Acute Gastrointestinal Research Articles

Predicting acute and late toxicity in prostate cancer stereotactic ablative radiotherapy: the role of dosimetric parameters and prostate volume.

Our objective was to identify the dosimetric parameters and prostate volume that most accurately predict the incidence of acute and late gastrointestinal (GI) and genitourinary (GU) toxicity in prostate cancer stereotactic ablative radiotherapy (SABR) treatments. We conducted aretrospective analysis of 122 patients who received SABR for prostate cancer at our clinic between March 2018 and September 2022 using afive-fraction SABR regimen. The existing plans of these patients were re-evaluated according to our institutional protocols (Hacettepe University [HU-1] and HU-2) as well as PACE‑B, RTOG 0938, and NRG GU005 dose-volume constraints. Univariate and multivariate logistic regression analyses were performed using SPSS version 23.0 (IBM, Armonk, NY, USA). The median follow-up was 24.7 months (0.8-94.4 months). For acute GU toxicity, moderate-dose regions were predictive for grade1-2 toxicity, while high-dose regions were more associated with grade3-4 toxicity. For late GU toxicity, moderate-high-dose regions were predictive. For GI toxicity, moderate-dose regions were important for both acute and late toxicity. The HU protocol encompassed all significant dosimetric factors influencing toxicity outcomes. Aprostate volume threshold of 60 cc was predictive of acute grade3-4 GU toxicity. Our study highlighted the critical role of moderate-dose regions for acute and late GI and GU toxicity. Prostate treatment plans should be rigorously evaluated, and moderate doses should be minimized. The HU protocol is an eligible choice for five-fraction SABR plans.

Budesonide, Added to PTCy-Based Regimen, for Prevention of Acute GI GVHD After Allogeneic Stem Cell Transplantation.

Oral budesonide exerts local effects with negligible systemic glucocorticoid activity, due to rapid first-pass metabolism, therefore, could potentially be efficacious in preventing gastrointestinal (GI) acute GVHD (aGVHD). We explored the use of budesonide, added to posttransplant cyclophosphamide (PTCy), tacrolimus, and mycophenolate mofetil, for prevention of GI aGVHD after allogeneic hematopoietic stem cell transplantation (AHSCT) in a prospective observational study and treated 80 patients with a median age of 53 years (range 19-74). Results were compared with a publicly available CIBMTR dataset of 646 patients who received PTCy-based GVHD prophylaxis (CIBMTR Study # GV17-02) (control). Cumulative incidence (CI) of 3-month grade 2-4 and grade 3-4 aGVHD in the budesonide and control groups were 3.8% vs. 34.4% (p < 0.001) and 1.3% vs. 9.8% (p = 0.029), respectively. One-year GRFS (70.5% vs. 31.5%, p < 0.001), PFS (73.4% vs. 52.8%, p = 0.003), and OS (80.1% vs. 64.2%, p = 0.038) were significantly higher in the budesonide group compared with control group. Propensity score-adjusted analyses showed that the addition of budesonide significantly decreased risk of aGVHD grade 2-4 (HR 0.29, p < 0.001), grade 3-4 (HR 0.12, p = 0.045), and cGVHD (HR 0.22, p < 0.001), which resulted in better GRFS (HR 0.38, p < 0.001), PFS (HR 0.58, p = 0.012), and OS (HR 0.72, p = 0.044). Similar results were found when using propensity score-matched analysis restricted to recipients of haploidentical transplantation. In conclusion, addition of budesonide to PTCy-based GVHD prophylaxis is safe and effective in preventing severe acute GI GVHD with significantly improved GRFS. These results could facilitate transition to peripheral blood grafts for all allogeneic transplant recipients.

Consequential Catastrophe: A Rare Interaction of Upper Gastrointestinal Haemorrhage and Acute Coronary Syndrome

Gastrointestinal (GI) bleeding is a common medical condition that results in up to 10% mortality rate. The severity of bleeding ranges from occult blood loss to massive hemorrhage, with the latter often resulting in rapid onset of anemia. Anemia is an independent risk factor for developing acute coronary syndrome (ACS). Here, we present a case of acute upper GI bleeding developing anemia, which led to ACS.

