Integrated Lactate Is Improved with a Novel Pharmacologic Inducer of the Endogenous Cytoprotective Heat Shock Protein 70I Gga and Potential COVID Applications

Introduction: Lactate is a common biomarker used in multiple surgical subspecialties. No one has previously measured coronary sinus lactate reduction as a result of drug administration. We therefore tested the hypothesis that IV geranylgeranylacetone (GGA), a novel agent used to treat human peptic ulcer disease, would result in reduced coronary sinus lactate production. Method(s): New Zealand adult rabbits (N=5 each) received IV 50 mg/kg GGA 24 hours before intervention, which consisted of Langendorff perfusion, 30 min of global normothermic cardioplegic arrest, followed by reperfusion. Myocardial release of lactate was measured. HSP70 was quantified by western blot. Differences between GGA+ and GGA- groups pre- and post-ischemia were analyzed by unpaired t-tests. Result(s): In the GGA- group, lactate increased immediately at one minute and throughout the duration of reperfusion. However, in GGA+ hearts, lactate also increased at one min of reperfusion but then continued to decrease throughout the remainder of reperfusion. Lactate was significantly less at every time point of reperfusion in GGA+. Integrated lactate area was significantly less throughout reperfusion in GGA+. Conclusion(s): GGA induced caused a marked decrease in coronary sinus lactate release during reperfusion. Simultaneously intravenously GGA induced myocardial HSP70i and reduced myocardial damage. Further study of the effects and mechanisms involved is indicated. Application to other organs is useful as well. Heat shock proteins (HSPS) are also antithrombotic. Given the thrombotic nature of Covid, induction of HSPS may be beneficial in decreasing the cardiac thoracic and vascular complications of Covid and allowing faster resolution of this disease during to vascular complications.

A Rare Manifestation of Unknown Hyperparathyroidism as a Perforated Peptic Ulcer.

Hypercalcemia is a common electrolyte abnormality with different causes. Hypercalcemia is most often associated with malignancy and primary hyperparathyroidism and malignancy together account for most cases. Primary hyperparathyroidism manifests as hypercalcemia owing to the overproduction of parathyroid hormone. In most cases, primary hyperparathyroidism manifests due to a solitary parathyroid adenoma. Based on calcium levels, hypercalcemia can be classified as mild, moderate, and severe. Hypercalcemia typically presents with non-specific clinical features. Here, we present the case of a 38-year-old male patient who presented to the emergency department (ED) with acute abdominal pain and a tender abdomen with absent bowel sounds. He had chest radiography and blood tests initially. Chest radiography showed left-sided pneumoperitoneum, and the patient was suspected to have a perforated peptic ulcer due to hypercalcemia secondary to a parathyroid adenoma during the second wave of the coronavirus disease 2019 (COVID-19) pandemic. The findings were confirmed by a computerized tomography scan of the abdomen, and the patient was treated with intravenous fluids for hypercalcemia and was managed conservatively for a sealed perforated peptic ulcer following discussion in the multi-disciplinary team meeting (MDT). The COVID-19 pandemic led to a long waiting list and delays in the timely management of patients requiring elective surgical intervention, such as parathyroidectomy. The patient made a complete recovery and had parathyroidectomy of the inferior right lobe two months later.

Ethnopharmaceutical importance of under-explored plant species Hyptissuaveolens (L.)

