Use Of Acid Suppression Research Articles

A cross-sectional study of national outpatient gastric acid suppressant prescribing in the United States between 2009 and 2015.

PurposeGastric acid suppressants are commonly used in the United States, and while generally well-tolerated, long-term use has been associated with infection, bone fractures, and nutrient malabsorption. The purpose of this study was to describe national trends in gastric acid suppressant use over a 7-year period.MethodsThis was a cross-sectional study using data from the National Ambulatory Medical Care Survey from 2009 to 2015. Gastric acid suppressant use was defined as any outpatient visit with a documented prescription for a proton pump inhibitor or histamine-2 receptor antagonist documented during the outpatient visit. Sample data weights were used to extrapolate to national estimates. Use was calculated as the number of prescriptions per total outpatient visits per year. Appropriateness of prescribing was assessed using FDA-approved indications listed in each visit.ResultsThese data represent 6.8 billion patient outpatient visits between 2009 and 2015, of which nearly 600 million (8.8%) had documented gastric acid suppressant use. The median (IQR) age of gastric acid suppressant users and non-gastric acid suppressant users was 62 (50–73) and 49 (25–65), respectively. Gastric acid suppressant use decreased from 9.0% in 2009 to 7.7% in 2012, and then increased to 9.7% in 2015. Proton pump inhibitor use was slightly higher in the Midwest (8.3%). Only 15.8% of gastric acid suppressant users had a documented indication.ConclusionsProton pump inhibitor use increased after 2012, and the majority of gastric acid suppressant users did not have a documented indication. Judicious gastric acid suppressant prescribing needs to be exercised, especially in the context of new safety data regarding long-term proton pump inhibitor use.

ACVIM consensus statement: Support for rational administration of gastrointestinal protectants to dogs and cats.

The gastrointestinal (GI) mucosal barrier is continuously exposed to noxious toxins, reactive oxygen species, microbes, and drugs, leading to the development of inflammatory, erosive, and ultimately ulcerative lesions. This report offers a consensus opinion on the rational administration of GI protectants to dogs and cats, with an emphasis on proton pump inhibitors (PPIs), histamine type‐2 receptor antagonists (H2RAs), misoprostol, and sucralfate. These medications decrease gastric acidity or promote mucosal protective mechanisms, transforming the management of dyspepsia, peptic ulceration, and gastroesophageal reflux disease. In contrast to guidelines that have been established in people for the optimal treatment of gastroduodenal ulcers and gastroesophageal reflux disease, effective clinical dosages of antisecretory drugs have not been well established in the dog and cat to date. Similar to the situation in human medicine, practice of inappropriate prescription of acid suppressants is also commonplace in veterinary medicine. This report challenges the dogma and clinical practice of administering GI protectants for the routine management of gastritis, pancreatitis, hepatic disease, and renal disease in dogs and cats lacking additional risk factors for ulceration or concerns for GI bleeding. Judicious use of acid suppressants is warranted considering recent studies that have documented adverse effects of long‐term supplementation of PPIs in people and animals.

A Nationwide Population-Based Cohort Study of Dementia Risk Among Acid Suppressant Users

Data regarding the potential link between acid suppressant use and dementia are inconsistent. This study assessed the association between cumulative exposure to proton pump inhibitors (PPIs) and histamine-2 receptor antagonists (H2RAs) and dementia risk among Korean adults. A population-based longitudinal study was conducted using the Korean National Health Insurance Corporation claims database merged with national health examination data for 2002-2013. The study cohort included 70,529 subjects who were dementia-free in 2007. Incident dementia was assessed throughout follow-up until 2013. Exposure to acid suppressants prior to 2007 was assessed using a standardized defined daily dose system. Potential associations between acid suppressant use and dementia risk were analyzed using time-dependent Cox regression estimated hazard ratios (HRs) and 95% confidence intervals (CIs). There were 1,297 cases of dementia during the study period. Multivariate analyses identified several factors associated with dementia risk: old age, female, current smoker, Type 2 diabetes, comorbidities, and use of nonaspirin nonsteroidal anti-inflammatory drugs. H2RA users had a significantly increased risk of dementia compared with non-H2RA users (HR 1.31, 95% CI 1.13-1.51), whereas PPI use was not associated with increased risk. Our results indicate that exposure to H2RAs (but not PPIs) is associated with increased dementia risk. Further randomized controlled trials and basic research examining the underlying mechanism are needed to confirm this association.