Comparing gastrointestinal dysfunction score and acute gastrointestinal injury grade for predicting short-term mortality in critically ill patients

BACKGROUND The prognosis of critically ill patients is closely linked to their gastrointestinal (GI) function. The acute GI injury (AGI) grading system, established in 2012, is extensively utilized to evaluate GI dysfunction and forecast outcomes in clinical settings. In 2021, the GI dysfunction score (GIDS) was developed, building on the AGI grading system, to enhance the accuracy of GI dysfunction severity assessment, improve prognostic predictions, reduce subjectivity, and increase reproducibility. AIM To compare the predictive capabilities of GIDS and the AGI grading system for 28-day mortality in critically ill patients. METHODS A retrospective study was conducted at the general intensive care unit (ICU) of a regional university hospital. All data were collected during the first week of ICU admission. The primary outcome was 28-day mortality. Multivariable logistic regression analyzed whether GIDS and AGI grade were independent risk factors for 28-day mortality. The predictive abilities of GIDS and AGI grade were compared using the receiver operating characteristic curve, with DeLong’s test assessing differences between the curves’ areas. RESULTS The incidence of AGI in the first week of ICU admission was 92.13%. There were 85 deaths (47.75%) within 28 days of ICU admission. There was no initial 24-hour difference in GIDS between the non-survival and survival groups. Both GIDS (OR 2.01, 95%CI: 1.25-3.24; P = 0.004) and AGI grade (OR 1.94, 95%CI: 1.12-3.38; P = 0.019) were independent predictors of 28-day mortality. No significant difference was found between the predictive accuracy of GIDS and AGI grade for 28-day mortality during the first week of ICU admission (Z = -0.26, P = 0.794). CONCLUSION GIDS within the first 24 hours was an unreliable predictor of 28-day mortality. The predictive accuracy for 28-day mortality from both systems during the first week was comparable.

Long-term outcomes and prognostic factors of short-course radiotherapy (SCRT) in rectal cancer: a monocentric retrospective study

PurposeTo evaluate efficacy and tolerance of short-course radiotherapy (SCRT) prior to possible chemotherapy (CHT) and surgery in 64 patients with locally advanced rectal cancer, in terms of acute and early late toxicity and survival outcomes with prognostic factors.MethodsSixty-four patients affected by rectal tumor were treated from 2008 to 2023 radiation therapy, with a total dose of 25 Gy in 5 fractions. The Kaplan–Meier method was used to estimate the rates of overall survival (OS), cancer specific survival (CSS), local control (LC), disease free survival (DFS) and metastasis free survival (MFS). Univariate analysis for prognostic factors was performed with the log-rank test, and Cox proportional hazards regression was used to estimate hazard ratios. Toxicity assessment has been considered in acute and in early late for gastrointestinal (GI), genitourinary (GU) districts.ResultsMedian follow-up was 49.6 months. The median OS was 65 months with 1-year, 2-year and 5-year OS at 90.6%, 77.7% and 60% respectively. CSS at the 1-year, 2-year and 5-year was 98.3%, 96.2% and 86.2% respectively. LC at 1-year, 2-year and 5-year was 93.4%, 89.4% and 87.2% respectively. DFS at the 1-year, 2-year and 5-year was 93.4%, 89% and 87% respectively. The status of lymph nodes at diagnosis was a prognostic factor in term of LC and DFS. Acute GI toxicity was G1 in 10 (15.6%) patients. Five (7.8%) patients had a G1 acute GU toxicity. Fifteen (23.4%) patients developed chronic GI toxicities.ConclusionsSCRT is an effective treatment in patients with rectal cancer and provides good outcomes with very low rates of toxicity profile.

Harnessing the microbiome: probiotics, antibiotics and their role in canine and feline gastrointestinal disease.

Unfavourable alterations of the host microbial environment, known as dysbiosis, have been identified in many canine and feline gastrointestinal (GI) diseases. As a result, normalisation of microbial composition and function has become an important therapeutic target. Given the complex and individualistic interplay between the resident microbiota, host and environment, a multimodal approach is often necessary when addressing dysbiosis in dogs and cats with GI disease. Systemic antibiotics are often empirically used to treat acute and chronic GI diseases. However, with modern genomic techniques demonstrating the profound negative effect antibiotics can have on the GI microbiota and the rapid emergence of resistant bacteria globally, there has been an increased focus on identifying antibiotic alternatives for use in small animal practice. Biotics, such as prebiotics, probiotics and synbiotics, are of growing interest due to their potential supportive effect on the microbiota. This article reviews the evidence for the use of biotics in canine and feline GI disease, highlighting how judicious use of antibiotics and targeted probiotic supplementation can enhance patient outcomes by promoting a balanced gut microbial environment.

