GI Bleeding in the Elderly

Purpose: To determine the risk factors contributing to and etiologies of gastrointestinal bleeding in an elderly patient population seen by Southwest Gastroenterology (SWGA) providers. Methods: This study reviews charts of patients with GI bleeding from documented sources between 1/1999 and 3/2006. The cases are gathered retrospectively from the clinical records of SWGA, a 12-person private, single specialty gastroenterology group serving community hospitals. Etiology and risk factors for GI hemorrhages are recorded in an elderly population, defined as patients age 55 and older. Results: GI hemorrhages are identified in 105 patients. The majority (83, 79%) of hemorrhages are upper GI bleeds (UGIB) comparing to 22 (21%) lower GI bleeds (LGIB). In the UGIB group, the most common etiology of bleed is gastric ulcer (29%). We also found 72% of UGIB patients on prescribed anticoagulation medications, including anti-platelet agents or non-steroidal anti-inflammatory drugs (NSAIDs). 20% of these patients are also positive for H. Pylori. Thirty patients in the UGIB group smoke or consume alcohol heavily (consuming more than 3 drinks per day for men and two drinks per day for women) while 2 patients smoke or consume alcohol in the LGIB group. Previous bleeds are common in both groups with 39 (41%) in UGIB and 9 (47%) in LGIB. Co-morbidity is the most common risk factor with 20 (91%) in LGIB and 73 (88%) in UGIB. In the peptic ulcer disease (PUD) bleeds, the majority (77%) are taking NSAIDs, while in the non-PUD bleeds, only 38% are currently on NSAIDs. Overall, there are 2 mortalities resulting from cardiovascular complications of GI bleeding. Conclusion: The etiologies of GI bleeds in this population are comparable to other studies in the literature. The ratio of UGIB to LGIB in this elderly population is also similar to that reported in the literature. The risk factors shown to be most correlated to bleeding are co-morbidities, previous episodes of bleeding, anticoagulation, NSAID use, smoking and alcohol use. NSAID use is significant in PUD bleed patients. This study reinforces that increased knowledge of etiology, incidence and contributing factors of GI bleeding are necessary for physicians to efficiently treat GI bleeds in the elderly population

Integrated modelling of social-ecological systems for climate change adaptation

Analysis of climate change risks in support of policymakers to set effective adaptation policies requires an innovative yet rigorous approach towards integrated modelling (IM) of social-ecological systems (SES). Despite continuous advances, IM still faces various challenges that span through both unresolved methodological issues as well as data requirements. On the methodological side, significant improvements have been made for better understanding the dynamics of complex social and ecological systems, but still, the literature and proposed solutions are fragmented. This paper explores available modelling approaches suitable for long-term analysis of SES for supporting climate change adaptation (CCA). It proposes their classification into seven groups, identifies their main strengths and limitations, and lists current data sources of greatest interest. Upon that synthesis, the paper identifies directions for orienting the development of innovative IM, for improved analysis and management of socio-economic systems, thus providing better foundations for effective CCA

An integrated approach of flood risk assessment in the eastern part of Dhaka City

The flood risk is a function of the flood hazard, the exposed values, and their vulnerability. In addition to extreme hydrological events, different anthropogenic activities such as extensive urbanization and land use play an important role in producing catastrophic floods. Considerations of both physical and social dimensions are therefore equally important in flood risk assessment. However, very often the risk assessment studies focus either on physical or social dimensions. In addition, the available studies often focus on economic valuation of only direct tangible costs. In this study, we provide an integrated flood risk assessment approach that goes beyond the valuation of direct tangible costs, through incorporating physical dimensions in hazard and exposure and social dimensions in vulnerability. The method has been implemented in the Dhaka City, Bangladesh, an area internationally recognized as hot spot for flood risk. In this study, flood hazards for different return periods are calculated in spatial environment using a hydrologic model, HECRAS. Vulnerability is assessed through aggregation of various social dimensions, i.e., coping and adaptive capacities, and susceptibility. We assess vulnerability for both baseline and improved scenarios. In the baseline scenario, current early warning for study area is considered. In the alternative scenario, the warning system is expected to improve. Aggregating hazard, exposure and vulnerability, risk maps (in terms of both tangible and intangible costs) of several return period floods are produced for both baseline and improved scenarios. Compared to traditional assessments, the integrated assessment approach used in this study generates more information about the flood risk. Consequently, the results are useful in evaluating policy alternatives and minimizing property loss in the study area

GI Bleeding in the Elderly

Purpose: To determine the risk factors contributing to and etiologies of gastrointestinal bleeding in an elderly patient population seen by Southwest Gastroenterology (SWGA) providers. Methods: This study reviews charts of patients with GI bleeding from documented sources between 1/1999 and 3/2006. The cases are gathered retrospectively from the clinical records of SWGA, a 12-person private, single specialty gastroenterology group serving community hospitals. Etiology and risk factors for GI hemorrhages are recorded in an elderly population, defined as patients age 55 and older. Results: GI hemorrhages are identified in 105 patients. The majority (83, 79%) of hemorrhages are upper GI bleeds (UGIB) comparing to 22 (21%) lower GI bleeds (LGIB). In the UGIB group, the most common etiology of bleed is gastric ulcer (29%). We also found 72% of UGIB patients on prescribed anticoagulation medications, including anti-platelet agents or non-steroidal anti-inflammatory drugs (NSAIDs). 20% of these patients are also positive for H. Pylori. Thirty patients in the UGIB group smoke or consume alcohol heavily (consuming more than 3 drinks per day for men and two drinks per day for women) while 2 patients smoke or consume alcohol in the LGIB group. Previous bleeds are common in both groups with 39 (41%) in UGIB and 9 (47%) in LGIB. Co-morbidity is the most common risk factor with 20 (91%) in LGIB and 73 (88%) in UGIB. In the peptic ulcer disease (PUD) bleeds, the majority (77%) are taking NSAIDs, while in the non-PUD bleeds, only 38% are currently on NSAIDs. Overall, there are 2 mortalities resulting from cardiovascular complications of GI bleeding. Conclusion: The etiologies of GI bleeds in this population are comparable to other studies in the literature. The ratio of UGIB to LGIB in this elderly population is also similar to that reported in the literature. The risk factors shown to be most correlated to bleeding are co-morbidities, previous episodes of bleeding, anticoagulation, NSAID use, smoking and alcohol use. NSAID use is significant in PUD bleed patients. This study reinforces that increased knowledge of etiology, incidence and contributing factors of GI bleeding are necessary for physicians to efficiently treat GI bleeds in the elderly population