Speculation as to why the Frequency of Eosinophilic Esophagitis Is Increasing.

The frequency of eosinophilic esophagitis (EoE), an immune/antigen-mediated disorder first described in 1993, has been increasing rapidly. The purpose of this review is to consider hypotheses proposed to explain this increase and to speculate on their validity. The hygiene hypothesis attributes the rise of EoE to modern hygienic conditions resulting in fewer childhood infections with microbes that might have protected against allergy development. Microbial dysbiosis, a change in the microbiome's composition and diversity caused by a modern affluent lifestyle, also might contribute to allergic conditions. Environmental factors including modern chemicals contaminating crops, livestock treated with hormones and antibiotics, food additives and processing changes, and pollutants in the air and water conceivably might predispose to EoE. One intriguing hypothesis attributes increasing EoE to increasing use of acid-suppressive medications like proton pump inhibitors, which might prevent peptic digestion of food allergens, increase gastric permeability, and alter the microbiome to favor food allergy development. In a recent pediatric case-control study, use of acid suppressants in infancy was by far the single strongest risk factor identified for later development of EoE. It remains unclear which, if any, of the above factors underlies the rising frequency of EoE. These factors need not be mutually exclusive, and the cause of EoE may well be multifactorial.

Acid Suppressant Use in Pregnancy and Asthma in Offspring: Should We Be Worried?

* Abbreviations: CI — : confidence interval GERD — : gastroesophageal reflux disease PPI — : proton pump inhibitor Gastroesophageal reflux disease (GERD) is the most common medical complaint in pregnancy, manifesting as heartburn and regurgitation. GERD occurs in 25% to 80% of women, with the prevalence varying according to definition and nationality.1–3 Initial management involves lifestyle changes and/or antacids, followed by a standard treatment of acid-suppressive medications such as histamine-2 receptor antagonists and proton pump inhibitors (PPIs).1 Maternal use of PPIs in pregnancy has been shown to be safe in relation to birth defects, spontaneous abortions, and preterm delivery.4,5 However, there is a growing number of epidemiologic studies to suggest that maternal use of acid-suppressive medications in pregnancy is associated with an increased risk of asthma in the offspring. In the current edition of Pediatrics , Lai et al6 have published a meta-analysis of 8 such studies, concluding that there is a risk of children developing asthma with prenatal exposure to PPIs (odds ratio: 1.34; 95% confidence interval [CI]: 1.18–1.52) and histamine-2 receptor antagonists (odds ratio: 1.57; 95% CI: 1.46–1.69). To explore this further, it is interesting to first ask the following question: why study prenatal acid-suppressive medication exposure and asthma in offspring? There are several … Address correspondence to Bronwyn K. Brew, PhD, Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Nobels vag 12a, Stockholm 17177, Sweden. E-mail: bronwyn.haasdyk.brew{at}ki.se

Impact of clinical pharmacist interventions on inappropriate prophylactic acid suppressant use in hepatobiliary surgical patients undergoing elective operations.

