Endoscopic iatrogenic esophageal perforation and management: a retrospective outcome analysis in the modern era.

INTRODUCTION: Iatrogenic esophageal perforation (IEP) is a severe adverse event (AE) of upper endoscopy procedures (UEPs) associated with morbidity. Management has shifted from surgery to endotherapy with clip closure (CC), self-expanding metal stent (SEMS), and vacuum therapy (VT). Limited analyses measure outcomes during contemporary interventional endoscopy periods. METHODS: IEPs associated with EGD, upper EUS, small bowel enteroscopy (SBE), and ERCP at a 3-hospital academic center from January 2011 to December 2023 were identified retrospectively from a centralized AE database. Additional information was obtained from medical records. Statistical analysis was performed using Microsoft Excel and STATA. RESULTS: Thirty-two IEPs from 26 EGDs, 4 EUS, 1 SBE, and 1 ERCP were identified. IEPs occurred mostly after dilation (bougie N = 7; balloon, N = 5) or foreign body removal (N = 6). Most IEPs occurred in the lower esophagus (N = 10) or gastroesophageal junction (N = 8). Diagnosis was made at a median 2 h after the injury by endoscopy (N = 14), CT scan (N = 12), esophagram (N = 5), or x-ray (N = 1). Initial treatment included conservative therapy alone (N = 7), CC (N = 3), SEMS (N = 14), SEMS plus CC (N = 3), or surgery (N = 3). Eleven patients required additional treatment including repeat SEMS or adjustment (N = 4) or VT (N = 1). No surgical interventions were required after 2013. The median hospital stay was 3 days. Disposition included discharge to home (N = 25), long-term care facility (N = 2), 4 deaths (12.5% of IEPs), and 1 unknown. CONCLUSIONS: IEPs are rare and occur throughout the esophagus after any UEP. The majority are recognized immediately and managed with endotherapy, or rarely, surgery today. These characteristics likely explain the low mortality in this study.

Optimizing Endoscopy Procedure Documentation Improves Guideline-Adherent Care in Upper Gastrointestinal Bleeding.

BACKGROUND AND AIMS: Upper GI bleeding (UGIB) is a common indication for inpatient esophagogastroduodenoscopy (EGD). Guideline adherence improves post-EGD care, including appropriate medication dosing/duration and follow-up procedures that reduce UGIB-related morbidity. We aimed to optimize and standardize post-EGD documentation to improve process and clinical outcomes in UGIB-related care. METHODS: We performed a prospective quality improvement study of inpatient UGIB endoscopies at an academic tertiary referral center during 6/2019-7/2021. Guidelines were used to develop etiology/severity-specific electronic health record note templates. Participants (39 faculty/15 trainees) completed 10-min training in template content/use. We collected pre/post-intervention process data on "Minimal Standard Report" (MSR) documentation including patient disposition, diet, and medications. We also recorded documentation of re-bleed precautions and follow-up procedures. Study outcomes included guideline-based medication prescriptions, ordering of follow-up EGD, and post-discharge re-bleeding. Pre/post-intervention analysis was performed using chi-square tests. RESULTS: From a pre-intervention baseline of 199 patients to 459 patients post-intervention, compliance improved with inpatient PPI (53.4-77.9%, p < 0.001) and discharge PPI (31.3-61.0%, p < 0.001) prescriptions. There was improvement in MSR completion (28.6-42.5%, p < 0.001). Compliance improved with octreotide prescriptions (75.0-93.6%, p = 0.002) and follow-up EGD order (61.3-87.1%, p < 0.001). There was no change in post-discharge re-bleeding. 82.6% of cases used templates. CONCLUSIONS: Our project leveraged endoscopy software to standardize documentation, resulting in improved clinical care behavior and efficiency. Our intervention required low burden of maintenance, and sustainability with high utilization over 9 months. Similar endoscopy templates can be applied to other health systems and procedures to improve care.

Prehospital Blood Administration in Pediatric Patients: A Case Report.

