Transfusion Strategies for Acute Upper Gastrointestinal Bleeding Original Article, N Engl J Med 2013;368:11-21. In the Abstract (page 11), the end of the first sentence under Results should have read, ". . . as compared with 61 assigned to the liberal strategy (14%), did not receive transfusions (P<0.001)," rather than ". . . as compared with 65 assigned to the liberal strategy (15%) . . . ." The article is correct at NEJM.org.

Background and objectives: To evaluate the predictive value of pre-endoscopic risk scores in patients with upper gastrointestinal bleeding (UGI-B).Patients and methods: The medical records of patients evaluated by emergency esophago-gastro-duodenoscopy (E-EGD) for suspected UGI-B outside regular working hours were retrospectively analysed.

Results:

During the 75 months of the study period 112 E-EGDs met the inclusion criteria. Mean age was 65.5 ± 14.7 years. 38.4 % of patients were female. Endoscopy revealed 41 gastro-duodenal ulcers, 16 Mallory-Weiss, 13 varices, 4 neoplasia. 72 patients received transfusions, 39 had endoscopic interventions. 2 patients were surgically treated, 16 had recurrent bleeding. 16 of the 110 patients died during hospitalisation. The following sensitivities were found for the Blatchford score (cut-off > 1), the clinical Rockall score (cut-off > 0) and the Adamopoulos score (cut-off > 2) in predicting need for clinical intervention (endoscopic or surgical intervention or transfusion): 100/97.7/93 %, recurrent bleeding: 100/100/93.8 %, in-hospital mortality: 100/93.8/93.8 %, respectively.

Conclusions:

The Blatchford score is a suitable tool in determining the need for clinical intervention and the risk of recurrent bleeding and death in patients with UGI-B. The clinical Rockall score and the Adamopoulos score (the latter had originally been developed to predict active UGI-B at endoscopy and was used with a lower cut-off in our study) are inferior alternatives.

A restrictive regime regarding the initiation of blood transfusions was found to be safe in a Spanish study that included 921 patients with upper gastrointestinal bleeding. Survival after 6 weeks was higher (95 vs. 91%) in the restrictive group (Hb 4.3 mmol/l) than in the liberal group (Hb 5.6 mmol/l). The restrictive regimen was found favourable in patients with cirrhosis (class Child-Pugh A and B). In the Netherlands, guidelines prescribe the use of the 4-5-6 rule for initiating blood transfusions, depending on comorbidity (according to ASA classification) for patients who are haemodynamically stable and an aggressive regime when unstable. Starting blood transfusions can be lifesaving and must not be withheld in those who are haemodynamically unstable, but when stable, nuance is needed. In conclusion, the right balance needs to be found between too little too late and too much too early.

Endoscopic hemostasis performed in the emergency room is difficult due to the presence of blood clots and food residue that makes obtaining a clear view of the bleeding vessel difficult. We experienced the efficacy of a newly developed inverted overtube to shorten the hemostatic time and obtain a clear endoscopic view with upper gastrointestinal bleeding patient who were transferred by ambulance car and required emergency endoscopy. The technique improved the endoscopic views and enabled us to perform the hemostatic procedures from the conventional standing position while freely and easily changing the patient's position. The presence of blood clots and food residue in the gastric fornix or upper gastric body makes identifying a bleeding exposed vessel impossible. This set-up significantly shortened the procedure time. The inverted overtube helped us obtain a clear view in patients who were laid in the right lateral position. Rapid identification of exposed vessels resulted in success of hemostasis.

Upper gastrointestinal bleeding is one of the most common emergencies in gastroenterology. The common causes of the upper gastrointestinal bleeding include peptic ulcer disease, gastric erosive mucosal disease and portal hypertension. Gastrointestinal arteriovenous malformation is a less common cause of gastrointestinal bleeding and these arteriovenous malformation are most commonly located in the large and small intestine. Pancreatic arteriovenous malformation is a rare condition in which there is tumor-like formation or vascular anomaly built up via an aberrant bypass anastomosis of the arterial and venous systems in the pancreas. Splenic artery is most commonly involved (42%), followed by gastroduodenal artery (22%) and small pancreatic arteries (25%). Clinically it may present as gastrointestinal hemorrhage which is occasionally fatal. Other presentations are abdominal pain, pancreatitis, duodenal ulcer, jaundice, and portal hypertension.We present a rare case of pancreatic arteriovenous malformation presenting as massive upper gastrointestinal bleeding.Since early surgery is a life saving treatment for such cases, hence, a high index of suspicion should be maintained especially when massive bleeding is detected from the medial wall of second part of duodenum.

Antidepressants are among the most commonly prescribed drugs in primary care in England and their use is increasing. This is largely due to longer durations of treatment of depression. Observational studies have shown some differences in adverse outcomes associated with different antidepressant drugs but relatively little is known about their relative safety particularly with long term use. The primary aim of this study is to determine the relative and absolute risks of pre-defined adverse events comparing different classes of antidepressant drugs in adults aged under 65 years and diagnosed with depression.The study will identify a cohort of patients with a first recorded diagnosis of depression between 1/1/2000 and 31/07/2011, and made between the ages of 20 to 64 years using a large primary care database (QResearch). Patients will be followed up until 1/08/2012. Details of all prescriptions for antidepressants in patients in the cohort will be extracted, including the date of each prescription, the type of antidepressant drug, the dose and total quantity prescribed. Prospectively recorded data will be used to ascertain information on adverse outcomes that occurred during follow-up and after entry into the cohort. These are: all-cause mortality, suicide, attempted suicide/self-harm, sudden death, antidepressant overdose/poisoning, myocardial infarction, stroke/transient ischaemic attack, cardiac arrhythmia, epilepsy/seizures, upper gastrointestinal bleeding, falls, fractures, adverse drug reactions and motor vehicle crashes. Cox proportional hazard models will be used to estimate the association of the outcomes with class of antidepressant drug adjusting for potential confounding variables. The analyses will also examine associations by duration and dose and with the most frequently prescribed individual antidepressant drugs. Self-controlled case series analyses will be used to estimate the relative incidence of the outcomes of interest for defined time periods of antidepressant use.The results of this study will help to establish the relative safety and balance of risks for different antidepressant drugs in people aged under 65.