HER2 Expression in Gastric and Gastroesophageal Junction Adenocarcinoma in a US Population: Clinicopathologic Analysis With Proposed Approach to HER2 Assessment

Recent evidence suggests that trastuzumab, a monoclonal antibody which targets HER2, in combination with chemotherapy is a therapeutic option in patients with HER2-positive gastric or gastroesophageal junction cancer. Widely accepted guidelines for HER2 testing in gastric and gastroesophageal junction cancer have not been established. The purpose of this study was to analyze the incidence and patterns of HER2 expression in gastric and gastroesophageal junction cancer using a tissue microarray approach, which closely simulates small biopsies routinely tested for HER2. One hundred sixty-nine patients, including 99 primary gastric adenocarcinomas and 70 primary gastroesophageal junction carcinomas were analyzed for HER2 overexpression by immunohistochemistry and HER2 gene amplification by fluorescence in situ hybridization using scoring schemes proposed by both American Society of Clinical Oncology/ College of American Pathologists (ASCO/CAP) and the results of the recently published Trastuzumab for Gastric cancer (ToGA) trial. In our analysis, 19 adenocarcinomas were HER2 positive, defined as either a HER2/CEP17 ratio > 2.2 and/or a 3+ HER2 immunohistochemistry score with either the ASCO/CAP or ToGA scoring schemes. Of the 19 HER2-positive adenocarcinomas, 8 (42%) exhibited a characteristic strongly intense basolateral membranous staining pattern which would be interpreted as negative (1+) using the accepted ASCO/CAP scoring scheme for HER2 assessment in breast carcinoma, but were correctly labeled as 3+ positive using the proposed ToGA scoring scheme. Of the 19 HER2-positive adenocarcinomas, 8 (42%) demonstrated heterogeneous HER2 protein expression by immunohistochemistry. Twelve of 99 (12%) gastric carcinomas were positive for HER2. Of these, HER2 was more often identified in intestinal-type adenocarcinomas (10 of 52, 19%) compared with diffuse (2 of 34, 6%) adenocarcinoma. Seven of 70 (10%) gastroesophageal junction carcinomas were positive for HER2 of which all were intestinal type (7 of 58, 12%). HER2 status or primary tumor site did not correlate with patient survival. Gastric and gastroesophageal junction adenocarcinomas typically display a characteristic basolateral membranous pattern of HER2 expression which is often heterogeneous rendering routine evaluation of HER2 status on small tissue samples challenging

Quantification of Liver Iron Overload with MRI: Review and Guidelines from the ESGAR and SAR

International audienceAccumulation of excess iron in the body, or systemic iron overload, results from a variety of causes. The concentration of iron in the liver is linearly related to the total body iron stores and, for this reason, quantification of liver iron concentration (LIC) is widely regarded as the best surrogate to assess total body iron. Historically assessed using biopsy, there is a clear need for noninvasive quantitative imaging biomarkers of LIC. MRI is highly sensitive to the presence of tissue iron and has been increasingly adopted as a noninvasive alternative to biopsy for detection, severity grading, and treatment monitoring in patients with known or suspected iron overload. Multiple MRI strategies have been developed in the past 2 decades, based on both gradient-echo and spin-echo imaging, including signal intensity ratio and relaxometry strategies. However, there is a general lack of consensus regarding the appropriate use of these methods. The overall goal of this article is to summarize the current state of the art in the clinical use of MRI to quantify liver iron content and to assess the overall level of evidence of these various methods. Based on this summary, expert consensus panel recommendations on best practices for MRI-based quantification of liver iron are provided

Ileitis

Inflammatory pathology of the distal small bowel is relatively common. Three major clinical situations can be considered: a normal-appearing ileumon endoscopy, isolated ileitis, and ileocolitis. Acute enteritis is usually infectious in origin. Histology is not the best method for the diagnosis of enteric infections,because most acute enteritides are non-specific histologically and stool cultures or stool examination has a higher diagnostic yield. Chronic enteritis is less common and most notably caused by chronic infections such as yersiniosis and tuberculosis, by drugs and, in the Western world, primarily by Crohn’s disease. Inflammation called “backwash ileitis” can be present in the terminal ileum in patients with UC. Terminal ileum endoscopy and biopsy are considered as the gold standard for the differential diagnosis of chronic enteritis. The presence of endoscopic lesions and/or a clinical presentation with inflammatory diarrhea are the major indications for a biopsy. As endoscopy is now more frequently performed, pathologists are more likely to receive small intestinal samples and have to know the different features and the possible differential diagnosis between these pathologies