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.

Upper gastrointestinal mucosal abnormalities and blood loss complicating low-dose aspirin and antithrombotic therapy.

BACKGROUND: Little is known about the site and nature of bleeding lesions related to low-dose aspirin and other antithrombotic agents. AIM: To describe the mucosal abnormalities in patients presenting with upper gastrointestinal bleeding while being treated with these drugs. METHODS: The endoscopic findings and clinical details were analysed in all patients presenting with haematemesis and/or melaena at a single centre during three calendar years. Associations between endoscopic findings and risk factors, including the intake of non-steroidal anti-inflammatory drugs, low-dose aspirin (75 mg daily) and other antithrombotic drugs including warfarin, clopidogrel, and dipyridamole, were assessed by logistic regression analysis. RESULTS: In 674 upper gastrointestinal bleeders, we found that the odds ratio for the presence of erosive oesophagitis in aspirin users was 2 (95% CI, 1-3; P = 0.03) and 3 (2-5; P = 0.0003) in patients taking other antithrombotic agents. In 41 patients with oesophagitis and taking these drugs, 36 (88%) had cardiovascular disease and only 4 (10%) had peptic symptoms. CONCLUSIONS: Erosive oesophagitis is common in patients with upper gastrointestinal bleeding taking low-dose aspirin or antithrombotic agents, and could potentially be confused with the coexisting heart disease.

Upper gastrointestinal haemorrhage associated with low-dose aspirin and anti-thrombotic drugs - a 6-year analysis and comparison with non-steroidal anti-inflammatory drugs.

BACKGROUND: Low-dose aspirin and other anti-thrombotic therapy has been increasingly used for vascular protection. AIM: To assess the possibility that the incidence of upper gastrointestinal blood loss has changed in subjects using these agents in comparison with non-steroidal anti-inflammatory drugs. METHODS: We studied the characteristics of all patients with acute upper gastrointestinal haemorrhage and attending a single hospital at 3 points over a 6-year period: 1996 (n = 204), 1999 (n = 224) and in 2002 (n = 252). RESULTS: The incidence of haemorrhage in subjects taking low-dose aspirin rose from 15 per 100 000 of the population per annum in 1996, to 18 in 1999 and 27 in 2002 (P = 0.004). The respective incidence in subjects taking other anti-thrombotic drugs was 4, 8, and 12 (P < 0.001). No significant change was detected in non-steroidal anti-inflammatory drug users. However, acute myocardial infarction mortality was 216 per 100 000 in 1996, 221 in 1999 and fell to 169 in 2002 (P < 0.001). CONCLUSIONS: The incidence of upper gastrointestinal haemorrhage in users of low-dose aspirin and other anti-thrombotic drugs has been steadily rising. This has been paralleled by a fall in cardiac mortality.

Gastric epithelial anti-microbial peptides--histological correlation and influence of anatomical site and peptic ulcer disease.

BACKGROUND AND AIMS: Natural anti-microbial peptides are increasingly recognised for their protective effects in mucosal surfaces. We, therefore, aimed at investigating their expression in the human stomach in a range of peptic conditions. METHODS: We assessed the expression of epithelial secretory leukocyte protease inhibitor, human beta-defensins (HBD1 and HBD2), and alpha-defensin (HD5) in gastric biopsies taken from 52 patients, median age of 55 years. Expression of peptide mRNA was determined using real-time quantitative polymerase chain reaction. The activity of gastritis was graded on a 0-3 scale. RESULTS: The antrum had a median secretory leukocyte protease inhibitor of 0.93 and HBD1 of 0.42, compared with 0.13 (P = 0.001) and 0.08 units (P = 0.002) respectively in the gastric body. The antral histological scores correlated positively with HBD2 expression (r = 0.69; P< 0.001) and negatively with HBD1 (r = -0.47; P = 0.006) particularly in the absence of aspirin. Patients with Helicobacter pylori gastritis, gastric or duodenal ulcers had lower expression of HBD1 and greater expression of HBD2 than in controls. The intake of aspirin by patients infected with H. pylori was associated with marked rise in the expression of HD5 and less expression of secretory leukocyte protease inhibitor. CONCLUSIONS: Gastric epithelial anti-microbial peptides are influenced by anatomical site, grade of gastritis, peptic ulceration, and can be modulated by aspirin.

Oesophagitis and bile reflux gastritis--clinical and histological assessments.

