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Background and study aims: Outbreaks of multi-drug resistant bacteria due to contaminated duodenoscopes and the Covid-19 pandemic have driven the development of single-use endoscopes. The first single-use gastroscope (Ambu aScope Gastro) is now available in Europe. Besides waste-disposal and cost issues, the infection risk and performance remain unclear. We aimed to evaluate single-use gastroscopes in patients with upper gastrointestinal bleeding. Patients and methods: Twenty consecutive patients presenting with stigmata of upper gastrointestinal bleeding were included in this case series between October and November 2022. The primary aim was the technical success rate defined as access to the descending duodenum and adequate assessment of the upper gastrointestinal tract for the presence of a bleeding site. Results: The primary aim was achieved in 19 out of 20 (95%) patients. The bleeding site was identified in 18 patients. A therapeutic intervention with a single-use gastroscope was performed in six cases (two cap-mounted clips, one standard hemoclip, , two variceal band ligations, one hemostatic powder, two adrenaline injections). Technical and clinical success were achieved in all six cases. Two crossovers to a standard gastroscope occurred. Conclusions: In this feasibility study, we propose a possible niche for single-use gastroscopes in patients presenting for urgent endoscopic evaluation and treatment of upper gastrointestinal bleeding.

Zusammenfassung Hintergrund und Fragestellung Die erhöhte Inzidenz tiefer Beinvenenthrombosen (TVT) bei Intensivpatienten mit COVID-19-Infektion ist mehrfach beschrieben worden. Kann das Thromboserisiko bei diesen Patienten durch standardisierte Systemtherapie gesenkt werden? Material und Methoden Nach Etablierung eines Therapiestandards mit Vollantikoagulation, Gabe von Dexamethason und Rekonvaleszentenplasma wurden 20 Patienten mit COVID-19-Pneumonie auf das Vorliegen einer TVT mittels Kompressionssonografie gescreent. Als Vergleichsgruppe dienten 20 COVID-Infizierte mit noch uneinheitlicher Therapie, die wir während der 1. Erkrankungswelle auf das Vorliegen einer Thrombose untersucht haben. Ergebnisse In der aktuellen Studienpopulation mit standardisiertem Therapieregime konnten wir keine Thrombose detektieren, wohingegen im COVID-Kollektiv unserer Voruntersuchung 20% der Erkrankten (n=4) eine TVT entwickelten. Lungenembolien traten in beiden Gruppen auf; 1 in der 1., 2 in der 2. Kohorte. Diskussion Durch Vollantikoagulation, Steroidgabe und Verabreichen von Rekonvaleszentenplasma konnte das TVT-Risiko gesenkt werden. Die dezidierte Bedeutung der einzelnen Komponenten ist nicht geklärt. Da Blutungen bei SARS-CoV-2-Infektion bisher nur selten beobachtet wurden, scheint eine großzügige Indikation zur Antikoagulation gerechtfertigt.

All chemicals can interfere with cellular membranes and this leads to baseline toxicity, which is the minimal toxicity any chemical elicits. The critical membrane burden is constant for all chemicals; that is, the dosing concentrations to trigger baseline toxicity decrease with increasing hydrophobicity of the chemicals. Quantitative structure-activity relationships, based on hydrophobicity of chemicals, have been established to predict nominal concentrations causing baseline toxicity in human and mammalian cell lines. However, their applicability is limited to hydrophilic neutral compounds. To develop a prediction model that includes more hydrophobic and charged organic chemicals, a mass balance model was applied for mammalian cells (AREc32, AhR-CALUX, PPARγ-BLA, and SH-SY5Y) considering different bioassay conditions. The critical membrane burden for baseline toxicity was converted into nominal concentration causing 10% cytotoxicity by baseline toxicity (IC10,baseline) using a mass balance model whose main chemical input parameter was the liposome-water partition constants (Klip/w) for neutral chemicals or the speciation-corrected Dlip/w(pH 7.4) for ionizable chemicals plus the bioassay-specific protein, lipid, and water contents of cells and media. In these bioassay-specific models, log(1/IC10,baseline) increased with increasing hydrophobicity, and the relationship started to level off at log Dlip/w around 2. The bioassay-specific models were applied to 392 chemicals covering a broad range of hydrophobicity and speciation. Comparing the predicted IC10,baseline and experimental cytotoxicity IC10, known baseline toxicants and many additional chemicals were identified as baseline toxicants, while the others were classified based on specificity of their modes of action in the four cell lines, confirming excess toxicity of some fungicides, antibiotics, and uncouplers. Given the similarity of the bioassay-specific models, we propose a generalized baseline-model for adherent human cell lines: log[1/IC10,baseline (M)] = 1.23 + 4.97 × (1 - e-0.236 log Dlip/w). The derived models for baseline toxicity may serve for specificity analysis in reporter gene and neurotoxicity assays as well as for planning the dosing for cell-based assays.

