(PD-L1)expression in lung cancer cells and subsequently contribute to immune escape,indicating its critical role in EGFR-driven lung tumors.This study characterized PD-L1 expression in patients with surgically resected EGFR-mutant non-small cell lung cancer(NSCLC).The effect of PD-L1 expression on clinical outcomes was also investigated in advanced EGFR-mutant NSCLC treated with EGFR-tyrosine kinase inhibitors(TKIs).Methods:In total,73 patients with surgically resected NSCLC and EGFR mutations were identified.PD-L1 expression and CD8+tumor-infiltrating lymphocyte(TIL)density were assessed by immunohistochemistry.A literature review of publications that assessed the predictive and prognostic value of PD-L1 expression in advanced EGFR-mutant NSCLC patients treated with EGFR-TKIs was performed.Results:Nineteen(26.0%)patients were positive for PD-L1 expression,which was significantly associated with concomitant KRAS mutation(P=0.020)and marginally associated with higher CD8+TILs density(P=0.056).Positive PD-L1 expression was associated with markedly inferior overall survival(OS)in multivariate analysis(P=0.032).The combination of PD-L1 and CD8+TILs expression could be used to stratify the population into three groups with distinct prognoses.A meta-analysis of six publications showed that positive PD-L1 expression was not associated with OS[hazard ratio(HR)=0.90;95%confidence interval(CI),0.42–1.38]or progression-free survival(HR=1.03;95 CI,0.73–1.33)in advanced EGFR-mutant NSCLC patients receiving EGFR-TKIs.Conclusions:PD-L1 expression tended to correlate with CD8+TIL expression,concomitant KRAS mutation,and poor survival in surgically resected EGFR-mutant NSCLC.PD-L1 expression was neither the predictive nor the prognostic factor in advanced EGFR-mutant NSCLC patients treated with EGFR-TKIs.

Clinical outcome in patients with hilar malignant strictures type Ⅱ Bismuth-Corlette treated by minimally invasive unilateral versus bilateral endoscopic biliary drainage

BACKGROUND:Stenting of malignant hilar strictures remains a standard endoscopic treatment in patients with unresectable tumors.The aim of this two-center prospective study was to compare unilateral versus bilateral drainage in hilar malignant stenosis Bismuth-Corlette type II.METHODS:During a 3-year period,a total of 49 patients with hilar tumors(Bismuth-Corlette type II) were referred for endoscopic treatment,following the criteria of unresectability.Ultrasound,computed tomography scan and magnetic resonance cholangiopancreatography(MRCP) were previously performed in all patients in order to facilitate endoscopic retrograde cholangiopancreatography(ERCP).The stricture was first passed by the hydrophilic guide-wire and then contrast medium was injected.Mechanical bile duct dilation was performed,followed by plastic stent placement only in the liver lobe which was previously opacified.The procedures were performed under conscious sedation.The patients were followed up for the next 12 months with a stent exchange every 3 months.Primary outcome was assessed by patient survival in the first 12 months after the procedure.RESULTS:All 49 patients were treated with ERCP while 39(79.59%) had successful stent placement.Among these,32 had hilar cholangiocarcinoma(82%) and 7(18%) had gallbladder cancer.Two groups of patients had Bismuth II strictures:A,21 patients(54%) with unilateral contrast injection and drainage,and B,18(46%) with bilateral contrast injection and drainage.A total of 57 plastic stents were used(10 Fr,89%;11.5 Fr,11%).Group B showed a lower bilirubin level 7 days after the procedure(P=0.008).Early complications were cholangitis(3 patients,2 in group A and 1 in group B) and acute pancreatitis(2 patients,1 each in A and B) with no statistical difference between the groups.Late complications were stent migration(5 patients,1 in A and 4 in B) and stent clogging(6 patients,2 in A and 4 in B) showing a significant difference between the groups(P<0.01).The first stent replacement after 3 months was successful in 87% of patients(four died due to disease progression and one due to cardiopulmonary insufficiency) showing no statistical difference between the groups.At 6 months follow-up,72% patients survived,with no statistical difference between the groups.A final follow-up(12 months) showed the survival rate of 18%(4 patients from group A and 3 from group B)(P>0.05).CONCLUSIONS:A minimally invasive approach,based on the criterion that every bile duct being opacified needs to be drained,is associated with a lower incidence of early complications.Considering that the clinical outcome measured by bilirubin level was lower in patients with bilateral drainage 7 days after the procedure,we assumed that drainage of 50% or more of the liver volume leads to sufficient drainage effectiveness.

