TC-325 superiority in Malignant Gastrointestinal Bleeding - An Individual Patient Data Meta-analysis of Randomized Trials.

BACKGROUND: The efficacy of topical hemostatic agents, recommended for peptic ulcer bleeding, remains poorly characterized in malignant gastrointestinal bleeding (GIB). METHODS: We performed an individual patient data (IPD) meta-analysis assessing the efficacy of topical hemostatic agents in malignant GIB. The literature was searched using OVID MEDLINE, EMBASE, and ISI Web of Sciencedatabases (database inception to November 2023). Only randomized controlled trials (RCTs) comparing topical hemostatic agents to conventional endoscopic modalities in malignant GIB were included. Original RCT patient-level data were obtained. PRISMA guidelines were followed. Quality of the evidence was evaluated using the revised Cochrane risk of bias tool, and certainty of evidence with the GRADE approach. The primary outcome was immediate hemostasis; secondary outcomes were 30-day rebleeding and the composite measure of further bleeding (persistent bleeding or 30-day rebleeding). Other outcomes were all-cause mortality, adverse events, and need for additional non-endoscopic treatment. Odds ratios (ORs) from endpoint comparisons were pooled using logistic regression models. FINDINGS: Overall, 985 citations were identified; 3 RCTs (n=160 patients) were included with all assessing TC-325 (Hemospray™). TC-325 achieved immediate hemostasis more often than conventional endoscopic modalities (OR=46.6 (5.89; 369.1)) (low level certainty). Thirty-day rebleeding (OR=0.28 (0.11; 0.70)) and further bleeding (OR=0.11 (0.05; 0.26)) were both significantly lower with TC-325 (very low level certainty). All-cause mortality and need for additional non-endoscopic treatment did not differ between groups. No adverse events were reported. Subgroup analysis confirmed TC-325 superiority in patients with upper GIB. INTERPRETATION: TC-325 appears superior to conventional endoscopic therapy in managing patients with malignant GIB. TC-325 results in improvements in immediate hemostasis, 30-day rebleeding and further bleeding, based on very low-to-low certainties of evidence.

The use of cap-mounted clips as a primary hemostatic modality in nonvariceal upper gastrointestinal bleeding: A systematic review and meta-analysis of randomized trials.

BACKGROUND: Cap-mounted-clips, especially Over-The-Scope-Clip (OTSC™), are recommended for recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB). There has been recent interest in their use as an initial hemostatic modality. We performed a systematic review of randomized controlled trials (RCTs) assessing cap-mounted clips' efficacy as a primary hemostatic modality in NVUGIB. METHODS: A literature search of MEDLINE, EMBASE, and ISI Web of Science databases up to April 2024 identified RCTs comparing cap-mounted clips to standard endoscopic therapy (SET) as a primary hemostatic modality in NVUGIB. The primary endpoint was the composite outcome of further bleeding (persistent or recurrent) at 30 days. Secondary outcomes included persistent bleeding at index endoscopy and 30-day rebleeding, individually. Other pertinent outcomes were also recorded. A meta-analysis was performed to determine pooled risk ratios (RRs), comparing cap-mounted clip to SET. Out of 516 citations, five RCTs (n = 555), all assessing OTSC™, were included. RESULTS: The composite outcome of further bleeding was lower with cap-mounted clip versus SET (RR = 0.33 [95% confidence interval {CI}: 0.20-0.54]). There was no difference in persistent bleeding at initial endoscopy (RR = 0.30 [95% CI: 0.07-1.30]), but 30-day rebleeding was lower with cap-mounted clip (RR = 0.38 [95% CI: 0.21-0.70]). There were no differences in other outcomes. Grading of the evidence ranged from very low to moderate, mainly due to risk of bias and imprecision. CONCLUSIONS: Cap-mounted clips may be an efficacious primary hemostatic modality, associated with a lower further bleeding at 30 days compared to SET in NVUGIB. However, due to limitations in existing evidence, further research must better characterize an optimal subgroup of patients benefiting most from this approach before adopting its routine use.

Peptic ulcer disease.

