Occult vs. overt upper gastrointestinal bleeding - inverse relationship and the use of mucosal damaging and protective drugs.

BACKGROUND: While efforts have focused on the prevention of overt upper gastrointestinal bleeding (UGIB), little is known about occult GIB, which might also originate from sites not protected by acid inhibition. AIM: To measure the incidence and outcomes of both overt and occult GIB over a 6-year period (2007-2012), and to assess the use of NSAIDs, anti-thrombotic therapy (ATT), proton pump inhibitors (PPIs), and iron therapy. METHODS: A sample of 300 patients (100 from each of three index years) with occult GIB was randomly selected and their outcomes were compared with those of patients with overt UGIB (N = 869). RESULTS: The incidence of overt UGIB fell from 140.1 per 100 000 population per annum in 2007 to 106.8 in 2010 and to 88.0 in 2012 (P < 0.001); while that of occult GIB rose from 243.1 to 263.6 and to 292.8 (P < 0.001) over the same period. The incidence of occult GIB was highly correlated with the number of prescriptions of PPIs per 1000 population (χ(2) trend = 11.80; P < 0.001). In the overt UGIB group, the median haemoglobin level on presentation was lowest (10.3) in patients taking NSAIDs/ATT plus PPIs compared with those taking PPIs alone (11.5), NSAIDs/ATT alone (10.4) or none of these drugs (12.7 g/dL) (P < 0.001, Kruskal-Wallis). CONCLUSIONS: An inverse trend seems to have formed in the incidence of overt vs. occult gastrointestinal bleeding in association with the wider use of PPIs and NSAIDs. An alternative approach to acid inhibition is needed to prevent gastrointestinal bleeding.

Blood lead level among Palestinian schoolchildren: a pilot study.

In Palestine, chronic exposure to lead has not been adequately addressed as a problem for children. To assess the exposure of Palestinian schoolchildren, we surveyed blood lead levels in 3 schools in Nablus city and collected demographic and clinical data. Blood samples were collected from 178 children (140 boys, 38 girls), age range 6-8 years. The overall mean blood lead level was 3.2 (SD 2.4) microg/dL, and 4.5% of children had levels above 10 microg/dL. Blood lead levels were significantly higher among children living in refugee camps near industrial/high traffic regions than among children living in residential areas of the city. Blood lead levels were positively correlated with family size (r = 0.15) and negatively correlated with household area (r = -0.18). Blood lead levels among these Palestinian schoolchildren were higher than those of other countries where leaded gasoline has been banned and seemed to be higher in more economically deprived children.

Blood lead level among Palestinian schoolchildren: a pilot study

In Palestine, chronic exposure to lead has not been adequately addressed as a problem for children. To assess the exposure of Palestinian school children, we surveyed blood lead levels in 3 schools in Nablus city and collected demographic and clinical data. Blood samples were collected from 173 children [140 boys/38 girls], age range 6-8 years. The overall mean blood lead level was 3.2 [SD 2.4] microg/dL, and 4.5% of children had levels above 10 microg/dL Blood lead levels were significantly higher among children living in refugee camps near industrial high traffic regions than among children living in residential areas of the city. Blood lead levels were positively correlated with family size [r = 0.15] and negatively correlated with household area [r =0.18]. Blood lead levels among these Palestinian schoolchildren were higher than those of other countries where leaded gasoline has been banned and seemed to be higher in more economically deprived children

Utilization and cost of antibacterial drugs in 2 general surgery units in Palestine measured using anatomical therapeutic chemical classification and defined daily dose methodology.