ObjectiveTo evaluate the impact and cost-benefit of clinical pharmacist interventions on inappropriate use of prophylactic acid suppressant in hepatobiliary surgical patients in a Chinese tertiary hospital.MethodsA retro-prospective intervention study of patients undergoing elective operations was performed in the Department of Hepatobiliary Surgery of the Affiliated Hospital of Southwest Medical University. Patients admitted from October to December 2015 and from October to December 2016, served as the pre-intervention and the post-intervention group, respectively. Clinical pharmacist interventions in the post-intervention group included real-time monitoring medical records and recommending that surgeons prescribe prophylactic acid suppressants according to the criteria established by the hospital administration. Then, the clinical outcomes of post-intervention group were compared with the pre-intervention group which lacked pharmacist interventions. In addition, cost-benefit analysis was conducted to determine the economic effects of implementing the clinical pharmacist interventions in acid suppressant prophylaxis in perioperative period.ResultsClinical pharmacist interventions significantly decreased the rate of the use of no indications for prophylactic acid suppressant and of the cases of inappropriate drug selection, dose, route, replacement and prolonged duration of prophylaxis (P < 0.05 or P < 0.001), resulting in significant increase by 10.65% in the percentage of cases adhering to all the criteria (P < 0.001). Moreover, significant reductions were found in the average usage quantity (P<0.001), mean cost (P = 0.03) and mean duration (P < 0.001) of prophylaxis acid suppressant. The ratio of the mean cost savings for acid suppressants to the mean cost of pharmacist time was 13.61:1.ConclusionThe clinical pharmacist’s real-time interventions facilitated the rational use of prophylactic acid suppressant and resulted in favorable economic outcomes in hepatobiliary surgery.

A systematic review of Clostridium difficile infection following reversal of ileostomy

The incidence of Clostridium difficile infection (CDI) has been reported to be as high as 4% following ileostomy reversal. CDI can be associated with significant morbidity. A systematic review on this subject has not been previously reported; our aim was to review the literature to establish incidence and to evaluate the factors that may contribute to an increased risk of CDI following ileostomy reversal. A systematic review of Ovid, Embase and Medline was undertaken. Search terms included C.difficile, reversal of ileostomy and ileostomy closure. Articles were included where at least one case of C.difficile-associated diarrhoea following reversal of defunctioning ileostomy was reported. Data extraction for articles was performed by two authors, using predefined data fields. The primary outcome measure was incidence of CDI amongst patients undergoing ileostomy reversal. Secondary outcomes were defunctioning time, antibiotic regime, acid suppression, time to onset of symptoms and study conclusions including colectomy and mortality rate. Eleven articles were included (five case reports and six cohort studies). The overall incidence of CDI was 1.8% (242/13728). The mean defunctioning time was 8.7months (range 6-12). A variety of antibiotic regimes were described. Mean time to onset of symptoms was 6days (range 3-14). Use of acid suppression, colectomy or mortality rate were frequently not reported. CDI should be recognized as a potentially life-threatening complication of ileostomy closure. Careful consideration should be given to peri-operative antibiotic regime, acid suppression, timing of reversal and appropriate preoperative counselling of patients.

Prenatal, intrapartum, and postnatal factors are associated with pediatric eosinophilic esophagitis

Multiple lines of evidence point to the potential importance of early-life environmental factors in the rapid increase in the incidence of eosinophilic esophagitis (EoE), but potential exposures have not been extensively studied. We sought to assess the association between prenatal, intrapartum, and postnatal factors and the development of pediatric EoE using a case-control study. Patients with EoE were recruited from an existing registry at Cincinnati Children's Hospital Medical Center (CCHMC). Population-based community control subjects were identified from a separate CCHMC registry. Mothers of study subjects were contacted and completed a Web-based questionnaire. Crude and adjusted models were used to estimate associations. Mothers of 127 cases and 121 control subjects were included. We observed a positive association between several early-life factors and EoE, including prenatal (maternal fever: adjusted odds ratio [aOR], 3.18; 95% CI, 1.27-7.98; preterm labor: aOR, 2.18; 95% CI, 1.06-4.48), intrapartum (cesarean delivery: aOR, 1.77; 95% CI, 1.01, 3.09), and infancy (antibiotic use: aOR, 2.30; 95% CI, 1.21-4.38; use of an acid suppressant: aOR, 6.05; 95% CI, 2.55-14.40) factors. We observed an inverse association between having a furry pet in infancy and EoE (aOR, 0.58; 95% CI, 0.34-0.97). No associations were observed for breast-feeding or maternal multivitamin or folic acid supplement use. Early-life factors, including maternal fever, preterm labor, cesarean delivery, and antibiotic or acid suppressant use ininfancy, were associated with risk of pediatric EoE; having apet in the home was protective. These results add to growing evidence that implicate early-life exposures in EoE pathogenesis.