Effectiveness and safety of first-generation protease inhibitors in clinical practice:Hepatitis C virus patients with advanced fibrosis

AIM:To evaluates the effectiveness and safety of the first generation,NS3/4A protease inhibitors(PIs) in clinical practice against chronic C virus,especially in patients with advanced fibrosis. METHODS:Prospective study and non-experimental analysis of a multicentre cohort of 38 Spanish hospitals that includes patients with chronic hepatitis C genotype 1,treatment-na?ve(TN) or treatment-experienced(TE),who underwent triple therapy with the first generation NS3/4A protease inhibitors,boceprevir(BOC) and telaprevir(TVR),in combination with pegylated interferon and ribavirin. The patients were treatment in routine practice settings. Data on the study population and on adverse clinical and virologic effects were compiled during the treatment period and during follow up.RESULTS:One thousand and fifty seven patients were included,405(38%) were treated with BOC and 652(62%) with TVR. Of this total,30%(n = 319) were TN and the remaining were TE:28%(n = 298) relapsers,12%(n = 123) partial responders(PR),25%(n = 260) null-responders(NR) and for 5%(n = 57) with prior response unknown. The rate of sustained virologic response(SVR) by intention-to-treatment(ITT) was greater in those treated with TVR(65%) than in those treated with BOC(52%)(P < 0.0001),whereas by modified intention-to-treatment(m ITT) no were found significant differences. By degree of fibrosis,56% of patients were F4 and the highest SVR rates were recorded in the non-F4 patients,both TN and TE. In the analysis by groups,the TN patients treated with TVR by ITT showed a higher SVR(P = 0.005). However,by m ITT there were no significant differences between BOC and TVR. In the multivariate analysis by m ITT,the significant SVR factors were relapsers,IL28 B CC and non-F4; the type of treatment(BOC or TVR) was not significant. The lowest SVR values were presented by the F4-NR patients,treated with BOC(46%) or with TVR(45%). 28% of the patients interrupted the treatment,mainly by non-viral response(51%):this outcome was more frequent in the TE than in the TN patients(57% vs 40%,P = 0.01). With respect to severe haematological disorders,neutropaenia was more likely to affect the patients treated with BOC(33% vs 20%,P ≤ 0.0001),and thrombocytopaenia and anaemia,the F4 patients(P = 0.000,P = 0.025,respectively). CONCLUSION:In a real clinical practice setting with a high proportion of patients with advanced fibrosis,effectiveness of first-generation PIs was high except for NR patients,with similar SVR rates being achieved by BOC and TVR.

Delayed postpancreatectomy hemorrhage as the role of endovascular approach:Four case reports

BACKGROUND Pancreatic resection is still associated with high morbidity rates and delayed postpancreatectomy hemorrhage(PPH)is the most feared complication as it may lead to hemorrhagic shock or serious septic complications.Today,endovascular approach represent safe and efficient method for minimally invasive management of extraluminal PPH.CASE SUMMARY We describe four patients whose postoperative recovery after pancreatic resection was complicated by postoperative pancreatic fistula(POPF)and visceral artery hemorrhage.In all cases endovascular approach was utilized and it resulted in satisfactory outcomes.We discuss modern diagnostic and therapeutic approach in this clinical scenario.CONCLUSION PPH is relatively uncommon,but it is a leading cause of surgical mortality after pancreatic surgery.Careful monitoring and meticulous follow-up are required for all patients post-operatively,especially in the case of confirmed POPF,which is the most significant risk factor for the development of a PPH.Angiography as a diagnostic and therapeutic method may be an optimal first-line treatment for the management of delayed PPHs.In our experience,endovascular treatment for hemorrhagic complications of pancreatic resections has shown satisfactory results.