BACKGROUND AND AIM:

Gastric cancer bleeding is not rare complication in patients with advanced gastric cancer (AGC). The aim of this study was to evaluate the efficacy and clinical outcomes of endoscopic therapy (ET) for upper gastrointestinal bleeding (UGIB) from unresectable AGC.

METHODS:

Data from 113 patients with UGIB from unresectable AGC who underwent ET at the National Cancer Center, Korea were analyzed retrospectively. Success rates of endoscopic hemostasis, rebleeding rates, mortality at 30 days, and overall survival (OS) rate after initial hemostasis were investigated.

RESULTS:

The initial hemostasis rate was 92.9% (105/113). Electrocoagulation was the most common method used (92.0%, 104/113) and combination ET was required in 34 patients (30.1%). Rebleeding occurred in 43 patients (41.0%); 3-day and 30-day rebleeding rates were 18.1% and 29.5%, respectively. Multivariate logistic regression analysis showed that transfusion of packed red blood cells (>5 units) was associated with early rebleeding (≤3 days after initial hemostasis) (odd ratio, 4.75; 95% confidential interval, 1.45-15.57; P=0.010). ET was attempted in 18 patients with rebleeding; hemostasis was achieved in 88.9%. The 30-day mortality rate after initial bleeding event was 15.9%. Median OS after initial hemostasis was 3.2 months. OS was lower for patients with early rebleeding than for those with late rebleeding (>3 days after initial hemostasis) or without rebleeding (1.0, 3.1, and 4.3 months, respectively; P=0.004).

CONCLUSIONS:

ET, primarily endoscopic electrocoagulation, achieved a high initial hemostasis rate for UGIB in patients with unresectable AGC. However, rebleeding frequently occurred and early rebleeding was associated with poor survival.

To investigate the curative effect of early enteral nutrition (EN) supplemented with probiotics (bifidobacterium) in patients with severe acute pancreatitis (ASP).Seventy SAP cases admitted from January 2005 to October 2012 were randomly assigned into parenteral nutrition (PN) group (n=22), EN group (n=25) and bifidobacterium added EN (P+EN) group (n=23). In P+EN group, patients were given their nutrition the same as that of EN, and also probiotics (bifidobacterium, 4 capsules every 12 hours, given through nasal gastric tube, each capsule weighing 210 mg). The routine treatment including anti-infection and anti-acid agents, and that of inhibition of pancreatic secretion were given, except for the different nutritional interventions in all groups. The blood samples were collected for e same measurements of interleukin-8 (IL-8) and tumor necrosis factor (TNF-α) by enzyme linked immunosorbent assay (ELISA), and for the C-reactive protein (CRP), lactic acid dehydrogenase (LDH), white blood cell (WBC) count, amylase and lipase by biochemistry assay 1 day before intervention of nutrition, and 7 days and 14 days after intervention. Changes in organ function and outcome were also recorded at the same time points.The plasma levels of IL-8, TNF-α, CRP, LDH, WBC count, amylase and lipase were significantly reduced after nutritional intervention compared with their levels on day 1 before intervention in all three groups. The plasma IL-8, TNF-α, CRP, lipase, LDH at 14 days after intervention of nutrition in P+EN group were significantly lower than those in PN group and EN group (IL-8: 21.00±7.07 μg/L vs. 48.00±10.32 μg/L, 32.00±9.30 μg/L; TNF-α: 44.3±10.9 ng/L vs. 132.1±34.1 ng/L, 67.8±22.3 ng/L; CRP: 35.0±12.4 mg/L vs. 103.2±49.2 mg/L, 63.0±29.2 mg/L; lipase: 269±79 U/L vs. 670±145 U/L, 310±78 U/L; LDH: 21.8±10.3 U/L vs. 78.1±37.4 U/L, 37.9±25.1 U/L, P<0.05 or P<0.01). The WBC count in P+EN group was significantly lower than that in PN group (5.9±3.0 ×10(9)/L, 6.3±3.2 ×10(9)/L vs. 9.6±3.0 ×10(9)/L, both P<0.05), but there was no significant difference in amylase between P+EN group and PN group (211±49 U/L, 236±52 U/L vs. 298±71 U/L, P>0.05). The gastrointestinal dysfunction score in P+EN, EN, PN groups 14 days after nutritional intervention was 0.28±0.05, 0.43±0.09, 0.71±0.11, respectively, with statistically significant differences (all P<0.01). Compared with PN and EN groups, the incidence of upper gastrointestinal bleeding (1 vs. 9, 2), infection and abscess (2 vs. 12, 5) was lower (all P<0.01), and hospital day was significantly shortened in P+EN group (10.4±3.9 days vs. 25.8±6.4 days, 13.4±5.2 days, both P<0.01). There was no significant statistical difference in mortality rate among three groups.Our results indicated that early EN with addition of probiotics (bifidobacterium) resulted in significant lowering of the level of pro-inflammatory cytokines, earlier restoration of gastrointestinal function, decrease of complications such as infection, and shortening of hospital day in patients with SAP.