Forrest Classification Research Articles

Treatment of nonvariceal upper gastrointestinal bleeding: endoluminal-endovascular-surgical

Nonvariceal upper gastrointestinal bleeding (UGIB) has a high mortality. Hematemesis sometimes with melena are the leading clinical symptoms. Peptic ulcers and (erosive) inflammation are common, whereas Mallory-Weiss syndrome, neoplasms, angiodysplasia and diffuse UGIB are less common. A risk stratification is based on the medical history, clinical presentation and laboratory tests, which are considered in the Glasgow-Blatchford score; however, which treatment approach is optimal? After stabilisation under restricted transfusion indications, temporary stoppage of anticoagulants and optimized coagulation is beneficial and proton pump inhibitors (PPI) should be started. Prokinetics improve the endoscopic conditions in UGIB. The use of an endoscopic Doppler probe optimizes localization of the bleeding site. The use of the Forrest classification and Helicobacter pylori diagnostics are recommended. Mechanical (clips, injection), thermal (argon plasma coagulation, APC) and topical (hemostatic powder) endoscopic treatment procedures are available. Endoluminal hemostasis is very effective. Only clip application is suitable as monotherapy whereas all other endoscopic options should be combined. Angiography followed by transarterial embolization (TAE) can be used for therapy. Despite the high primary success rate, the risk of rebleeding is high. Surgery as the primary treatment is rarely necessary, although effective. Compared to TAE complications are higher, but there is no difference regarding mortality. Endoscopy remains the gold standard for the initial diagnostics and treatment of UGIB. In cases of rebleeding repeated endoscopy is recommended. With persistent UGIB an endovascular procedure should be evaluated. Surgery remains an important salvage option.

The recurrent bleeding risk of a Forrest IIc lesion at the second-look endoscopy can be indicated by high Rockall scores ≥ 6.

BackgroundThe Forrest classification is widely applied to guide endoscopic hemostasis for peptic ulcer bleeding. Accordingly, practice guidelines suggest medical treatment only for ulcer with a Forrest IIc lesion because it has low rebleeding risk even without endoscopic therapy, ranging from 0 to 13%. However, the risk ranges widely and it is unclear who is at risk of rebleeding with such a lesion. This study assessed whether the Rockall score, which evaluates patients holistically, could indicate the risk of recurrent bleeding among patients with a Forrest IIc lesion at the second-look endoscopy.MethodsPatients who had peptic ulcer bleeding with Ia-IIb lesions received endoscopic hemostasis at the primary endoscopy, and they were enrolled if their Ia-IIb lesions had been fading to IIc at the second-look endoscopy after 48- to 72-h intravenous proton pump inhibitor (PPI) infusion. Primary outcomes were rebleeding during the 4th–14th day and 4th–28th day after the first bleeding episode.ResultsThe prospective cohort study enrolled 140 patients, who were divided into a Rockall scores ≥ 6 group or a Rockall scores < 6 group. The rebleeding rates in the Rockall scores ≥ 6 group and the Rockall scores < 6 group during the 4th–14th day and the 4th–28th day were 13/70 (18.6%) versus 2/70 (2.9%), p = 0.003 and 17/70 (24.3%) versus 3/70 (4.3%), p = 0.001, respectively, based on an intention-to-treat analysis and 5/62 (8.1%) versus 0/68 (0%), p = 0.023 and 6/59 (10.2%) versus 0/67 (0%), p = 0.009, respectively, based on a per-protocol analysis. The Kaplan–Meier curves showed that the Rockall scores ≥ 6 group had a significantly lower cumulative rebleeding-free proportion than the Rockall scores < 6 group (p = 0.01).ConclusionsCombined Rockall scores ≥ 6 on arrival with a Forrest IIc lesion at the second-look endoscopy can identify patients at risk of recurrent peptic ulcer bleeding following initial endoscopic and intravenous PPI treatment.Trial registration Trial registration identifier: NCT01591083

Clinical and statistical aspects of gastrointestinal bleeding course in patients with cardiovascular system pathology.