Annual prevalence estimates of peptic ulcer disease range between 0·12% and 1·5%. Peptic ulcer disease is usually attributable to Helicobacter pylori infection, intake of some medications (such as aspirin and non-steroidal anti-inflammatory medications), or being critically ill (stress-related), or it can be idiopathic. The clinical presentation is usually uncomplicated, with peptic ulcer disease management based on eradicating H pylori if present, the use of acid-suppressing medications-most often proton pump inhibitors (PPIs)-or addressing complications, such as with early endoscopy and high-dose PPIs for peptic ulcer bleeding. Special considerations apply to patients on antiplatelet and antithrombotic agents. H pylori treatment has evolved, with the choice of regimen dictated by local antibiotic resistance patterns. Indications for primary and secondary prophylaxis vary across societies; most suggest PPIs for patients at highest risk of developing a peptic ulcer, its complications, or its recurrence. Additional research areas include the use of potassium-competitive acid blockers and H pylori vaccination; the optimal approach for patients at risk of stress ulcer bleeding requires more robust determinations of optimal patient selection and treatment selection, if any. Appropriate continuation of PPI use outweighs most possible side-effects if given for approved indications, while de-prescribing should be trialled when a definitive indication is no longer present.

Endoscopic management of intraprocedural bleeding during endoscopic interventions.

Endoscopic resection techniques have evolved over time, allowing effective and safe resection of the majority of pre-malignant and early cancerous lesions in the gastrointestinal tract. Bleeding is one of the most commonly encountered complications during endoscopic resection, which can interfere with the procedure and result in serious adverse events. Intraprocedural bleeding is relatively common during endoscopic resection and, in most cases, is a mild and self-limiting event. However, it can interfere with the completion of the resection and may result in negative patient-related outcomes in severe cases, including the need for hospitalization and blood transfusion as well as the requirement for radiological or surgical interventions. Appropriate management of intraprocedural bleeding can improve the safety and efficacy of endoscopic resection, and it can be readily achieved with the use of several endoscopic hemostatic tools. In this review, we discuss the recent advances in the approach to intraprocedural bleeding complicating endoscopic resection, with a focus on the various endoscopic hemostatic tools available to manage such events safely and effectively.

Assessment, Resuscitation and Medical Management of Variceal and Nonvariceal Gastrointestinal Bleeding.

Upper gastrointestinal bleeding (UGIB) continues to be an important cause for emergency room visits and carries significant morbidity and mortality. Early resuscitative measures form the basis of the management of patients presenting with UGIB and can improve the outcomes of such patients including lowering mortality. In this review, using an evidence-based approach, we discuss the initial assessment and resuscitation of patients presenting with UGIB including identifying clues from history and physical examination to confirm UGIB, preendoscopic risk assessment tools, the role of early fluid resuscitation, utilization of blood products, use of pharmacologic interventions, and the optimal timing of endoscopy.

An IoT-Based Road Bridge Health Monitoring and Warning System.

Recent earthquakes worldwide have led to significant loss of life and structural damage to infrastructure, especially road bridges. Existing bridge monitoring systems have limitations, including restricted detection capabilities, subjectivity, human error, labor-intensive inspections, limited access to remote areas, and high costs. Aging infrastructures pose a critical concern for organizations and government funding policies, showing signs of decay and impending structural failure. To address these challenges, this research proposes an IoT-based bridge health status monitoring and warning system that is wireless, low-cost, durable, and user-friendly. The proposed system builds upon engineering standards and guidelines to classify bridge health status into categories ranging from excellent to collapse condition. It incorporates deflection, vibration, temperature, humidity, and infrared sensors, combined with IoT and a fuzzy logic algorithm. The primary objective is to reduce bridge maintenance costs, extend lifespans, and enhance transportation safety through an early warning system via a mobile application. Additionally, a Google Maps interface has been developed to display bridge conditions along with real-time traffic video. To validate the proposed system, a 3-D prototype model was constructed and tested. Practical testing of the fuzzy logic algorithm aligned with the simulation outcomes, demonstrating expected accuracy in determining bridge health status.

Review article: Advances in the management of lower gastrointestinal bleeding.

