Enrique Quintero

Risk of upper gastrointestinal ulcer bleeding associated with selective cyclo-oxygenase-2 inhibitors, traditional non-aspirin non-steroidal anti-inflammatory drugs, aspirin and combinations

Background: The risks and benefits of coxibs, non-steroidal anti-inflammatory drugs (NSAIDs), and aspirin treatment are under intense debate. Objective: To determine the risk of peptic ulcer upper gastrointestinal bleeding (UGIB) associated with the use of coxibs, traditional NSAIDs, aspirin or combinations of these drugs in clinical practice. Methods: A hospital-based, case–control study in the general community of patients from the National Health System in Spain. The study included 2777 consecutive patients with endoscopy-proved major UGIB because of the peptic lesions and 5532 controls matched by age, hospital and month of admission. Adjusted relative risk (adj RR) of UGIB determined by conditional logistic regression analysis is provided. Results: Use of non-aspirin-NSAIDs increased the risk of UGIB (adj RR 5.3; 95% confidence interval (CI) 4.5 to 6.2). Among non-aspirin-NSAIDs, aceclofenac (adj RR 3.1; 95% CI 2.3 to 4.2) had the lowest RR, whereas ketorolac (adj RR 14.4; 95% CI 5.2 to 39.9) had the highest. Rofecoxib treatment increased the risk of UGIB (adj RR 2.1; 95% CI 1.1 to 4.0), whereas celecoxib, paracetamol or concomitant use of a proton pump inhibitor with an NSAID presented no increased risk. Non-aspirin antiplatelet treatment (clopidogrel/ticlopidine) had a similar risk of UGIB (adj RR 2.8; 95% CI 1.9 to 4.2) to cardioprotective aspirin at a dose of 100 mg/day (adj RR 2.7; 95% CI 2.0 to 3.6) or anticoagulants (adj RR 2.8; 95% CI 2.1 to 3.7). An apparent interaction was found between low-dose aspirin and use of non-aspirin-NSAIDs, coxibs or thienopyridines, which increased further the risk of UGIB in a similar way. Conclusions: Coxib use presents a lower RR of UGIB than non-selective NSAIDs. However, when combined with low-dose aspirin, the differences between non-selective NSAIDs and coxibs tend to disappear. Treatment with either non-aspirin antiplatelet or cardioprotective aspirin has a similar risk of UGIB.

A Nationwide Study of Mortality Associated with Hospital Admission Due to Severe Gastrointestinal Events and Those Associated with Nonsteroidal Antiinflammatory Drug Use

BACKGROUND:The worst outcome of gastrointestinal complications is death. Data regarding those associated with nonsteroidal antiinflammatory drug (NSAID) or aspirin use are scarce.AIM:To determine mortality associated with hospital admission due to major gastrointestinal (GI) events and NSAID/aspirin use.METHODS:The study was based on actual count of deaths from two different data sets from 2001. Study 1 was carried out in 26 general hospitals serving 7,901,198 people. Study 2 used a database from 197 general hospitals, representative of the 269 hospitals in the Spanish National Health System. Information regarding gastrointestinal complications and deaths was obtained throughout the Minimum Basic Data Set (CIE-9-MC) provided by participating hospitals. Deaths attributed to NSAID/aspirin use were estimated on the basis of prospectively collected data from hospitals of study 1.RESULTS:The incidence of hospital admission due to major GI events of the entire (upper and lower) gastrointestinal tract was 121.9 events/100,000 persons/year, but those related to the upper GI tract were six times more frequent. Mortality rate was 5.57% (95% CI = 4.9–6.7), and 5.62% (95% CI = 4.8–6.8) in study 1 and study 2, respectively. Death rate attributed to NSAID/aspirin use was between 21.0 and 24.8 cases/million people, respectively, or 15.3 deaths/100,000 NSAID/aspirin users. Up to one-third of all NSAID/aspirin deaths can be attributed to low-dose aspirin use.CONCLUSION:Mortality rates associated with either major upper or lower GI events are similar but upper GI events were more frequent. Deaths attributed to NSAID/ASA use were high but previous reports may have provided an overestimate and one-third of them can be due to low-dose aspirin use.