Modern society continues to pollute the environment with larger quantities of chemicals that have also become more structurally and functionally diverse. Risk assessment of chemicals can hardly keep up with the sheer numbers that lead to complex mixtures of increasing chemical diversity including new chemicals, substitution products on top of still abundant legacy compounds. Fortunately, over the last years computational tools have helped us to identify and prioritize chemicals of concern. These include toxicokinetic models to predict exposure to chemicals as well as new approach methodologies such as in-vitro bioassays to address toxicodynamic effects. Combined, they allow for a prediction of mixtures and their respective effects and help overcome the lack of data we face for many chemicals. In this study we propose a high-throughput approach using experimental and predicted exposure, toxicokinetic and toxicodynamic data to simulate mixtures, to which a virtual population is exposed to and predict their mixture effects. The general workflow is adaptable for any type of toxicity, but we demonstrated its applicability with a case study on neurotoxicity. If no experimental data for neurotoxicity were available, we used baseline toxicity predictions as a surrogate. Baseline toxicity is the minimal toxicity any chemical has and might underestimate the true contribution to the mixture effect but many neurotoxicants are not by orders of magnitude more potent than baseline toxicity. Therefore, including baseline-toxic effects in mixture simulations yields a more realistic picture than excluding them in mixture simulations. This workflow did not only correctly identify and prioritize known chemicals of concern like benzothiazoles, organochlorine pesticides and plasticizers but we were also able to identify new potential neurotoxicants that we recommend to include in future biomonitoring studies and if found in humans, to also include in neurotoxicity screening.

In critically ill patients an intra-abdominal hypertension (IAH) is a frequent phenomenon. An IAH is defined as an intra-abdominal pressure (IAP) persistently ≥ 12 mm Hg and an abdominal compartment syndrome is defined as an IAP with a persistent pressure ≥ 20 mm Hg in combination with newly occurring organ failure. The bladder pressure serves as a surrogate parameter for the IAP, which should be measured noninvasively in a standardized manner. An undetected and untreated IAH worsens the prognosis of critically ill patients.Eine intraabdominelle Hypertension (IAH) ist ein häufiges Phänomen bei kritisch kranken Patienten und ist als ein anhaltender intraabdomineller Druck (IAP) ≥ 12 mm Hg definiert. Ein abdominelles Kompartmentsyndrom (ACS) ist definiert als eine IAP mit einem anhaltenden Druck ≥ 20 mm Hg in Zusammenschau mit einem neu aufgetretenen Organversagen. Als Surrogatparameter für die IAP dient der Blasendruck, der standardisiert nichtinvasiv gemessen werden sollte. Eine nicht erkannte und nicht therapierte IAH verschlechtert die Prognose des kritisch kranken Patienten.

