Effects of anti-thrombotic drugs on all-cause mortality after upper gastrointestinal bleeding in Japan: A multicenter study with 2205 cases.

OBJECTS: Although anti-thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti-thrombotic agents on in-hospital mortality following UGIB. METHODS: Information on clinical parameters, including usage of anti-thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high-volume centers in Japan between 2011 and 2018. The all-cause in-hospital mortality rate was evaluated according to the usage of anti-thrombotic agents. RESULTS: Clinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty-five (29.3%) patients used anti-thrombotic agents. The all-cause in-hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end-stage malignancy, 96 deaths (bleeding-related, n = 22 ; non-bleeding-related, n = 74) were considered "preventable." Overall, the "preventable" mortality rate in anti-thrombotic users was significantly higher than that in non-users (6.0% vs. 3.7%, P < 0.05). However, the "preventable" mortality of anti-thrombotic users showed a marked improvement over time; although the rate in users remained significantly higher than that in non-users until 2015 (7.3% vs. 4.2%, P < 0.05), after 2016, the difference was no longer statistically significant (4.8% vs. 3.5%). CONCLUSIONS: Although the usage of anti-thrombotic agents worsened the outcomes after UGIB, the situation has recently been improving. We speculate that the recent revision of the Japanese guidelines on the management of anti-thrombotic treatment after UGIB may have partly contributed to improving the survival of users of anti-thrombotic agents.

Nature and treatment outcomes of bleeding post-bulbar duodenal ulcers.

BACKGROUND: Although post-bulbar duodenal ulcers (PBDUs) could become a source of upper gastrointestinal bleeding, the whole picture of the disease is unknown. We compared the characteristic features and treatment outcomes after endoscopic hemostasis between PBDUs and bulbar duodenal ulcers (BDUs). METHODS: Data on duodenal ulcers with evidence of endoscopically-active bleeding were extracted from the data that were retrospectively collected from 12 institutes in Japan between 2011 and 2018. Rebleeding and in-hospital mortality were compared between patients with PBDUs and those with BDUs by logistic regression analyses. RESULTS: Among 468 consecutive patients with bleeding duodenal ulcers, 96 (20.5%) had endoscopically-confirmed PBDUs. PBDUs were more frequently observed in patients with a poor general condition in comparison to BDUs. The rates of rebleeding and in-hospital mortality in patients with PBDUs were approximately three times higher than those in patients with BDUs (PBDU vs. BDU: 29.2% vs. 10.2% [P < 0.0001] and 14.6% vs. 5.1% [P = 0.0029], respectively). Although the high in-hospital mortality in PBDUs could be explained, to a lesser extent, by the likelihood of rebleeding, and, to a greater extent, by the patients' poor general condition, the presence of a PBDU itself was largely responsible for the high rebleeding rates in PBDUs. CONCLUSION: This is the first study focusing on the nature and treatment outcomes of bleeding PBDUs. PBDUs were associated with much higher rebleeding and mortality rates in comparison to BDUs, and the likelihood of rebleeding may be derived from their unique anatomic location.

Multiferroic Dislocations in Ferroelectric PbTiO3.

Ultrathin multiferroics with coupled ferroelectric and ferromagnetic order parameters hold promise for novel technological paradigms, such as extremely thin magnetoelectric memories. However, these ferroic orders and their functions inevitably disappear below a fundamental size limit of several nanometers. Herein, we propose a novel design strategy for nanoscale multiferroics smaller than the critical size limit by engineering the dislocations in nonmagnetic ferroelectrics, even though these lattice defects are generally believed to be detrimental. First-principles calculations demonstrate that Ti-rich PbTiO3 dislocations exhibit magnetism due to the local nonstoichiometry intrinsic to the core structures. Highly localized spin moments in conjunction with the host ferroelectricity enable these dislocations to function as atomic-scale multiferroic channels with a pronounced magnetoelectric effect that are associated with the antiferromagnetic-ferromagnetic-nonmagnetic phase transitions in response to polarization switching. The present results thus suggest a new field of dislocation (or defect) engineering for the fabrication of ultrathin magnetoelectric multiferroics and ultrahigh density electronic devices.

Multiferroic Domain Walls in Ferroelectric PbTiO3 with Oxygen Deficiency.

Atomically thin multiferroics with the coexistence and cross-coupling of ferroelectric and (anti)ferromagnetic order parameters are promising for novel magnetoelectric nanodevices. However, such ferroic order disappears at a critical thickness in nanoscale. Here, we show a potential path toward ultrathin multiferroics by engineering an unusual domain wall (DW)-oxygen vacancy interaction in nonmagnetic ferroelectric PbTiO3. We demonstrate from first-principles that oxygen vacancies formed at the DW unexpectedly bring about magnetism with a localized spin moment around the vacancy. This magnetism originates from the orbital symmetry breaking of the defect electronic state due to local crystal symmetry breaking at the DW. Moreover, the energetics of defects shows the self-organization feature of oxygen vacancies at the DW, resulting in a planar-arrayed concentration of magnetic oxygen vacancies, which consequently changes the deficient DWs into multiferroic atomic layers. This DW-vacancy engineering opens up a new possibility for novel ultrathin multiferroic.