Constipation and colonoscopy

Constipation is a significant sociomedical problem,which can be caused by various reasons.In the diagnostic approach to patients with constipation,the following data are usually sufficient:History,complete physical examination(including rectal examination),and additional diagnostic tests.A colonoscopy is not a necessary diagnostic method for all patients with constipation.However,if patients have alarm symptoms/signs,that suggest an organic reason for constipation,a colonoscopy is necessary.The most important alarm symptoms/signs are age>50 years,gastrointestinal bleeding,new-onset constipation,a palpable mass in the abdomen and rectum,weight loss,anemia,inflammatory bowel disease,and family history positive for colorectal cancer.Most endoscopists do not like to deal with patients with constipation.There are two reasons for this,namely the difficulty of endoscopy and the adequacy of preparation.Both are adversely affected by constipation.To improve the quality of colonoscopy in these patients,good examination techniques and often more extensive preparation are necessary.Good colonoscopy technique implies adequate psychological preparation of the patient,careful insertion of the endoscope with minimal insufflation,and early detection and resolution of loops.Bowel preparation for colonoscopy often requires prolonged preparation and sometimes the addition of other laxatives.

Interactivity software tools for teaching in ophthalmology

The use of interactive audience software,such as audience response systems(ARS),in medical education has become increasingly popular in recent years.This technology allows instructors to engage students in real time,encouraging active participation and promoting effective learning.The benefits of interactive audience software in medical education include increased student engagement,promotion of active learning,and enhanced learning outcomes.However,there are also several challenges to its implementation,including technical difficulties,careful planning and preparation,over-reliance on technology,and ethical concerns related to privacy and data security.The cost of implementing interactive audience software may also be a barrier for some institutions.This paper specifically reviews six interactive software platforms,including Socrative,Quizizz,Pear Deck,Slido,Wooclap and ClassPoint.These platforms allow for real-time assessment of student understanding,feedback,and participation.They also enable instructors to adjust their teaching strategies based on student responses and feedback.Overall,interactive audience software has shown great potential to enhance learning and engagement in medical education.It is important for instructors to carefully consider the benefits and challenges of its implementation.While the cost of implementing interactive audience software may be a barrier for some institutions,there are free and low-cost options available.

Could near focus endoscopy,narrow-band imaging,and acetic acid improve the visualization of microscopic features of stomach mucosa?

BACKGROUND Conventional magnifying endoscopy with narrow-band imaging(NBI)observation of the gastric body mucosa shows dominant patterns in relation to the regular arrangement of collecting venules,subepithelial capillary network,and gastric pits.AIM To evaluate the effectiveness of a new one-dual(near)focus,NBI mode in the assessment of the microscopic features of gastric body mucosa compared to conventional magnification.METHODS During 2021 and 2022,68 patients underwent proximal gastrointestinal endoscopy using magnification endoscopic modalities subsequently applying acetic acid(AA).The GIF-190HQ series NBI system with dual focus capability was used for the investigation of gastric mucosa.At the time of the endoscopy,the gastric body mucosa of all enrolled patients was photographed using the white light endoscopy(WLE),near focus(NF),NF-NBI,AA-NF,and AA-NF-NBI modes.RESULTS The WLE,NF and NF-NBI endoscopic modes for all patients(204 images)were classified in the same order into three groups.Two images from each patient for the AA-NF and AA-NF-NBI endoscopic modes were classified in the same order.According to all three observers who completed the work independently,NF magnification was significantly superior to WLE(P<0.01),and the NF-NBI mode was significantly superior to NF magnification(P<0.01).After applying AA,the three observers confirmed that AA-NF-NBI was significantly superior to AA-NF(P<0.01).Interobserver kappa values for WLE were 0.609,0.704,and 0.598,respectively and were 0.600,0.721,and 0.637,respectively,for NF magnification.For the NF-NBI mode,the values were 0.378,0.471,and 0.553,respectively.For AA-NF,they were 0.453,0.603,and 0.480,respectively,and for AA-NF-NBI,they were 0.643,0.506,and 0.354,respectively.CONCLUSION When investigating gastric mucosa in microscopic detail,NF-NBI was the most powerful endoscopic mode for assessing regular arrangement of collecting venules,subepithelial capillary network,and gastric pits among the five endoscopic modalities investigated in this study.AA-NF-NBI was the most powerful endoscopic mode for analyzing crypt opening and intervening part.