To evaluate imaging patterns of a COVID-19 infection of the lungs on chest radiographs and their value in discriminating this infection from other viral pneumonias. All 321 patients who presented with respiratory impairment suspicious for COVID-19 infection between February 3 and May 8, 2020 and who received a chest radiograph were included in this analysis. Imaging findings were classified as typical for COVID-19 (bilateral, peripheral opacifications/consolidations), non-typical (findings consistent with lobar pneumonia), indeterminate (all other distribution patterns of opacifications/consolidations), or none (no opacifications/consolidations). The sensitivity, specificity, as well as positive and negative predictive value for the diagnostic value of the category "typical" were determined. Chi² test was used to compare the pattern distribution between the different types of pneumonia. Imaging patterns defined as typical for COVID-19 infections were documented in 35/111 (31.5 %) patients with confirmed COVID-19 infection but only in 4/210 (2 %) patients with any other kind of pneumonia, resulting in a sensitivity of 31.5 %, a specificity of 98.1 %, and a positive and negative predictive value of 89.7 % or 73 %, respectively. The sensitivity could be increased to 45.9 % when defining also unilateral, peripheral opacifications/consolidations with no relevant pathology contralaterally as consistent with a COVID-19 infection, while the specificity decreases slightly to 93.3 %. The pattern distribution between COVID-19 patients and those with other types of pneumonia differed significantly (p 0.0001). Although the moderate sensitivity does not allow the meaningful use of chest radiographs as part of primary screening, the specific pattern of findings in a relevant proportion of those affected should be communicated quickly as additional information and trigger appropriate protective measures. · COVID-19 infections show specific X-ray image patterns in 1/3 of patients.. · Bilateral, peripheral opacities and/or consolidations are typical imaging patterns.. · Unilateral, peripheral opacities and/or consolidations should also raise suspicion of COVID-19 infection..· Kasper J, Decker J, Wiesenreiter K et al. Typical Imaging Patterns in COVID-19 Infections of the Lung on Plain Chest Radiographs to Aid Early Triage. Fortschr Röntgenstr 2021; 193: 1189 - 1196. Bewertung der Befundmuster einer pulmonalen COVID-19-Infektion im Thorax-Röntgen und ihres Werts bei der Abgrenzung zu anderen viralen Pneumonien. Alle Patienten, die sich zwischen dem 3. Februar und dem 8. Mai 2020 mit Atemnot vorstellten und bei denen der Verdacht auf eine COVID-19-Infektion bestand, wurden, sofern eine Thorax-Röntgenaufnahme durchgeführt wurde, in diese Analyse einbezogen (n = 321). Die bildgebenden Befunde wurden als typisch für COVID-19 (bilaterale, periphere Verschattungen/Konsolidierungen), nicht typisch (Befund passend zur Lobärpneumonie), unbestimmt (alle anderen Verteilungsmuster von Infiltraten) oder keine (keine Infiltrate) klassifiziert. Zur Beurteilung des diagnostischen Werts der Kategorie “typisch” wurden Sensitivität, Spezifität sowie positiver und negativer prädiktiver Wert bestimmt. Der Chi-Quadrat-Test wurde verwendet, um die Musterverteilung zwischen den verschiedenen Arten von Pneumonien zu vergleichen. Infiltratmuster, die als typisch für eine COVID-19-Infektion definiert wurden, wurden bei 35/111 (31,5 %) Patienten mit bestätigter COVID-19-Infektion dokumentiert, aber nur bei 4/210 (2 %) Patienten mit irgendeiner anderen Art von Lungenentzündung, was zu einer Sensitivität von 31,5 %, einer Spezifität von 98,1 % sowie einem positiven und negativen prädiktiven Wert von 89,7 % bzw. 73 % führte. Die Sensitivität konnte auf 45,9 % erhöht werden, wenn auch unilaterale, periphere Verschattungen/Konsolidierungen ohne relevante Pathologie kontralateral als typisch für eine COVID-19-Infektion berücksichtigt wurden. Dabei nahm die Spezifität nur geringfügig auf 93,3 % ab. Die Verteilung der Infiltratmuster auf die benannten Kategorien zwischen COVID-19-Patienten und Patienten mit sonstigen Arten von Lungenentzündungen unterschied sich signifikant (p 0,0001). Die moderate Sensitivität erlaubt zwar nicht den sinnvollen Einsatz des Röntgen-Thorax im Rahmen des primären Screenings, das spezifische Befundmuster in einem relevanten Anteil der Betroffenen sollte jedoch als zusätzliche Information rasch kommuniziert werden und entsprechende Schutzmaßnahmen triggern. · COVID-19-Infektionen zeigen bei 1/3 der Patienten spezifische Infiltratmuster im Röntgenbild.. · Bilaterale, periphere Verschattungen und/oder Konsolidierungen sind typische Infiltratmuster.. · Unilaterale, periphere Verschattungen und/oder Konsolidierungen sollten ebenso den Verdacht auf eine COVID-19-Infektion wecken..