We have collected, processed and analyzed the results of treatment of 329 patients with gastrointestinal bleedings in which the course of the underlying disease is aggravated by the pathology of the cardiovascular system, in Communal institution "Dnipro Clinical Emergency Care Association" of Dnipro City Council» in the period for 2017. First, the frequency of background diseases was determined, chronic pathology being 93.4%. Ischemic heart disease (IHD): cardiosclerosis of various origins (post-infarction, diffuse, atherosclerotic), hypertonic disease (HD) - HD-I, HD-II, HD-III are the most common, while acute disorders of cerebral circulation, the state after coronary artery bypass surgery, renal artery bypass, arrhythmias, acute myocardial infarction made up 16 (5%), 1 (0.3%), 3 (1%), 1 (0.3%), respectively. Secondly, the quality of endoscopic hemostasis in case of ulcerative bleeding from the stomach, duodenum, gastroenteroanastomosis, was assessed by Forrest classification, connecting the results with the accompanying pathology of the cardiovascular system. We found that active bleeding F I was determined in 24 people (7.3%), of which F Ia – in 14 (4.3%), F Ib – in 10 (3%). Unstable hemostasis with a high risk of recurrent F II bleeding, was observed in 251 patients, which makes up 76.2%, and F III – in 54 (16.5%). The degree of blood loss was directly influenced by drug – anticoagulants, antiplatelet agents, hypotensive drugs, as well as their combinations, aimed at correcting the rheological properties of blood. Depending on the degree of blood loss, the quality of hemostasis, the general condition of the patient, the treatment tactics for this cohort of patients was determined. 313 patients received conservative treatment, which made up 95.1%. 16 patients were operated. Postoperative mortality is 12,5%. The overall mortality of the above cohort is 10%.

EFFICACY OF ENDOSCOPIC HEMOCLIPS AND INTERMITTENT INTRAVENOUS PPI IN PEPTIC ULCER BLEEDING

Background: Efficacy of continuous intravenous proton- pump inhibitors (IV PPI) and hemoclips alone was proved, but data about combination of an application of endoscopy clips and intermittent IV PPI in Vietnam was still limited. This study aimed to assess the efficacy of endoscopy hemoclip combined with intermittent IV PPI in the patients of peptic ulcer bleeding. Patients and methods: 34 patients diagnosed as peptic ulcer bleeding, having Forrest classification of Ia, Ib, IIa and IIb, were enrolled. Esomeprazole was administered as 80 mg IV bolus followed by intermittent IV injection of 40 mg/8h during 72h. Results: Immediate hemostasis was achieved in all 34 patients. Only 1 patient (2.9%) had early rebleeding. No severe complications was found in this study. Conclusion: Combination of endoscopy hemoclips and intermittent PPI showed effective, safe in patients of peptic ulcer bleeding. Key words: Peptic ulcer bleeding, intermittent PPI, endoscopy hemoclip

Quick SOFA vs Rockall preendoscopy scores for risk assessment in patients with nonvariceal upper gastrointestinal bleeding: a retrospective cohort study

BackgroundSeveral scoring systems are used to evaluate the severity of nonvariceal upper gastrointestinal bleeding (NVUGB) and the risk of rebleeding or death. The most commonly used scoring systems include the Rockall score, Glasgow-Blatchford score, and Forrest classification. However, the use of simpler definitions, such as the quick Sequential Organ Failure Assessment (qSOFA) score, to make a clinical decision is reasonable in areas with limited time and/or material resources and in low- and middle-income countries.MethodsPatients with NVUGB whose medical records included information required to calculate the qSOFA and Rockall preendoscopy scores at the time of bleeding in the emergency department or another non-intensive care unit department were included in the study. The area under the receiver operating characteristic curve (AUROC) and 95% confidence interval (95% CI) were estimated for the ability of the qSOFA and Rockall preendoscopy scores to predict mortality.ResultsThe qSOFA and Rockall preendoscopic scores at the time of bleeding confirmation could be calculated for 218 patients. The mortality rate increased from 3.4% in patients with a qSOFA score = 0 to 88.9% in patients with a qSOFA score = 3 (P < 0.001). The AUROC for prediction of mortality was 0.836 (95% CI 0.748–0.924) for the qSOFA score and 0.923 (95% CI 0.884–0.981) for the Rockall preendocopy score (P = 0.059).ConclusionsAn increase in the qSOFA score is associated with adverse outcomes in patients with NVUGB. The simple qSOFA score can be used to predict mortality in patients with NVUGB as an alternative when Rockall preendoscopy score is incomplete for which the comorbidity is unknown.