Prehospital blood administration programs have demonstrated success both on the battlefield and throughout civilian emergency medical services programs. While previous research often discusses the use of prehospital blood administration for adult trauma and medical patients, few studies have reported the benefits of prehospital blood administration for pediatric patients. This case report describes treatment received by a 7-year-old female gunshot victim who was successfully treated by a prehospital blood administration program in the southern United States.

Activities and social contact as antecedents to sleep onset time in U.S. adolescents.

This study evaluated adolescents' evening patterns in activities, social contact, and location to better understand antecedents to adolescents' sleep onset time (SOT). The SOT is important for sleep duration and related health outcomes. Using a nationally representative sample of 15- to 18-year-old adolescents from the American Time Use Survey (N = 10,341; 47% female; 57% white), structural equation modeling demonstrated that late SOTs mediated links between evening activities, social contact, locations, and shorter sleep durations. Passive leisure, time in public locations, and time with friends late in the evenings were associated with later SOTs, whereas homework and active leisure did not. Parents and practitioners can use this information to carefully evaluate evening activities, social contact, and location to support healthy SOTs for adolescents across time.

Tibiofemoral Load Magnitude and Distribution During Load Carriage.

Chronic exposure to high tibiofemoral joint (TFJ) contact forces can be detrimental to knee joint health. Load carriage increases TFJ contact forces, but it is unclear whether medial and lateral tibiofemoral compartments respond similarly to incremental load carriage. The purpose of our study was to compare TFJ contact forces when walking with 15% and 30% added body weight. Young healthy adults (n = 24) walked for 5 minutes with no load, 15% load, and 30% load on an instrumented treadmill. Total, medial, and lateral TFJ contact peak forces and impulses were calculated via an inverse dynamics informed musculoskeletal model. Results of 1-way repeated measures analyses of variance (α = .05) demonstrated total, medial, and lateral TFJ first peak contact forces and impulses increased significantly with increasing load. Orthogonal polynomial trends demonstrated that the 30% loading condition led to a curvilinear increase in total and lateral TFJ impulses, whereas medial first peak TFJ contact forces and impulses responded linearly to increasing load. The total and lateral compartment impulse increased disproportionally with load carriage, while the medial did not. The medial and lateral compartments responded differently to increasing load during walking, warranting further investigation because it may relate to risk of osteoarthritis.

Racial Disparities in Adherence to Quality Indicators in Barrett's Esophagus: An Analysis Using the GIQuIC National Benchmarking Registry.

INTRODUCTION: Racial disparities in outcomes in esophageal adenocarcinoma are well established. Using a nationwide registry, we aimed to compare clinical and endoscopic characteristics of blacks and whites with Barrett's esophagus (BE) and adherence to defined quality indicators. METHODS: We analyzed data from the Gastrointestinal Quality Improvement Consortium Registry between January 2012 and December 2019. Patients who underwent esophagogastroduodenoscopy with an indication of BE screening or surveillance, or an endoscopic finding of BE, were included. Adherence to recommended endoscopic surveillance intervals of 3-5 years for nondysplastic BE and adherence to Seattle biopsy protocol were assessed. Multivariate logistic regression was conducted to assess variables associated with adherence. RESULTS: A total of 100,848 esophagogastroduodenoscopies in 84,789 patients met inclusion criteria (blacks-3,957 and whites-96,891). Blacks were less likely to have histologically confirmed BE (34.3% vs 51.7%, P < 0.01), had shorter BE lengths (1.61 vs 2.35 cm, P < 0.01), and were less likely to have any dysplasia (4.3% vs 7.1%, P < 0.01). Although whites were predominantly male (62.2%), about half of blacks with BE were female (53.0%). Blacks with nondysplastic BE were less likely to be recommended appropriate surveillance intervals (OR 0.78; 95% CI 0.68-0.89). Adherence rates to the Seattle protocol were modestly higher among blacks overall (OR 1.12, 95% CI 1.04-1.20), although significantly lower among blacks with BE segments >6 cm. DISCUSSION: The use of sex as a risk factor for BE screening may be inappropriate among blacks. Fewer blacks were recommended appropriate surveillance intervals, and blacks with longer segment BE were less likely to undergo Seattle biopsy protocol.