Rain events may impact the chemical pollution burden in rivers. Forty-four small streams in Germany were profiled during several rain events for the presence of 395 chemicals and five types of mixture effects in in vitro bioassays (cytotoxicity; activation of the estrogen, aryl hydrocarbon, and peroxisome proliferator-activated receptors; and oxidative stress response). While these streams were selected to cover a wide range of agricultural impacts, in addition to the expected pesticides, wastewater-derived chemicals and chemicals typical for street runoff were detected. The unexpectedly high estrogenic effects in many samples indicated the impact by wastewater or overflow of combined sewer systems. The 128 water samples exhibited a high diversity of chemical and effect patterns, even for different rain events at the same site. The detected 290 chemicals explained only a small fraction (

The lancet / Regional health. Europe 15, 100330 (2022). doi:10.1016/j.lanepe.2022.100330, Published by Elsevier, [Amsterdam]

Modern pathology 35(8), 1013-1021 (2022). doi:10.1038/s41379-022-01069-9, Published by Nature Publishing Group, London

In this study, we aimed to develop an artificial intelligence clinical decision support solution to mitigate operator-dependent limitations during complex endoscopic procedures such as endoscopic submucosal dissection and peroral endoscopic myotomy, for example, bleeding and perforation. A DeepLabv3-based model was trained to delineate vessels, tissue structures and instruments on endoscopic still images from such procedures. The mean cross-validated Intersection over Union and Dice Score were 63% and 76%, respectively. Applied to standardised video clips from third-space endoscopic procedures, the algorithm showed a mean vessel detection rate of 85% with a false-positive rate of 0.75/min. These performance statistics suggest a potential clinical benefit for procedure safety, time and also training.

It has been reported that the risk of deep vein thrombosis is greater in patients with COVID-19 infection. We have now investigated whether a standardised therapy can reduce the risk of DVT.After establishing standard therapy with anticoagulation, steroids and convalescent plasma, we screened 20 patients with COVID-19 pneumonia for DVT by ultrasound examination. The comparison group contained 20 COVID patients with inconsistent therapy, who were examined for the presence of thrombosis during the first wave.In the current patient population with standard therapy, we could not detect any thrombosis, and in the prior patients group only 25% of patients developed DVT. Pulmonary embolism was found in one patient in the first cohort and two in the second.The risk of DVT could be reduced through anticoagulation, and administration of steroids and convalescent plasma. The specific significance of the individual components has not yet been clarified. Since bleeding is a rarely observed in SARS-CoV-2 infections, a generous indication for anticoagulation seems to be justified.Die erhöhte Inzidenz tiefer Beinvenenthrombosen (TVT) bei Intensivpatienten mit COVID-19-Infektion ist mehrfach beschrieben worden. Kann das Thromboserisiko bei diesen Patienten durch standardisierte Systemtherapie gesenkt werden?Nach Etablierung eines Therapiestandards mit Vollantikoagulation, Gabe von Dexamethason und Rekonvaleszentenplasma wurden 20 Patienten mit COVID-19-Pneumonie auf das Vorliegen einer TVT mittels Kompressionssonografie gescreent. Als Vergleichsgruppe dienten 20 COVID-Infizierte mit noch uneinheitlicher Therapie, die wir während der 1. Erkrankungswelle auf das Vorliegen einer Thrombose untersucht haben.In der aktuellen Studienpopulation mit standardisiertem Therapieregime konnten wir keine Thrombose detektieren, wohingegen im COVID-Kollektiv unserer Voruntersuchung 20% der Erkrankten (n=4) eine TVT entwickelten. Lungenembolien traten in beiden Gruppen auf; 1 in der 1., 2 in der 2. Kohorte.Durch Vollantikoagulation, Steroidgabe und Verabreichen von Rekonvaleszentenplasma konnte das TVT-Risiko gesenkt werden. Die dezidierte Bedeutung der einzelnen Komponenten ist nicht geklärt. Da Blutungen bei SARS-CoV-2-Infektion bisher nur selten beobachtet wurden, scheint eine großzügige Indikation zur Antikoagulation gerechtfertigt.