Acute gastrointestinal symptoms associated with oil spill exposures among U.S. coast guard responders to the Deepwater Horizon oil spill

PurposeResearch investigating gastrointestinal (GI) symptoms from oil spill-related exposures is sparse. We evaluated prevalent GI symptoms among U.S. Coast Guard responders deployed to the Deepwater Horizon oil spill cleanup. MethodsCrude oil (via skin contact, inhalation, or ingestion routes), combined crude oil/oil dispersant exposures, other deployment exposures, deployment characteristics, demographics, and acute GI symptoms during deployment (i.e., nausea/vomiting, diarrhea, stomach pain, and constipation) were ascertained cross-sectionally via a post-deployment survey (median time between deployment end and survey completion 185 days) (N = 4885). Log-binomial regression analyses were employed to calculate prevalence ratios (PRs) and 95 % confidence intervals (CI). Effect modification was evaluated. ResultsIn adjusted models, responders in the highest (versus lowest) tertile of self-reported degree of skin contact to crude oil were more than twice as likely to report nausea/vomiting (PR=2.45; 95 %CI, 1.85–3.23), diarrhea (PR=2.40; 95 %CI, 2.00–2.88), stomach pain (PR=2.51; 95 %CI, 2.01–3.12), and constipation (PR=2.21; 95 %CI, 1.70–2.89). Tests for trend were statistically significant (p < 0.05). Results were similar for crude oil exposure via inhalation and ingestion. Higher PRs for all symptoms were found with combined crude oil/dispersant exposure than with crude oil exposure alone. ConclusionsThese results indicate positive associations between self-reported crude oil and combined crude oil/oil dispersant exposures and acute GI symptoms.

Safety of Pelvic and Abdominal Radiation Therapy for Patients With Inflammatory Bowel Disease: A Dosimetric Analysis of Acute Bowel Toxicity

ObjectivesInflammatory bowel disease (IBD) has been considered a relative contraindication to radiation therapy (RT) due to the potential greater risk of RT-induced toxicities. This study aims to assess acute toxicity outcomes in patients with IBD treated with abdominal/pelvic RT. MethodsAfter institutional review board approval, patients with IBD who received RT to the abdomen/pelvis were identified from an institutional research repository and their electronic medical records were reviewed. The IBD cohort was matched 1:1 with controls according to all of the following: radiotherapy, gender, disease site, age, and year of RT. Acute toxicity was defined as toxicity occurring within 3 months of RT. Primary outcomes were assessed via univariable logistic regression models and predicted probability of acute toxicity and acute gastrointestinal (GI) toxicity were plotted for the most significant covariates. IBD and control control cohorts were compared on demographic and toxicity variables using chi-square/Fisher's exact tests and Kruskal-Wallis tests where appropriate. ResultsWe identified 62 patients with median age of 64 years (interquartile range [IQR] 54-70) who received RT from 2006-2022. Patients were treated with intensity-modulated RT (38; 61.3%), 3-dimensional conformal RT (12; 19.4%), and stereotactic body RT/brachytherapy (12; 19.4%). After RT, 28 (45.2%) and 23 (37.1%) patients experienced grade ≥2 acute (any) and acute GI toxicity, respectively. Higher overall RT dose and RT dose to small bowel were found to be signicantly associated with increased risk of grade ≥2 acute toxicities (OR=1.041 per unit Gy, 95% CI 1.005-1.084, p=0.034 and OR=1.046, 95% CI 1.018-1.082, p=0.003, respectively). Between IBD and control cohorts, there were no significant differences in grade ≥2 acute (any) and acute GI toxicities (p=0.710 and p=0.704, respectively). ConclusionIn patients with IBD treated with abdominal/pelvic RT for malignancy, RT was effective and well-tolerated. RT treatment planning should carefully consider the location(s) of IBD inflammation and dose to bowel structures, in particular, dose to small bowel.

Increased Mortality in a Nationwide Study of Gastrointestinal Hospitalizations in the United States During the 2020 Coronavirus Pandemic.