Plants store a variety of important secondary metabolites with pharmacognostic and pharmacological implications, some of which have the potential to become super medicines in the future. In-vivo generation of these metabolites is influenced bya number of biotic and abiotic factors resulting in a constant accumulation of various phytochemicals and their derivatives that could be relevant in future medication research and development. There are over 70,000 plant species are employed ethnomedicinally in various ancient medical systems such as Ayurveda, Siddha, and Unani, as well as in Allopathy. The goal of this study is to look into the therapeutic potential of secondary metabolites as well as the probable pharmacological and pharmacognostic significance of the under-explored/underutilized plant Hyptissuaveolens (L.) Poit.Almost all parts of this plant are being employed in conventional drug to treat various diseases. It has been reported that it shows protection against peptic ulcer diseases and has anti-cancerous properties. The leaves of Hyptissuaveolenssecreted essential oil by hydrodistillation have been linked to the genus Hyptis' broad range of biological activity. It contains phytochemicals like alkaloids, tannins, saponins, flavonoids, terpenoids, minerals (like calcium, magnesium, sodium) and metals (like zinc and iron). The ursolic acid found in H. suaveolens can be used as a COVID-19 virus treatment agent. In addition, the ethnobotanical study claims that the beneficial plant has neuroprotective, antioxidant, antibacterial, antidiarrhoeal, anthelmintic, anti-inflammatory, wound healing, insecticidal, antimitotic, anti-proliferative, antisecretory, hepatoprotective, and acaricidal properties. The phytochemicals and extracts obtained from the plant have a great deal of therapeutic promise. As a result, we can use this plant for a variety of purposes.

Vaccination of patients with chronic urticaria

Background: The importance of vaccination in today's world is extremely important given the COVID-19 epidemic. About 30% of the world's population suffers from allergies. Among them, 25% of patients according to the WHO, had an episode of urticaria at least once in their life. Urticaria is one of the most common allergic diseases, which is the highest in-patient admission toll at Dnipro Allergy Center. During the year 2021, 600 patients with urticaria were treated in the hospital. Patients with chronic recurrent urticaria do not want to be vaccinated because of the fear of complications such as anaphylaxis.Vaccination of urticaria patients without complications. Method(s): The study involved 45 patients aged 18 to 65 years, with a mean age of 34.3 +/- 1.0 (13 males and 32 females). The average experience of the disease is 3.6 +/- 0.8 years. Patients with chronic recurrent urticaria were admitted to the in-patient unit. Prior to vaccination, they were tested for tryptase levels, a detailed platelet blood test, coagulogram, D-dimer, and ECG. Result(s): Many patients had concominant gastrointestinal pathology in the form of gastro-esophageal reflux disease (GERD) -20 patients (44.4%), peptic ulcer disease disease -17 patients (37.7%), or stomach pathology in 45 patients (100%), which required proton pump inhibitors (PPI). Given that PPIs are a risk factor for anaphylaxis, according to EAACI documents, PPIs were discontinued three days before vaccination. Serum tryptase levels were elevated in 3 patients (13 mug/l, 16 mug/l, 32 mug/l). All patients underwent premedication. At normal serum tryptase levels, patients received 1-fold dose of desloratadine, and at high serum tryptase levels: 13 mug/l, 16 mug/l and 32 mug/l, patients received 4-fold dose of desloratadine. After 30 minutes vaccination shot was carried out without side effects and without complications of allergic nature. The second vaccination shot was also protected by antihistamines, so all the patients we observed had received 2 shots of the vaccine not complicated by side effects such as fever or allergic reactions. Conclusion(s): All patients were vaccinated without complications. In urticaria patients, serum tryptase levels should be determined prior to vaccination. Depending on the level of tryptase, appropriate premedication is prescribed: with a high level of tryptase -4- fold dose of desloratodine, with a normal level -1- fold dose. All patients with urticaria should be diagnosed with concomitant pathology in order to correct the basic therapy before vaccination.

Prevalence, causes, medical interventions, and mortality outcome of acute gastrointestinal bleeding among COVID-19 inpatients.

