CYP2C19 loss-of-function alleles are not associated with higher prevalence of gastrointestinal bleeds in those who have been prescribed antidepressants: Analysis in a British-South Asian cohort.

AIMS: CYP2C19 is a hepatic enzyme involved in the metabolism of antidepressants associated with increased gastrointestinal bleed (GIB) risk. The aim of our study was to explore a possible association between loss-of-function CYP2C19 genotypes and GIB in South Asian ancestry participants prescribed antidepressants. METHODS: Genes & Health participants with a record in Barts Health NHS Trust (N 22 753) were studied using a cross-sectional approach. CYP2C19 diplotypes were assessed and metabolizer type inferred from consortia guidance. Fisher's exact test was used to compare the prevalence of GIB in different metabolizer categories. Multivariable regression was used to test for association between antidepressant prescriptions and GIB, and between CYP2C19 metabolizer state and GIB in the subcohort prescribed antidepressants. RESULTS: Antidepressants were frequently prescribed (47%, N = 10 612). A total of 864 participants (4%) had a GIB; 534 (62%) had been prescribed a CYP2C19 metabolized antidepressant. There was an independent association between antidepressant prescriptions and GIB events (odds ratio 1.8, confidence interval 1.5-2.0, P < 0.0001). There was no relationship between CYP2C19 inferred poor (P 0.56) or intermediate (P 0.53) metabolizer status and GIB in those prescribed an antidepressant in unadjusted analysis. A multivariable logistic regression model did not show an independent association between poor (P 0.54) or intermediate (P 0.62) CYP2C19 metabolizers and GIB in the subcohort prescribed antidepressants. CONCLUSIONS: CYP2C19 dependent antidepressants are associated with increased GIB prevalence. GIB appeared independent from CYP2C19 metabolizer genotype in individuals who had been prescribed antidepressants. Precision dosing based on CYP2C19 genetic information alone is unlikely to reduce GIB prevalence.

Mortality, Risk Factors and Disparities Associated with Esophageal Variceal Bleeding in Children's Hospitals in the US.

OBJECTIVES: To use a large administrative database to determine the mortality, risk factors, and comorbidities of esophageal variceal bleeding in children. STUDY DESIGN: Retrospective cohort study using Pediatric Health Information System data from 50 tertiary children's hospitals in the US. International Classification of Diseases (ICD) codes (FY 2020 ICD-10 update and revision 10 of ICD-9) from 2004 through 2019 identified children 18 years and younger with variceal bleeding and complications. Univariate analyses used the Student t -test for continuous variables (age) and the χ2 test for categorical variables (all others). A mixed-effects linear regression was performed for multiple variables. RESULTS: There were 1902 patients who had 3399 encounters for esophageal variceal bleeding. The mortality rate for variceal bleeding was 7.3%, increasing to 8.8% by 6 weeks; any mortality during the study was 20.1%. Transfusion was required in 54.7% of encounters, and 42.6% were admitted to the intensive care unit. Variceal bleeding encounters were complicated by peptic ulcer disease (6.9%), bacteremia (11.4%), acute renal failure (5.1%), mechanical ventilation (18%), ascites (21.3%), and peritonitis (3.3%). Multivariable mixed-effects logistic regression showed that Black race (OR, 2.59; P < .001) or Hispanic ethnicity (OR, 2.31; P = .001), but not sex, household income, or insurance type, were associated with increased mortality. Bacteremia, peritonitis, mechanical ventilation, acute renal failure, and transfusion were associated with higher mortality (ORs of 2.29, 2.18, 1.93, 6.33, and 1.81, respectively; P < .001, .005, .011, <.001, and .005, respectively). CONCLUSIONS: The 6-week mortality rate for variceal bleeding in children is 8.8%. Black or Hispanic children are at higher risk of dying. Serious morbidities associated with variceal hemorrhage impact mortality. These data can inform consideration of prophylactic or therapeutic interventions for children at risk.

Development and Validation of a Scoring System to Predict Severe Acute Lower Gastrointestinal Bleeding in Vietnamese.