BACKGROUND: Lower gastrointestinal bleeding (LGIB) is a common emergency with substantial associated morbidity and mortality. Elective colonoscopy plays an essential role in management, with an even more important role for radiology in the acute setting. Recent advances in the management of patients with LGIB warrant review as the management has recently evolved. AIMS: To provide a comprehensive and updated overview of advances in the approach to patients with LGIB METHODS: We performed a comprehensive literature search to examine the current data for this narrative review supplemented by expert opinion. RESULTS: The incidence of LGIB is increasing worldwide, partly related to an ageing population and the increasing use of antithrombotics. Diverticulosis continues to be the most common aetiology of LGIB. Pre-endoscopic risk stratification tools, especially the Oakland score, can aid appropriate patient triage. Adequate resuscitation continues to form the basis of management, while appropriate management of antithrombotics is crucial to balance the risk of worsening bleeding against increased cardiovascular risk. Radiological imaging plays an essential role in the diagnosis and treatment of acute LGIB, especially among unstable patients. Colonoscopy remains the gold-standard test for the elective management of stable patients. CONCLUSIONS: The management of LGIB has evolved significantly in recent years, with a shift towards radiological interventions for unstable patients while reserving elective colonoscopy for stable patients. A multidisciplinary approach is essential to optimise the outcomes of patients with LGIB.

Oral microbiota analyses of paediatric Saudi population reveals signatures of dental caries.

BACKGROUND: Oral microbiome sequencing has revealed key links between microbiome dysfunction and dental caries. However, these efforts have largely focused on Western populations, with few studies on the Middle Eastern communities. The current study aimed to identify the composition and abundance of the oral microbiota in saliva samples of children with different caries levels using machine learning approaches. METHODS: Oral microbiota composition and abundance were identified in 250 Saudi participants with high dental caries and 150 with low dental caries using 16 S rRNA sequencing on a NextSeq 2000 SP flow cell (Illumina, CA) using 250 bp paired-end reads, and attempted to build a classifier using random forest models to assist in the early detection of caries. RESULTS: The ADONIS test results indicate that there was no significant association between sex and Bray-Curtis dissimilarity (p ~ 0.93), but there was a significant association with dental caries status (p ~ 0.001). Using an alpha level of 0.05, five differentially abundant operational taxonomic units (OTUs) were identified between males and females as the main effect along with four differentially abundant OTUs between high and low dental caries. The mean metrics for the optimal hyperparameter combination using the model with only differentially abundant OTUs were: Accuracy (0.701); Matthew's correlation coefficient (0.0509); AUC (0.517) and F1 score (0.821) while the mean metrics for random forest model using all OTUs were:0.675; 0.054; 0.611 and 0.796 respectively. CONCLUSION: The assessment of oral microbiota samples in a representative Saudi Arabian population for high and low metrics of dental caries yields signatures of abundances and diversity.

Pre-Endoscopic Scores Predicting Low-Risk Patients with Upper Gastrointestinal Bleeding: A Systematic Review and Meta-Analysis.

BACKGROUND: Several risk scores have attempted to risk stratify patients with acute upper gastrointestinal bleeding (UGIB) who are at a lower risk of requiring hospital-based interventions or negative outcomes including death. This systematic review and meta-analysis aimed to compare predictive abilities of pre-endoscopic scores in prognosticating the absence of adverse events in patients with UGIB. METHODS: We searched MEDLINE, EMBASE, Central, and ISI Web of knowledge from inception to February 2023. All fully published studies assessing a pre-endoscopic score in patients with UGIB were included. The primary outcome was a composite score for the need of a hospital-based intervention (endoscopic therapy, surgery, angiography, or blood transfusion). Secondary outcomes included: mortality, rebleeding, or the individual endpoints of the composite outcome. Both proportional and comparative analyses were performed. RESULTS: Thirty-eight studies were included from 2153 citations, (n = 36,215 patients). Few patients with a low Glasgow-Blatchford score (GBS) cutoff (0, ≤1 and ≤2) required hospital-based interventions (0.02 (0.01, 0.05), 0.04 (0.02, 0.09) and 0.03 (0.02, 0.07), respectively). The proportions of patients with clinical Rockall (CRS = 0) and ABC (≤3) scores requiring hospital-based intervention were 0.19 (0.15, 0.24) and 0.69 (0.62, 0.75), respectively. GBS (cutoffs 0, ≤1 and ≤2), CRS (cutoffs 0, ≤1 and ≤2), AIMS65 (cutoffs 0 and ≤1) and ABC (cutoffs ≤1 and ≤3) scores all were associated with few patients (0.01-0.04) dying. The proportion of patients suffering other secondary outcomes varied between scoring systems but, in general, was lowest for the GBS. GBS (using cutoffs 0, ≤1 and ≤2) showed excellent discriminative ability in predicting the need for hospital-based interventions (OR 0.02, (0.00, 0.16), 0.00 (0.00, 0.02) and 0.01 (0.00, 0.01), respectively). A CRS cutoff of 0 was less discriminative. For the other secondary outcomes, discriminative abilities varied between scores but, in general, the GBS (using cutoffs up to 2) was clinically useful for most outcomes. CONCLUSIONS: A GBS cut-off of one or less prognosticated low-risk patients the best. Expanding the GBS cut-off to 2 maintains prognostic accuracy while allowing more patients to be managed safely as outpatients. The evidence is limited by the number, homogeneity, quality, and generalizability of available data and subjectivity of deciding on clinical impact. Additional, comparative and, ideally, interventional studies are needed.