Present situation of minimally invasive surgical treatment for early gastric cancer

Minimally invasive surgery is a kind of surgical operation,which is performed by using professional surgical instruments and equipment to inactivate,resect,repair or reconstruct the pathological changes,deformities and wounds in human body through micro-trauma or micro-approach,in order to achieve the goal of treatment,its surgical effect is equivalent to the traditional open surgery,while avoiding the morbidity of conventional surgical wounds.In addition,it also has the advantages of less trauma,less blood loss during operation,less psychological burden and quick recovery on patients,and these minimally invasive techniques provide unique value for the examination and treatment of gastric cancer patients.Surgical minimally invasive surgical techniques have developed rapidly and offer numerous options for the treatment of early gastric cancer(EGC):endoscopic mucosal resection(EMR),underwater EMR(UEMR),endoscopic submucosal dissection(ESD),endoscopic full-thickness resection(EFTR),endoscopic submu-cosal excavation(ESE),submucosal tunnel endoscopic resection,laparoscopic and endoscopic cooperative surgery(LECS);Among them,EMR,EFTR and LECS technologies have a wide range of applications and different modific-ations have been derived from their respective surgical operations,such as band-assisted EMR(BA-EMR),conven-tional EMR(CEMR),over-the-scope clip-assisted EFTR,no-touch EFTR,the inverted LECS,closed LECS,and so on.These new and improved minimally invasive surgeries are more precise,specific and effective in treating different types of EGC.

Prospective study of hepatitis B and D epidemiology and risk factors in Romania:A 10-year update

BACKGROUND The global burden of hepatitis D virus(HDV)infection represents a major medical challenge and a public health crisis worldwide.However,there is a lack of accurate data on the epidemiology and risk factors for HDV.Hepatitis B virus(HBV)and HDV coinfection causes the most severe form of viral hepatitis,leading to a higher cumulative incidence of liver-related events compared with HBV monoinfection,including the need for liver transplantation and death.AIM To investigate the epidemiology,natural history,risk factors and clinical management of HBV and HDV coinfection in Romanian patients.METHODS This prospective study was conducted between January and July 2022 in six tertiary gastroenterology and hepatology referral centres in Romania.All consecutive adults admitted for any gastroenterology diagnosis who were HBV-positive were enrolled.Patients with acute hepatitis or incomplete data were excluded.Of the 25390 individuals who presented with any type of gastroenterology diagnosis during the study period,963 met the inclusion criteria.Testing for anti-HDV antibodies and HDV RNA was performed for all participants.Demographic and risk factor data were collected by investigators using medical charts and patient questionnaires.All data were stored in an anonymized online database during the study.RESULTS The prevalence of HBV was 3.8%;among these patients,the prevalence of HBV/HDV coinfection was 33.1%.The median age of the study population was 54.0 years,and it consisted of 55.1%men.A higher prevalence of HBV/HDV coinfection was observed in patients 50–69 years old.Patients with HBV/HDV coinfection were significantly older than those with HBV monoinfection(P=0.03).Multivariate multiple regression analysis identified female gender(P=0.0006),imprisonment(P<0.0001),older age at diagnosis(P=0.01)and sexual contact with persons with known viral hepatitis(P=0.0003)as significant risk factors for HDV.CONCLUSION This study shows that HDV infection among those with HBV remains endemic in Romania and updates our understanding of HDV epidemiology and associated risk factors.It emphasizes the need for systematic screening for HDV infection and collaborative initiatives for controlling and preventing HBV and HDV infection.