Risk factors for delayed bleeding by onset time after endoscopic submucosal dissection for gastric neoplasm

Post-endoscopic submucosal dissection bleeding (PEB) is one of the important complications after endoscopic submucosal dissection (ESD), but still difficult to predict. The present study aimed to identify significant risk factors for PEB according to onset time. Between November 2008 and January 2016, a total of 1864 lesions resected via ESD were analyzed. PEB was classified as either early or late according to onset time (within or after 24 hours post-ESD, respectively). During second-look endoscopy, the artificial ulcer bed was subjected to Forrest classification. A high risk of stigma was defined as active spurting bleeding, oozing bleeding, and a non-bleeding visible vessel in the ulcer. The endoscopic factors and medications associated with PEB were analyzed. PEB occurred in 77 lesions (4.1%): early only in 46 (2.4%), late only in 22 (1.1%), and early and late in 9 (0.4%). Among 55 early PEB events, 25 were asymptomatic and diagnosed during second-look endoscopy. Age ≤65 years, resection size ≥30 mm, procedure time ≥20 min, lower third of the stomach, erosion, and clopidogrel use were significantly associated with early PEB. If the number of risk factors were ≤1, the risk of early PEB was 0.6%. For late PEB, the mid to upper third of the stomach, undifferentiated carcinoma, erosion, high risk of stigma during second-look endoscopy, history of early PEB, and clopidogrel use were significant risk factors. If risk factors were absent, the risk of late PEB was 0.1%. For patients at high risk of early PEB, selective second-look endoscopy might be a useful. For patients at high risk of late PEB, careful monitoring of bleeding should be considered.

Koeficijent varijacije distribucije eritrocita I trombocita kao prediktora u utvrđivanju prognoze krvarenja iz gornjih partija gastrointestinalnog trakta

Background and Aim: Acute upper gastrointestinal bleeding (AUGIB) is one of the most common medical emergencies. Early detection of at-risk patients is beneficial with respect to treatment and prognosis. We investigated whether severity of ulcers were associated with red blood cell distribution width (RDW), plateletcrit (PCT), mean platelet volume (MPV) and platelet distribution width (PDW). Materials and Methods: All patients presenting to the emergency department with AUGIB between January 2014 and December 2017 were included in the study. Endoscopy reports, complete blood counts, patient demographic characteristics, and endoscopy results were obtained retrospectively from hospital records. Patients with grade I or grade II ulcers (based on the Forrest classification) were compared in regard to these parameters. Results: In total, 373 male and 211 female patients with a mean age ± SD of 66.36 ± 17.36 were included in this study. Ulcers were detected in 396 of 584 patients (67.8%). There were no differences with respect to RDW or platelet indices between groups. Conclusions: Patients presenting with AUGIB should receive rapid diagnosis and treatment. In this study of patients with AUGIB grouped by bleeding aetiology, probable early prognostic parameters were not associated with bleeding severity among patients diagnosed with gastric or duodenal ulcers.

Üst gastrointestinal sistem kanamalı hastalarda kronik böbrek yetmezliğinin risk faktörleri ve endoskopi sonuçlarına etkisinin değerlendirilmesi

Aim: Acute upper gastrointestinal system (GIS) bleeding is one of the leading causes of mortality and morbidity. Presence of concomitant disease in upper GIS bleeding is a mortality-associated risk factor, and chronic renal insufficiency (CRI) is one of these concomitant diseases. In the present study, patients with CRI, who had upper GIS bleeding and been treated as inpatient between January 2016 and January 2017 at Tepecik Training and Research Hospital Clinic of Gastroenterology, and the patients that had upper GIS bleeding without renal insufficiency were comparatively investigated in terms of demographic characteristics, presence of concomitant disease, drug usage, endoscopic results, Forrest classification, and need for endoscopic intervention and mortality. Materials and Methods: A total of 194 patients were retrospectively evaluated. The CRI group with a glomerular filtration rate (GFR) lower than 60 mL/min/1.73 m2 comprised 90 patients, whereas the control group with a GFR of 60 mL/min/1.73 m2 and higher comprised 104 patients.Results: As the result of the study, it was determined that CRI group was older and 96% of the patients had a concomitant disease. Drug usage rate was higher than the control group with aspirin used most frequently. Endoscopy was performed on Day 1 in more than 70% of the cases. Conclusion: Hospital mortality rate was higher in CRI group (5.66% vs 2.88%, p=0.475) with lower total mortality rate found in the present study as compared to the literature.