OBJECTIVE: This study aimed to evaluate the prevalence, causes, medical interventions, and mortality outcome of acute gastrointestinal bleeding (AGIB) among COVID-19 patients hospitalized during the delta pandemic in Vietnam. METHODS: The medical records of COVID-19 patients hospitalized in a tertiary hospital in Vietnam from July to October 2021 were retrospectively collected. Data regarding age, sex, comorbidities, COVID-19 severity, onset time of AGIB, therapeutic interventions for AGIB, and mortality outcome were analyzed. RESULTS: Of 1567 COVID-19 inpatients, 56 (3.6%) had AGIB. The independent risk factors for AGIB in COVID-19 inpatients included age (OR = 1.03, 95% CI: 1.01-1.04, p = .003), male sex (OR = 1.86, 95% CI: 1.06-3.26, p = .03), chronic liver disease (OR = 6.21, 95% CI: 2.97-13.00, p < .001), and chronic kidney disease (OR = 2.17, 95% CI: 1.01-4.65, p = .047). Among 34 AGIB patients undergoing endoscopy, upper AGIB was determined in 24 (70.6%) patients. Peptic ulcer disease and hemorrhagic erosive gastritis were the most common causes (64.7%, 22/34). The therapeutic interventions for AGIB included blood transfusion (76.8%, 43/56), endoscopic hemostasis (23.5%, 8/34), and surgery (1.8%, 1/56). The mortality rate in the AGIB group was significantly higher than that in the non-AGIB group (46.4% vs. 27.7%, OR = 2.26, 95% CI: 1.32-3.87, p = .002). However, the majority (76.9%) of deaths in COVID-19 inpatients with AGIB were not bleeding-related. CONCLUSIONS: Age, male sex, chronic liver disease, and chronic kidney disease are risk factors for AGIB among COVID-19 inpatients. Peptic ulcer disease is the most common cause. COVID-19 inpatients with AGIB have a higher risk of mortality, but a large percentage of deaths are not bleeding-related.

Since there is not enough information of sudden digestive tract bleeding among Asian populations with COVID-19, this study aimed to measure the proportion of existing cases, causes, medical treatments and deaths of sudden digestive tract bleeding in COVID-19 patients who were hospitalized during the Delta-variant pandemic in Vietnam. We collected medical records of 1567 COVID-19 patients from a specialty hospital in Vietnam from July to October 2021. Sudden digestive tract bleeding was present in 3.6% of COVID-19 inpatients. The risk of sudden digestive tract bleeding was higher in COVID-19 patients who were old, male, or had long-term liver or kidney disease. The most common cause of sudden digestive tract bleeding among COVID-19 inpatients were stomach ulcers. In addition, COVID-19 inpatients with sudden digestive tract bleeding had a higher risk of death, but a large proportion of deaths were not bleeding-related.

Extrapulmonary manifestations of SARS-CoV-2: a new coronavirus infection as an aggravating factor in peptic ulcer disease

The global pandemic of the new coronavirus infection (COVID-19) has become an extreme challenge for the health care of the whole world since 2020. The main target of the SARS-CoV-2 virus is the lungs, but at the same time, more and more evidence is accumulating that the new coronavirus can also affect other organs and systems, such as the heart, blood vessels, kidneys, intestines, and brain. Thus, adequate management of a coronavirus patient means not only the therapy of viral pneumonia, but also the timely diagnosis and treatment of damage to other organs. The analysis of predictor factors of severe course and fatal outcome in COVID-19 indicates the aggravating role of comorbid pathology, such as cardiovascular diseases, diabetes mellitus, chronic obstructive pulmonary disease, chronic gastrointestinal diseases. Therefore, in addition to measures to prevent infection with SARS-CoV-2, measures should also be taken to control the comorbid conditions present in the patient. ACE2 receptors, which the virus uses to penetrate human cells, can also be expressed in the esophagus, stomach, small and large intestines, liver and pancreas. This makes the frequency of gastroenterological symptoms in COVID-19 high, which is caused both by the defeat of the digestive organs by the coronavirus itself and by the exacerbation of chronic gastrointestinal diseases against the background of infection and its aggressive therapy. At the same time, the presence and severity of digestive diseases significantly affect the clinical course of COVID-19. This article is devoted to the pathogenesis, clinical picture, approaches to the diagnosis and therapy of erosive ulcerative lesions of the stomach and duodenum against the background of a new coronavirus infection. © 2022 Global Media Technologies. All rights reserved.