Gastric mucosal vascular ectasias causing bleeding in cirrhosis

To characterize bleeding from gastric red spots in patients with cirrhosis, three groups of patients were studied: (a) 11 cirrhotic patients bleeding from gastric red spots, (b) 18 nonbleeding cirrhotic patients without gastric red spots, and (c) 13 noncirrhotic patients with endoscopic normal mucosa (controls). Histologic examination of antral biopsy specimens revealed a diffuse capillary ectasia without inflammation in 8 of the 11 cirrhotic patients with gastric lesions. Morphometric analysis disclosed a significantly greater mean mucosal capillary cross-sectional area in cirrhotic patients with gastric lesions (mean +/- SE, 1371 +/- 320 microns2) than in those without gastric lesions (541 +/- 61 microns2) (p less than 0.005) or controls (353 +/- 20 microns2) (p less than 0.001). Hypergastrinemia was detected in 8 of the 11 cirrhotic patients with lesions, in 2 of the 18 cirrhotic patients without gastric lesions, and in none of the controls (p less than 0.001). Gastrin serum levels correlated significantly (r = 0.80) with mean mucosal capillary cross-sectional area in patients with cirrhosis. Pepsinogen I serum levels below 20 ng/ml were observed in 7 of the 11 cirrhotic patients with lesions, in 1 of the 18 cirrhotic patients without lesions, and in none of the controls. These data indicate that bleeding from gastric red spots in patients with cirrhosis is a distinct entity characterized by vascular ectasia of the gastric mucosa. This condition seems to be associated with hypergastrinemia and low serum levels of pepsinogen I.

PARACENTESIS VERSUS DIURETICS IN THE TREATMENT OF CIRRHOTICS WITH TENSE ASCITES

72 cirrhotics with tense ascites were randomly assigned to treatment with either paracentesis plus intravenous albumin infusion (38 patients) or diuretics (34 patients). Paracentesis was not associated with significant changes in renal function. The clinical course of the disease was similar in the two groups of patients, both during their hospital stay and during follow-up.

Delayed gastric emptying induced by inhibitors of nitric oxide synthase in rats.

The effect of the nitric oxide (NO) synthase inhibitor, NG-nitro-L-arginine methyl ester, on gastric emptying of a non-nutrient solution was investigated in conscious rats. NG-Monomethyl-L-arginine (10 mg/kg i.v.) and NG-nitro-L-arginine methyl ester (3 or 10 mg/kg i.v.) inhibited the 20-min rate of gastric emptying of liquids by 34%, 69% and 84% respectively, whereas the 0.3 mg/kg of NG-nitro-L-arginine methyl ester or 3 mg/kg of NG-monomethyl-L-arginine had no effect. The inhibitory effect of NG-nitro-L-arginine methyl ester (3 mg/kg) was prevented by L-arginine (300 mg/kg i.v.), but not by D-arginine (300 mg/kg i.v.). NG-Nitro-L-arginine methyl ester (0.3-10 mg/kg) induced a dose-related increase in mean blood pressure up to 161 +/- 10 mm Hg. Spontaneous hypertensive rats with a mean blood pressure of 180 +/- 5 mm Hg had a gastric emptying rate of 51.9 +/- 6.1%. These data indicate that NO synthase inhibitors given i.v. at doses that inhibit NO synthase, delay gastric emptying through mechanisms which are unrelated to changes in arterial blood pressure.

Impact of an educational video-based strategy on the behavior process associated with colorectal cancer screening: A randomized controlled study

BACKGROUND Low public awareness is an important barrier for colorectal cancer screening participation. AIM To evaluate the impact of educational intervention on the health behavior process, patient knowledge and compliance with colorectal cancer screening in the average-risk population. METHODS 158 subjects (aged 50-79 years) were randomly assigned either to watch a non-medical video or a colorectal cancer educational video. Before and after watching the experimental or control videotape, participants completed a five-item questionnaire that assessed their knowledge about risk factors for colorectal cancer, age of risk, warning symptoms, 5-year prognosis, and incidence. Subjective risk perception for developing colorectal cancer, barriers or benefits of screening, and intention to be screened were also investigated. Finally, subjects received a faecal occult blood test kit and were requested to use and return it within 2 weeks. RESULTS Participants in the video-based intervention group showed significant improvement in knowledge of colorectal cancer scores (P<0.001) and decreased barrier scores. The intervention group returned significantly more faecal occult blood tests than controls (69.6% vs. 54.4%, P=0.035). The intervention had a positive effect on modifying attitudes and intention to take part in screening. Additionally, the intervention was a predictor of compliance (OR 2.0; 95% CI=1.02-3.84, P=0.044). CONCLUSION Video-based intervention significantly reduced barriers to screening and improved participant awareness and compliance with colorectal cancer screening with faecal occult blood test.