Multiferroic Vacancies at Ferroelectric PbTiO(3) Surfaces.

Multiferroics in nanoscale dimensions are promising for novel functional device paradigms, such as magnetoelectric memories, due to an intriguing cross-coupling between coexisting ferroelectric and (anti)ferromagnetic order parameters. However, the ferroic order is inevitably destroyed below the critical dimension of several nanometers. Here, we demonstrate a new path towards atomic-size multiferroics while resolving the controversial origin of dilute ferromagnetism that unexpectedly emerges in nanoparticles of nonmagnetic ferroelectric PbTiO(3). Systematic exploration using predictive quantum-mechanical calculations demonstrates that oxygen vacancies formed at surfaces induce ferromagnetism due to local nonstoichiometry and orbital symmetry breaking. The localized character of the emerged magnetization allows an individual oxygen vacancy to act as an atomic-scale multiferroic element with a nonlinear magnetoelectric effect that involves rich ferromagnetic-antiferromagnetic-nonmagnetic phase transitions in response to switching of the spontaneous polarization.

A simple prediction score for in-hospital mortality in patients with nonvariceal upper gastrointestinal bleeding.

BACKGROUND: No prediction scores for the mortality of both inpatients and outpatients who developed nonvariceal upper gastrointestinal bleeding (UGIB) without endoscopic findings have been established. We aimed to derive and validate a novel prediction score for in-hospital mortality. METHODS: We conducted a three-stage, multicenter retrospective study. In the derivation stage, patients with nonvariceal UGIB at six institutions were enrolled to derive the prediction score by logistic regression analysis. External validation of the score was performed to analyze discrimination by patients at six other institutions. Then the performance of this score was compared with that of four existing scores. RESULTS: We enrolled 1380 and 825 patients in the derivation and validation cohorts, respectively. A prediction score (CHAMPS-R Score) comprising seven variables (Charlson Comorbidity Index ≥ 2, in-hospital onset, albumin < 2.5 g/dL, altered mental status, Eastern Cooperative Oncology Group performance status ≥ 2, steroids, and rebleeding) with equal-weight scores was established, with high discriminative ability in both derivation and validation cohorts (c statistic, 0.91 and 0.80, respectively). When rebeeding was excluded from the score (an onset model; CHAMPS Score), this score also achieved high discriminative ability (c statistic, 0.90 and 0.81, respectively). The prediction scores had significantly higher discriminative ability than the Glasgow Blatchford Score, AIMS65, ABC Score, and clinical Rockall Score in both cohorts (all, p < 0.05). CONCLUSIONS: We derived and externally validated prediction scores for in-hospital mortality in patients with nonvariceal UGIB. The CHAMPS Score might be optimal for managing such patients. Its mobile application is freely available ( https://apps.apple.com/app/id1565716902 for iOS and https://play.google.com/store/apps/details?id=hatta.CHAMPS for Android).

Vimentin-positive gastric adenocarcinoma arising in a hyperplastic polyp.

We report a case of vimentin-positive early gastric adenocarcinoma arising in a hyperplastic polyp (HP). A 72-year-old Japanese man was admitted for the detailed examination of a gastric polyp. He had a subtotal gastrectomy due to acute abdomen 12 years ago. Upper endoscopy revealed a pedunculated polyp measuring approximately 2 cm on the greater curvature of upper body of the remnant stomach. Magnifying endoscopy revealed that the microsurface pattern was irregular and partially absent accompanied with irregular microvessels at the upper end of the polyp. We speculated that the lesion was an adenocarcinoma arising in the HP. Endoscopic submucosal dissection (ESD) was performed. Histological examination of the ESD specimen revealed that the lesion consisted of well- to poorly differentiated adenocarcinoma at the protruding lesion and foveolar hyperplastic epithelia at the base of the polyp. Immunohistochemically, most of tumor cells that comprised poorly-differentiated adenocarcinoma were positive for both cytokeratin and vimentin. Although carcinomas have occasionally been found in HPs, the histological features of the present case are considered extremely unusual. To the best of our knowledge, this is the first case of vimentin-positive early gastric carcinoma arising in a HP.

Aortoesophageal fistula after thoracic endovascular aortic repair diagnosed and followed with endoscopy.

A 70-year-old man reported dysphagia two months after undergoing thoracic endovascular aortic repair (TEVAR). An endoscopic examination revealed a fistula between the esophagus and the thoracic aortic aneurysm, and computed tomography (CT) showed that the thoracic aortic aneurysm had increased in size. The patient was diagnosed with an aortoesophageal fistula (AEF), and surgical replacement of the thoracic aorta was performed. AEFs are a rare but typically fatal complication after TEVAR. Physicians should consider a diagnosis of AEF and perform endoscopic examinations and CT in patients who undergo TEVAR and subsequently complain of dysphagia.