American Journal of Gastroenterology最新文献

Article Title: The San Diego Consensus for Laryngopharyngeal Symptoms and Laryngopharyngeal Reflux Disease.

Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most used medications worldwide. A major limitation of these drugs is gastrointestinal (GI) mucosal injury. Several gastroprotective agents have been recommended but are limited by their long-term effects. Rebamipide is a promising mucoprotective agent, but its efficacy is not established. We performed a meta-analysis assessing the efficacy of rebamipide in preventing NSAID-induced GI mucosal breaks as compared with placebo and the standard proton-pump inhibitors (PPIs).

Methods: Four electronic databases were searched from inception to October 2023 for randomized controlled trials that compared rebamipide with placebo or PPIs. Data were pooled to obtain the risk ratio (RR) with 95% confidence interval (CI). Heterogeneity and publication bias were assessed with I2 statistic and funnel plot, respectively.

Results: A total of 472 studies were screened, with 13 studies included. Pooled analyses showed that rebamipide significantly reduced the incidence of NSAID-induced GI mucosal breaks as compared with placebo (RR 0.55, 95% CI 0.31-0.99, P ≤ 0.00001). Rebamipide is also comparable with the standard PPIs in preventing NSAID-induced mucosal breaks (RR 1.00, 95% CI 0.51-1.95, P = 1.00). Regarding addition of rebamipide to PPIs, there are still insufficient data to support its effect on further improving prevention of GI mucosal breaks as compared with PPIs alone (RR 0.72, 95% CI 0.43-1.21; P = 0.11).

Discussion: Rebamipide is effective in preventing NSAID-induced GI mucosal breaks. Rebamipide may also be as good as the standard PPIs in preventing NSAID-induced GI mucosal breaks and, hence, may be an alternative, especially in those with contraindications to long-term PPI use.

Objectives: MELD-lactate (MELD-LA) score is an independent predictor of inpatient mortality and organ failure validated in over 8,600 patients across diverse settings. However, its utility in sepsis, particularly when combined with lactate clearance (LA clearance), has not been fully evaluated. In this study, we examined the dynamic role of MELD-LA with 24-hour LA clearance as a predictor of 30-day mortality in critically ill patients with cirrhosis and sepsis.

Methods: We analyzed cirrhosis patients with sepsis admitted to the ICU in a large U.S. healthcare system (20 hospitals) from 2014-2022, examining MELD-LA and LA clearance within 24 hours as predictors of 30-day mortality. We externally validated our findings in the APASL-ACLF Research Consortium, a multinational Asian cohort (31 centers) from 2009-2019.

Results: A total of 3,879 cirrhosis patients with sepsis were admitted to the ICU (43.2% female, 20.5% Hispanic, 12.4% on dialysis; mean initial LA 4.5 mmol/L, MELD 20.8, MELD-LA 17.6). Survivors showed a median lactate change of -1.04 (35% clearance) compared to -0.4 (12%) for non-survivors. LA clearance within 24 hours was influenced by the presenting MELD-LA. In the North American cohort, ≥35% LA clearance was associated with improved 30-day survival (OR 0.41, 95% CI 0.31-0.53; p<0.001). Similarly, in the APASL cohort (n=1,259), ≥35% clearance was linked to a 60% reduction in mortality (OR 0.42, 95% CI 0.28-0.62; p<0.001). When stratified by LA clearance, patients with LA clearance of ≥35% had a higher percentage of early administration of resuscitative measures than those with LA clearance of < 10% especially with regards to early antibiotic administration (82.5% vs 67.6%; p-value <0.001).

Conclusion: Early reduction in initial LA by one-third predicts 30-day mortality and may indicate treatment response in cirrhosis patients with sepsis in the ICU. Combining MELD-LA and LA clearance early enables better risk stratification and informs management.

Objective: To perform a proof-of-concept study to evaluate the performance of individual and combined anorectal manometry (ARM) and balloon expulsion testing (BET) parameters for diagnosing dyssynergic defecation (DD) using machine learning (ML).

Methods: A single gastrointestinal motility specialist assessed (2008-2018) 307 patients. A machine learning model was constructed on ARM/BET data. BET was weight-based in 235 patients and time-based in 72 patients. Missing data were imputed. Data were split 75% train/25% test with preprocessing performed. Five common ML models were trained, and performance was compared using receiver-operating characteristic (ROC) area under the curve (AUC) and accuracy based on 100 bootstrapped samples. The most accurate models were fine-tuned and evaluated on the test set.

Results: The median age was 40 years, BMI 22.2 kg/m2, and 81% were female. Two-hundred and twenty-two (72.3%) patients had a clinical diagnosis of DD. Compared to patients without clinical diagnosis of DD, patients with DD had significantly lower rectoanal pressure gradient (RAG) (median -34.7 [IQR -57.1, -13.0] vs. -24.6 [IQR -44.5, -2.4] mmHg, p=0.009) and more abnormal BET (59.5% vs 11.8%, p<0.001). Four features were retained in the optimized model as predictors of DD: abnormal BET, greater resting anal pressure (RAP), and more negative RAG. The optimal parameter was abnormal BET (p=0.003), but combinations of two manometry results (RAP and RAG) yielded positive predictive values (PPV) >80%. The optimized logistic regression (LR) model had an AUC of 0.878, with a sensitivity of 75.0% and specificity of 81.8% at a probability threshold of 0.704.

Conclusion: Abnormal BET, or combination of two manometric parameters (RAP and RAG), provide >80% PPV for diagnosing DD in patients with chronic constipation.