Strengths and limitations of risk stratification tools for patients with upper gastrointestinal bleeding: a narrative review.

INTRODUCTION: Despite advances in the management of patients with upper gastrointestinal bleeding (UGIB), associated morbidity and mortality remain significant. Most patients, however, will experience favorable outcomes without a need for hospital-based interventions. Risk assessment scores may assist in such early risk-stratification. These scales may optimize identification of low-risk patients, resulting in better resource utilization, including a reduced need for early endoscopy and fewer hospital admissions. The aim of this article is to provide an updated detailed review of risk assessment scores in UGIB. AREA COVERED: A literature review identified past and currently available pre-endoscopic risk assessment scores for UGIB, with a focus on low-risk prediction. Strengths and weaknesses of the different scales are discussed as well as their impact on clinical decision-making. EXPERT OPINION: The current evidence supports using the Glasgow Blatchford Score as it is the most accurate tool available when attempting to identify low-risk patients who can be safely managed on an outpatient basis. Currently, no risk assessment tool appears accurate enough in confidently classifying patients as high risk. Future research should utilize more standardized methodologies, while favoring interventional trial designs to better characterize the clinical impact attributable to the use of such risk stratification schemes.

EFFECT OF HEAT TREATMENT DURATION AND COOLING CONDITIONS ON TENSILE PROPERTIES AND HARDNESS OF SELECTIVE-LASER-MELTED COBALT-CHROMIUM ALLOY.

The mechanical properties of cobalt-chromium (Co-Cr) alloys produced through selective laser melting (SLM) can be enhanced by the application of the post-heat treatment, but it is still unclear how long the heat treatment should last and how the cooling rate affects the tensile properties and hardness of the alloy. Aim of this study - investigate the effects of heat treatment for one hour and six hours, respectively, at 1150 C, and three cooling conditions (AC, FC, and WC), on the tensile strength, elongation, and hardness of SLM Co-Cr alloy specimens. Thirty-five Dumbbell shaped specimens (50×12×2 mm) (ISO 6892-1:2016), and thirty-five rectangular-shaped specimens (34×13×1.5 mm) ISO (22674:2016) were manufactured and divided into seven groups, based on the use of heat or cold and the duration of both. Tensile strength and Vickers hardness tests were performed on the specimens. When it comes to tensile strength, the (FC1) group took the bottom spot with a score of (991.21 MPa) while the control group came out on top, boasting an impressive (1362.41 MPa). When it came to elongation, the control group had the lowest score (4%), while the best-treated group scored (17%). The lowest and highest value of tensile strength was similarly affected. Water-quenched groups showed better tensile properties and hardness than other groups. As a result, increasing the cooling rate is an effective way to improve the ductility and hardness of the SLM Co-Cr alloy.

Topical hemostatic agents in the management of upper gastrointestinal bleeding: a meta-analysis.