Background The impact of the coronavirus disease-2019 (COVID-19) pandemic on patients with acute gastrointestinal (GI) presentations including acute pancreatitis, diverticulitis, and GI bleeding, requiring hospitalization, has not been fully characterized at the population level in the United States. Aims We used the National Inpatient Sample to describe inpatient gastroenterology outcomes in the United States during the first year of the pandemic (2020), using 2018 and 2019 as comparator years. Methods Using the National Inpatient Sample, we explored year-to-year and month-to-month trends in hospitalizations, length of stay, and inpatient mortality for GI presentations, including luminal, biliary, infectious, inflammatory, and pancreatic diseases, with regression modeling. Relative change was used to compare time periods. Results We observed significantly lower rates of hospitalization for most acute GI conditions in 2020 relative to 2019. Despite this, we noted an increase in all-cause mortality (0.9% in 2019 and 1.1% in 2020, p<0.001) and hospital costs for patients hospitalized with acute presentations of GI-related conditions in 2020 relative to 2019. Importantly, we also observed increased mortality among COVID-19-positive patients who were hospitalized foracute pancreatitis (OR 2.56; 95% CI 1.37-6.53), variceal upper GI bleeding (OR 2.88; 95% CI 1.29-3.84), ulcerative colitis (OR 4.50; 95% CI 1.14-7.74), and acute cholangitis (OR 2.43; 95% CI 1.14-4.93). In 2020, the lowest number of admissions for all conditions occurred in April, coinciding with lockdowns ordered by most state governments. Conclusions Acute GI-related hospitalizations, in general, decreased in 2020but this was associated with higher hospital costs and all-cause mortality increased compared with the pre-pandemic period.

Evaluating a hypofractionated radiotherapy schedule for prostate cancer at an institution in South Africa

Background: Hypofractionated radiotherapy (HFRT) in the treatment of prostate cancer (PCa) has logistical and cost advantages, especially in a resource constrained setting. Studies have demonstrated equivalent efficacy with HFRT schedules using Intensity Modulated Radiation Therapy (IMRT) as treatment modality. However, higher rates of acute and late gastrointestinal (GI) and genitourinary (GU) toxicity have been reported when compared to conventionally fractionated radiotherapy (CFRT). In this study, we evaluate the efficacy and toxicity rates of a HFRT schedule using 3D conformal radiotherapy (RT) as treatment modality.Aim: With this study, we aim to describe the safety and outcomes of a definitive HFRT schedule used for localised PCa. We hypothesise that there is no difference in the biochemical relapse rate and incidence rates of normal tissue toxicities between patients receiving CFRT and HFRT schedules.Setting: This RT schedule was used at Tygerberg Academic Hospital in South Africa for the treatment of localised prostate cancer.Methods: This is a retrospective study in which the records of patients diagnosed with localised PCa were reviewed. Patients were treated with either CFRT regimen to a total of 74Gy in 37 daily fractions for 5 days a week or a HFRT regimen to a total of 65Gy in 26 daily fractions for 4 days per week.Results: In all, 116 patients were included in the study with a median follow-up of 57.2 months from the start of RT. No statistically significant differences in overall survival (OS) and biochemical relapse-free survival were found between the two schedules. A significant difference in acute GI toxicity was observed, with a higher incidence noted in the HFRT schedule. No significant differences were observed in late GI toxicity or in early and late GU toxicities.Conclusion: This study observes a hypofractionated regimen using three-dimensional conformal radiation therapy (3DCRT) with similar efficacy and RT-related toxicities to CFRT.Contribution: The HFRT schedule used in this study could be useful in hospitals with limited access to resources.

Should Prophylactic Endotracheal Intubation Be Performed in Upper Gastrointestinal Bleeding?

No consensus exists on the standard of intraoperative airway management approach to prevent endoscopy complications in acute gastrointestinal (GI) bleeding. Eight years after our initial meta-analysis, we reassessed the effect of prophylactic endotracheal intubation in acute GI bleeding in hospitalized patients. Multiple databases were reviewed in 2024, identifying 10 studies that compared prophylactic endotracheal intubation (PEI) versus no intubation in acute upper GI bleeding in hospitalized patients. Outcomes of interest included pneumonia, length of hospital stay, aspiration, and mortality. The odds ratio (OR) or mean difference (MD) using the random effects model was calculated for each outcome. In total, 11 studies (10 retrospective, one prospective) were included in the meta-analysis (n = 7,332). PEI demonstrated statistically significant higher odds of pneumonia (OR = 5.83; 95% confidence interval (CI) = 3.15-10.79; p < 0.01) and longer length of stays (MD = 0.84; 95% CI = 0.12-1.56; p = 0.02). However, mortality (OR = 1.68; 95% CI = 0.78-3.64; p = 0.19) and aspiration (OR = 2.79; 95% CI = 0.89-8.7; p = 0.08) were not statistically significant. PEI before esophagogastroduodenoscopy for hospitalized upper GI bleeding patients is associated with an increased incidence of pneumonia within 48 hours and prolonged hospitalization but no statistically significant increased risk of mortality or aspiration.