Endoscopy is most frequently performed in intensive care units (ICU) for gastrointestinal bleeding; however, there are other indications for performing an endoscopy on the ICU. This article shows the indications for this, the background and the peri-interventional and postinterventional management. The endoscopic placement of a postpyloric feeding tube is a well-established procedure. For anastomotic leakage in the esophagus and rectum, the endoscopic vacuum therapy is the treatment of choice. Gastrointestinal motility disorders are a frequent phenomenon in critically ill patients and are associated with increased mortality. With a cecal diameter 9-12 mm, endoscopic decompression can be performed; however, this is associated with an increased risk of perforation and should only be carried out after the failure of conservative treatment.Am häufigsten werden Endoskopien auf Intensivstationen im Rahmen gastrointestinaler Blutungen durchgeführt. Es gibt aber auch andere Indikationen für eine Endoskopie auf der „intensive care unit“ (ICU). Der vorliegende Beitrag zeigt diese, die Hintergründe sowie das peri- und postinterventionelle Management auf. Die endoskopische Anlage einer jejunalen Ernährungssonde ist ein gut etabliertes Verfahren. Allerdings ist die Medikamentengabe über jejunale Ernährungssonden erschwert. Bei Insuffizienzen von Anastomosen in Ösophagus und Rektum ist die endoskopische Vakuumtherapie die Therapie der Wahl. Störungen der gastrointestinalen Motilität sind ein häufiges Phänomen bei kritisch kranken Patienten und mit einer erhöhten Mortalität assoziiert. Bei einem Zökumdurchmesser 9–12 mm kann eine endoskopische Dekompression durchgeführt werden, die allerdings mit einem erhöhten Perforationsrisiko assoziiert ist und erst nach Versagen einer konservativen Therapie erfolgen sollte.

Introduction Risk stratification in upper gastrointestinal bleeding (UGIB) currently relies on clinical parameters and risk scores. HemoPill® acute (Ovesco Endoscopy, Tuebingen, Germany) is a pill-shaped, orally administered sensor capsule for real-time blood detection. The aim of this study was to evaluate the system in clinical routine. Material and methods Sixty-one consecutive patients in whom the HemoPill® had been used at 12 international hospitals between July 2019 and March 2020 were retrospectively analysed. Indications for application were the clinical suspicion of UGIB, small bowel bleeding, of rebleeding after hemostasis. Primary endpoints were technical success and bleeding detection/exclusion. Secondary endpoints included adverse events and change of clinical course. Results The capsule was used in 45 (73%) patients with UGIB, in 12 (20%) patients with small bowel bleeding and in four (7%) patients for exclusion of rebleeding. Technical success was 98%. 35/60 (58%) cases were capsule-positive and among these, endoscopy showed bleeding in 20/35 (57%) cases. None of the 25 capsule-negative patients rebled. Emergency endoscopy could be avoided in 18/25 (72%) cases. Serious adverse events did not occur. Conclusion HemoPill®-based blood detection is feasible and safe. Negative capsule results might 'downgrade' the need for urgent endoscopy.

Background COVID-19 is only partly understood, and the level of evidence available in terms of pathophysiology, epidemiology, therapy, and long-term outcome remains limited. During the early phase of the pandemic, it was necessary to effectively investigate all aspects of this new disease. Autopsy can be a valuable procedure to investigate the internal organs with special techniques to obtain information on the disease, especially the distribution and type of organ involvement. Methods During the first wave of COVID-19 in Germany, autopsies of 19 deceased patients were performed. Besides gross examination, the organs were analyzed with standard histology and polymerase-chain-reaction for SARS-CoV-2. Polymerase chain reaction positive localizations were further analyzed with immunohistochemistry and RNA-in situ hybridization for SARS-CoV-2. Results Eighteen of 19 patients were found to have died due to COVID-19. Clinically relevant histological changes were only observed in the lungs. Diffuse alveolar damage in considerably different degrees was noted in 18 cases. Other organs, including the central nervous system, did not show specific micromorphological alterations. In terms of SARS-CoV-2 detection, the focus remains on the upper airways and lungs. This is true for both the number of positive samples and the viral load. A highly significant inverse correlation between the stage of diffuse alveolar damage and viral load was found on a case and a sample basis. Mediastinal lymph nodes and fat were also affected by the virus at high frequencies. By contrast, other organs rarely exhibited a viral infection. Moderate to strong correlations between the methods for detecting SARS-CoV-2 were observed for the lungs and for other organs. Conclusions The lung is the most affected organ in gross examination, histology and polymerase chain reaction. SARS-CoV-2 detection in other organs did not reveal relevant or specific histological changes. Moreover, we did not find CNS involvement.