BACKGROUND/AIMS: The prevalence of acute lower gastrointestinal bleeding (ALGIB) has progressively increased worldwide but there are few studies in Asian populations. This study aimed to develop and validate a scoring system to predict severe ALGIB in Vietnamese. METHODS: Risk factors for severe ALGIB were identified by multiple logistic regression analysis using data from a retrospective cohort of 357 patients admitted to a tertiary hospital. These factors were weighted to develop the severe acute lower gastrointestinal bleeding (SALGIB) score to predict severe ALGIB. The performance of SALGIB was validated in a prospective cohort of 324 patients admitted to 6 other hospitals using area under the receiver operating characteristics curve (AUC) analysis. RESULTS: There were four factors at admission independently associated with severe ALGIB in the derivation cohort: heart rate ≥ 100/min, systolic blood pressure < 100 mmHg, hematocrit < 35%, and platelets ≤ 150 × 103/µL. The SALGIB score determined severe ALGIB with AUC values of 0.91 and 0.86 in the derivation and validation cohorts, respectively. A SALGIB score < 2 associated with low risk of severe ALGIB in both cohorts (3.7% and 1.2%; respectively). CONCLUSIONS: The SALGIB score has good performance in discriminating risk of severe ALGIB in Vietnamese.

Non-vitamin K antagonist oral anticoagulants in very elderly east Asians with atrial fibrillation: A nationwide population-based study.

BACKGROUND: The evidence of effectiveness and safety of the non-vitamin K antagonist oral anticoagulants (NOACs) among elderly East Asians is limited. OBJECTIVES: We aimed to describe the effectiveness and safety outcomes associated with NOACs and warfarin among elderly Koreans aged ≥80 years. METHODS: Using the Korean Health Insurance Review and Assessment service database, patients with atrial fibrillation (AF) who were naïve to index oral anticoagulant between 2015 and 2017 were included in this study (20,573 for NOACs and 4086 for warfarin). Two treatment groups were balanced using the inverse probability of treatment weighting (IPTW) method. The clinical outcomes including ischemic stroke, major bleeding including intracranial hemorrhage (ICH) and gastrointestinal bleeding (GIB), and a composite of these outcomes were evaluated. RESULTS: Compared to warfarin, NOACs were associated with lower risks of ischemic stroke (hazard ratio 0.74 [95% confidence interval 0.62-0.89]), and composite outcome (0.78 [0.69-0.90]). NOACs showed nonsignificant trends towards to lower risks of GIB and major bleeding than warfarin. The risk of ICH of NOAC group was comparable with the warfarin group. Among NOACs, apixaban and edoxaban showed better composite outcomes than warfarin. Among the clinical outcomes, only ischemic stroke and the composite outcome had a significant interaction with age subgroups (80-89 years and ≥90 years, P-for-interaction = .097 and .040, respectively). CONCLUSION: NOACs were associated with lower risks of ischemic stroke and the composite outcome (ischemic stroke and major bleeding) compared to warfarin in elderly East Asians. Physicians should be more confident in prescribing NOACs to elderly East Asians with AF.

Ethnic inequality in non-steroidal anti-inflammatory drug-associated harm in New Zealand: A national population-based cohort study.

PURPOSE: Non-steroidal anti-inflammatory drugs (NSAIDs) are associated with many serious complications and they are widely used in New Zealand (NZ). However, differences in NSAID-associated risk for these complications between ethnic groups are largely unknown. We assessed ethnic disparities in risk of hospital admission for upper gastrointestinal bleeding (UGIB), heart failure, and acute kidney failure (AKF) in NZ's primary care population prescribed and dispensed NSAIDs. METHODS: Retrospective cohort study utilising national pharmaceutical dispensing and hospital admissions data 2007 to 2015. Patient follow-up included 90-day periods following the dispensing of NSAIDs. Risk for each adverse outcome in Maori, Pacific, European, and Asian patients was estimated using multivariable Poisson regression adjusting for age, sex, deprivation, comorbidity and concurrent drug use. RESULTS: 3 023 067 patients were dispensed NSAIDs between 2008 and 2015. Their total intended duration of NSAID treatment encompassed 2 353 140 patient-years. Maori, Pacific and Asian patients were younger than European patients (all P < .001). After adjusting for other risk factors, Maori (rate ratio: 2.54, 95% confidence interval: 2.23-2.90) and Pacific patients (3.17, 2.69-3.74) were more likely to be hospitalised for UGIB than Europeans (reference), and heart failure (Maori: 2.48, 2.24-2.74; Pacific: 1.97, 1.69-2.30). Risk of AKF was higher in Maori (1.46, 1.23-1.74). Higher risk for UGIB and HF in Maori and Pacific patients was most pronounced in males and patients aged <60 years. CONCLUSIONS: Inequalities exist in the incidence of serious adverse outcomes experienced by different ethnic groups in NZ while using NSAIDs. Interventions to promote safer use of these medicines are required to reduce this inequity.