Testing the developmental hypothesis of the HPA axis in a tropical passerine: Dampened corticosterone response and faster negative feedback in nestling lance-tailed manakins (Chiroxiphia lanceolata).

When vertebrates are exposed to stressors, the subsequent acute increase in glucocorticoids by the hypothalamic-pituitaryadrenal (HPA) axis triggers a suite of adaptive responses, including mobilization of stored energy and repression of non-essential processes. However, chronic exposure to high concentrations of glucocorticoids can lead to metabolic dysregulation, impaired immune function, and cognitive decline. In developing young, this hormonal stress response shows considerable variation. Generally, the physiological stress response of young of precocial species is comparable to that of adults, whereas offspring of altricial species exhibit an attenuated response compared to adults. The developmental hypothesis of the HPA axis proposes that the dampened stress response in dependent offspring is an adaptive response to avoid the negative effects of elevated glucocorticoids, particularly in altricial species where young lack the ability to mitigate stressful stimuli.We aimed to test the developmental hypothesis in a tropical avian species, the lance-tailed manakin (Chiroxiphia lanceolata). We predicted that nestlings of this altricial species should have a dampened corticosterone response, in both magnitude and duration, compared to that of adults. We also predicted that recently fledged hatch-year birds would display a response intermediate to that of adults and nestlings. We quantified circulating corticosterone levels in adults, recently fledged hatch-year birds, and 11-day-old nestlings using a standardized capture and restraint protocol. Nestlings showed a lower maximal corticosterone response and faster negative feedback compared to adults. Further, five post-fledging hatch-year birds showed a feedback response intermediate to those of nestlings and adults. However, we caution against generalizing about fledgling responses beyond this study due to the small sample (n = 5). Interestingly, lance-tailed manakin nestlings appear to return to baseline concentrations faster than nestlings of temperate species. These results support the developmental hypothesis of the HPA axis explaining variation in stress response. This study is the first to assess the development of the hormonal stress response in nestlings of a tropical bird, which is of interest because of our still-developing understanding of how tropical and temperate species differ physiologically. Finally, findings here underscore the importance of validating and adjusting sampling protocols that quantify nestling stress responses, as sampling timelines identified for adults may underestimate the magnitude of the nestling stress response.

3D MRI in Musculoskeletal Oncology.

Advances in magnetic resonance imaging (MRI) technology now enable the feasible three-dimensional (3D) acquisition of images. With respect to the imaging of musculoskeletal (MSK) tumors, literature is beginning to accumulate on the use of 3D MRI acquisition for tumor detection and characterization. The benefits of 3D MRI, including general advantages, such as decreased acquisition time, isotropic resolution, and increased image quality, are not only inherently useful for tumor imaging, but they also contribute to the feasibility of more specialized tumor-imaging techniques, such as whole-body MRI, and are reviewed here. Disadvantages of 3D acquisition, such as motion artifact and equipment requirements, do exist and are also discussed. Although further study is needed, 3D MRI acquisition will likely prove increasingly useful in the evaluation of patients with tumors of the MSK system.

Global changes may be promoting a rise in select cyanobacteria in nutrient-poor northern lakes.