Patterns of futile care for comorbidities in colorectal cancer patients near the end of life.

e18242 Background: Futile care includes interventions that no longer provide benefit, may cause significant harm, and/or lack sufficient utility to justify the required resources. Cancer care such as chemotherapy use has been shown to be overly aggressive near the end of life. We hypothesized that futile care for non-cancer comorbidities in terminal colorectal cancer (CRC) patients may also be prevalent and associated with specific clinical factors. Methods: We constructed a large retrospective cohort of decedents aged ≥18 years who were diagnosed with CRC during 2008-2012 and who died by the end of 2013. We analyzed population-based data through linked provincial files with information on cancer management, pharmacy records, hospital discharges, and vital statistics. We defined endpoints for futile care as ≥1 hospitalization and/or ≥1 prescription for statins, dihydropyridine calcium channel blockers (CCBs), or acid suppressants within 2 months preceding death. Different time points were used in sensitivity analyses. Results: We included 2,530 patients. Median age at CRC diagnosis and death was 70 (IQR 61-79) and 72 (IQR 62-80) years, respectively. Among them, 59% were men, 66% had colon cancer, and 87% were diagnosed with advance disease. Median time from diagnosis to death was 452 (IQR 201-800) days. In terms of futile care, 4.7% had hospitalizations, 8.7% received statins, 6.8% received CCBs, and 38.2% received acid suppressants within 2 months prior to death. In multivariate analyses, there were no clear associations between demographics and hospitalizations. With respect to medication use, advanced age was correlated with increased use of statins (OR 2.235, 95%CI 1.469-3.401, p &lt; 0.001) and CCBs (OR 2.039, 95%CI 1.304-3.190, p = 0.002), but inversely associated with use of acid suppressants (OR 0.750, 95%CI 0.598-0.941, p = 0.013). Men were also more likely to receive statins (OR 1.653, 1.099-2.488, p = 0.016), but less likely to receive acid suppressants (OR 0.764, 0.608-0.960, p = 0.021). Conclusions: Even near death, a fair number of decedents with CRC continued to receive medications for comorbidities that were unlikely to provide clinically meaningful benefits. Futile care was more prevalent in men and in the elderly.

Routine Use of Postoperative Acid Suppression (GI Prophylaxis) in Non-Critically Ill Pediatric Appendectomy Patients.

Overutilization of routine gastrointestinal (GI) prophylaxis has been a focus of research for more than a decade in North American and European countries given its potential to increase costs and cause adverse clinical effects.1,2 Prescription of antacids in inpatient units and their prolonged use cause changes in the intestinal microbiota with consequent increased risk for Clostridium difficile –associated disease3–5 and nosocomial pneumonia.1,2,6,7 According to the Choosing Wisely recommendation by the Society of Hospital Medicine, routine GI prophylaxis is not recommended for adults on general medical or surgical floors.8 The American Society of Health System Pharmacists “Therapeutic Guidelines on Stress Ulcer Prophylaxis” state that patients admitted to the noncritical care hospital setting with <2 risk factors for bleeding should not receive routine stress ulcer prophylaxis.9 In pediatric patients, established risk factors for clinically significant stress ulcer–related bleeding and thus potential need for acid suppression include respiratory failure with the need for mechanical ventilation, coagulopathy, a Pediatric Risk of Mortality Score of ≥10,10 shock, and thermal injuries.11,12 There is currently a paucity of formal guidelines on GI prophylaxis outside the ICU in pediatric patients. Whether GI prophylaxis is routinely …

Association of Gastric Acid Suppression With Recurrent Clostridium difficile Infection