Public Awareness of Colorectal Cancer Screening: Knowledge, Attitudes, and Interventions for Increasing Screening Uptake

Colorectal cancer ranks as one of the most incidental and death malignancies worldwide. Colorectal cancer screening has proven its benefit in terms of incidence and mortality reduction in randomized controlled trials. In fact, it has been recommended by medical organizations either in average-risk or family-risk populations. Success of a screening campaign highly depends on how compliant the target population is. Several factors influence colorectal cancer screening uptake including sociodemographics, provider and healthcare system factors, and psychosocial factors. Awareness of the target population of colorectal cancer and screening is crucial in order to increase screening participation rates. Knowledge about this disease and its prevention has been used across studies as a measurement of public awareness. Some studies found a positive relationship between knowledge about colorectal cancer, risk perception, and attitudes (perceived benefits and barriers against screening) and willingness to participate in a colorectal cancer screening campaign. The mentioned factors are modifiable and therefore susceptible of intervention. In fact, interventional studies focused on average-risk population have tried to increase colorectal cancer screening uptake by improving public knowledge and modifying attitudes. In the present paper, we reviewed the factors impacting adherence to colorectal cancer screening and interventions targeting participants for increasing screening uptake.

Risk for high-grade dysplasia or invasive carcinoma in colorectal flat adenomas in a Spanish population.

AIM to determine the frequency and malignancy risk of colonic flat adenomas among patients with colorectal polyps in a Spanish population. METHODS 1300 consecutive colonoscopic examinations were reviewed; 640 polyps were detected and removed endoscopically in 298 patients. Chromoendoscopy with 0.2% indigo carmine was applied to clarify the macroscopical appearance of flat lesions. The following data was collected for flat and protruding polyps: size, location (proximal or distal to splenic flexure), histology (neoplastic or non neoplastic), high grade dysplasia (HGD) and submucosal invasive carcinoma (SIC) or beyond. RESULTS 490 polyps (76.6%) were adenomas and 150 (23.4%) hyperplastic; 114 (23.3%) adenomas were flat (3 flat-depressed) whereas 376 (76.7%) were protruding. The diameter of flat and protruding adenomas was 9.2 +/- 7.9. mm and 7.0 +/- 5.9 mm, respectively (p < 0.001). A proximal location was more frequent for flat (63.1%) than for protruding adenomas (48.7%) (p = 0.003). The rate of HGD or SIC was significantly higher in flat than in protruding adenomas (7.0 vs 2.6%; p < 0.04). Two of the 3 flat-depressed lesions (both <or= 10 mm in diameter) were carcinomas (T1 and T2, respectively). Flat adenomas had an increased risk for HGD or SIC (OR = 2,7; CI, 1,04-7,04; p < 0.05). CONCLUSIONS In a Spanish population, flat adenomas represent nearly one quarter of all colorectal neoplastic polyps, their most frequent location being the right colon and they bear a higher risk of malignancy than protruding adenomas, especially for the flat depressed type.

Impact of physician specialty on the cost of nonvariceal upper GI bleeding care

OBJECTIVE:Upper GI bleeding (UGIB) is a common medical emergency that leads to a high consumption of medical resources and costs. We aimed to analyze the influence of physician specialty on the costs of nonvariceal UGIB care.METHODS:We retrospectively assessed 350 nonvariceal UGIB episodes that were primarily cared for by gastroenterologists (n = 142), internists (n = 67), or surgeons (n = 141). Gastroenterologists followed evidence-based clinical protocols that included early endoscopy and early hospital discharge for uncomplicated bleeding. A risk score system was used to control for severity of illness. Linear regression analyses were performed to find out predictors of costs and the influence of specialist care on length of stay (LOS).RESULTS:The overall mean hospital cost was significantly lower in patients cared for by gastroenterologists (EUR 1630) than in those managed by internists (EUR 3745, p < 0.001) or surgeons (EUR 2513, p < 0.05). The mean LOS was the variable with highest influence on total cost. Patients cared for by gastroenterologists had a mean LOS significantly shorter (7.3 days) than that of those treated by internists (16.2 days, p < 0.001) or surgeons (11 days, p < 0.001). Hospital costs and LOS differences were maintained when adjusting for severity of illness. In caring for low risk patients, nongastroenterologists had a higher probability of having a hospital stay longer than 4 days (odds ratio = 18.4, CI = 4.6–73.6, p < 0.001).CONCLUSION:The implementation of specific evidence-based protocols by gastroenterologists reduces length of hospital stay and saves medical costs in patients with nonvariceal UGIB, especially those at low risk.

Association of Helicobacter pylori-related Distal Gastric Cancer with the HLA Class II Gene DQB1 * 0602 and cagA + Strains in a Southern European Population

Background.  Distinct human leukocyte antigen (HLA)‐DQ genes have been associated with an increased or reduced risk for gastric cancer, but its association with Helicobacter pylori status is controversial. In the present study we evaluated the influence of host HLA DQA1 and DQB1 loci, H. pylori genotype, and socio‐economic factors on predicting H. pylori‐associated distal gastric cancer in a southern European population.