Has the Number of Upper Gastrointestinal Bleeding Cases Presenting to the Emergency Department Decreased During the COVID-19 Pandemic?: A Single-Center Experience

Objective: In the period of the coronavirus disease-19 (COVID-19) pandemic, upper gastrointestinal endoscopy was either postponed or canceled, except for emergencies, due to the high risk of transmission. Our study aimed to evaluate the effect of the COVID-19 pandemic on patients with upper gastrointestinal bleeding presenting to the emergency department and to compare it with the data before the pandemic. Material(s) and Method(s): In this single-center, retrospective study, patients were divided into 2 groups: pre-COVID-19 (pre-C) (March 2019-March 2020) and post-COVID-19 (post-C) (March 2020-March 2021). Patients who presented to the emergency department with upper gastrointestinal bleeding during these periods and underwent endoscopic examination were included in the study. Result(s): Endoscopy for upper gastrointestinal bleeding was urgently performed in 125 patients in the pre-C period and in 89 (29% decrease) patients in the post-C period. The Glasgow-Blatchford Score was higher in the pre-C period (p=0.02). Peptic ulcers were the most common cause of bleeding in both groups. High-risk peptic ulcer (forrest 1a/1b/2a/2b), and malignancy were observed more frequently in the post-C period (p=0.003, p=0.04;respectively). Endoscopic combined treatment rate was higher in the post-C group (p<0.001). Re-bleeding ratios were similar for both the groups (p=0.48). Conclusion(s): During the post-C period, the number of upper gastrointestinal bleeding cases admitted to the emergency department decreased significantly. However, the rate of high-risk peptic ulcer and malignancy in the etiology of upper gastrointestinal bleeding increased in the post-C period. Copyright © 2022 by Turkiye Klinikleri.

RISK FACTORS OF HIGH RISK UPPER GASTROINTESTINAL BLEEDING IN PATIENTS WITH CORONAVIRUS 2019 INFECTION

Background: Gastrointestinal (GI) bleeding is one of the impactful complications in patients hospitalized from Covid-19 infection. The previous study showed the risk factors of overall (upper and lower) GI bleeding in patients with Covid-19 infection but no study focused on patients with upper GI bleeding (UGIB). This study aimed to identify the risk factors and outcomes of patients who were hospitalized from Covid-19 infection and developed UGIB. Methods: This is a retrospective in university-hospital which enrolled patients who were admitted due to Covid-19 infection and developed UGIB between April and October 2021. The primary outcome was the associated factors of high risk UGIB defined by having hematemesis or fresh blood from NG tube or hematochezia plus hemodynamic instability. The secondary outcomes were etiologies of high risk UGIB and mortality in those patients. Results: Of 7,214 patients hospitalized though the period, 49 patients (0.7%) had evidence of UGIB. The majority were male (63.3%) with mean ages of 70+12 years. Twenty-seven from 49 patients (55.1%) had mechanical ventilator, 40 patients (81.6%) received systemic corticosteroids, and 13 patients (26.5%) received anticoagulants for venous thromboembolic prophylaxis. Seven from 49 patients (14%) had high risk UGIB;5 hematemesis (71.4%), 1 fresh blood from NG tube (14.3%), and 1 hematochezia (14.3%). There was no significant difference in term of number of patient taking antiplatelets, anticoagulants, or steroids and severity of COVID-19 infection (e.g. Mechanical ventilator needed) between two groups. The emergency endoscopy was performed in 6/7 (85.7%) patients and showed 5 peptic ulcer with non-bleeding visible vessel and 1 gastric lymphoma with blood oozing (Table 1). All 6 patients underwent endoscopic hemostasis including adrenaline injection, bipolar coaptation, clipping, Hemospray®, and over-the-scope clip. There was a robust result when conducting uni- (p=0.005) and multi-variate analysis (OR 6.38;95%CI 1.04-38.92;p= 0.045) that an absence of proton-pump inhibitor (PPI) use was the significant risk factor of high risk UGIB in targeted patients (Table 2). The overall mortality rate in patients with UGIB was 20/49 (40.8%) and 1 from 20 patients (5.0%) expired from UGIB due to moribund condition and unsuitable for endoscopy. None of patients with high risk UGIB and underwent therapeutic endoscopy expired during admission. Conclusion: Our study demonstrated that the absence of PPI use was a sole significant risk factor for high risk UGIB which required therapeutic endoscopy in patients with COVID-19 infection. We suggest that PPI prophylaxis should be prescribed in those patients once they need hospitalization regardless of the severity of COVID-19 infection and anticoagulant usage to minimize the severity of UGIB.(Table Presented)

