Diagnosis and Management of Non-Variceal Gastrointestinal Hemorrhage: A Review of Current Guidelines and Future Perspectives.

Non-variceal gastrointestinal bleeding (GIB) is a significant cause of mortality and morbidity worldwide which is encountered in the ambulatory and hospital settings. Hemorrhage form the gastrointestinal (GI) tract is categorized as upper GIB, small bowel bleeding (also formerly referred to as obscure GIB) or lower GIB. Although the etiologies of GIB are variable, a strong, consistent risk factor is use of non-steroidal anti-inflammatory drugs. Advances in the endoscopic diagnosis and treatment of GIB have led to improved outcomes. We present an updated review of the current practices regarding the diagnosis and management of non-variceal GIB, and possible future directions.

Home return following invasive mechanical ventilation for the oldest-old patients in medical intensive care units from two US hospitals.

BACKGROUND: The aging of the US population has been associated with an increase in intensive care unit (ICU) utilization and correspondingly, invasive mechanical ventilation (IMV) among the oldest-old (age ≥80 years). While previous studies have examined ICU and IMV outcomes in the elderly, very few have focused on patient-centered outcomes, specifically home return, in the oldest-old. We investigated the rate of immediate home return following IMV in the medical ICU in previously home-dwelling oldest-old patients relative to that of a comparison group of 50-70-year olds. METHODS: Data were extracted retrospectively from patient records at Elmhurst Hospital Center in Elmhurst, NY, USA, encompassing the period from January 2009 to May 2014 and Jacobi Medical Center in the Bronx, NY, USA, from January 2010 to March 2014. Medical ICU admissions within those date ranges were screened for possible inclusion into one of two study groups based on age: ≥80 years old and 50-70 years old. The primary end point was hospital discharge: home return versus no home return (death or nonhome discharge). Cox proportional hazards' regression models were used to estimate crude and multivariable-adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) for failure to return home. RESULTS: A total of 375 patients were included in the analysis: 279 (74%) patients aged 50-70 years and 96 (26%) patients aged ≥80 years. Compared to 50-70-year olds, being ≥80 years old was associated with a nearly two-fold greater risk of no home return: adjusted HR: 1.96; 95% CI 1.43-2.67. The oldest-old was at significantly increased risk of both being discharged to a skilled nursing facility or subacute rehabilitation (adjusted HR: 2.19; 95% CI 1.33-3.59) as well as of dying in the hospital (adjusted HR: 1.81; 95% CI 1.21-2.71). CONCLUSION: Previously home-dwelling oldest-old are at significantly increased risk of failing to return home immediately following medical ICU admission with IMV as compared to patients aged 50-70 years. These results can help medical ICU staff establish appropriate expectations when addressing the families of their oldest patients. Further studies are needed to evaluate the potential for delayed home return among the oldest old and to assess the ability of frailty indices to predict home return within this ICU population.

Differences in risk factor-colorectal adenoma associations according to non-steroidal anti-inflammatory drug use.

OBJECTIVE: Because multiple observational studies and large, randomized controlled trials indicate that NSAIDs strongly reduce the risk of colorectal neoplasms, we investigated whether NSAID use masks associations of various other risk factors with colorectal neoplasms. MATERIALS AND METHODS: Using pooled data from three case-control studies of incident, sporadic colorectal adenoma (pooled n=789 cases, 2035 polyp-free controls), using multivariable logistic regression, we investigated various risk factor-colorectal adenoma associations stratified by NSAID use. RESULTS: Example multivariable-adjusted odds ratios [95% confidence intervals (CI)] for those in the highest relative to the lowest quartiles of exposure, by regular nonaspirin NSAID nonuse/use, respectively, were 1.57 (95% CI: 0.96-2.55) versus 1.14 (95% CI: 0.37, 3.49) for total fat, 1.37 (95% CI: 0.86-2.18) versus 0.70 (95% CI: 0.23-2.25) for saturated fat, 0.93 (95% CI: 0.68-1.28) versus 1.30 (95% CI: 0.61-2.75) for calcium, 0.89 (95% CI: 0.64-1.23) versus 1.38 (95% CI: 0.65-2.94) for total fruits and vegetables, and 0.85 (95% CI: 0.65-1.11) versus 0.94 (95% CI: 0.52-1.71) for physical activity. For current versus never smokers, the odds ratios (95% CIs) among regular non-NSAID users/nonusers were 2.91 (95% CI: 2.22-3.82) versus 1.75 (95% CI: 0.90-3.41), respectively, and for those who were obese versus those who were normal weight, they were 1.67 (95% CI: 1.28-2.17) versus 1.19 (95% CI: 0.69-2.04), respectively. CONCLUSION: Our findings suggest that regular nonaspirin NSAID use may mask, beyond simple confounding, associations of major risk factors with colorectal adenoma, and support routinely assessing such associations stratified by regular nonaspirin NSAID use.