Ablative Radiation Therapy for Unfavorable Prostate Tumors (ABRUPT): Preliminary Analysis of Toxicity and Quality of Life from a Prospective Study

To assess late gastrointestinal (GI) and genitourinary (GU) side effects in patients with organ-confined unfavorable prostate cancer (PCa) treated with single-dose ablative radiation therapy (SDRT). Thirty patients enrolled in a single-arm prospective trial received 24 Gy SDRT to the whole prostate with urethra-sparing and organ motion control delivered on a Linac platform with a 10 MV flattening filter-free single partial arc. Androgen deprivation therapy was prescribed as per standard of care. Treatment-related acute and late GU and GI toxicities (Common Terminology Criteria for Adverse Events_v5 scale) and quality of life (QoL) outcomes (European Organisation for Research and Treatment of Cancer [EORTC] QLQ-PR25/C30, International Prostate Symptom Score [IPSS]) were assessed at different time points. Minimal important difference (MID) was established as a change of >0.5 pooled standard deviations from baseline. Statistical analysis included analysis of variance and logistic regression. Median follow-up was 18 months (range, 6-31 months), with no ≥G3 late side effects observed. G2 late GI and G2 late GU toxicities occurred in 1 and 2 patients, respectively. GI toxicity of any grade correlated with maximum rectal dose (P = .021). Lower baseline QoL score (P = .025), higher baseline IPSS score (P = .049), acute GU toxicity (P = .029), and acute urinary domain MID (P = .045) predicted GU toxicity of any grade. In multivariate analysis (MVA), only baseline QoL score (odds ratio [OR], 0.95, P = .031) and acute GU toxicity (OR, 8.4, P = .041) remained significant. Significant QoL change was observed only in the urinary domain (P = .005), with a median increase from 8 to 17. Late urinary MID correlated with acute urinary MID (P = .003), acute QoL MID (P = .029), acute GU toxicity (P = .030), and lower baseline urinary score (P = .033). In MVA, only acute urinary MID predicted late urinary MID (OR, 9.7, P = .035). Our findings provide promising data on the feasibility and safety of 24 Gy whole-gland SDRT with urethra-sparing and organ motion control, in association with androgen deprivation therapy and an adequate prophylactic medication, in organ-confined unfavorable PCa. Long-term follow-up is needed to confirm these results.

Impact of Rectal Spacer on Toxicity Reduction in Men Treated With Proton Versus Photon Therapy

PurposeRectal toxicity after prostate cancer (PCa) radiation therapy (RT) may be greater with protons compared with photon intensity-modulated RT, perhaps due to lateral penumbra and end-of-range uncertainty. Rectal spacers (RSs) have been shown to mitigate RT-associated acute/late rectal toxicity in men treated with photons. The relative benefit of RS in men treated with protons versus photons is unknown. We hypothesize that RS will confer greater bowel toxicity benefits in PCa treated with protons versus photons. Materials and MethodsWe conducted a single institution, retrospective review of men receiving photon intensity-modulated RT or pencil-beam scanning proton RT for localized PCa. Four cohorts were compared: photon with or without RS, and proton with or without RS. Acute (<3 months), late (≥3 months), and most recent toxicity were compared among the 4 cohorts. The cumulative incidence of physician-reported grade 1 to 2 gastrointestinal (GI) toxicity (common terminology criteria for adverse events V5.0) was compared using χ2 or Fisher exact test. Patient-reported toxicity was evaluated using the International Prostate Expanded Prostate Composite Index-Clinical Practice and compared using linear mixed modeling. ResultsIn total, 164 patients were eligible for analysis: 38 photons without RS, 50 photons with RS, 26 protons without RS, and 50 protons with RS. The median follow-up was 17.6 months. In proton patients, acute (6.12% vs 30.77%, P = .009) and most recent (4.26% vs 26.09%, P = .01) G1-2 GI toxicity was lower with versus without RS. In photon patients, there were no significant differences in toxicity with versus without RS. No significant differences in patient-reported outcomes were observed with versus without RS in photon or proton groups. ConclusionThe rectal spacer was associated with lower G1-2 acute and most recent GI toxicity in men treated with protons; this difference was not observed in men treated with photons. While this study is limited by sample size, a relatively greater benefit of RS with proton versus photon therapy was observed.