Sex and race and/or ethnicity differences in patients undergoing radiofrequency ablation for Barrett's esophagus: results from the U.S. RFA Registry.

BACKGROUND: Little is known about differences in Barrett's esophagus (BE) characteristics by sex and race and/or ethnicity or these differences in response to radiofrequency ablation (RFA). OBJECTIVE: We compared disease-specific characteristics, treatment efficacy, and safety outcomes by sex and race and/or ethnicity in patients treated with RFA for BE. DESIGN: The U.S. RFA patient registry is a multicenter collaboration reporting processes and outcomes of care for patients treated with RFA for BE. PATIENTS: Patients enrolled with BE. INTERVENTIONS: RFA. MAIN OUTCOME MEASUREMENTS: We assessed safety (stricture, bleeding, perforation, hospitalization), efficacy (complete eradication of intestinal metaplasia [CEIM]), complete eradication of dysplasia, and number of treatments to CEIM by sex and race and/or ethnicity. RESULTS: Among 5521 patients (4052 men; 5126 white, 137 Hispanic, 82 African American, 40 Asian, 136 heritage not identified), women were younger (60.0 vs 62.1 years) and had shorter BE segments (3.2 vs 4.4 cm) and less dysplasia (37% vs 57%) than did men. Women were almost twice as likely to stricture (odds ratio 1.7; 95% confidence interval, 1.2-2.3). Although white patients were predominantly male, about half of African Americans and Asians with BE were female. African Americans and Asians had less dysplasia than white patients. Asians and African Americans had more strictures than did white patients. There were no sex or race differences in efficacy. LIMITATIONS: Observational study with non-mandated paradigms, no central laboratory for reinterpretation of pathology. CONCLUSION: In the U.S. RFA patient registry, women had shorter BE segments and less-aggressive histology. The usual tendency toward BE in men was absent in African Americans and Asians. Posttreatment stricture was more common among women and Asians. RFA efficacy did not differ by sex or race.

Impact of ethnicity in upper gastrointestinal hemorrhage.

GOALS: To examine ethnicity's role in the etiology and outcome of upper gastrointestinal hemorrhage (UGIH). BACKGROUND: UGIH is a serious condition with considerable associated morbidity and mortality. MATERIALS AND METHODS: We analyzed 2196 patients admitted with acute UGIH between January 2006 and February 2012. Complete clinical data were gathered prospectively and entered into our GI Bleed Registry, which captures demographic and clinical variables. Results were analyzed using the χ² analyses and the analysis of variance techniques with Tukey multiple comparisons. RESULTS: Among 2196 patients, 620 (28%) were black, 625 (29%) white, 881 (40%) Hispanic, and 70 (3%) were members of other ethnicities. Gastroduodenal ulcers (25%), esophageal varices (25%), and esophagitis (12%) were the most frequently identified causes of UGIH. Blacks experienced a high rate of gastroduodenal ulcers (199/620), whereas Hispanics most commonly had esophageal varices. In all ethnicities, the most common cause of bleeding in patients younger than 35 or older than 65 years was gastroduodenal ulcer disease. However, among patients aged 35 to 64 years, there were differences in the etiology of UGIH. Blacks aged 50 to 64 years frequently experienced gastroduodenal ulcers, whereas Hispanics aged 35 to 49 years typically had esophageal varices. Rebleeding rates were significantly lower in whites (5.8%) than in Hispanics (9.9%) or blacks (8.7%) (P=0.02). CONCLUSIONS: By examining a diverse population, we conclude that UGIH may follow trends. Hispanics were likely to have esophageal varices and higher rebleeding rates, whereas blacks were likely to have ulcers and the highest mortality. Whites were equally likely to have ulcers or varices, but a lower rate of rebleeding.