Publication trends in noninvasive cardiovascular imaging: 1991-2011: a retrospective observational study.

The last twenty years have seen an explosive growth in cardiovascular disease research. The purpose of our study was to evaluate the characteristics of published research in the field of non-invasive cardiovascular imaging research from 1991-2011. Our aims were to determine: (1) the origin of the studies (international or from the U.S.) (2) differences in funding sources for U.S. publications and (3) if there has been an evolving trend pertaining to the mode of imaging. We evaluated characteristics of original research articles from Circulation, Circulation cardiovascular imaging, Journal of the American College of Cardiology (JACC), Journal of the American College of Cardiology cardiovascular imaging, Journal of the American Medical Association and the New England Journal of Medicine for the years 1991-91, 2001-02 and 2010-11. To establish trends for contributions for U.S. based studies and proportions of U.S. based studies receiving NIH funding in the study period, data was compared using a chi-square test. A two sided p value of less than or equal to 0.05 was used as the threshold for significance. Differences in modes of imaging under study were made by comparing average number of publications between the data sets in the study period using a t-test analysis. A total of 5431 studies were reviewed; 594 studies were selected as per the standardized abstraction criteria. U.S. based publications outnumbered international publications; its' share declined from 77% in 1991-92 to 57% in 2010-2011 (p<0.0001). Funding for U.S. publications by the National Institutes of Health (NIH) remained static (1991-92: 40%; 2001-02: 49%; 2010-11: 42%). A decline was seen in the investigation of echocardiography (47%, p=0.44); cardiac computed tomography and cardiac magnetic resonance imaging studies grew 6.5 times (p=0.002) and 7-fold (p=0.01) respectively. Nuclear cardiology imaging fell by more than 50% (p=0.02). The last twenty years have seen a globalization of research in non-invasive cardiovascular imaging with a shift in focus towards investigation of cardiac magnetic resonance imaging. The decline in U.S. based publications coupled with a stasis in NIH funding may call for increased federal support for non-invasive imaging research.

Methadone, QTc prolongation and torsades de pointes: Current concepts, management and a hidden twist in the tale?

Methadone is a drug that has found widespread utility in the management of opioid addiction and pain. Along with its popularity, methadone has also earned an infamous reputation for causing prolongation of the QT interval and an increased risk of torsades de pointes. In this article we will give a brief overview of the long QT syndromes, followed by an in-depth look at the current pathophysiologic mechanisms of methadone induced QT prolongation, a review of the existing literature and the current concepts regarding the prevention and management of methadone induced torsades de pointes. In addition, we explore the idea and implications of a genetic link between methadone induced prolongation of the QT interval and torsades de pointes.

Spontaneous coronary artery dissection causing acute myocardial infarction in a 62-year-old postmenopausal woman without co-morbidities: a case report.

INTRODUCTION: Spontaneous coronary artery dissection is an important yet rare cause of acute coronary syndrome. The available literature shows a higher risk factor for women, notably during pregnancy and puerperium. The incidence in postmenopausal women is exceedingly rare, and is more commonly seen in association with concurrent predisposing factors.We illustrate an extremely rare case of a 62-year-old post-menopausal woman presenting with an acute myocardial infarction secondary to spontaneous dissection of the left anterior descending artery. Subsequent investigations did not reveal the presence of any co-morbidities.To the best of our knowledge, our patient is one of the oldest documented cases of spontaneous coronary artery dissection on record, and is notable for having no known underlying risk factors for development of spontaneous coronary artery dissection.Given the paucity of literature on spontaneous coronary artery dissection, particularly in postmenopausal women, we believe this case will provide further insight into the clinical presentation and management of this rare entity. CASE PRESENTATION: A 62-year-old previously healthy postmenopausal Hispanic woman presented with chest pain and was found to have an ST elevation myocardial infarction. Cardiac catheterization revealed a dissection in her left anterior descending artery. Revascularization was deferred; our patient received appropriate medical management and remained asymptomatic. A full panel of tests was done to exclude underlying connective tissue disorders and vasculitis. On subsequent follow-up, our patient continued to do well and all work-up was reported as negative. CONCLUSION: We describe the varied presentation and subsequent management of a case of spontaneous coronary artery dissection and highlight the importance of considering spontaneous coronary artery dissection as a differential diagnosis even in older, postmenopausal women.The consequences of a delay in diagnosis and appropriate management are associated with a high mortality and morbidity; hence we believe that reporting all cases of spontaneous coronary artery dissection, particularly in postmenopausal women, will add invaluable information to the limited literature on this rare condition.