Analysis of the fecal metagenome in pelvic radiation survivors with or without chronic gastrointestinal toxicity.

e24041 Background: Whole pelvis radiation therapy (WPRT) is often used as a definitive or adjuvant treatment in patients with genitourinary, gynecologic, and gastrointestinal (GI) malignancies. Irradiation of nearby bowel can cause acute and chronic GI symptoms, which can affect patients’ quality of life. Radiation therapy has been shown to alter the microbial flora and may select for pathogenic species, which may enhance toxicity. Characteristics of the fecal metagenome in patients with or without chronic GI toxicity is unknown. Severity of GI symptoms can vary between patients who receive a similar radiation dose to normal bowel; therefore, there is a critical need to evaluate the interaction of RT and microbial species in the development of toxicity. Methods: An institutional database was used to identify survivors that completed WPRT for prostate, gynecologic, and anal cancer within the last 5 years. Patients were excluded if they had evidence of recurrent disease requiring additional therapy. Eligible patients were asked to participate via telephone. Consenting patients provided a stool sample and completed a customized PRO-CTCAE form (scale 1-5) assessing chronic GI symptoms. Comprehensive shotgun metagenomics were performed on stool. Stool was sequenced using an Illumina NextSeq500. The fecal metagenome in patients with or without chronic GI symptoms were compared. Patients were dichotomized by PRO-CTCAE diarrhea score (0-1 [mild] vs ≥2 [moderate-severe]). Raw reads were processed with Kneaddata for trimming, Kracken2 for taxonomic profiling, and Bracken for abundance estimation for bacterial, fungal and viral genomes using sequences from the National Center for Bioinformatics to determine quantitative genus and species differences. For microbial diversity assessments, estimated inverse Simpson and Shannon indices were performed. Results: Fecal metagenome and PRO-CTCAE results were available for 13 survivors. Thirty percent (n = 4) of patients reported moderate to severe diarrhea. The mean age was 66 years, 38% were male, 46% received concurrent or adjuvant chemotherapy, and the mean time from completion of WPRT to stool analysis was 34 months (range 14-62 months). Conventional radiation bowel constraints were met for each patient. Several species were enriched in patients with mild GI toxicity. Notably, Akkermansia muciniphilia had the largest differential enrichment in patients with without chronic GI toxicity. Conclusions: In this cohort of patients, A. muciniphilia, a mucin-degrading bacteria that modulates the gut barrier integrity and mucin layer thickness, was enriched in patients with no to mild diarrhea compared to patients with moderate to severe diarrhea. A. muciniphilia supplementation has been shown to decrease systemic inflammation in Western diet-fed mice. Evaluation of A. muciniphilia as a radioprotective gut bacterium warrants further evaluation.

Acute Gastrointestinal Injury in Critically Ill Patients in a South Indian Intensive Care Unit: A Prospective, Observational, Preliminary Study.

Introduction The acute gastrointestinal injury (AGI) score was proposed by the Working Group on Abdominal Problems of the European Society of Intensive Care Medicine (ESICM) as a tool to define and grade gut dysfunction. There have not been any studies in India to validate this tool. The objectiveof this preliminary study was primarily to study the frequency of AGI in the first week of ICU stay in critically ill patients in ourintensive care unit (ICU). We also sought to determine the risk factors predisposing to the development of AGIand to determine the prognostic implication of gastrointestinal (GI) injury in critically ill patients. Materials and methods A prospective, observational, preliminary, single-center study was conducted on critically ill patients (APACHE II > 8) who were on enteral tube feeds and admitted to a mixed ICU of a tertiary care hospital. Anthropometric data, admission diagnosis, APACHE II score, and comorbidities were recorded. Data of daily heart rate, mean arterial pressure, dose of vasopressors, intra-abdominal pressure, fluid balance, feeding intolerance, mechanical ventilation, and laboratory tests were noted for the first seven days of ICUstay or till ICU discharge, whichever was earlier. The occurrence of AGIscore (1-4) during the first seven days of critical illness was the primary outcome of interest. Patient outcome at 28 days was recorded and the impact of the occurrence of AGI on patient outcome was analyzed using the Chi-square test. The patient characteristics associated with AGI were characterized as risk factors and analyzed using a multivariate model. Results Data were collected from 33 patients over 201 patient days. The frequency of acute GI dysfunction in the first seven days of ICU stay in our group of patients was 45.45% (15/33). APACHE II, fluid balance, creatinine, and lactate were identified as possible predictors ofGI injury based on existing literature. These four variables were entered into an ordinal logistic regression model to assess their ability to predict the occurrence ofGI Injury. When fitted into a predictive model, only fluid balance and creatinine were predictive of the final model (p-value < 0.05). A greater fluid balance was predictive in the final model of the development ofGI injury;however,it showed negligible clinical significance (OR: 1.00033, 95% CI: 1.000051-1.00061). Lower creatinine levels were predictive in the final model of the development of AGI Injury,as demonstrated by the negative coefficient. Creatinine also had a greater clinical significance (OR: 0.63, 95% CI: 0.44-0.90) in the development ofAGI. The impact of the AGI scores on mortality was analyzed. The number of patient days with higher AGI scores was significantly associated with increased mortality at 28 days (p-value < 0.001). Conclusion The study showed that nearly half of the critically ill patients included in the study developed acute GI dysfunction.We could not identify any predictors ofGI injury based on our results. The result suggested an association between the severity of GI dysfunction and mortality at 28 days.