Background and study aims Novel topical hemostatic agents have shown promising results in treating patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, data are limited even in published meta-analyses as to their role, especially compared to conventional endoscopic approaches. The aim of this study was to perform a highly comprehensive systematic review assessing the effectiveness of topical hemostatic agents in UGIB in different clinical settings. Methods We performed a literature search of OVID MEDLINE, EMBASE, and ISI Web of Knowledge databases through September 2021. Studies assessing the efficacy of topical hemostatic agents in UGIB were included. Main outcomes were immediate hemostasis and overall rebleeding. Results A total of 980 citations were identified and 59 studies with a total of 3,417 patients were included in the analysis. Immediate hemostasis was achieved in 93 % (91 %; 94 %), with similar results according to etiology (NVUGIB vs. variceal), topical agent used, or treatment strategy (primary vs. rescue). The overall rebleeding rate was 18 % (15%; 21 %) with the majority of rebleeds occurring in the first 7 days. Among comparative studies, topical agents achieved immediate hemostasis more often than standard endoscopic modalities (OR 3.94 [1.73; 8.96), with non-different overall rebleeding odds (OR 1.06 [0.65; 1.74]). Adverse events occurred in 2 % (1 %; 3 %). Study quality was overall low to very low. Conclusions Topical hemostatic agents are effective and safe in the management of UGIB with favorable outcomes when compared to conventional endoscopic modalities across a variety of bleeding etiologies. This is especially true in novel subgroup analyses that assessed immediate hemostasis and rebleeding among RCTs and in malignant bleeding. Due to methodological limitations of available data, additional studies are needed to ascertain their effectiveness more confidently in the management of patients with UGIB.

An update on the management of non-variceal upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) continues to be a common gastrointestinal emergency that carries significant morbidity and mortality. The epidemiology of UGIB has been changing over the last few decades with an overall decrease in peptic ulcer disease and increase in the prevalence of other etiologies including vascular lesions and malignancy. Appropriate risk assessment and patient stratification are crucial to ensuring that optimal care is delivered to patients and some risk assessment tools have shown excellent ability to define a low-risk group who can be managed as outpatients safely. Regardless of the etiology of UGIB, resuscitative interventions by primary care providers remain the most important initial measures to improve the outcome for patients including hemodynamic stabilization, an appropriate blood transfusion strategy, with or without acid-lowering agents, while also providing subsequent urgent endoscopic assessment and intervention. In addition, with increasing use of antithrombotic agents in clinical practice and its associated risk of bleeding, the management of such agents in the acute setting has become a real challenge to all physicians. In this article, we provide an up-to-date, evidence-based, practical review of recent changes and advances in UGIB with a focus on non-variceal etiologies.

Oral microbiota analyses of Saudi sickle cell anemics with dental caries.

OBJECTIVES: The objectives of this study were to identify the composition of oral microbiota in a cohort of patients with sickle cell anemia (SCA) and a high mean number of decayed, missing, and filled permanent teeth (DMFT) and compare it to a cohort of patients with SCA and a low number of DMFT and elucidate the effect of fetal haemoglobin levels on the oral microbiota composition. METHODS: Patients who had been diagnosed with SCA, who were homozygous for sickling ß-globin mutation (ßS/ßS), who had Arab-Indian haplotype, and who ranged in age from 5 to 12 years were included in this study. Oral saliva from each participant (n = 100) was collected in GeneFiX™ Saliva DNA Microbiome Collection tube and DNA was extracted using GeneFiX™ DNA Isolation Kits. The composition of oral 16S rRNA from patients with SCA and high dental caries (n = 27, DMFT ≥5) and low dental caries (n = 73, DMFT ≤4) was analysed. Sequencing was performed on an Ion Personal Genome Machine using, Ion PGM Hi-Q view Sequencing 400-bp kit. RESULTS: We observed an overall increase in abundance of Proteobacteria, Chloroflexi, and Bacteroidetes in the high DMFT index group compared to those with a low DMFT index. In addition, there was an overall increased abundance of microbiota from Proteobacteria, Fusobacteria, Firmicutes, and Bacteroidetes in the patients with SCA with low fetal haemoglobin compared to those with high fetal haemoglobin (P < .05). Enterobacteriaceae species were the most significant abundant species of bacteria found in both the high DMFT index group and low fetal haemoglobin cohort (P < .05). CONCLUSIONS: Our data indicate that SCA in Saudi patients with high DMFT have a higher predominance of pathogenic bacteria compared to those with low DMFT. Furthermore, SCA in Saudi patients with low fetal haemoglobin have a higher predominance of pathogenic bacteria compared to those with higher fetal haemoglobin.