2021 Owen H Wangensteen Scientific Forum of the American College of Surgeons

The proceedings contain 629 papers. The topics discussed include: barriers to Covid-19 vaccination in underserved minorities: impact of health care access and sociodemographic perspectives;concomitant cholecystectomy during initial bariatric surgery does not increase risk of postoperative complications or bile duct injuries;identifying behavioral facilitators to weight loss after bariatric surgery: are there differences between Medicaid and non-Medicaid patients?;impact of post-discharge phone calls on nonurgent hospital returns;laparoscopic heller myotomy is associated with fewer postoperative complications compared to the thoracoscopic approach: a NSQIP study;population-wide analysis of the effect of bariatric surgery on idiopathic intracranial hypertension in obese patients;reducing operating room inefficiencies via a novel surgical app shortens the duration of laparoscopic Roux-en-y gastric bypass;subtotal gastrectomy vs gastroenterostomy in duodenal obstruction secondary to peptic ulcer disease: results of a retrospective nationwide study;and enhanced recovery after bariatric surgery: further reduction in opioid use with the introduction of dexmedetomidine and transverse abdominis plane block.

ASCORBIC ACID DEFICIENCY IS PREVALENT IN UPPER GASTROINTESTINAL BLEEDING AND INDEPENDENTLY PREDICTS POORER OUTCOMES: A PROSPECTIVE COHORT STUDY

Background: Upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency and carries a high morbidity and mortality. There are multiple risk factors for poorer outcomes, including malnutrition. Ascorbic acid is a water-soluble vitamin present in most plant foods. Dietary deficiency leads to scurvy, which may alter the natural history of UGIB through impaired tissue and mucosal integrity. Traditionally thought to be rare in developed countries, Vitamin C deficiency (VCD) is now well described in patients with pneumonia, sepsis and COVID-191, 2. There is a paucity of literature investigating the prevalence and clinical significance of VCD in UGIB;interim findings reported by our group suggested a prevalence of >30%. Aim: The aim of this study was to establish the prevalence of VCD in patients presenting with UGIB and its association with clinical outcomes. Methods: We conducted a prospective cohort study of adult patients presenting with UGIB to two metropolitan tertiary hospitals in Melbourne, Australia over a 12-month period (March 2020 to March 2021). Fasting Vitamin C levels were obtained on admission. Patients were risk stratified using the AIMS65 score and baseline demographic data and outcomes were recorded. The primary outcome was the prevalence of VCD (serum Vitamin C level <23mcmol/L) and severe VCD (<12mcmol/L). Secondary outcomes included a composite endpoint of adverse events (AE), comprising inpatient death, intensive care unit (ICU) admission, rebleeding, surgery, angioembolisation or massive transfusion (≥4 units of red cells). Multivariate logistic regression was used to determine the association between Vitamin C levels and the secondary endpoints. Subgroup analyses were performed in variceal and non-variceal UGIB and high- (AIMS65≥2) and low-risk (AIMS65 0-2) UGIB. Results: 227 patients were included. The mean age was 65±17 years, 145 (63.9%) were male and median AIMS65 score was 1 (IQR 1-2). The aetiology of UGIB was variceal bleeding in 20.3%, peptic ulcer disease (PUD) in 44.1% and other causes in 35.7%. The mean Vitamin C level was 40±26mcmol/L. In terms of patient outcomes, inpatient mortality was 4%, ICU admission occurred in 11.9% and mean length of stay (LOS) was 7.7±9.7 days. Red cell transfusion was required in 63.4% of patients with a mean requirement of 2.2±2.8 units. VCD was identified in 74 patients (32.6%) with severe deficiency in 32 (14.1%). VCD was associated with significantly higher in-hospital mortality (9.5% vs. 1.3%, p=0.01), prolonged LOS (10.8 vs. 6.2 days, p<0.01), rebleeding (17.6% vs. 7.88%, p=0.05) and a higher composite endpoint of AE (77% vs. 54.9%, p<0.01). At multivariate logistic regression, high-risk UGIB (OR 3.24, CI 1.42-7.42), VCD (OR 2.28, CI1.11-4.71) and chronic liver disease (OR 11.66, CI 2.92-46.64) were all independently associated with the composite endpoint of AE. At subgroup analysis, VCD was associated with a significantly increased composite endpoint of AE in patients with non-variceal (74% vs. 51%, p<0.01) and low-risk UGIB (66% vs. 44%, p=0.04). Conclusion: VCD is highly prevalent in patients with UGIB and associated with poorer outcomes, including higher mortality, rebleeding and LOS. Interventional studies are required to determine the impact of early Vitamin C supplementation on clinical outcomes.