Incidence of upper gastrointestinal haemorrhage in Maori and New Zealand European ethnic groups, 2001-2010.

BACKGROUND: To date no incidence figures for upper gastrointestinal haemorrhage (UGIH) in New Zealand have been published. AIMS: To determine the incidence of UGIH in a demographically defined population, and to assess variation in incidence associated with demographic parameters. METHODS: Between 17 March 2001 and 12 October 2010, all patients presenting to Waikato Hospital with UGIH were prospectively ascertained, and clinical, epidemiological and laboratory data were collected. Incidence rates were calculated, and were age adjusted to the World Health Organization world standard population. Parameters associated with trends in incidence were examined. RESULTS: There were 1360 UGIH events, yielding a crude incidence of 59.2 per 100,000 adults (age ≥ 15 years) per year (all quoted incidence figures per 100,000 adults per year), and an age-adjusted incidence (AAI) of 46.4. AAI was higher for Maori compared with New Zealand Europeans (91.3 vs 37.0, rate ratio (RR) = 2.47, P < 0.001). Maori were more likely to have a gastric ulcer at endoscopy (odds ratio (OR) = 2.21, P < 0.001). For those tested for Helicobacter pylori (n = 702), Maori were more likely to be infected (OR = 2.12, P < 0.001). AAI was higher for males (61.1 vs 33.6, RR = 1.82, P < 0.001). Males were more likely to have a duodenal ulcer at endoscopy (OR = 1.79, P < 0.001). AAI incidence decreased from the first to the second half of the study period (53.6 vs 45.8, RR = 1.17, P < 0.001). CONCLUSION: AAI of UGIH in the Waikato region was 46.4. This was significantly higher in Maori and in males, and decreased over the study period. These data will provide a comparison for future assessment of trends in UGIH.

Upper Gastrointestinal Bleeding in Japanese Patients Prescribed Antithrombotic Drugs: Differences in Trends over Time.

BACKGROUND/AIMS: We studied the features of upper gastrointestinal bleeding (UGIB) in patients taking antithrombotic drugs. METHODOLOGY: The records of 430 patients taking antithrombotic drugs who underwent emergency endoscopy for UGIB in Saga Medical School Hospital between 2002 and 2011 were studied. We also compared the characteristics of our cohort of 11,919 patients prescribed antithrombotic drugs in our hospital between 2002 and 2011. UBGI patients of variceal bleeding were not included in this study. RESULTS: 186 patients presented with UGIB in the first period (2002-2006) and 244 in the second period (2007-2011). The proportion of patients infected with Helicobacter pylori was lower in the second period, while the proportion taking antithrombotic drugs rose significantly. Peptic ulcer disease was responsible for the majority of bleeding episodes; however, bleeding from other sources is increasing. In the whole cohort, the risk of UGIB was 1.08%; however, of the 31.8% who also took an acid-secretion inhibitor only 18 (0.28%) developed bleeding. In contrast, 102 (1.87%) of those not taking an acid-secretion inhibitor developed UGIB, a statistically significant difference. CONCLUSION: Risk of UGIB in Japanese patients taking antithrombotics was 1.01% and the incidence is increasing. Acid-secretion inhibitors reduced the risk of antithrombotic drug-related UGIB.

Gastrointestinal bleeding associated with antithrombotic therapy in the elderly in Japan.