This study compared the utilization and cost of antibacterial agents in surgical units of 2 government hospitals in Palestine. The consumption and cost of drugs was estimated in the units over a 1-month period in 2010 using the anatomical therapeutic chemical classification and defined daily doses (DDD) per 100 bed-days. The total consumption of antibacterial agents was 414.1 DDD and 591.5 DDD at Thabet and Rafidia hospitals respectively. These corresponded to 133.6 DDD/100 bed-days and 162.2 DDD/100 bed-days respectively, figures that were higher than those reported in surgical units in many other countries. Total cost of antibacterial agents during the study period was 24 800 and 23481 NIS for Rafidia and Thabet hospitals respectively. Approximately 11.2% and 18.0% of the total antibiotic DDD in Rafidia and Thabet hospitals were given to patients with clean surgeries in which antibiotic prophylaxis is not indicated.

Utilization and cost of antibacterial drugs in 2 general surgery units in Palestine measured using anatomical therapeutic chemical classification and defined daily dose methodology

This study compared the utilization and cost of antibacterial agents in surgical units of 2 government hospitals in Palestine. The consumption and cost of drugs was estimated in the units over a 1-month period in 2010 using the anatomical therapeutic chemical classification and defined daily doses [DDD] per 100 bed-days. The total consumption of antibacterial agents was 414.1 DDD and 591.5 DDD at Thabet and Rafidia hospitals respectively. These corresponded to 133.6 DDD/100 bed-days and 162.2 DDD/100 bed-days respectively, figures that were higher than those reported in surgical units in many other countries. Total cost of antibacterial agents during the study period was 24 800 and 23 481 NIS for Rafidia and Thabet hospitals respectively. Approximately 11.2% and 18.0% of the total antibiotic DDD in Rafidia and Thabet hospitals were given to patients with clean surgeries in which antibiotic prophylaxis is not indicated

Antibiotic resistance of bacterial strains isolated from patients with community-acquired urinary tract infections: an exploratory study in Palestine.

BACKGROUND AND OBJECTIVES: No studies about resistance of bacteria isolated from patients with community-acquired urinary tract infections (CA-UTI) or local guidelines for antibiotic use in these infections have been published or established in the West Bank, Palestine. The objectives of this study were to determine the (1) type and frequency of isolated bacteria and (2) their resistance to commonly used antibiotics. METHODS: A cross sectional study on community urinary isolates was carried out in Nablus, Palestine between November 2009 and April 2010. A convenience sampling method was used for collection of specimens. RESULTS: A total of 375 specimens were collected from 306 (81.6%) females and 69 (18.4%) males. Three hundred and thirty nine (90.4%) of isolated uropathogens were Gram-negative bacteria, of which 243 (71.7%) were Escherichia coli. Thirty six (9.6 %) of the total isolates were Gram-positive bacteria, of which 21 (58.3%) were Staphylococcus saprophyticus. High resistance rates were recorded for E. coli against trimethoprim/sulfamethoxazole (37%), nitrofurantoin (29%), ampicillin (65%), and nalidixic acid (37%). E. coli showed low resistance to amoxicillin/clavulanic acid, ciprofloxacin, cefotaxime and ceftriaxone with rates of 12.2, 17.2, 11.1, and 11.1% respectively. CONCLUSION: E. coli was the most frequent bacterium in the studied sample and showed high resistance to first-line antibiotics. Our results highlight the need for developing local guidelines where elevated resistance to antibiotics should influence prescribing decisions.

Clinical trial: the incidence and early mortality after peptic ulcer perforation, and the use of low-dose aspirin and nonsteroidal anti-inflammatory drugs.