Gastric acid suppression has been associated with an increased risk of primary Clostridium difficile infection (CDI), but the risk of recurrent CDI in patients taking gastric acid suppressant medications is unclear. To perform a systematic review and meta-analysis to evaluate the association between gastric acid suppressants and recurrent CDI. MEDLINE, EMBASE, the Cochrane Central Register, the Cochrane Database, and Web of Science were searched from January 1, 1995, to September 30, 2015, for studies assessing the association between gastric acid suppressant exposure and recurrent CDI. Search terms included Clostridium difficile, pseudomembranous colitis, proton pump inhibitor, and histamine H2 blocker. Case-control studies, cohort studies, and clinical trials that included patients with CDI who did or did not receive gastric acid suppressant therapy and who were evaluated for recurrent CDI were included, with no restriction on study setting (inpatient or outpatient). The Newcastle-Ottawa scale was used to assess the methodologic quality of included studies. In this scale, case-control and cohort studies were scored on selection, comparability, and ascertainment of the outcome of interest. Data were independently abstracted to a predetermined collection form by 2 investigators. Summary odds ratio estimates with 95% CIs were calculated using the random-effects model and software to calculate the pooled effect size of studies reporting multivariate analyses. Risk of recurrent infection in patients with CDI and its association with use of gastric acid suppressant medication. Sixteen observational studies were included, together reporting 7703 patients with CDI; among these, 1525 patients (19.8%) developed recurrent CDI. The rate of recurrent CDI in patients with gastric acid suppression was 22.1% (892 of 4038 patients) compared with 17.3% (633 of 3665) in patients without gastric acid suppression, which indicated an increased risk by meta-analysis (odds ratio [OR], 1.52; 95% CI, 1.20-1.94; P < .001). There was significant heterogeneity among the studies, with an I2 value of 64%. Subgroup analyses of studies adjusting for age and potential confounders confirmed an increased risk of recurrent CDI with use of gastric acid suppressants (OR, 1.38; 95% CI, 1.08-1.76; P = .02). Meta-analyses of observational studies suggest that patients who receive gastric acid suppressants may be at increased risk for recurrent CDI. These data should be interpreted with caution because they may be confounded owing to the observational design of the individual studies. It may be reasonable to re-evaluate the need for these medications in patients with CDI.

Targeting, Monitoring and Effect of Oral Iron Therapy on Haemoglobin Levels in Older Patients Discharged to Primary Care from Inpatient Rehabilitation: A Cohort Study Using Routinely Collected Data.

Oral iron is commonly prescribed to older patients with suspected or confirmed iron-deficiency anaemia; however, few studies have examined the effectiveness of oral iron therapy in the real world in this population. We therefore determined the prevalence of iron deficiency in older people prescribed oral iron, examined the response mounted to therapy and ascertained predictors of response to oral iron. We analysed a routinely collected, linked dataset from older patients who had undergone inpatient rehabilitation between 1999 and 2011. An initial analysis examined patients within this cohort who were prescribed iron after rehabilitation and derived three groups based upon their ferritin and transferrin indices: probably, possibly and not iron deficient. A second analysis compared pre- and post-treatment haemoglobin to determine the degree of response to iron therapy across each category of deficiency. Finally, patient demographics, linked biochemistry data and comorbid disease based on International Classification of Disease (ICD-10) codes from previous hospital admissions were used in regression modelling to evaluate factors affecting response to therapy. A total of 490 patients were prescribed oral iron within 90 days of rehabilitation discharge. Of these, 413 (84%) had iron indices performed; 94 (23%) were possibly deficient, 224 (54%) were probably deficient, and 95 (23%) were not deficient. Of the 490 patients, 360 had both pre- and post-treatment haemoglobin data and iron indices; probably deficient patients mounted a slightly greater response to oral iron (17 vs. 12g/L for not deficient; p<0.05). Only pre-treatment haemoglobin, mean cell volume and lower gastrointestinal pathology were significant predictors of a response to oral iron therapy. Notably, acid-suppressant use was not a predictor of response. We conclude that many older patients are exposed to oral iron without good evidence of either iron deficiency or a significant response to therapy.