Endoscopic suturing for management of peptic ulcer-related upper gastrointestinal bleeding: a preliminary experience.

Background and study aims Acute non-variceal upper gastrointestinal bleeding (UGIB) due to peptic ulcer disease (PUD) remains a common and challenging emergency managed by gastroenterologists. The proper role of endoscopic suturing on the management of PUD-related UGIB is unknown. Patients and methods This is an international case series of patients who underwent endoscopic suturing for bleeding PUD. Primary outcome was rate of immediate hemostasis and rate of early rebleeding (within 72 hours). Secondary outcomes included technical success, delayed rebleeding (> 72 hours), and rate of adverse events (AEs). Results Ten patients (mean age 66.7 years, 30 % female) were included in this study. Nine (90 %) had prior failed endoscopy hemostasis with an average of 1.4 ± 0.7 (range 1 – 3) prior endoscopic sessions. Forrest classification was Ib in 5 (50 %), IIa in 3 (30 %), IIb in 1(10 %), and IIc in 1 (10 %). Mean suturing time was 13.4 ± 5.6 (range 3.5 to 20) minutes. Technical success was 100 %. Rate of immediate hemostasis was 100 % and rate of early rebleeding was 0 %. Mean number of sutures was 1.5 (range, 1 – 4). No AEs were observed. Delayed recurrent bleeding was not observed in any cases after a median of 11 months (range 2 – 56), after endoscopic suturing. Conclusions Oversewing of a bleeding or high-risk ulcer using endoscopic suturing appears to be a safe and effective method for achieving endoscopic hemostasis. It may be considered as rescue endoscopic therapy when primary endoscopic hemostasis fails to control the bleeding or when hemorrhage recurs after successful control of bleeding.

Assessment of endoscopic Doppler to guide hemostasis in high risk peptic ulcer bleeding

Introduction: Rebleeding or emergency surgery in failed endoscopic therapy of peptic ulcer bleeding are associated with high rates of morbidity and mortality. The clinical benefit of an endoscopic Doppler (ED) examination prior to endoscopic injection therapy was evaluated in high risk ulcer patients for rebleeding episode. Standard injection therapy (non-Doppler (ND)) was compared with targeted injection therapy after examination of the supplying vessel in the ulcer base by the ED.Materials and methods: Sixty patients with peptic ulcer bleeding (Forrest Ia–IIa; Rockall score of 5 or higher) were included in the study. Patients were assigned to ED or ND group with conventional therapy by chance. In the ND group injection was directed by the visual aspect of the ulcer, whereas in ED therapy was directed by ED.Results: Thirty-five patients were allocated to the ED group, and 25 to the ND group, respectively. No significant differences in patient or ulcer characteristics were observed regarding ulcer size, localization, Forrest classification or endoscopic treatment. Recurrent bleeding was observed in 7/35 (20%) in the ED group and in 13/25 (52%) of patients in the ND group (p = .013). Fewer ED patients needed surgery for rebleeding (1/35 vs. 6/25; p = .017). Bleeding related, but not all-cause mortality was significantly lower in the ED group (1/35 vs. 6/25, p = .017).Discussion: In this comparative analysis, use of ED to guide hemostatic therapy was associated with a significant reduction in recurrence of bleeding, surgical intervention and bleeding associated mortality.