Factors predicting poor prognosis in ischemic colitis

AIM： To determine the clinical, analytical and endoscopic factors related to ischemic colitis （IC） severity. METHODS： A total of 85 patients were enrolled in a retrospective study from January 1996 to May 2004. There were 53 females and 32 males （age 74.6 ± 9.4 years, range 45-89 years）. The patients were diagnosed as IC. The following variables were analyzed including age, sex, period of time from the appearance of symptoms to admission, medical history, medication, stool frequency, clinical symptoms and signs, blood tests （hemogram and basic biochemical profile）, and endoscopic findings. Patients were divided in mild IC group and severe IC group （surgery and/or death）. Qualitative variables were analyzed using chi-square test and parametric data were analyzed using Student＇s t test （P 〈 0.05）. RESULTS： The mild IC group was consisted of 69 patients （42 females and 27 males, average age 74.7 ± 12.4 years）. The severe IC group was composed of 16 patients （11 females and 5 males, average age of 73.8 ± 12.4 years）. One patient died because of failure of medical treatment （no surgery）, 15 patients underwent surgery （6 after endoscopic diagnosis and 9 after peroperatory diagnosis）. Eight of 85 patients （9.6%） died and the others were followed up as out-patients for 9.6 ± 3.5 mo. Demographic data, medical history, medication and stool frequency were similar in both groups （P 〉 0.05）. Seriously ill patients had less hematochezia than slightly ill patients （37.5% vs 86.9%, P = 0.000）. More tachycardia （45.4% vs 10.1%, P = 0.011） and a higher prevalence of peritonism signs （75% vs 5.7%, P = 0.000） were observed in the severe IC group while the presence and intensity of abdominal pain were similar between two groups. Two patients with severe IC had shock when admitted. Regarding analytical data, more seriously ill patients were found to have anemia and hyponatremia than the mildly ill patients （37.5% vs 10.1%, P = 0.014 and 46.6% vs 14.9%, P = 0.012, respectively）. Stenosis was the only endoscopic finding that appeared more frequently in seriously ill patients than in slightly ill patients （66.6% vs 17.3%, P = 0.017）. CONCLUSION： The factors that can predict poor prognosis of IC are the absence of hematochezia, tachycardia and peritonism, anemia and hyponatremia and stenosis.

Colorectal cancer population screening programs worldwide in 2016: An update

Colorectal cancer(CRC)is the third most commonly diagnosed cancer in the world.The incidence and mortality show wide geographical variations.Screening is recommended to reduce both incidence and mortality.However,there are significant differences among studies in implementation strategies and detection.This review aimed to present the results and strategies of different screening programs worldwide.We reviewed the literature on national and international screening programs published in Pub Med,on web pages,and in clinical guidelines.CRC Screening programs are currently underway in most European countries,Canada,specific regions in North and South America,Asia,and Oceania.The most extensive screening strategies were based on fecal occult blood testing,and more recently,the fecal immunochemical test(FIT).Participation in screening has varied greatly among different programs.The Netherlands showed the highest participation rate(68.2%)and some areas of Canada showed the lowest(16%).Participation rates were highest among women and in programs that used the FIT test.Men exhibited the greatest number of positive results.The FIT test has been the most widely used screening program worldwide.The advent of this test has increased participation rates and the detection of positive results.

Protons pump inhibitor treatment and lower gastrointestinal bleeding: Balancing risks and benefits

Proton pump inhibitors(PPIs) represent a milestone in the treatment of acid-related diseases, and are the mainstay in preventing upper gastrointestinal bleeding in high-risk patients treated with nonsteroidal antiinflammatory drugs(NSAIDs) or low-dose aspirin. However, this beneficial effect does not extend to the lower gastrointestinal tract. PPIs do not prevent NSAID or aspirin-associated lower gastrointestinal bleeding(LGB). PPIs may increase both small bowel injury related to NSAIDs and low-dose aspirin treatment and the risk of LGB. Recent studies suggested that altering intestinal microbiota by PPIs may be involved in the pathogenesis of NSAID-enteropathy. An increase in LGB hospitalization rates may occur more frequently in older patients with more comorbidities and are associated with high hospital resource utilization, longer hospitalization, and increased mortality. Preventive strategies for NSAID and aspirin-associated gastrointestinal bleeding should be directed toward preventing both upper and lower gastrointestinal damage. Future research should be directed toward identifying patients at low-risk for gastrointestinal events associated with the use of NSAIDs or aspirin to avoid inappropriate PPI prescribing. Alternatively, the efficacy of new pharmacologic strategies should be evaluated in high-risk groups, with the aim of reducing the risk of both upper and lower gastrointestinal bleeding in these patients.