Prevalence of Hepatitis B Virus infection in the Gulf Cooperation Council: a systematic review and meta-analysis.

BACKGROUND: Hepatitis B virus (HBV) infection is a global public-health problem. Since the introduction of an effective vaccine, the epidemiology of HBV infection is changing. We aimed to estimate the prevalence of HBV infection in the Gulf Cooperation Council (GCC) region and delineate any variation in member-countries, special sub-groups, and over time. METHODS: This is a systematic review and meta-analysis to review studies of HBV prevalence in the GCC region. Databases were searched and all studies from inception to July 31st, 2021, were considered for inclusion. The pooled HBV prevalence was analyzed using the random-effect model after assessment for heterogeneity. True prevalence was adjusted using the Rogan-Gladen estimator. Pre-defined subgroup analysis was performed, and publication bias was assessed. RESULTS: Overall, 99 studies (n = 1,944,200 participants) met the inclusion criteria. The overall HBV apparent prevalence was 3.05% (95% CI 2.60, 3.52) and the true prevalence was 1.67% (95% CI 1.66, 1.68). The apparent prevalence varied between subgroups. Over time, the apparent prevalence of HBV infection has declined from 9.38% (95% CI 7.26, 11.74) before 1990 to 1.56% (95% CI 1.07, 2.12) during the period 2010 to 2020. CONCLUSION: Over the last four decades the overall prevalence of HBV infection in the GCC region has decreased from high- to low-endemicity level. However, due to poor methodology of the included studies, further high-quality community-based studies are needed to obtain more precise estimate of HBV infection in this region.

An IoT Machine Learning-Based Mobile Sensors Unit for Visually Impaired People.

Visually impaired people face many challenges that limit their ability to perform daily tasks and interact with the surrounding world. Navigating around places is one of the biggest challenges that face visually impaired people, especially those with complete loss of vision. As the Internet of Things (IoT) concept starts to play a major role in smart cities applications, visually impaired people can be one of the benefitted clients. In this paper, we propose a smart IoT-based mobile sensors unit that can be attached to an off-the-shelf cane, hereafter a smart cane, to facilitate independent movement for visually impaired people. The proposed mobile sensors unit consists of a six-axis accelerometer/gyro, ultrasonic sensors, GPS sensor, cameras, a digital motion processor and a single credit-card-sized single-board microcomputer. The unit is used to collect information about the cane user and the surrounding obstacles while on the move. An embedded machine learning algorithm is developed and stored in the microcomputer memory to identify the detected obstacles and alarm the user about their nature. In addition, in case of emergencies such as a cane fall, the unit alerts the cane user and their guardian. Moreover, a mobile application is developed to be used by the guardian to track the cane user via Google Maps using a mobile handset to ensure safety. To validate the system, a prototype was developed and tested.

Cholangiocarcinoma: A diagnostic dilemma on cytology.

BACKGROUND: Cholangiocarcinoma is a relatively rare form of adenocarcinoma which may resemble adenocarcinoma of pancreatobiliary origin or adenocarcinomas from many other sites in the body. As a result, its diagnosis relies mainly on clinical history and morphology. CASE: A 64-year-old male with cirrhosis and worsening liver failure underwent fine needle aspiration of a radiologically detected liver mass. Cytological material showed a monomorphic population of cells arranged singly and in clusters, reminiscent of a neuroendocrine tumour (NET). Cell block morphology added to the diagnostic dilemma by showing a delicate vasculature among the tumour cells. Immunohistochemistry on the cell block revealed that cells were positive for CK7 and CK19 and negative for synaptophysin and chromogranin, thereby pointing towards a pancreatobiliary origin for the tumour and excluding an NET. CONCLUSION: In the case of liver aspirates, even when encountering confusing morphological entities, it is imperative to keep in mind the possibility of a rare neoplasm such as cholangiocarcinoma. In the absence of core needle biopsy, cell block sections prepared from aspirated material can provide appreciable immunohistochemistry results to resolve the diagnostic dilemma.