BACKGROUND: It is not clear whether the incidence or early mortality related to peptic ulcer perforation has changed. AIM: To evaluate the incidence and mortality related to peptic ulcer perforation while considering the intake of low-dose aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs). METHODS: We recorded the numbers and details of all patients presenting in our region of Scotland with perforation between 1997 and 2006 including demography, drug usage and 30-day mortality. RESULTS: In subjects aged >65 years, the annual incidence of perforation was 32.7 per 10(5) of the age-specific population, of whom 10.7 per 10(5) were taking low-dose aspirin and 12.0 taking NSAIDs. These were all significantly higher (P < 0.001) than the corresponding incidence in subjects aged < or =65 years (6.6 per 10(5) overall, 1.1 taking aspirin and 2.5 taking NSAIDs). There was an increasing trend with time in the number of patients taking NSAIDs (chi(2) = 4.57, P = 0.03). Using univariate analysis, 30-day mortality was associated with aspirin [odds ratio, 2.32 (95% C.I., 1.20-4.47), P = 0.01] but not with NSAIDs. The strongest predictors of mortality were increasing age and comorbidity. CONCLUSIONS: Perforation remains common in elderly patients including users of NSAIDs and aspirin. Early mortality is also noted in association with increasing age and comorbidity, but not independently with drug intake.

Upper gastrointestinal bleeding and the changing use of COX-2 non-steroidal anti-inflammatory drugs and low-dose aspirin.

BACKGROUND: Rofecoxib was withdrawn in 2004. AIM: To assess the incidence of upper gastrointestinal bleeding in the context of the changing use of cyclo-oxygenase-2 non-steroidal anti-inflammatory drugs and low-dose aspirin. METHODS: We examined the characteristics of patients developing upper gastrointestinal bleeding in a defined population in south-west Scotland. The primary comparisons were made between two calendar years, preceding and following the withdrawal of rofecoxib. RESULTS: The overall incidence of upper gastrointestinal bleeding rose from 98.7 in 2002 to 143 per 10(5) of the population per annum in 2005 (chi(2) = 21.1; P < 0.001). The rise in the incidence was associated with using low-dose aspirin, from 26.6 to 38.4 per 10(5) (chi(2) = 5.4; P = 0.02), other antithrombotic drugs, from 12.1 to 30.2 per 10(5) (chi(2) = 19.6; P < 0.001), and excess alcohol, from 23.5 to 36.4 per 10(5) (chi(2) = 7.1; P = 0.008), but insignificantly with using non-steroidal anti-inflammatory drugs, from 13.3 to 16.1 per 10(5) (chi(2) = 0.64; P = 0.4). After adjustment for the concomitant use of these drugs, there was no significant trend in the incidence of upper gastrointestinal bleeding associated with non-steroidal anti-inflammatory drugs over the period of 1996-2005. CONCLUSION: The rise in the incidence of upper gastrointestinal bleeding was weakly related to the change in use of non-steroidal anti-inflammatory drugs. Instead, it probably reflected the increasing use of low-dose aspirin, other antithrombotic drugs and alcohol.

Clinical outcome in upper gastrointestinal bleeding complicating low-dose aspirin and antithrombotic drugs.

BACKGROUND: The current risk stratification systems in upper gastrointestinal bleeding do not correct for the intake of low-dose aspirin and other antithrombotic drugs. AIM: To test the Blatchford scores in evaluating the clinical outcome in bleeders using these drugs. METHODS: We calculated the Blatchford scores in 510 bleeders, including 123 on low-dose aspirin, 44 on other antithrombotic drugs, and 68 on non-steroidal anti-inflammatory drugs. RESULTS: The median clinical scores distributed according to aetiological risk factors were as follows: no risk factors, 5; non-steroidal anti-inflammatory drugs, 8; aspirin, 7; other antithrombotics, 6; excess alcohol, 4; multiple risk factors, 7; (P = 0.003, Kruskal-Wallis test). Scores correlated positively with the duration of admission in the entire group (r(s) = 0.285; P < 0.001) and in those taking aspirin and antithrombotics (r(s) = 0.211; P = 0.029). The median scores in patients requiring the blood transfusion were 10 in the entire group and 11 in users of aspirin or antithrombotics, compared with 3 and 4, respectively, in those not transfused (P < 0.001). CONCLUSIONS: The Blatchford scores are significantly elevated in users of non-steroidal anti-inflammatory drugs, low-dose aspirin, and other antithrombotic drugs. They correlate positively with the duration of admission and the need for blood transfusion.