Comparison of monopolar hemostatic forceps with soft coagulation versus hemoclip for peptic ulcer bleeding: a randomized trial (with video)

Although various methods are used in the treatment of peptic ulcer bleeding, there is not a standard recommended approach. The choice depends on multiple factors such as location of the ulcer, clinical experience of the endoscopist, and local facilities of the clinic. We aimed to compare the efficacy of monopolar hemostatic forceps soft coagulation (MHFSC) and hemoclips (HCs) in the treatment of peptic ulcer-related upper GI bleeding. The study group included patients who had GI bleeding due to Forrest 1a, 1b, and 2a gastric or duodenal ulcers within 1 year. Patients with bleeding diathesis, history of gastrectomy, pregnancy, or younger than age 18 years were excluded. The remaining were randomized to MHFSC and HC treatment groups and compared in terms of clinical and endoscopic features, initial hemostasis success rates, recurrent bleeding rates within the first 7 days, time to achieve hemostasis, length of hospitalization stay, and adverse events. One hundred twelve patients were randomized to MHFSC (n= 56) and HC (n= 56) groups. There was no statistically significant difference between the groups with respect to demographic features, medications, underlying chronic diseases, location, and Forrest classification of the ulcers. The initial hemostasis success rate was 98.2% (55/56) in the MHFSC group and 80.4% (45/56) in the HC group (P= .004). Recurrent bleeding was detected in 2 patients in the MHFSC group (3.6%) and 8 patients in the HC group (17.7%; P= .04). The duration of endoscopic procedures (302 ± 87.8 vs 568 ± 140.4 seconds) and the length of hospital stay (3.50 ± 1.03 vs 4.37 ± 1.86 days) were significantly shorter in the MHFSC group. There were no adverse events in either group. MHFSC is more effective in achieving initial hemostasis compared with HCs in the treatment of peptic ulcer bleeding and provides a shorter procedure time and a lower recurrent bleeding rate.

The activity of hemostatic and oxidative-reduction systems according to different classes of ulcer bleeding

Haemostatic therapy of ulcer bleeding (UB) is based on activation of the coagulation system and depression of the fibrinolytic one. Though not so much attention is paid to the oxidation-reduction system. Aim of the study — To elaborate the recommendations on optimization of hemostatic therapy. Were examined 25 patients with UB. 4 patients were evaluated by Forrest classification, type ІВ, 5 – type ІІА, 6 — type ІІВ, and 10 — type ІІІС. Patients with type ІВ had endoscopic haemostasis procedures. All patients got a standard haemostatic complex. Two patients who were evaluated by Forrest classification type ІІА had bleeding recurrence. The following data was determined in blood plasma: fibrinolytic and proteolytic activity, fibrinase, antithrombin ІІІ, prothrombin index, isolated double bonds, diene conjugates, cetodienes and conjugated trienes, oxidation of neutral and alkaline proteins, malonic aldehyde, renew glutathione, catalase. Patients who were evaluated by Forrest classification type ІІА had both a disorder of redox system and hemostasis system balance, caused by a violation of synthesis of its factors. This contributes to the occurrence of bleeding recurrence. The results of redox system together with the criteria for hemostasis condition can be used to predict the recurrence of ulcer bleeding. Medicinal measures need to be adjusted, and antioxidants together with hepatoprotectors to be prescribed. So, patients with UB recurrence have an excessive activation of lipoperoxidation, low level of basic proteins, decrease in functional capacity of antioxidant mechanisms and hemostasis system imbalance, caused by a violation of synthesis of its factors, it is essential to take into account while predicting UB recurrence, and in case of UB one should add to the medication management those means that inhibit the activity of lipid oxidation and contribute to the restoration of synthesis processes of hemostasis factors. The prospect of further development is the assessment of the effectiveness of an optimized treatment complex.