The interacting effects of global changes-including increased temperature, altered precipitation, reduced acidification and increased dissolved organic matter loads to lakes-are anticipated to create favourable environmental conditions for cyanobacteria in northern lakes. However, responses of cyanobacteria to these global changes are complex, if not contradictory. We hypothesized that absolute and relative biovolumes of cyanobacteria (both total and specific genera) are increasing in Swedish nutrient-poor lakes and that these increases are associated with global changes. We tested these hypotheses using data from 28 nutrient-poor Swedish lakes over 16 years (1998-2013). Increases in cyanobacteria relative biovolume were identified in 21% of the study sites, primarily in the southeastern region of Sweden, and were composed mostly of increases from three specific genera: Merismopedia, Chroococcus and Dolichospermum. Taxon-specific changes were related to different environmental stressors; that is, increased surface water temperature favoured higher Merismopedia relative biovolume in low pH lakes with high nitrogen to phosphorus ratios, whereas acidification recovery was statistically related to increased relative biovolumes of Chroococcus and Dolichospermum. In addition, enhanced dissolved organic matter loads were identified as potential determinants of Chroococcus suppression and Dolichospermum promotion. Our findings highlight that specific genera of cyanobacteria benefit from different environmental changes. Our ability to predict the risk of cyanobacteria prevalence requires consideration of the environmental condition of a lake and the sensitivities of the cyanobacteria genera within the lake. Regional patterns may emerge due to spatial autocorrelations within and among lake history, rates and direction of environmental change and the niche space occupied by specific cyanobacteria.

Endoscopic Eradication Therapy for Barrett's Neoplasia: Where Do We Stand a Decade Later?

PURPOSE OF REVIEW: Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer associated with increasing incidence and poor survival. Early identification and effective treatment of BE-related neoplasia prior to the development of invasive adenocarcinoma are essential to limiting the morbidity and mortality associated with this cancer. In this review, we summarized the recent evidence guiding endoscopic eradication therapies (EET) for neoplastic BE. RECENT FINDINGS: New sampling technologies and the application of artificial intelligence (AI) systems have potential to revolutionize early neoplasia detection in BE. EET for BE are safe and effective in achieving complete eradication of intestinal metaplasia (CE-IM) and reducing the progression to EAC, a practice endorsed by all GI society guidelines. EET should be considered in patients with high-grade dysplasia (HGD), intramucosal carcinoma (IMC), and select cases with low-grade dysplasia (LGD). The increasing use of endoscopic submucosal dissection (ESD) in the West may allow EET of select cases with submucosal EAC. Post-EET surveillance strategies will continue to evolve as knowledge of specific risk factors and long-term neoplasia recurrence rates improve. In the last decade, major advancements in EET for neoplastic BE have been achieved. These now represent the standard of care in the management of BE-related dysplasia and intramucosal cancer.

Development of the corticosterone stress response differs among passerine species.

Glucocorticoids are steroid hormones which increase dramatically in response to a physical or perceived stressor. However, developing young of altricial species typically have a damped glucocorticoid stress response. The developmental hypothesis posits that the physiological stress response should develop concurrently with an individual's ability to respond to a challenge. The dampened response may benefit an organism, as chronic exposure to glucocorticoids can have short- and long-term detrimental effects, and altricial young are unable to escape most stressors. However, we do not know if or why species with similar ontogeny vary in their development of the physiological stress response. We assessed levels of baseline and stress-induced corticosterone (the main avian glucocorticoid) in six passerine species with varying life-history strategies, including a brood parasite, the brown-headed cowbird (Molothrus ater). Circulating baseline corticosterone levels increased with nestling age for all species. Stress-induced corticosterone levels sampled at 15-min post-capture significantly increased with nestling age at a similar rate and magnitude in brown-headed cowbirds, eastern phoebes (Sayornis phoebe), hooded warblers (Setophaga citrina), red-winged blackbirds (Agelaius phoeniceus), and song sparrows (Melospiza melodia). However, gray catbird (Dumetella carolinensis) nestlings showed an extremely dampened elevation in corticosterone in response to stress, even near fledge. Gray catbirds are unusual among songbirds, as they are open-ended song learners. Stress during development can profoundly influence avian song learning and performance abilities. However, further study is necessary to determine if there is a relationship between nestling adrenocortical activity and open- versus closed-ended song learning.

Cultural Contributors to Ego-Resiliency and Associations with Depressive Problems in Midwestern Latino Youth.