BACKGROUND/AIMS: We summarize data of patients with gastrointestinal bleeding (GIB) and discuss the relationship between antithrombotic drug use and age in patients with GIB. METHODOLOGY: One-hundred and twenty patients with GIB were divided into two groups according to age (=75 years old and <75 years old). The causes and clinical outcome of each group were compared. RESULTS: Forty-two patients received antithrombotic therapy. The main antithrombotic drugs were low dose aspirin (38 patients), ticlopidine (5 patients) and warfarin (3 patients). Compared with younger GIB patients, elderly patients had more coexisting illness and antithrombotic drugs. In patients taking antithrombotic drugs, upper GIB is more frequent than those not taking antithrombotic drugs (p<0.05) and antithrombotic drugs were the risk for GIB from erosive lesions of the esophagus or stomach. In the lower gastrointestinal tract, there was no difference of incidence related to antithrombotic use. The initial endoscopic hemostasis was performed in 14 patients. Eight varices patients received endoscopic vanding and 6 of 43 gastroduodenal ulcer patients had mechanical clip hemostasis. CONCLUSIONS: From our findings, antithrombotic drugs were considered to be a risk for GIB. It might be important to prevent or minimize GIB in elderly patients prescribed antithrombotic drugs.

Epidemiology of lower gastrointestinal bleeding in China: single-center series and systematic analysis of Chinese literature with 53,951 patients.

OBJECTIVES: The epidemiology of lower gastrointestinal bleeding (LGIB) in Western populations has been reported; however, there are scant Asian reports. The aim of the present study was to determine the etiology of LGIB in a Chinese population by reporting a retrospective case series and a systematic analysis of Chinese literature. METHODS: A large colonoscopy database in a tertiary endoscopic center was searched to identify all patients with the indication of LGIB. The data, including patients' sex, age, endoscopic and pathological findings, were collected and analyzed. A comprehensive database search of the Chinese literature was carried out to obtain all relevant studies. RESULTS: In our series, a total of 720 patients with LGIB were included. There were 425 males and 295 females with a median age of 50 years, the most common etiologies of LGIB were inflammatory bowel disease (IBD; 30.2%), polyps (23.4%) and cancer (10.7%). In 30.2% of all the patients, no obvious causes were identified. A systematic analysis of Chinese literature found an additional 160 studies providing relevant data in 53,951 patients. Overall, colorectal cancer (24.4%), colorectal polyps (24.1%), colitis (16.8%), anorectal disease (9.8%) and IBD (9.5%) were the most common etiologies of LGIB. The main etiologies were different between adults, the elderly and children. CONCLUSION: The study shows colorectal cancer, colorectal polyps, colitis, anorectal disease and IBD were the most common etiologies of LGIB in the Chinese adult and elderly population, whereas colorectal polyps, chronic colitis and intussusception were the main causes of LGIB in Chinese children. Whereas diverticulum, the most common cause of LGIB in Western populations, is uncommon in China.

Regional distinction for the clinical severity of Behçet's disease in Korea: four university-based medical centers study.

OBJECTIVES: To analyse the clinical manifestations and severity of Behçet's disease (BD) in Korea according to geographic region of residence, and to identify risk factors associated with clinical severity. METHODS: We enrolled 246 BD patients (88 males) who fulfilled the criteria of the International Study Group for BD. These patients were assigned into two groups: a Western group comprising 127 residents in west regions and an Eastern group comprising 119 residents of the SoBaek Mountains situated in the center of Korea. Clinical severity was assessed using a severity scoring index of BD. RESULTS: BD patients from the Western group had a greater prevalence of typical skin lesions, deep vein thrombosis, gastrointestinal bleeding, posterior/ panuveitis, and retinal vasculitis than did the Eastern group (p<0.001, p=0.009, p=0.032, and p=0.007, respectively). The Western group also had higher severity scores than did the Eastern group (5.88±2.5 for the Western group vs. 4.94±2.6 for the Eastern group, p=0.004). Male BD patients had higher severity scores than did female patients (6.14±2.8 vs. 5.03±2.4, p=0.001). The disease duration of BD in the Western group showed a significant association with total severity scores (r=0231, p=0.009), but this was not observed for the Eastern group. CONCLUSIONS: We found distinct differences in the clinical manifestations as well as severity of BD according to geographic region in Korean BD patients. Males, particularly those from the Western region of Korea, had significantly higher severity scores than did females.