Risk factor analysis for early rebleeding in patients with peptic ulcer bleeding

Objective To explore the risk factors for early rebleeding in patients with peptic ulcer bleeding (PUB). Methods From June 2006 to May 2017, a total of 1 210 hospitalized patients with PUB from The General Hospital of Ningxia Medical University were enrolled. Totally 1 040 patients with bleeding stopped after the treatment were taken as the control group. And 170 patients with early rebleeding were as the rebleeding group. The clinical data of the patients in two groups were analyzed. Chi-square test, t-test and multivariate factors analysis were performed for statistical analysis. Results Between control group and rebleeding group, there were statistical significances in gender, age, place of residence, hematemesis, shock, volume of blood transfusion, anticoagulant use, combined diseases, hemoglobin level, albumin level, urea nitrogen, neutrophil ratio, platelet count, ulcer location, maximum ulcer diameter, Forrest classification and endoscopic treatment (all P<0.05). The rate of endoscopic hemostasis of rebleeding group (92.56%, 112/121) was lower than that of control group (98.70%, 228/231), and the difference was statistically significant (χ2=13.609, P=0.001). The result of multivariate logistic regression analysis showed that Forrest classification (odds ratio(OR)=7.735, P<0.01), hemoglobin (OR=7.332, P=0.040), shock (OR=5.245, P<0.01) and ulcer size (OR=2.360, P=0.029) were independent risk factors for rebleeding in patients with PUB. The effect of Forrest classification better than hemoglobin, hemoglobin better than shock and shock better than ulcer size in assessing the risk of rebleeding. Conclusions Forrest classification, hemoglobin, shock, ulcer size are the risk factors for rebleeding in patients with PUB. Endoscopic hemostasis can reduce the risk of rebleeding. Key words: Peptic ulcer hemorrhage; Rebleeding; Risk factors

Effectiveness of the polysaccharide hemostatic powder in non-variceal upper gastrointestinal bleeding: Using propensity score matching.

Recently, the application of hemostatic powder to the bleeding site has been used to treat active upper gastrointestinal bleeding (UGIB). We aimed to assess the effectiveness of the polysaccharide hemostatic powder (PHP) in patients with non-variceal UGIB. We reviewed prospectively collected 40 patients with UGIB treated with PHP therapy between April 2016 and January 2017 (PHP group) and 303 patients with UGIB treated with conventional therapy between April 2012 and October 2014 (conventional therapy group). We compared the rate of successful hemostasis and the rebleeding between the two groups after as well as before propensity score matching using the Glasgow-Blatchford score and Forrest classification. Thirty patients treated with the PHP and 60 patients treated with conventional therapy were included in the matched groups. Baseline patient characteristics including comorbidities, vital signs, and bleeding scores were similar in the matched groups. The rate of immediate hemostasis and 7-day and 30-day rebleeding were also similar in the two groups before and after matching. In the subgroup analysis, no significant differences in immediate hemostasis or rebleeding rate were noted between PHP in monotherapy and PHP combined with a conventional hemostatic method. At 30days after the therapy, there were no significant PHP-related complications or mortality. Given its safety, the PHP proved feasible for endoscopic treatment of UGIB, having similar effectiveness as that of conventional therapy. The PHP may become a promising hemostatic method for non-variceal UGIB.

Efficacy of hemostatic powder in preventing bleeding after gastric endoscopic submucosal dissection in high-risk patients.

The prevention of post-endoscopic submucosal dissection (ESD) bleeding in high-risk patients is an important problem. This study evaluated the efficacy of polysaccharide hemostatic powder in preventing post-ESD bleeding in high-risk patients. Patients at high risk for post-ESD bleeding were prospectively enrolled between December 2015 and July 2016. A high risk of post-ESD bleeding was considered if the patients were taking antithrombotic agents or had undergone a large resection (specimen size ≥40mm). The endpoints were Forrest classification of the post-ESD ulcer on second-look endoscopy 2days after the procedure and bleeding rates within 48h and at 4weeks. Forty-four patients underwent gastric ESD and treatment with hemostatic powder. Among them, 33 patients (70.5%) underwent large resection (≥40mm) without antithrombotic therapy, and 13 patients (29.5%) received antithrombotic therapy. The mean resected specimen size was 55.3±13.9mm. The proportion of high-risk delayed bleeding lesions (Forrest IIa) at second-look endoscopy was 4.5% (2/44). The overall bleeding rate was 9.1% (4/44). There was no early bleeding event. The median (interquartile range) timing of bleeding after the procedure was 12.5 (interquartile range 10.3-15.5) days. The bleeding rate in the large resection (≥40mm) group without antithrombotic therapy and the antithrombotic therapy group was 3.2% (1/33) and 23.1% (3/13), respectively. Hemostatic powder may be a promising new simple and effective method to prevent early post-ESD bleeding in high-risk patients, especially for those with larger resection. (Clinical trial registration number: NCT02625792).