Ego-resiliency is an enduring psychological construct reflecting how individuals-adapt to environmental stressors, conflict, and change which is linked to positive adjustment. Ego-resiliency has not been examined in Latino youth, despite their high risk for mental health problems; nor have cultural precursors to ego-resiliency been examined. Given these gaps, we examined whether familism values (supportive, obligation, and referent) were associated with ego-resiliency and, in turn, depressive problems in Latino adolescents across two time points (N = 123, mean age = 11.53). Results indicated that supportive familism was associated positively with ego-resiliency and negatively with depressive problems. Ego-resiliency negatively predicted depressive problems across time, controlling for prior levels, suggesting that ego-resiliency may have long-term effects on depressive problems in Latino youth.

Developmental antecedents of adolescent optimism in rural midwestern U.S. Latinx youth.

AIMS: Decades of scientific research have found optimism to have wide-ranging effects on individuals' health and well-being. Researchers have largely examined optimism in adults, but have begun addressing the benefits of optimism in adolescents. Challenges and stressors in adolescence can threaten youths' subjective well-being; therefore, identifying factors that contribute to the growth of optimism could have important health implications. However, researchers have more often examined the effect of optimism on youth outcomes rather than factors that might positively or negatively contribute to the development of optimism. METHODS: We assessed how salient developmental tasks (resilience, ethnic pride, and school attachment), family stress, and depressive problems individually contribute to Latinx youths' optimism at two time points (N = 123, 58.8% female, M age = 11.54 years). RESULTS: We found support for associations between both resilience and school attachment and optimism, but findings were weaker across time and with stressors included in the model. Depressive problems also appeared to weaken optimism across time. CONCLUSION: Given the established links between optimism and health, it will be important for researchers to continue to identify factors that contribute to the development of youth optimism, and assess whether they could be used in interventions to foster optimism.

Comparison of clinical prediction tools and identification of risk factors for adverse outcomes in acute lower GI bleeding.

BACKGROUND AND AIMS: Limited data exist on prediction of adverse outcomes in patients with acute lower GI bleeding (LGIB). The purpose of our study was to compare the ability of existing validated clinical risk scores to predict relevant outcomes in LGIB. METHODS: We performed a prospective observational study of patients admitted with LGIB who underwent colonoscopy at a single center between April 2016 and September 2017. Seven risk scores were calculated at admission (Strate, NOBLADS, Sengupta, Oakland, Blatchford, AIMS65, and Charlson Comorbidity Index). The risk of severe LGIB was determined via univariable and multivariable logistic regression. Area under the receiver operating characteristic curve (AUC) analysis was used to compare the scores. RESULTS: We included 170 patients admitted with LGIB requiring colonoscopy. Fifty-two percent (n = 89) fit criteria for severe bleeding. Patients with severe bleeding had lower admission hemoglobin levels (8.6 g/dL vs 11.1 g/dL; P = .0001), were more likely to have blood transfusions (85% vs 36%; P < .0001), intensive care unit stays (49% vs 19%; P < .0001), and had a longer length of stay (6 days vs 4 days; P = .0009). The Oakland score was best for prediction of severe bleeding (AUC, .74), Blatchford score for blood transfusion (AUC, .87), and Strate score for in-hospital recurrent bleeding (AUC, .66) and endoscopic intervention (AUC, .62). The strongest individual predictors of severe bleeding were low admission hemoglobin (odds ratio, 1.28 per 1-g/dL decrease; P = .0015; 95% confidence interval, 1.10-1.49) and low albumin (odds ratio, 2.56 per 1-g/dL decrease; P = .02; 95% confidence interval, 1.16-5.56). CONCLUSION: Admission albumin and hemoglobin levels were the strongest predictors of severe bleeding. No singular clinical risk tool had the best predictive ability across all outcomes.

Direct and indirect effects of the El Niño Southern Oscillation on development and survival of young of a tropical passerine.