Upper gastro-intestinal bleeding: aetiology and demographic profile based on endoscopic examination at Dhulikhel Hospital, Kathmandu University Hospital.

BACKGROUND: The upper gastrointestinal bleeding (UGIB) is defined as bleeding within the intraluminal gastrointestinal tract from any location between the upper oesophagus to the duodenum at the ligament of Treitz. It is one of the important medical emergencies worldwide. OBJECTIVE: The objective of this study is to study the aetiology of upper gastrointestinal bleeding based on endoscopic examination findings in patients of various demographic characteristics. MATERIALS AND METHODS: This is a retrospective observational study. The endoscopic record book from 2007 January to 2009 October was reviewed for all the cases who underwent oesophago-gastro-duodenoscopic examination for upper GI bleeding. The clinico-epidemiological data of all the patients was reviewed and analyzed in concert with the aetiology of bleeding. RESULTS: A total of 90 patients (58 males, 32 females; mean age 45.32+ 18.47 years) of upper gastrointestinal bleeding was studied and analyzed in terms of aetiology of bleeding and demographic profile. Among the ethnic groups, Aryan 46 (51%) was the most common ethnic group to have upper GI bleeding followed by Newars 24 (27%), Mongolians 16 (18%), Dalits 3 (3%) and others 1 (1%). Out of 90 patients, 47( 52.2%) cases was less than 45 years of age, 30(33.3%) of 46 to 65 age ; and 13(14.4 %) more than 65 years of age. Gastric ulcer 23(25.6%) was the most common endoscopic finding, followed by oesophageal varices 14 (15.6%), acute erosive/haemorrhagic gastropathy 11 (12.2%), duodenal ulcer 9(10%), growth 7(7.8%), vascular lesions 3(3.3%), Mallory-Weiss tear 1(1.1%), fundal varices 1(1.1%) and, no cause was identified in 21(23.3%) cases. The peptic ulcer bleeding was the most common finding in Aryan 22(47.9%), whereas oesophageal varices and growth were more common in Newar 7(29.2%) and 3 (12.5%) respectively. CONCLUSION: Peptic ulcer disease is the most common cause of upper GI bleeding which was most commonly found in Aryan population; followed by oesophageal varices and growth as second and third most common causes and were more prevalent in Newar and Mongolian people.

Changes on the disease pattern of primary colorectal cancers in Southern China: a retrospective study of 20 years.

PURPOSE: Some changes on the disease pattern of colorectal cancer (CRC) have occurred in some Asian countries recently. However, nothing is known about it in China lately. The present study is to determine whether there are any changes on the disease pattern of CRC in Southern China. PATIENTS AND METHODS: Data were collected from all consecutive patients accepting colonoscopy in our endoscopy center during the last 20 years. The sociodemographic data, clinical presentations, endoscopic descriptions, and histological subtypes of patients confirmed as CRC by pathology were analyzed retrospectively. RESULTS: A total of 37,578 patients accepted colonoscopy from 1987 to 2006, in which 2,876 patients were diagnosed as CRC. The median age of patients in the 2nd decade (1997-2006; 62 years) was getting older than the 1st decade (1987-1996; 58 years; P = 0.043). Hematochezia was the most frequent symptom (55.8%), while rectum was the most common site distribution of CRC (51.0%). The incidence of right-sided colonic cancers in the 2nd decade (21.0%) was higher than the 1st decade (17.3%; P = 0.0314). Histologically, adenocarcinoma was the most common (92.4%), of which moderately differentiated tumors were more frequent (67.7%). CRCs with high-grade malignancy were more likely to occur in the 1st decade (P < 0.0001). CONCLUSIONS: Rectum remains the most common site of CRC in southern China. But a rightward shift in the site distribution has occurred and patients are getting older. Tumors with high-grade malignancy have the tendency to decrease.

Etiological spectrum of esophageal varices due to portal hypertension in Indian children: is it different from the West?

BACKGROUND AND AIM: Information about portal hypertension (PHT) in children is meagre. We therefore studied the spectrum and outcome of PHT in children (

Epidemiology and outcomes of hypoglycemia in patients with advanced diabetic kidney disease on dialysis: A national cohort study.