Clinical, endoscopic and therapeutic features of bleeding Dieulafoy’s lesions: case series and literature review

ObjectiveDieulafoy’s lesions (DLs) are a rare but potentially life-threatening source of gastrointestinal (GI) haemorrhage. They are responsible for roughly 1%–6.5% of all cases of acute non-variceal GI bleeding.Here, we describe...

Treatment Related Acute Toxicities Between Treatment with 3D-CRT and IMRT in Localised Prostate Cancer.

To compare the acute toxicities of two radiation treatment techniques, intensity modulated radiation therapy (IMRT), and 3-dimensional conformal radiation therapy (3D-CRT) in localised prostate adenocarcinoma. Descriptive study. Place and Duration of the Study:Department of Oncology, Dr. Ziauddin Hospital, Karachi, Pakistan, from July 2016 to June 2022. Patients with localised prostate adenocarcinoma who underwent treatment using two different advanced radiotherapy techniques i.e., IMRT and 3D-CRT were recruited during the study period. They were followed up for six months for acute gastrointestinal (GI) and genitourinary (GU) adverse events (acute toxicities) related to both treatment modalities according to Modified radiation therapy oncology group (RTOG) criteria. The acute toxicities were assessed at the 2nd, 4th, and 6th week during treatment and at the 3rd and 6th month after treatment. There were 78 patients, with 39 patients in each group. The mean age was 68 ± 10 years in the 3D-CRT and 68 ± 07 years in the IMRT group. Patients in the IMRT group exhibited markedly lower treatment-related acute GI and GU effects at the end of 4th and 6th weeks for anorectal pain (p = 0.04) and (p = 0.01) and burning micturition (p = 0.003) and (p = 0.01), respectively. Furthermore, at 3 months anorectal pain (p = 0.02), loose stools (p = 0.005), and burning micturition (p = 0.01) were present and at 6 months anorectal pain was (p = 0.01) still present. Radiation therapy modalities 3D-CRT and IMRT both showed acceptable toxicity profile in the management of localised prostate cancer, while IMRT group exhibited significantly lower treatment-related acute GI and GU effects. 3D-CRT (3-Dimensional Conformal Radiation Therapy), IMRT (Intensity-Modulated Radiation Therapy), Radiation toxicity.

P53 promotes revival stem cells in the regenerating intestine after severe radiation injury

Ionizing radiation induces cell death in the gastrointestinal (GI) epithelium by activating p53. However, p53 also prevents animal lethality caused by radiation-induced acute GI syndrome. Through single-cell RNA-sequencing of the irradiated mouse small intestine, we find that p53 target genes are specifically enriched in regenerating epithelial cells that undergo fetal-like reversion, including revival stem cells (revSCs) that promote animal survival after severe damage of the GI tract. Accordingly, in mice with p53 deleted specifically in the GI epithelium, ionizing radiation fails to induce fetal-like revSCs. Using intestinal organoids, we show that transient p53 expression is required for the induction of revival stem cells and is controlled by an Mdm2-mediated negative feedback loop. Together, our findings reveal that p53 suppresses severe radiation-induced GI injury by promoting fetal-like reprogramming of irradiated intestinal epithelial cells.