Endothelial progenitor cells as a therapeutic option in intracerebral hemorrhage

Intracerebral hemorrhage （ICH） is the most severe cerebrovascular disease, which represents a leading cause of death and disability in developed countries. However, therapeutic options are limited, so is mandatory to investigate repairing processes after stroke in order to develop new therapeutic strategies able to promote brain repair processes. Therapeutic angiogenesis and vasculogenesis hold promise to improve outcome of ICH patients. In this regard, circulating endothelial progenitor cells （EPCs） have recently been suggested to be a marker of vascular risk and endothelial function. Moreover, EPC levels have been associated with good neurological and functional outcome as well as reduced residual hematoma volume in ICH patients. Finally, experimental and clinical studies indicate that EPC might mediate endothelial cell regeneration and neovascularization. Therefore, EPC-based therapy could be an excellent therapeutic option in ICH. In this mini-review, we discuss the present status of knowledge about the possible therapeutic role of EPCs in ICH, molecular mechanisms, and the future perspectives and strategies for their use in clinical practice.

Obstructive shock secondary to fungal prosthetic aortic valve endocarditis

Dear editor,Fungal endocarditis is a rare disease with a poor prognosis,suboptimal diagnostic tools responsible for long diagnostic delays in most cases,and poorly defined activity of most antifungal agents in endocarditis.^([1])The burden of diagnosis still lies with clinicians:they need a

Elevated intra-abdominal pressure:A review of current knowledge

Elevated intra-abdominal pressure(IAP)is a known cause of increased morbidity and mortality among critically ill patients.Intra-abdominal hypertension(IAH)and abdominal compartment syndrome can lead to rapid deterioration of organ function and the development of multiple organ failure.Raised IAP affects every system and main organ in the human body.Even marginally sustained IAH results in malperfusion and may disrupt the process of recovery.Yet,despite being so common,this potentially lethal condition often goes unnoticed.In 2004,the World Society of the Abdominal Compartment Syndrome,an international multidisciplinary consensus group,was formed to provide unified definitions,improve understanding and promote research in this field.Simple,reliable and nearly costless standardized methods of non-invasive measurement and monitoring of bladder pressure allow early recognition of IAH and timely optimized management.The correct,structured approach to treatment can have a striking effect and fully restore homeostasis.In recent years,significant progress has been made in this area with the contribution of surgeons,internal medicine specialists and anesthesiologists.Our review focuses on recent advances in order to present the complex underlying pathophysiology and guidelines concerning diagnosis,monitoring and treatment of this life-threatening condition.

Impact of triple antithrombotic therapy in patients with acute coronary syndrome undergoing percutaneous coronary intervention in real-world practice

Objective The optimal antithrombotic regimen for patients on oral anticoagulation （OAC） after acute coronary syndrome （ACS） and percutaneous coronary intervention （PCI） remains debated. This study sought to evaluate the efficacy and safety of OAC plus clopidogrel with or without aspirin in a real-world setting. Methods We retrospectively analyzed data from an international, multi-center registry be- tween 2003 and 2014 （n = 15,401）. Patients with ACS and receiving OAC after PCI were screened. The composite primary endpoint was 1-year all-cause death, re-infarction, or severe bleeding. Results The final analysis enrolled 642 patients including 62 patients （9.7%） with OAC and clopidogrel （dual therapy）, and 580 patients （90.3%） with the combination of aspirin, OAC and clopidogrel （triple therapy）. Pa- tients on triple therapy were more often female and were more likely to have comorbidities. There was no significant difference regarding the primary end point between dual therapy with triple therapy patients [17.74% vs. 17.24%; unadjusted hazard ratio （HR）： 1.035; 95% confi- dence interval （CI）： 0.556-1.929; adjusted HR： 1.026; 95% CI： 0.544-1.937]. However, the re-infarction rate was significantly higher in dual therapy than triple therapy patients （14.52% vs. 5.34%; unadjusted HR： 2.807; 95% CI： 1.329-5.928; adjusted HR： 2.333; 95% CI： 1.078-5.047）. In addition, there was no difference between two regimes in all-cause death and severe bleeding. Conclusions In real-life patients with ACS following PCI and with an indication of OAC, triple therapy was not associated with an increased rate of adverse out- comes compared to dual therapy. Moreover, it decreased risk of re-infarction and did not increase risk of severe bleeding.