BACKGROUND: Patients with advanced diabetic kidney disease (DKD) behave differently to diabetic patients without kidney disease. We aimed to investigate the associations of hypoglycemia and outcomes after initiation of dialysis in patients with advanced DKD on dialysis. METHODS: Using National Health Insurance Research Database, 20,845 advanced DKD patients beginning long-term dialysis between 2002 and 2006 were enrolled. We investigated the incidence of severe hypoglycemia episodes before initiation of dialysis. Patients were followed from date of first dialysis to death, end of dialysis, or 2008. Main outcomes measured were all-cause mortality, myocardial infarction (MI), and subsequent severe hypoglycemic episodes after dialysis. RESULTS: 19.18% patients had at least one hypoglycemia episode during 1-year period before initiation of dialysis. Advanced DKD patients with higher adapted Diabetes Complications Severity Index (aDCSI) scores were associated with more frequent hypoglycemia (P for trend < 0.001). Mortality and subsequent severe hypoglycemia after dialysis both increased with number of hypoglycemic episodes. Compared to those who had no hypoglycemic episodes, those who had one had a 15% higher risk of death and a 2.3-fold higher risk of subsequent severe hypoglycemia. Those with two or more episodes had a 19% higher risk of death and a 3.9-fold higher risk of subsequent severe hypoglycemia. However, previous severe hypoglycemia was not correlated with risk of MI after dialysis. CONCLUSIONS: The rate of severe hypoglycemia was high in advanced DKD patients. Patients with higher aDCSI scores tended to have more hypoglycemic episodes. Hypoglycemic episodes were associated with subsequent hypoglycemia and mortality after initiation of dialysis. We studied the associations and further study is needed to establish cause. In addition, more attention is needed for hypoglycemia prevention in advanced DKD patients, especially for those at risk patients.

Digestive and urologic hemorrhage after intravenous thrombolysis for acute ischemic stroke: Data from a Chinese stroke center.

Objective Intravenous thrombolysis with recombinant tissue plasminogen activator (rt-PA) is considered the most effective treatment method for AIS; however, it is associated with a risk of hemorrhage. We analyzed the risk factors for digestive and urologic hemorrhage during rt-PA therapy. Methods We retrospectively analyzed patients with AIS who underwent intravenous thrombolysis with rt-PA during a 5-year period in a Chinese stroke center. Data on the demographics, medical history, laboratory test results, and clinical outcomes were collected. Results 338 patients with AIS were eligible and included. Logistic regression multivariate analysis showed that gastric catheter was significantly correlated with digestive hemorrhage, while age and urinary catheter were significantly correlated with urologic hemorrhage. Most hemorrhagic events were associated with catheterization after 1 to 24 hours of rt-PA therapy. Conclusions In summary, gastric and urinary catheters were correlated with digestive and urologic hemorrhage in patients with AIS undergoing rt-PA therapy. Well-designed controlled studies with large samples are required to confirm our findings.

Increased use of selective serotonin reuptake inhibitors in patients admitted with gastrointestinal haemorrhage: a multicentre retrospective analysis.

BACKGROUND: Selective serotonin reuptake inhibitors (SSRIs) can adversely affect platelet function and impair haemostasis. Various bleeding complications have been reported in persons taking SSRIs including an increased risk of gastrointestinal haemorrhage (GIH). AIM: To evaluate SSRI use in patients hospitalized with GIH compared with controls. METHODS: A retrospective, multicentre case-control study determined use of SSRIs, non-steroidal anti-inflammatory drugs (NSAIDs), aspirin, clopidogrel, coumadin and enoxaparin in patients admitted with GIH and age- and sex-matched controls. Exclusion criteria included liver disease, portal hypertension or bleeding diathesis. RESULTS: A total of 579 cases were matched with 1000 controls. SSRI use was 19.2% in cases and 13.6% in controls [OR (95% CI) = 1.5 (1.2-2.0); P = 0.003]. NSAIDs were used by 7.3% of cases and 3.8% of controls [OR = 2.0 (1.3-3.1); P = 0.003]. SSRI use was more strongly associated with lower [1.8 (1.2-2.8)] rather than upper [1.3 (0.83-1.9)] GIH. Significant interactions existed for SSRI use with NSAIDs and aspirin. CONCLUSIONS: Patients admitted with GIH gastrointestinal bleeding were more likely to be taking SSRIs than controls. This association exists for lower as well as upper GIH. Physicians should be aware of this risk particularly in patients already using medications that increase GIH risk.