BACKGROUND AND AIMS: Little is known concerning the relationship between oesophagitis and bile reflux (chemical) gastritis despite the numerous studies on gastritis related to Helicobacter pylori. Given the importance of bile in the pathogenesis of both gastric and oesophageal disorders, we aimed at assessing the chemical gastritis score in patients with or without oesophagitis. METHODS: Chemical/bile reflux gastritis score and bile reflux index were assessed in gastric biopsies taken from patients with oesophagitis and gastric surgery (group 1, n=9), gastric surgery without oesophagitis (group 2, n= 11), and oesophagitis without gastric surgery (group 3, n= 10). Endoscopic oesophageal damage was also graded on a 0-5 scale. RESULTS: Group 1 had a median (interquartile range) chemical score of 6 (4-9) compared with 8 (6-10) in group 2, and 1 (0-2) in group 3 (p=0.001; Kruskal-Wallis test for multiple group comparisons). Both the reflux gastritis score and bile reflux index were lowest in patients with intact stomachs. However, the oesophageal scores were 2 (1-2) in group 1 compared with 3 (2-5) in group 3 (p=0.01). CONCLUSION: Patients with post-surgical stomachs have similar chemical and related scores regardless of the presence or absence of oesophagitis. Despite the higher chemical gastritis scores, patients with gastric surgery, exposed mainly to bile reflux, have milder oesophagitis than those with intact stomachs, exposed to both gastric acid and bile.

Urinalysis for interleukin-8 in the non-invasive diagnosis of acute and chronic inflammatory diseases.

BACKGROUND AND AIMS: Given its role in mediating inflammation, the use of urinary interleukin-8 (IL-8) was assessed in the non-invasive diagnosis of acute and chronic inflammatory diseases. METHODS: IL-8 was measured by an enzyme linked immunosorbent assay in random urine samples (1 ml each) carrying code numbers and taken from 208 patients: 177 adults and 31 children presenting with a range of active or inactive inflammatory conditions. RESULTS: In the appropriate controls and in patients with inactive inflammation, the median urinary IL-8 levels ranged from 7-12 pg/ml, compared with 104 pg/ml in active ulcerative colitis (p = 0.002), 54 in active Crohn's disease (p = 0.025), 93 in active rheumatoid arthritis (p = 0.001), 107 in acute cholecystitis (p<0.0001), 127 in acute appendicitis (p = 0.0001), and 548 pg/ml in urinary tract infection (p<0.0001). Children with non-viral inflammation/infection also had higher IL-8 values (median, 199 pg/ml; p = 0.0001) than those with viral infection (median, 7 pg/ml) or non-specific conditions (median, 10 pg/ml). In the study group as a whole urinary IL-8 values correlated positively with peripheral blood white cell count (r = 0.32; p < 0.001), erythrocyte sedimentation rate (r = 0.41; p<0.001), and C-reactive protein (r = 0.33; p<0.001). CONCLUSION: Taking the appropriate clinical situation into account, urinary IL-8 measurement helps in the non-invasive assessment of active inflammation in at least a number of common acute and chronic conditions.

Reflux and Barrett's oesophagitis after gastric surgery--long-term follow-up and implications for the roles of gastric acid and bile in oesophagitis.

BACKGROUND: The role of gastric acid is difficult to separate from that of bile in oesophageal reflux, and the complications of this can take many years to develop. Gastric surgery patients provide a good model for both significant bile reflux and marked gastric acid inhibition. AIM: To study the oesophageal abnormalities in gastric surgery patients undergoing long-term follow-up, compared with patients with intact stomachs. METHODS: Two hundred and forty adult patients were endoscoped regardless of their age, sex or type of surgical procedure. Oesophageal damage was graded on a scale of 0-5, and biopsies were taken to exclude neoplasia, to diagnose Barrett's oesophagus and to identify Helicobacter pylori. RESULTS: Of the 240 patients studied, 140 had undergone gastric surgery 27 years (19-31 years) [median (interquartile range)] prior to endoscopy, and these patients had milder oesophageal scores and fewer cases of Barrett's oesophagitis. Of the 119 patients with post-surgical bile reflux gastritis, 31 (26%) had oesophagitis, two (1.7%) had Barrett's oesophagitis and oesophageal scores of 0 (0-1) were found. These results compared with corresponding values of 37 (37%; P = 0.11), 11 (11%; P = 0.007) and 0 (0-2) (P = 0.046), respectively, in 100 patients with intact stomachs. In addition, of the 83 patients with vagotomy, 19 had oesophagitis (23%; P = 0.05), none had Barrett's oesophagitis and lower oesophageal scores (P = 0.02) were found. CONCLUSIONS: The prevalence and severity of reflux and Barrett's oesophagitis are not increased in patients with a long history of gastric surgery, particularly after vagotomy, and despite being at risk of bile reflux.