A review on ethnomedicinal and phytopharmacological potential of traditionally wild and endemic plant Berberis tinctoria Lesch

Introduction: Berberis tinctoria an evergreen shrub, endemic and predominantly found at a higher altitude of the Nilgiri Biosphere Reserve, India. This leaf and fruit are edible, which are also used in homeopathic remedies for countless illnesses. Objectives: B. tinctoria with diverse ethnomedicinal uses was focused in the prevailing study to detailed the phytochemical and pharmacological properties for further imminent research in this species. Materials and methods: Published data in this review were all gathered from the online bibliographical databases: PubMed, Elsevier, Scopus, Google Scholar, Web of Science, and local ethnic community peoples of Kurumba and Toda. Results: B. tinctoria was used as a Ayurvedic and homeopathy medicine by the tribal communities. The previous findings of B. tinctoria were used for skin diseases, wound healing, inflammatory, menorrhagia, diarrhea, jaundice, and a snakebites. The phytochemical studies revealed that secondary metabolites, antioxidants, and antimicrobial activity as a result of major alkaloid isoforms of berberine, berbamine, jatrorrhizine, etc. Conclusion: B. tinctoria is an important plant due to the presence of bioactive phytochemicals, especially berberine protoberberine group of benzylisoquinoline. As a result of its diverse ethnopharmacological importance, as well as numerous commercial products and novel bioactive compounds yet to be discovered for future drug discovery and development.

Emerging role of mitochondrial DAMPs, aberrant mitochondrial dynamics and anomalous mitophagy in gut mucosal pathogenesis.

Gastroduodenal inflammation and ulcerative injuries are increasing due to expanding socio-economic stress, unhealthy food habits-lifestyle, smoking, alcoholism and usage of medicines like non-steroidal anti-inflammatory drugs. In fact, gastrointestinal (GI) complications, associated with the prevailing COVID-19 pandemic, further, poses a challenge to global healthcare towards safeguarding the GI tract. Emerging evidences have discretely identified mitochondrial dysfunctions as common etiological denominators in diseases. However, it is worth realizing that mitochondrial dysfunctions are not just consequences of diseases. Rather, damaged mitochondria severely aggravate the pathogenesis thereby qualifying as perpetrable factors worth of prophylactic and therapeutic targeting. Oxidative and nitrosative stress due to endogenous and exogenous stimuli triggers mitochondrial injury causing production of mitochondrial damage associated molecular patterns (mtDAMPs), which, in a feed-forward loop, inflicts inflammatory tissue damage. Mitochondrial structural dynamics and mitophagy are crucial quality control parameters determining the extent of mitopathology and disease outcomes. Interestingly, apart from endogenous factors, mitochondria also crosstalk and in turn get detrimentally affected by gut pathobionts colonized during luminal dysbiosis. Although mitopathology is documented in various pre-clinical/clinical studies, a comprehensive account appreciating the mitochondrial basis of GI mucosal pathogenesis is largely lacking. Here we critically discuss the molecular events impinging on mitochondria along with the interplay of mitochondria-derived factors in fueling mucosal damage. We specifically emphasize on the potential role of aberrant mitochondrial dynamics, anomalous mitophagy, mitochondrial lipoxidation and ferroptosis as emerging regulators of GI mucosal pathogenesis. We finally discuss about the prospect of mitochondrial targeting for next-generation drug discovery against GI disorders.