Aims We report the case of a 54-year old male who was admitted to our intensive care unit due to respiratory failure andCOVID-19 disease. The patients' comorbidities were allergic asthma and obesity;he was on no regular medication. On day15 after admission to the ICU, invasive ventilation was started, and on day 19, melena, with a drop in hemoglobin levelfrom 12.9 g/dl to 8.5 g/dl, was observed. Methods In the emergency gastroscopy, three ulcerations were seen in the duodenal bulb. Two ulcerations showed visiblevessels (Forrest IIa), and were treated with a standard hemoclip as well as an “Over-the-Scope-Clip” (OTSC, Ovesco). Thethird ulceration was covered by a large clot (F IIb). After mobilization of the clot, the ulceration was seen to have perforatedinto the retroperitoneum. Results The patient underwent emergency surgery in which the perforation was sutured. Conclusions Studies have shown a high risk for gastrointestinal complications, such as gastrointestinal ischemia and ileusin critically ill patients with COVID-19 disease. In this case, we postulate that critically ill patients with COVID-19 may havea higher risk of GI bleeding and ulcer perforation. However, it is unclear whether these complications can be specificallyattributed to the underlying COVID-19 disease or the therapeutic anticoagulation, which all critically ill patients with COVID-19 recieve as standard of care. Further studies are needed to confirm or rule out these assumptions. Nevertheless, specialattention should be paid to gastrointestinal complications in critically ill COVID-19 patients.

MAIN RECOMMENDATIONS 1 ESGE recommends in patients with acute upper gastrointestinal hemorrhage (UGIH) the use of the Glasgow–Blatchford Score (GBS) for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy.Strong recommendation, moderate quality evidence. 2 ESGE recommends that in patients with acute UGIH who are taking low-dose aspirin as monotherapy for secondary cardiovascular prophylaxis, aspirin should not be interrupted. If for any reason it is interrupted, aspirin should be re-started as soon as possible, preferably within 3–5 days.Strong recommendation, moderate quality evidence. 3 ESGE recommends that following hemodynamic resuscitation, early (≤ 24 hours) upper gastrointestinal (GI) endoscopy should be performed. Strong recommendation, high quality evidence. 4 ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved. Strong recommendation, high quality evidence. 5 ESGE recommends for patients with actively bleeding ulcers (FIa, FIb), combination therapy using epinephrine injection plus a second hemostasis modality (contact thermal or mechanical therapy). Strong recommendation, high quality evidence. 6 ESGE recommends for patients with an ulcer with a nonbleeding visible vessel (FIIa), contact or noncontact thermal therapy, mechanical therapy, or injection of a sclerosing agent, each as monotherapy or in combination with epinephrine injection. Strong recommendation, high quality evidence. 7 ESGE suggests that in patients with persistent bleeding refractory to standard hemostasis modalities, the use of a topical hemostatic spray/powder or cap-mounted clip should be considered. Weak recommendation, low quality evidence. 8 ESGE recommends that for patients with clinical evidence of recurrent peptic ulcer hemorrhage, use of a cap-mounted clip should be considered. In the case of failure of this second attempt at endoscopic hemostasis, transcatheter angiographic embolization (TAE) should be considered. Surgery is indicated when TAE is not locally available or after failed TAE. Strong recommendation, moderate quality evidence. 9 ESGE recommends high dose proton pump inhibitor (PPI) therapy for patients who receive endoscopic hemostasis and for patients with FIIb ulcer stigmata (adherent clot) not treated endoscopically. (a) PPI therapy should be administered as an intravenous bolus followed by continuous infusion (e. g., 80 mg then 8 mg/hour) for 72 hours post endoscopy. (b) High dose PPI therapies given as intravenous bolus dosing (twice-daily) or in oral formulation (twice-daily) can be considered as alternative regimens.Strong recommendation, high quality evidence. 10 ESGE recommends that in patients who require ongoing anticoagulation therapy following acute NVUGIH (e. g., peptic ulcer hemorrhage), anticoagulation should be resumed as soon as the bleeding has been controlled, preferably within or soon after 7 days of the bleeding event, based on thromboembolic risk. The rapid onset of action of direct oral anticoagulants (DOACS), as compared to vitamin K antagonists (VKAs), must be considered in this context.Strong recommendation, low quality evidence.