Flexible fibreoptic bronchoscopy in Basra, Iraq: a 20-month experience.

This prospective study represents our experiences in using fibreoptic bronchoscopy (FOB) in the evaluation of different thoracic lesions. Over a 20-month period, 203 patients (151 males and 52 females) (age range: 15-100 years) underwent bronchoscopies. The patients had a wide range of symptoms and/or radiographic abnormalities. The majority had cough and shortness of breath; haemoptysis was a common symptom. In all, 148 patients had neoplasms and 55 had non-neoplastic lesions. The most common malignancy was bronchogenic carcinoma (91 confirmed, 33 suspected). Other neoplasms included pulmonary metastases and mediastinal tumours. The non-neoplastic chest lesions included pulmonary tuberculosis, pulmonary hydatid cyst, lung abscess and resolving chest infection and chronic bronchitis. FOB was most useful in the diagnosis of bronchogenic carcinoma (positive diagnostic yield of 73%). It was least useful in diagnosing mediastinal tumours.

Flexible fibreoptic bronchoscopy in Basra, Iraq: a 20-month experience

This prospective study represents our experiences in using fibreoptic bronchoscopy [FOB] in the evaluation of different thoracic lesions. Over a 20-month period, 203 patients [151 males and 52 females] [age range: 15-100 years] underwent bronchoscopies. The patients had a wide range of symptoms and/or radiographic abnormalities. The majority had cough and shortness of breath; haemoptysis was a common symptom. In all, 148 patients had neoplasms and 55 had non-neoplastic lesions. The most common malignancy was bronchogenic carcinoma [91 confirmed, 33 suspected]. Other neoplasms included pulmonary metastases and mediastinal tumours. The non-neoplastic chest lesions included pulmonary tuberculosis, pulmonary hydatid cyst, lung abscess and resolving chest infection and chronic bronchitis. FOB was most useful in the diagnosis of bronchogenic carcinoma [positive diagnostic yield of 73%]. It was least useful in diagnosing mediastinal tumours

Non-steroidal anti-inflammatory drug gastropathy and Helicobacter pylori infection.

The interest in the interaction between NSAIDs and Helicobacter pylori derives its importance from its potential to provide a different strategy to combat the common problem of NSAID-related peptic ulcers and their life threatening complications. Studies assessing this subject have differed in almost every aspect of their methodology, including the definition of a NSAID user as well as the types, doses, duration, and the indications for NSAID use. They also differed in their end points, the tests for the assessment of Helicobacter pylori, and the regimes used for its eradication. However, NSAIDs and Helicobacter pylori are known to share a number of important pathogenic mechanisms, and the prevalence of the infection is high in cohorts of ulcer patients taking NSAIDs. Eradication of Helicobacter pylori using bismuth-based regimes has also been more successful and beneficial in preventing the occurrence or relapse of NSAID-related ulcers than regimes using proton pump inhibitors.

Neutrophils, Helicobacter pylori, and nonsteroidal anti-inflammatory drug ulcers.

BACKGROUND & AIMS: Gastric injury by nonsteroidal anti-inflammatory drugs (NSAIDs) is minimal in neutropenic animals. This study examined peptic ulcer development in the presence or absence of gastric neutrophils in patients requiring long-term use of NSAIDs. METHODS: Gastric histology, neutrophils, and Helicobacter pylori were assessed in 120 patients randomized to receive placebo or 20 or 40 mg famotidine twice daily as prophylaxis against NSAID-related ulcers and who underwent endoscopy at 0, 4, 12, and 24 weeks. RESULTS: In 43 patients without gastric neutrophils, ulcers developed in 1 of 14 (7.7%) taking placebo, 2 of 16 (12.5%) taking 20 mg famotidine, and none of 13 taking 40 mg famotidine. However, in 77 patients with neutrophils, ulcers developed in 13 of 28 (47. 4%) taking placebo (P < 0.001), 3 of 26 (12.6%) taking 20 mg famotidine, and 3 of 23 (13%) taking 40 mg famotidine. Eight of 46 patients (17%) without H. pylori had neutrophils compared with 69 of 74 (93%) with both H. pylori and neutrophils (P < 0.001). CONCLUSIONS: Gastric neutrophils increase the incidence of ulceration in long-term NSAID users. Because neutrophils exist with H. pylori, eradicating this infection might prevent NSAID-related peptic ulcers.