Respiratory disease and the oesophagus: reflux, reflexes and microaspiration.

Gastro-oesophageal reflux is associated with a wide range of respiratory disorders, including asthma, isolated chronic cough, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease and cystic fibrosis. Reflux can be substantial and reach the proximal margins of the oesophagus in some individuals with specific pulmonary diseases, suggesting that this association is more than a coincidence. Proximal oesophageal reflux in particular has led to concern that microaspiration might have an important, possibly even causal, role in respiratory disease. Interestingly, reflux is not always accompanied by typical reflux symptoms, such as heartburn and/or regurgitation, leading many clinicians to empirically treat for possible gastro-oesophageal reflux. Indeed, costs associated with use of acid suppressants in pulmonary disease far outweigh those in typical GERD, despite little evidence of therapeutic benefit in clinical trials. This Review comprehensively examines the possible mechanisms that might link pulmonary disease and oesophageal reflux, highlighting the gaps in current knowledge and limitations of previous research, and helping to shed light on the frequent failure of antireflux treatments in pulmonary disease.

Concomitant use of antiacids in patients with advanced hepatocellular carcinoma (HCC) receiving sorafenib therapy.

e14103Background: There are reports suggesting that concomitant use of tyrosine kinase inhibitors (TKIs) and gastric acid suppression reduces overall survival. This single centre study is looking a...

Practice Patterns and Outcomes in Patients with Esophagitis

Background: Gastroesophageal reflux disease (GERD) is a chronic condition in which acid from the stomach damages the native esophageal mucosa and commonly causes symptoms of heartburn, regurgitation, and dysphagia. Complications of GERD include erosive esophagitis, Barrett’s esophagus (BE), and esophageal cancer. Our objectives were to understand the practice patterns in the management of patients with esophagitis, characterize patients with esophagitis who presented to Saint Louis University Hospital (SLUH) for endoscopy, and to evaluate short-term outcomes in these patients Methods: We identified patients with an endoscopic diagnosis of esophagitis, who presented to SLUH for upper endoscopy for any indication between January 1st and December 31st 2009. After exclusion criteria were considered, a total of 96 patients were identified for the study. Laboratory and pathology data were reviewed for initial and follow up endoscopy. Demographics, severity of esophagitis, length of BE, follow-up recommendations, and outcomes were recorded. Results: Of the 96 patients involved in the study, 7 had suspected BE on EGD. Among those patients with suspected BE, 4 had a follow up EGD, none of which showed severe esophagitis. Although 23 of the 96 patients (23%) had esophageal biopsies, only 2 had tissue pathology confirming Barrett’s esophagus. Further findings are presented in this paper. Conclusion: Our data demonstrates, among other findings, that we are not optimizing acid suppression use in disease processes that are acid mediated. More research and development of standardized protocols to guide care for patients with esophagitis and help decrease endoscopy costs are warranted.

Gastric Acid Suppressant Prophylaxis in Pediatric Intensive Care: Current Practice as Reflected in a Large Administrative Database.