Am haufigsten werden Endoskopien auf Intensivstationen im Rahmen gastrointestinaler Blutungen durchgefuhrt. Es gibt aber auch andere Indikationen fur eine Endoskopie auf der „intensive care unit“ (ICU). Der vorliegende Beitrag zeigt diese, die Hintergrunde sowie das peri- und postinterventionelle Management auf. Die endoskopische Anlage einer jejunalen Ernahrungssonde ist ein gut etabliertes Verfahren. Allerdings ist die Medikamentengabe uber jejunale Ernahrungssonden erschwert. Bei Insuffizienzen von Anastomosen in Osophagus und Rektum ist die endoskopische Vakuumtherapie die Therapie der Wahl. Storungen der gastrointestinalen Motilitat sind ein haufiges Phanomen bei kritisch kranken Patienten und mit einer erhohten Mortalitat assoziiert. Bei einem Zokumdurchmesser > 9–12 mm kann eine endoskopische Dekompression durchgefuhrt werden, die allerdings mit einem erhohten Perforationsrisiko assoziiert ist und erst nach Versagen einer konservativen Therapie erfolgen sollte.

Background & Aims Conventional endoscopic mucosal resection (CEMR) with submucosal injection is the current standard for the resection of large, nonmalignant colorectal polyps. We investigated whether underwater endoscopic mucosal resection (UEMR) is superior to CEMR for large (20–40mm) sessile or flat colorectal polyps. Methods In this prospective randomized controlled study, patients with sessile or flat colorectal polyps between 20 and 40 mm in size were randomly assigned to UEMR or CEMR. The primary outcome was the recurrence rate after 6 months. Secondary outcomes included en bloc and R0 resection rates, number of resected pieces, procedure time, and adverse events. Results En bloc resection rates were 33.3% in the UEMR group and 18.4% in the CEMR group (P = .045); R0 resection rates were 32.1% and 15.8% for UEMR vs CEMR, respectively (P = .025). UEMR was performed with significantly fewer pieces compared to CEMR (2 pieces: 45.5% UEMR vs 17.7% CEMR; P = .001). The overall recurrence rate did not differ between both groups (P = .253); however, subgroup analysis showed a significant difference in favor of UEMR for lesions of >30 mm to ≤40 mm in size (P = .031). The resection time was significantly shorter in the UEMR group (8 vs 14 minutes; P Conclusions UEMR is superior to CEMR regarding en bloc resection, R0 resection, and procedure time for large colorectal lesions and shows significantly lower recurrence rates for lesions >30 mm to ≤40 mm in size. UEMR should be considered for the endoscopic resection of large colorectal polyps.

Background Corona virus disease 2019 (COVID‐19) patients are at increased risk for thromboembolic events. It is unclear whether the risk for gastrointestinal (GI) bleeding is also increased. Methods We considered 4128 COVID‐19 patients enrolled in the Lean European Open Survey on SARS‐CoV‐2 (LEOSS) registry. The association between occurrence of GI bleeding and comorbidities as well as medication were examined. In addition, 1216 patients from COKA registry were analyzed focusing on endoscopy diagnostic findings. Results A cumulative number of 97 patients (1.8%) with GI bleeding were identified in the LEOSS registry and COKA registry. Of 4128 patients from the LEOSS registry, 66 patients (1.6%) had a GI bleeding. The rate of GI bleeding in patients with intensive care unit (ICU) admission was 4.5%. The use of therapeutic dose of anticoagulants showed a significant association with the increased incidence of bleeding in the critical phase of disease. The Charlson comorbidity index and the COVID‐19 severity index were significantly higher in the group of patients with GI bleeding than in the group of patients without GI bleeding (5.83 (SD = 2.93) vs. 3.66 (SD = 3.06), p

Schwere Blutungen unter antithrombotischer Therapie sind im intensivmedizinischen Alltag haufig und herausfordernd, einerseits muss eine rasche Blutungskontrolle erreicht werden, andererseits mussen thromboembolische Komplikationen vermieden werden. In dem Leitthemenbeitrag wird eine kurze Ubersicht uber die direkten oralen Antikoagulanzien, therapeutische Optionen und konkrete Handlungsanweisungen gegeben. Neben Allgemeinmasnahmen bei mit direkten oralen Antikoagulanzien (DOAK-)assoziierten Majorblutungen stehen im Wesentlichen Prothrombinkonzentrate (PPSB) und Idarucizumab als Antidottherapie zur Verfugung. Bei Blutungen unter Heparinen steht als mogliches Antidot Protaminsulfat zur Verfugung. Insbesondere zum Stellenwert von Andexanet alfa in der Therapie von Faktor-Xa-Inhibitor-assoziierten Blutungen sind weitere Studien erforderlich.