The El Niño Southern Oscillation (ENSO) is a global phenomenon that influences climate variation and, in turn, the ecological processes affecting the abundance and distribution of populations across taxa. For example, the ENSO can profoundly influence the development and survival of pelagic species, but the extent to which the ENSO affects offspring of terrestrial species is less well known. We used piecewise structural equation modeling to investigate the direct and indirect relationship between the ENSO and offspring development and survival in a terrestrial tropical passerine, the lance-tailed manakin (Chiroxiphia lanceolata). The Oceanic Niño Index (ONI), a measure of the ENSO, was negatively related to individual growth rate, maximum number of lesion developed by nestlings, and hatching day-of-year; which in turn mediated indirect effects on fledging success and recruitment. Further the ONI was a better predictor of nestling development compared to local temperature and rainfall. Our study establishes a link between the ENSO and the development and survival of young of a terrestrial species and underscores the need to better understand how offspring cope with global climate variation.

Frequency of eating alone is associated with adolescent dietary intake, perceived food-related parenting practices and weight status: cross-sectional Family Life, Activity, Sun, Health, and Eating (FLASHE) Study results.

OBJECTIVE: To examine relationships between frequency of adolescents eating alone (dependent variable) and diet, weight status and perceived food-related parenting practices (independent variables). DESIGN: Analyses of publicly available, cross-sectional, web-based survey data from adolescents. SETTING: Online consumer opinion panel. SUBJECTS: A US nationwide sample of adolescents (12-17 years) completed Family Life, Activity, Sun, Health, and Eating (FLASHE) Study surveys to report demographic and family meal characteristics, weight, dietary intake, home food availability and perceptions of parenting practices. Parents provided information about demographic characteristics. Logistic regression analyses were used to test for associations between variables. RESULTS: About 20 % of adolescents reported often eating alone (n 343) v. not often eating alone (n 1309). Adjusted odds of adolescents often eating alone were significantly higher for non-Hispanic Black compared with non-Hispanic White adolescents (OR=1·7) and for overweight or obese compared with normal- or underweight adolescents (OR=1·6). Adjusted odds of adolescents eating alone were significantly lower for those who reported that fruits and vegetables were often/always available in the home (OR=0·65), for those who perceived that parents had expectations about fruit and vegetable intake (OR=0·71) and for those who agreed with parental authority to make rules about intake of junk food/sugary drinks (OR=0·71). Junk food and sugary drink daily intake frequency was positively associated with often eating alone. CONCLUSIONS: Often eating alone was related to being overweight/obese, having less healthy dietary intake and perceptions of less supportive food-related parenting practices.

Parental restrictive feeding with Latinx adolescents: Examining the role of adolescent effortful control.

The objective of this study was to test if youth effortful control, a general process of self-regulation that is rooted in temperament, uniquely predicts maternal restrictive feeding with Latinx adolescents above and beyond demographic/contextual factors, prior use of restrictive feeding, and common markers of obesity-proneness. The study sample consisted of Latinx fifth and sixth graders and their mothers residing in the Midwestern U.S. (N =  97 dyads). Effortful control, maternal restrictive feeding, demographic/contextual factors, and markers of obesity proneness were measured across two waves of data collection approximately one year apart. Results demonstrated an inverse relation between effortful control and maternal restrictive feeding after controlling for Time 1 demographic/contextual factors, maternal BMI, maternal restrictive feeding, youth BMI z-score, and perceived youth weight. Future directions include testing for the presence of an ironic feedback process such that Latinx mothers' attempts to overcome deficits in their children's self-regulation skills through restrictive feeding may be inadvertently maintaining the problem.

Associations between Effortful Control, Cortisol Awakening Response, and Depressive Problems in Latino Preadolescents.