ROAR-A: re-optimization based Online Adaptive Radiotherapy of anal cancer, a prospective phase II trial protocol

BackgroundChemo-radiotherapy with curative intent for anal cancer has high complete remission rates, but acute treatment-related gastrointestinal (GI) toxicity is significant. Toxicity occurs due to irradiation of surrounding normal tissue. Current radiotherapy requires the addition of large planning margins to the radiation field to ensure target coverage regardless of the considerable organ motion in the pelvic region. This increases the irradiated volume and radiation dose to the surrounding normal tissue and thereby toxicity. Online adaptive radiotherapy uses artificial intelligence to adjust the treatment to the anatomy of the day. This allows for the reduction of planning margins, minimizing the irradiated volume and thereby radiation to the surrounding normal tissue.This study examines if cone beam computed tomography (CBCT)-guided oART with daily automated treatment re-planning can reduce acute gastrointestinal toxicity in patients with anal cancer.Methods/designThe study is a prospective, single-arm, phase II trial conducted at Copenhagen University Hospital, Herlev and Gentofte, Denmark. 205 patients with local only or locally advanced anal cancer, referred for radiotherapy with or without chemotherapy with curative intent, are planned for inclusion. Toxicity and quality of life are reported with Common Terminology Criteria of Adverse Events and patient-reported outcome questionnaires, before, during, and after treatment. The primary endpoint is a reduction in the incidence of acute treatment-related grade ≥ 2 diarrhea from 36 to 25% after daily online adaptive radiotherapy compared to standard radiotherapy. Secondary endpoints include all acute and late toxicity, overall survival, and reduction in treatment interruptions.ResultsAccrual began in January 2022 and is expected to finish in January 2026. Primary endpoint results are expected to be available in April 2026.DiscussionThis is the first study utilizing online adaptive radiotherapy to treat anal cancer. We hope to determine whether there is a clinical benefit for the patients, with significant reductions in acute GI toxicity without compromising treatment efficacy.Trial registrationClinicalTrials.gov Identifier: NCT05438836. Danish Ethical Committee: H-21028093

Evaluation of the safety and efficacy of high-dose rate brachytherapy for radiorecurrent prostate cancer: asystematic review and meta-analysis.

High-dose-rate brachytherapy (HDR-BT) plays an important role in the treatment of locally recurrent prostate cancer after definitive treatment. The objective of this study is to summarize the efficacy and toxicity of HDR-BT in these patients. We performed asystematic review of PubMed and EMBASE from inception to July 2023. The primary endpoint was relapse-free survival (RFS) in different subgroups, and the secondary endpoint was gastrointestinal (GI) and genitourinary (GU) toxicity. Asemi-automated tool (WebPlotDigitizer) and anew Shiny application combined with Rsoftware (R: a language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria; https://www.R-project.org/ ) helped to reconstruct survival curves. Twenty-six studies met the inclusion criteria for quantitative analysis, including 1447 patients. Atotal of 761 patients from 13studies were included in survival reconstruction, and the median RFS time was 61.2 months (57.6-72.0months). The estimated 2‑, 3‑, and 5‑year rates were 75.9% (95% confidence interval [CI] 72.8 ~ 79.2%), 66.7% (95% CI 63.0 ~ 70.5%), and 52.3% (95% CI 47.5 ~ 57.4%), respectively. Whole-gland irradiation with multiple fractions (≥ 2F) resulted in better RFS compared with focal gland irradiation with fewer fractions (1F mostly; hazard ratio [HR]: 0.60, 95% CI 0.47-0.77, p < 0.0001). According to the different median time from primary treatment to salvage therapy (TRS) and median age at recurrence, short median TRS (56-67.2 months vs. 70-120 months; HR 0.52, 95% CI 0.68-0.40; p < 0.0001) and younger median age (60-70years vs. 71-75years; HR 0.58, 95% CI 0.46-0.74; p < 0.0001) were positive factors for RFS. The cumulative incidences estimated for grade ≥ 3 acute and late GU toxicities were 1% (95% CI 0 ~ 1%) and 5% (95% CI 4 ~ 7%), respectively. Three patients (3/992) experienced grade ≥ 3 late GI toxicity, and no cases of grade ≥ 3 acute GI toxicity were reported. HDR-BT has ahigh safety profile and good RFS benefit for salvage treatment of radiorecurrent prostate cancer. In terms of RFS, whole-gland irradiation with multiple fractions seems to be better than focal gland irradiation with fewer fractions, while short TRS and younger age are good prognostic factors. In view of the low level of evidence in the included studies and the large heterogeneity of each study, these conclusions still need to be confirmed by randomized controlled trials.