Stress-related gastrointestinal bleeding may occur in PICU patients. Raising gastric pH with acid suppressant medications is the accepted treatment. We describe the use of histamine 2 receptor blockers and proton pump inhibitors and associated factors among a national sample of PICU patients. Retrospective cohort analysis using Pediatric Health Information System clinically detailed administrative database. Forty-two children's hospitals throughout the United States. All hospitalizations for all patients 20 years old or younger, admitted directly to a PICU, from January 1, 2007, through December 31, 2011. None. The exposure of interest was treatment with a histamine 2 receptor blocker, proton pump inhibitor, or both on the first day of PICU admission. Demographics, principal and additional diagnoses, and procedure codes were assessed. For each hospitalization, principal diagnosis, coagulation disorder, head trauma, spinal trauma, severe burns, sepsis, gastrointestinal hemorrhage, mechanical ventilation, blood product transfusion, and 10 complex chronic conditions were identified. The frequency of principal diagnoses was determined to identify the most prevalent PICU diseases. Acid suppressant use was categorized as high or low. Three hundred and thirty-six thousand ten inpatient hospitalizations were sampled. Histamine 2 receptor blocker or proton pump inhibitor was used in 60.0%, with histamine 2 receptor blocker alone in 70.4%, proton pump inhibitor alone in 17.8%, and both agents in 11.8%. Use increased over the sample years 2007 through 2011. Gastrointestinal bleeding occurred in 1.32% of hospitalizations with transfusion needed in 0.1%. Among most prevalent diagnoses, histamine 2 receptor blocker and proton pump inhibitor use ranged from 33% to 87%. Sepsis, coagulopathy, and mechanical ventilation identified higher use. Use of histamine 2 receptor blocker or proton pump inhibitor among hospitals varied considerably ranging from 28% to 87%. Histamine 2 receptor blocker and proton pump inhibitor are prescribed in most PICU patients, but significant variation exists across health conditions and hospitals. Institutional preferences likely influence variation. Gastrointestinal hemorrhage is infrequent in the current era. Study data limitations prevent examination of associations between medication use and patient outcomes.

Survey of contemporary feeding practices in critically ill children in the Asia-Pacific and the Middle East.

Nutrition is a fundamental component of care of critically ill children. Determining variation in nutritional practices within paediatric intensive care units (PICUs) allows for review and improvement of nutrition practices. The aim was to survey the nutrition practices and perspectives of paediatric intensivists and dieticians in Asia-Pacific and the Middle East. A questionnaire was developed to collect data on (1) the respondent's and institution's characteristics, (2) nutritional assessments and nutrient delivery practices, and (3) the perceived importance and barriers to optimal enteral feeding in the PICU. We analysed 47 responses from 35 centres in 18 different countries. Dedicated dietetic services were only present in 13 (37%) centres and regular nutrition assessments were conducted in only 12 (34%) centres. In centres with dedicated dieticians, we found greater use of carbohydrate, fat additives and special formulas. Two thirds [31 (66%)] of respondents used total fluids to estimate energy requirements. Only 11 (31%) centres utilized feeding protocols. These centres had higher use of small bowel feeding, acid suppressants, laxatives and gastric residual volume thresholds. When dealing with feed intolerance, they were also more likely to start a motility agent. There was also a lack of consensus on when feeding should start and the use of adjuncts. Nutrition practices and barriers are unique in Asia-Pacific and the Middle East and strongly reflect a lack of dietetic services. Future effort should focus on developing a uniform approach on nutrition practices to drive paediatric critical care nutrition research in these regions.

Risk of spontaneous bacterial peritonitis associated with gastric Acid suppression.

The primary objective of this study was to determine the association between the use of gastric acid suppressants (GAS) and the risk of developing spontaneous bacterial peritonitis (SBP) in patients with advanced liver cirrhosis (LC). A case-control study nested within a cohort of 480,000 representatives of Taiwan National Health Insurance beneficiaries was carried out. A case was matched with 100 controls on age, gender, and index date of SBP diagnosis. GAS use was identified from the 1-year period before the index date. Conditional logistic regression analysis was used to adjust for various unbalanced covariates between users and nonusers of GAS. A total of 947 cases of SBP were identified among the 86,418 patients with advanced LC. A significant increased risk of developing SBP was found to be associated with current (within 30 days), and recent (within 30-90 day) use of 2 different classes of GAS: proton pump inhibitors (PPIs) and histamine 2 receptor antagonists (H2RAs). The confounder adjusted rate ratio (aRR) for the current use of PPIs was 2.77 (95% CI: 1.90-4.04) and H2RAs was 2.62 (95% CI: 2.00-3.42). The risk of SBP attenuated for the recent use of PPIs (aRR: 2.20, 95%CI: 1.60-3.02) or H2RAs (aRR: 1.72, 95% CI: 1.25-2.37). In addition, sensitivity analysis using hospitalized SBP as the primary outcome showed a similar risk for the current use of PPIs (aRR, 3.24; 95% CI: 2.08-5.05) and H2RAs (aRR 2.43; 95% CI 1.71-3.46). Furthermore, higher cumulative days of gastric acid suppression were associated with a higher risk of SBP (trend P < 0.0001). To conclude, exposure to GAS was associated with an increased risk of SBP in patients with advanced LC. The association was more pronounced in current PPI users compared with nonusers.