Patients with Treatment-Requiring Chronic Graft versus Host Disease after Allogeneic Stem Cell Transplantation Have Altered Metabolic Profiles due to the Disease and Immunosuppressive Therapy: Potential Implication for Biomarkers.

Chronic graft versus host disease (cGVHD) is a common long-term complication after allogeneic hematopoietic stem cell transplantation. The objective of our study was to compare the metabolic profiles for allotransplant recipients and thereby identify metabolic characteristics of patients with treatment-requiring cGVHD. The study included 51 consecutive patients (29 men and 22 women; median age: 44 years, range: 15–66 years) transplanted with peripheral blood stem cells derived from human leukocyte antigen-matched family donors. All serum samples investigated by global metabolomic profiling were collected approximately 1 year posttransplant (median 358 days). Thirty-one of the 51 patients (61%) had cGVHD 1 year posttransplant. The affected organs were (number of patients) liver/bile duct (23), eyes (15), gastrointestinal tract (14), skin (13), mouth (10), lungs (3), and urogenital tract (1). We compared the metabolic profile for patients with and without cGVHD, and a Random Forrest Classification Analysis then resulted in 75% accuracy in differentiating the two groups. The 30 top-ranked metabolites from this comparison included increased levels of bile acids, several metabolites from the cytokine-responsive kynurenine pathway for tryptophan degradation, pro-inflammatory lipid metabolites, phenylalanine and tyrosine metabolites derived from the gut microbial flora, and metabolites reflecting increased oxidative stress. However, nine of these 30 top-ranked metabolites were probably altered due to cyclosporine or steroid treatment, and we therefore did a hierarchical clustering analysis including all 51 patients but only based on the other 21 cGVHD-specific metabolites. This analysis identified three patient subsets: one cluster included mainly patients without cGVHD and had generally low metabolite levels; another cluster included mainly patients with cGVHD (most patients with at least three affected organs) and high metabolite levels, and the last intermediate group including cGVHD patients with limited organ involvement. We conclude that allotransplant recipients with cGVHD have an altered metabolic profile caused both by the disease and its immunosuppressive treatment.

Prediction of clinical outcome in patients with nonvariceal gastrointestinal bleeding using Forrest classification and Rockall score

Background Predicting outcome of upper gastrointestinal bleeding has significant importance to reduce mortality, duration of hospital stay, and medical cost.Objective The aim was to investigate the predictive value of Forrest classification and Rockall score in assessing rebleeding rate and mortality rate in patients with nonvariceal gastrointestinal bleeding (NVUGIB).Patients and methods A total of 518 patients with NVUGIB from January 2013 to July 2017 were enrolled in this retrospective study. Logistic regression analysis was used to assess the association between these scores and clinical outcome.Results Forrest classification is significantly associated with rebleeding, whereas Rockall score is closely associated with mortality. The risks of rebleeding in patients with Forrest Ia-b [odds ratio (OR): 39.2; 95% confidence interval (CI):19.2–79.8], FIIa (OR: 29.7; 95% CI:13.5–65.4), and FIIb (OR: 6.5; 95% CI: 3.0–14.1) were significantly increasing compared with FIII. The risks of mortality in patients with Rockall score 4–6 (OR: 9.4; 4.1–21.6), 7–11 (OR: 101.5; 50.2–205.3), were significantly increasing compared with the group with Rockall score less than 4.Conclusion Forrest classification can be used as a predictor for rebleeding and Rockall score can be used as a predictor for mortality in patients with NVUGIB.