Upper gastrointestinal hemorrhage in African-American and Hispanic elderly patients.

OBJECTIVES: To investigate the frequency and etiology of upper gastrointestinal hemorrhage (UGIH) in African-American and Hispanic elderly patients, and to determine the risks and benefits of endoscopic intervention. SETTING: An inner-city county hospital serving predominantly African-American and Hispanic populations. METHODS: Records of 290 patients, 65 to 95 years of age, with diagnosis of UGIH, were reviewed retrospectively, 12 White and 8 Asian patients were excluded. RESULTS: Source of bleeding remained unidentified in 25 of 270 patients and they were also excluded. Endoscopic findings in 245 patients were: 59 gastric ulcers, 52 duodenal ulcers, 49 gastric erosions, 37 gastroesophageal varices, 25 Mallory Weiss tears, 15 angiodysplasias, 13 Dieulafoy's lesions, 12 portal hypertensive gastropathies, 8 esophageal cancers with bleeding, and 7 gastric cancers with bleeding; 32 patients had more than one lesion. Endoscopic therapy was administered to 159 patients, and was helpful in stopping bleeding and/or delaying surgery in 102 patients. Overall, there were 59 deaths, mostly due to underlying multiple system disease. There was no death directly due to endoscopy. CONCLUSIONS: Acute UGIH in African-American and Hispanic elderly patients is a serious condition, associated with significant morbidity and mortality. Benefits of endoscopy should be offered to all such patients, and endoscopy should not be withheld because of age alone.

Lower gastrointestinal hemorrhage in African-American and Hispanic elderly patients.

OBJECTIVES: To investigate the frequency and etiology of lower gastrointestinal hemorrhage (LGIH) in African-American and Hispanic elderly patients and to determine its natural history and the risks and benefits of therapeutic interventions. SETTING: Inner-city community teaching hospital serving predominantly African-American and Hispanic populations. METHODS: Records of 236 patients, 65 to 103 years of age, with a diagnosis of LGIH were reviewed retrospectively, over a period of 7 years, (9 White and 6 Asian patients were excluded). RESULTS: In 21 patients, the source of bleeding was located in the upper gastrointestinal tract, and these patients were excluded from the study. The source of bleeding remained unidentified in 16 of 200 patients, and they were also excluded. Bleeding was so profuse in 19 patients that satisfactory endoscopy could not be performed and emergency angiography and/or surgery was required. Endoscopic results were available in 165 patients and included: internal hemorrhoids in 60 (active bleeding in 23) patients, diverticular bleeding in 55, angiodysplasia in 50, polyps in 37, cancer in 23, drug-induced (anti-coagulants, non-steroidal anti-inflammatory drugs) lesions in 20, ischemic colitis in 15, ulcerative colitis in 10, solitary rectal ulcer in 9, Crohn's disease in 8, and colonic varices in 6 patients. Forty-eight patients had more than one lesion. Endoscopic therapy was given to 101 patients and was helpful in stopping bleeding and/or delaying surgery in 69 patients. Overall, there were 43 deaths, mostly due to underlying multiple system disease. Mortality rates did not differ by race/ethnicity or gender. Older elderly (76-85 yrs.; P < 0.01) and (> 85 yrs.; P < 0.001) had higher mortality rates. None of the deaths were directly due to endoscopy. CONCLUSIONS: Despite the small number of patients, our study suggests that acute LGIH in African-American and Hispanic elderly patients is a common condition, with the potential to become a life-threatening event. All such patients should be offered the benefits of early endoscopy and therapeutic interventions, unless contraindicated by their advanced directives. A patient's advanced age should not be a deterrent to any of the diagnostic or therapeutic interventions.