In critically ill patients an intra-abdominal hypertension is a common phenomenon. An IAH is defined as an IAP persistent ≥ 12 mmHg, an abdominal compartment syndrome is defined as an IAP persistent ≥ 20 mmHg in combination with new organ failure. The bladder pressure serves as a surrogate parameter for the IAP. The bladder pressure should be measured in a standardized manner. The therapy of IAH should be individualized.

Chemicals emitted into the environment are typically present at low concentrations but may act together in mixtures. Concentration-response curves of in vitro bioassays were often linear for effect levels30%, and the predictions for concentration addition (CA) of similarly acting chemicals and for independent action (IA) of dissimilarly acting chemicals overlapped. We derived a joint CA/IA mixture model for the low-effect level portion of concentration-response curves. In a first case study, we evaluated the cytotoxicity of over 200 mixtures of up to 17 components that were mixed in concentration ratios as they occurred in river water. The predictions of the full IA model were indistinguishable from the predictions of the full CA model up to 10% effect, confirming the applicability of the joint CA/IA mixture model at low effect levels. In a second case study, we evaluated if environmental concentrations trigger effects at levels low enough for the joint CA/IA mixture model to apply. The detected concentrations were scaled by their toxic potencies to estimate the mixture effect of the detected chemicals in a complex mixture. In 86% of 156 samples the effects fell in the validity range of the joint CA/IA mixture model (10% effect level), confirming the CA assumption for toxic unit summation. The joint CA/IA mixture model is not suitable for testing specific mixture hypotheses and interactions of chemicals in mixtures, where more refined models are required; but it is helpful for the interpretation of effects of complex (multicomponent) environmental mixtures, especially for water samples with relatively low effect level. Environ Toxicol Chem 2020;39:2552-2559. © 2020 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals LLC on behalf of SETAC.

Background Endoscopic mucosal resection (EMR) is the standard treatment of ampullary and nonampullary duodenal adenomas. EMR of large (10–29 mm) and giant (≥ 30 mm) lesions carries a risk of complications such as delayed bleeding and perforation. Prospective data on duodenal EMR are scarce. This study aimed to evaluate the efficacy of endoscopic procedures (clipping and coagulation of visible vessels) to prevent complications after EMR of large and giant lesions. Methods 110 patients with 118 adenomas (29 ampullary and 89 nonampullary) were included prospectively. Results 15 lesions were small (12.7 %), 68 were large (57.6 %), and 35 were giant (29.7 %). Endoscopic prevention of delayed complications was performed in 81.4 % (n = 96) of all lesions and 94.3 % (n = 33) of giant lesions. Complete resection was achieved in 111 lesions (94.1 %). Complications were 22 delayed bleedings (18.6 %), 3 intraprocedural perforations (2.5 %), 2 delayed perforations (1.7 %), and 1 stricture (0.8 %). Major complications were associated with lesions size ≥ 30 mm (28.6 % vs. 9.6 %; P = 0.02) and ampullary adenomas (27.6 % vs. 11.2 %; P = 0.07). All minor bleeding and 75 % of major bleeding episodes were treated endoscopically; 25 % of major bleedings needed radiologic embolization. Two fatal courses were observed when delayed perforation occurred after EMR of giant lesions. Residual adenoma was detected in 20.4 % at first follow-up. Conclusions EMR of giant duodenal neoplasia carries a substantial risk of major complications and recurrences. Resection technique and prevention of delayed complications need to be improved. Further measures should be evaluated in randomized studies.

In critically ill patients an intra-abdominal hypertension is a common phenomenon. An IAH is defined as an IAP persistent ≥ 12 mmHg, an abdominal compartment syndrome is defined as an IAP persistent ≥ 20 mmHg in combination with new organ failure. The bladder pressure serves as a surrogate parameter for the IAP. The bladder pressure should be measured in a standardized manner. The therapy of IAH should be individualized.