The present study examined associations between effortful control, a trait marker of self-regulation, adaptive HPA system functioning (as reflected by the CAR), and concurrent and longitudinal depressive problems, in a sample of preadolescent Latino youth (N = 119, mean age = 11.53 years, 59% female). We hypothesized that trait readiness for self-regulation (e.g., effortful control) could be related to physiological state readiness for self-regulation (e.g., CAR), and that both may counter depressive problems. We found that youth's CAR was positively associated with effortful control, and negatively with youth depressive problems. Effortful control and youth depressive problems were also negatively associated. Longitudinal relations of CAR and effortful control on depressive problems at T2 were not significant in the structural equation model after controlling for T1 depressive problems, although these variables were significant in the bivariate correlations. Results suggest that both trait-regulation and physiological regulation may counter depressive problems in Latino youth.

Rebleeding vs Thromboembolism After Hospitalization for Gastrointestinal Bleeding in Patients on Direct Oral Anticoagulants.

BACKGROUND & AIMS: Little is known about outcomes of patients hospitalized for gastrointestinal bleeding (GIB) while they are taking direct oral anticoagulants (DOAC). We aimed to determine the frequency at which patients resume DOAC therapy following hospitalization for GIB in a real-world setting, and the risks and benefits. METHODS: We conducted a retrospective analysis of medical claims data from the Truven Health Marketscan Commercial Claims and Encounters Database, from January 1, 2010, through December 31, 2014. We collected data on 1338 adults treated with DOACs and hospitalized for GIB (dabigatran, n = 679; rivaroxaban, n = 608, apixaban, n = 51). Patients who developed GIB within 1 year of DOAC initiation, and had a DOAC claim filled within 1 month of GIB, were included in the analysis. Postdischarge readmissions due to thromboembolism and recurrent GIB within 90 days were reviewed. We used proportional hazards to identify factors associated with thromboembolism and recurrent GIB. RESULTS: The median age of patients who did not resume DOAC therapy was older (79 vs 78 y for patients who did resume DOAC therapy; P = .0005). Higher proportions of patients who did not resume DOAC had heart failure (25% vs 20% who did resume DOAC therapy; P = .01), received blood (36% vs 24%; P < .0001), and required intensive care (18% vs 12%; P = .003). Restarting DOAC therapy within 30 days was not associated with thromboembolism within 90 days (hazard ratio [HR], 0.98; 95% CI, 0.37-2.21) or recurrent GIB (HR, 1.44; 95% CI 0.72-2.68). On multivariate regression, prior venous thromboembolism was associated with postdischarge thromboembolism (HR, 3.30; 95% CI, 1.29-7.38), and thienopyridine use was associated with recurrent GIB (HR, 3.12; 95% CI, 1.55-5.81). A higher proportion of patients who resumed treatment with rivaroxaban, compared with other DOACs, had recurrence of GIB (log rank, P = .04). CONCLUSIONS: In a retrospective analysis of medical claims data from adults treated with DOACs and hospitalized for GIB, we found that older patients who require blood and intensive care were less likely to restart treatment with DOACs after GIB. Resuming DOAC therapy was not associated with thromboembolism within 90 days or recurrence of GIB; a history of venous thromboembolism and thienopyridine use were associated with a risk of subsequent thromboembolism and GIB respectively.

State-of-the-Art Diagnosis and Treatment of Melanoma: Optimal Multidetector Computed Tomographic Practice to Identify Metastatic Disease and Review of Innovative Therapeutic Agents.

The incidence of melanoma has risen dramatically over the past several decades. Oncologists rely on the ability of radiologists to identify subtle radiographic changes representing metastatic and recurrent melanoma in uncommon locations on multidetector computed tomography (MDCT) as the front-line imaging surveillance tool. To accomplish this goal, MDCT acquisition and display must be optimized and radiologist interpretation and search patterns must be tailored to identify the unique and often subtle metastatic lesions of melanoma. This article describes MDCT acquisition and display techniques that optimize the visibility of melanoma lesions, such as high-contrast display windows and multiplanar reconstructions. In addition, innovative therapies for melanoma, such as immunotherapy and small-molecule therapy, have altered clinical management and outcomes and have also changed the spectrum of therapeutic complications that can be detected on MDCT. Recent advances in melanoma therapy and potential complications that the radiologist can identify on MDCT are reviewed.