Endoscopic Collagen Spray A Novel Method Which can be Used as an Adjunct to Conventional Hemostatic Techniques in Peptic Ulcer Bleeding

Aim: To study endoscopic collagen spray as a hemostatic agent in peptic ulcer bleeding not controlled by conventional therapy. Methods: In this prospective study, endoscopic collagen spray, VGM’s Haemoseal spray has been used in the treatment of peptic ulcer bleeding, as a single agent or in combination with other agents. Haemoseal Spray Kit consists of air pump, Haemoseal probe, a 7.5 Fr spray catheter, 230 cm in length and a pre-loaded collagen cartridge that contains 5 grams of powder. A maximum of 2 grams is applied depending on the area to be covered. Results: Eighteen consecutive patients, who presented with peptic ulcer bleeding were included. There were sixteen patients with duodenal ulcer and two patients with gastric ulcer. The hemorrhagic ulcers were Forrest classification category Ib in sixteen patients and Ia in two patients. After spraying collagen, the bleeding stopped within seconds in all the patients. Repeat endoscopy after 48 hours showed no rebleeding. One patient had an arterial spurt from duodenal ulcer. Collagen spray was used initially as there was poor visibility. After 24 hours, repeat endoscopy revealed visible vessel with no bleeding. Hemoclipping could be achieved. There were no side effects experienced by the patients. Conclusion: Collagen spray is a safe and effective endoscopic hemostatic agent in treatment of peptic ulcer bleeding not controlled by conventional therapy.

Can exhaled volatile organic compounds predict asthma exacerbations in children?

Background. Asthma control does not yet meet the goals of asthma management guidelines. Non-invasive monitoring of airway inflammation may help to improve the level of asthma control in children. Objectives. (1) To identify a set of exhaled volatile organic compounds (VOCs) that is most predictive for an asthma exacerbation in children. (2) To elucidate the chemical identity of predictive biomarkers. Methods. In a one-year prospective observational study, 96 asthmatic children participated . During clinical visits at 2 month intervals, asthma control, fractional exhaled nitric oxide, lung function (FEV1, FEV1/VC) and VOCs in exhaled breath were determined by means of gas chromatography time-of-flight mass spectrometry. Random Forrest classification modeling was used to select predictive VOCs, followed by plotting of receiver operating characteristic-curves (ROC-curves). Results. An inverse relationship was found between the predictive power of a set of VOCs and the time between sampling of exhaled breath and the onset of exacerbation. The sensitivity and specificity of the model predicting exacerbations 14 days after sampling were 88% and 75%, respectively. The area under the ROC-curve was 90%. The sensitivity for prediction of asthma exacerbations within 21 days after sampling was 63%. In total, 7 VOCs were selected for the classification model: 3 aldehydes, 1 hydrocarbon, 1 ketone, 1 aromatic compound, and 1 unidentified VOC. Conclusion. VOCs in exhaled breath showed potential for predicting asthma exacerbations in children within 14 days after sampling. Before using this in clinical practice, the validity of predicting asthma exacerbations should be studied in a larger cohort.

Comparison of heater probe coagulation and argon plasma coagulation in the management of Mallory–Weiss tears and high-risk ulcer bleeding

Background and study aimsUpper gastrointestinal (GI) bleeding is a common medical emergency. Endoscopic treatments often lead to better therapeutic outcomes than conventional conservative treatments. This study aimed to investigate and compare the use of heater probe coagulation (HPC) and argon plasma coagulation (APC) together with epinephrine injection for the treatment of Mallory–Weiss tears and high-risk ulcer bleeding. Patients and methodsA total of 97 patients (54 in the HPC group and 43 in the APC group) who were diagnosed with upper GI bleeding secondary to a Mallory–Weiss tear or high-risk gastric or duodenal ulcers were included in the study. Lesions were classified according to the Forrest classification. The HPC and APC groups were compared in terms of initial haemostasis, re-bleeding in the early period, need for surgery, average need for transfusion, and duration of hospital stay. ResultsThere were no significant differences between the HPC and APC groups in terms of ensuring initial haemostasis (98% vs. 97.5%, p>0.05), re-bleeding rates (17% vs. 19%, p>0.05), need for surgery (2% vs. 9%, p>0.05), average need for transfusion (3.7±2.11 vs. 3.4±2.95 units, p>0.05), and average duration of hospital stay (4.6±2.24vs. 5.3±3.23days, p>0.05). ConclusionThere was no difference between HPC and APC when used together with epinephrine injection for the treatment of Mallory–Weiss tear and high-risk ulcer bleeding.