Use of proton pump inhibitors is associated with fractures in young adults: a population-based study.

Proton pump inhibitors (PPIs) are associated with risk for fracture in osteoporotic adults. In this population-based study, we found a significant association between PPIs and fracture in young adults, with evidence of a dose-response effect. Young adults who use PPIs should be cautioned regarding risk for fracture. Proton pump inhibitors (PPIs) are associated with fracture in adults with osteoporosis. Because PPI therapy may interfere with bone accrual and attainment of peak bone mineral density, we studied the association between use of PPIs and fracture in children and young adults. We conducted a population-based, case-control study nested within records from general medical practices from 1994 to 2013. Participants were 4-29 years old with ≥ 1 year of follow-up who lacked chronic conditions associated with use of long-term acid suppression. Cases of fracture were defined as the first incident fracture at any site. Using incidence density sampling, cases were matched with up to five controls by age, sex, medical practice, and start of follow-up. PPI exposure was defined as 180 or more cumulative doses of PPIs. Conditional logistic regression was used to estimate the odds ratio and confidence interval for use of PPIs and fracture. We identified 124,799 cases and 605,643 controls. The adjusted odds ratio for the risk of fracture associated with PPI exposure was 1.13 (95% CI 0.92 to 1.39) among children aged < 18 years old and 1.39 (95% CI 1.26 to 1.53) among young adults aged 18-29 years old. In young adults but not children, we observed a dose-response effect with increased total exposure to PPIs (p for trend <0.001). PPI use was associated with fracture in young adults, but overall evidence did not support a PPI-fracture relationship in children. Young adults who use PPIs should be cautioned regarding potentially increased risk for fracture, even if they lack traditional fracture risk factors.

Prevalence and outcome of gastrointestinal bleeding and use of acid suppressants in acutely ill adult intensive care patients.

To describe the prevalence of, risk factors for, and prognostic importance of gastrointestinal (GI) bleeding and use of acid suppressants in acutely ill adult intensive care patients. We included adults without GI bleeding who were acutely admitted to the intensive care unit (ICU) during a 7-day period. The primary outcome was clinically important GI bleeding in ICU, and the analyses included estimations of baseline risk factors and potential associations with 90-day mortality. A total of 1,034 patients in 97 ICUs in 11 countries were included. Clinically important GI bleeding occurred in 2.6 % (95 % confidence interval 1.6-3.6 %) of patients. The following variables at ICU admission were independently associated with clinically important GI bleeding: three or more co-existing diseases (odds ratio 8.9, 2.7-28.8), co-existing liver disease (7.6, 3.3-17.6), use of renal replacement therapy (6.9, 2.7-17.5), co-existing coagulopathy (5.2, 2.3-11.8), acute coagulopathy (4.2, 1.7-10.2), use of acid suppressants (3.6, 1.3-10.2) and higher organ failure score (1.4, 1.2-1.5). In ICU, 73 % (71-76 %) of patients received acid suppressants; most received proton pump inhibitors. In patients with clinically important GI bleeding, crude and adjusted odds for mortality were 3.7 (1.7-8.0) and 1.7 (0.7-4.3), respectively. In ICU patients clinically important GI bleeding is rare, and acid suppressants are frequently used. Co-existing diseases, liver failure, coagulopathy and organ failures are the main risk factors for GI bleeding. Clinically important GI bleeding was not associated with increased adjusted 90-day mortality, which largely can be explained by severity of comorbidity, other organ failures and age.