STUDY METHODS AND INTERIM RESULTS OF RANDOMIZED CONTROLLED TRIAL (RCT) OF BLOOD FLOW MONITORING TO PREVENT DELAYED POST-POLYPECTOMY INDUCED ULCER HEMORRHAGE (DPPIUH)

DDW 2022 Author Disclosures: Dennis Jensen: NO financial relationship with a commercial interest ;Rome Jutabha: NO financial relationship with a commercial interest ;Gareth Dulai: NO financial relationship with a commercial interest ;Noam Jacob: NO financial relationship with a commercial interest ;Jeffrey Gornbein: NO financial relationship with a commercial interest Background and Aims: The best strategy to prevent DPPIUH is controversial. Some colonoscopists recommend hemoclip closure of PPIU’s but this has mixed success rates in different RCT’s and is reported not to be cost effective. In addition to known risks, arterial blood flow detected in PPIU’s is an important predictor of DPPIUH. Our AIMS are to report study methods and interim results of a RCT of blood flow monitoring to prevent DPPIUH. Methods: This is an ongoing blinded RCT at several major Los Angeles Medical Centers by experienced colonoscopists. Outpatients having colonoscopies are screened and consented for enrollment. Sessile and multilobulated polyps are removed by EMR techniques. Thermal coagulation is used for polypectomies in this study. Randomized patients are stratified by whether they take chronic anti-platelet or anti-thrombotic drugs and have PPIU’s of 10-40 mm;or those without bleed drugs and have PPIU’s between 15-40 mm. By opening a sealed envelope after polypectomies, randomization is to either standard management (e.g. following ASGE guidelines of bleed drugs) or DEP interrogation of the PPIU and guided treatment of the artery with hemoclips or multipolar probe coagulation in the PPIU until blood flow is eradicated. Patients and their care givers were blinded to treatments allocated during colonoscopy. Prospective follow-up is by a research coordinator contacting each patient at 7, 14, and 30 days to record whether any complications (e.g. pain, vomiting, or bleeding);or rectal bleeding and its severity (e.g. # and days of bloody BM’s);whether they sought ER, clinic, or telemedicine care for bleeding;or were hospitalized. Major DPPIUH was diagnosed in patients with hospitalization for severe bleeding and/or for 3 or more days of ongoing severe rectal bleeding but refusal of hospitalization because of high rates of COVID here. Demographic, laboratory, colonoscopic, and pathology results are recorded on standard forms along with 30-day outcomes. Patients are assigned a code, data are entered onto HIPAA compliant computer files by a data manager and managed with SAS. With half the projected sample size randomized and followed up (e.g. 133 of 268 total), this is a planned interim analysis of the primary outcome - rates of DPPIUH by treatment. Severe adverse events (SAE’s) were also reviewed. Results: For 133 high risk patients randomized to date, 67 are in the standard group and 66 in the DEP group. The groups were well matched in risk factors – see Table 1. Overall, the Doppler group had lower rates of delayed PPIU bleeding – both major and total- see Table 2. There were no SAE’s. Conclusions: The major DPPIUH rate was higher with standard treatment than DEP treatment (7.46 % vs. 0 %), as was the rate of Total DPPIUH (10.45 % vs. 1.52%). Based upon these promising results, this RCT will continue. [Formula presented] [Formula presented]

Changes in the Proportion of Gastrointestinal Emergency Endoscopy and Peptic Ulcer Disease During the COVID-19 Pandemic: A Local Retrospective Observational Study From Vietnam.

OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has disrupted the practice of gastrointestinal (GI) endoscopy units and may increase the risk of digestive disorders. We described the situational changes in GI endoscopy and peptic ulcer disease (PUD) proportion during COVID-19 in Vietnam and examined the associated factors. METHODS: A retrospective ecological study was conducted on data of Hanoi Medical University Hospital, Vietnam. The number of upper GI endoscopy and the proportion of GI emergency endoscopy and PUD were compared between 2019 and 2020 by month (January to June). Log-binomial regression was used to explore associated factors of GI emergency endoscopy and PUD. RESULTS: The number of endoscopies decreased remarkably during the nationwide social distancing in April 2020. Compared to April 2019, the proportion in April 2020 of both GI emergency endoscopy [4.1 vs. 9.8%, proportion ratio (PR) 2.39, 95% CI 2, 2.87], and PUD [13.9 vs. 15.8%; PR, 1.14; 95% CI, 1.01, 1.29] was significantly higher. In log-binomial models, the proportion of GI emergency endoscopy was higher in April 2020 compared to April 2019 (adjusted PR, 2.41; 95% CI, 2.01, 2.88). Male sex and age of ≥50 years were associated with an increased PUD and GI emergency conditions. CONCLUSION: The proportion of both GI emergency endoscopy and PUD was significantly higher during the time of the state of emergency due to the ongoing COVID-19 pandemic in 2020 when compared to 2019 at the same health facility in Vietnam. The findings suggest that healthcare delivery reforms during the era of an emerging pandemic are required to reduce digestive disorders, in particular, and chronic diseases in general.

Current Status and Future Perspective of Artificial Intelligence in the Management of Peptic Ulcer Bleeding: A Review of Recent Literature.

With the decreasing incidence of peptic ulcer bleeding (PUB) over the past two decades, the clinician experience of managing patients with PUB has also declined, especially for young endoscopists. A patient with PUB management requires collaborative care involving the emergency department, gastroenterologist, radiologist, and surgeon, from initial assessment to hospital discharge. The application of artificial intelligence (AI) methods has remarkably improved people's lives. In particular, AI systems have shown great potential in many areas of gastroenterology to increase human performance. Colonoscopy polyp detection or diagnosis by an AI system was recently introduced for commercial use to improve endoscopist performance. Although PUB is a longstanding health problem, these newly introduced AI technologies may soon impact endoscopists' clinical practice by improving the quality of care for these patients. To update the current status of AI application in PUB, we reviewed recent relevant literature and provided future perspectives that are required to integrate such AI tools into real-world practice.

Upper gastrointestinal bleeding in COVID-19 inpatients: Incidence and management in a multicenter experience from Northern Italy.

BACKGROUND: COVID-19 patients have an increased susceptibility to develop thrombotic complications, thus thromboprophylaxis is warranted which may increase risk of upper gastrointestinal bleeding (UGIB). Our aim was to evaluate incidence of UGIB and use of upper GI endoscopy in COVID-19 inpatients. METHODS: The medical and endoscopic management of UGIB in non-ICU COVID-19 patients has been retrospectively evaluated. Glasgow Blatchford score was calculated at onset of signs of GI bleeding. Timing between onset of signs of GI bleeding and execution, if performed, of upper GI endoscopy was evaluated. Endoscopic characteristics and outcome of patients were evaluated overall or according to the execution or not of an upper GI endoscopy before and after 24h. RESULTS: Out of 4871 COVID-19 positive patients, 23 presented signs of UGIB and were included in the study (incidence 0.47%). The majority (78%) were on anticoagulant therapy or thromboprophylaxis. In 11 patients (48%) upper GI endoscopy was performed within 24h, whereas it was not performed in 5. Peptic ulcer was the most common finding (8/18). Mortality rate was 21.7% for worsening of COVID-19 infection. Mortality and rebleeding were not different between patients having upper GI endoscopy before or after 24h/not performed. Glasgow Blatchford score was similar between the two groups (13;12-16 vs 12;9-15). CONCLUSION: Upper GI bleeding complicated hospital stay in almost 0.5% of COVID-19 patients and peptic ulcer disease is the most common finding. Conservative management could be an option in patients that are at high risk of respiratory complications.