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    ABSTRACT: Gastrointestinal (GI) bleeding is a common clinical condition that is increasingly seen in an aging population and frequently requires hospitalization and intervention, with significant morbidity and mortality. Obscure GI bleeding (OGIB) is defined as loss of blood with no source identified after upper endoscopy and colonoscopy. Whether an obscure site of bleeding is clinically evident or silent, it constitutes a diagnostic and therapeutic challenge for the clinician. Gastroenterology and radiology provide the essential diagnostic tools used to evaluate suspected OGIB, each with its strengths and weaknesses. Small bowel series and conventional enteroclysis have a limited role in OGIB. Computed tomographic (CT) enterography and CT enteroclysis are noninvasive techniques with promising results in evaluation of small bowel disease and silent OGIB. CT angiography is a useful triaging tool for diagnosing or excluding active GI hemorrhage, localizing the site of bleeding, and guiding subsequent treatment. Tagged red blood cell scanning is the most sensitive technique for detection of active GI bleeding and allows imaging over a prolonged period, making it useful for detecting intermittent bleeding. Capsule endoscopy has emerged as an important tool for investigating OGIB, but it may soon have competition from double-balloon enteroscopy, a diagnostic technique that can also facilitate therapy.
    Radiographics 01/2010; 30(1):235-52. · 2.79 Impact Factor
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    ABSTRACT: Rivaroxaban and dabigatran are new oral anticoagulants that specifically inhibit factor Xa and thrombin, respectively. Clinical studies on the prevention and treatment of venous and arterial thromboembolism show promising results. A major disadvantage of these anticoagulants is the absence of an antidote in case of serious bleeding or when an emergency intervention needs immediate correction of coagulation. This study evaluated the potential of prothrombin complex concentrate (PCC) to reverse the anticoagulant effect of these drugs. In a randomized, double-blind, placebo-controlled study, 12 healthy male volunteers received rivaroxaban 20 mg twice daily (n=6) or dabigatran 150 mg twice daily (n=6) for 2½ days, followed by either a single bolus of 50 IU/kg PCC (Cofact) or a similar volume of saline. After a washout period, this procedure was repeated with the other anticoagulant treatment. Rivaroxaban induced a significant prolongation of the prothrombin time (15.8±1.3 versus 12.3±0.7 seconds at baseline; P<0.001) that was immediately and completely reversed by PCC (12.8±1.0; P<0.001). The endogenous thrombin potential was inhibited by rivaroxaban (51±22%; baseline, 92±22%; P=0.002) and normalized with PCC (114±26%; P<0.001), whereas saline had no effect. Dabigatran increased the activated partial thromboplastin time, ecarin clotting time (ECT), and thrombin time. Administration of PCC did not restore these coagulation tests. Prothrombin complex concentrate immediately and completely reverses the anticoagulant effect of rivaroxaban in healthy subjects but has no influence on the anticoagulant action of dabigatran at the PCC dose used in this study. Clinical Trial Registration- URL: http://www.trialregister.nl. Unique identifier: NTR2272.
    Circulation 09/2011; 124(14):1573-9. · 15.20 Impact Factor
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    ABSTRACT: Colloid solutions are widely used in fluid resuscitation of critically ill patients. There are several choices of colloid and there is ongoing debate about the relative effectiveness of colloids compared to crystalloid fluids. To assess the effects of colloids compared to crystalloids for fluid resuscitation in critically ill patients. We searched the Cochrane Injuries Group's specialised register, CENTRAL, MEDLINE, EMBASE, the National Research Register, Web of Science and MetaRegister. Bibliographies of trials and review articles retrieved were searched. The searches were last updated in December 2006. Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. Cross-over trials and trials in pregnant women and neonates were excluded. Two authors independently extracted data and rated quality of allocation concealment. Trials with a 'double-intervention', such as those comparing colloid in hypertonic crystalloid to isotonic crystalloid, were analysed separately. The analysis was stratified according to colloid type and quality of allocation concealment. We identified 63 eligible trials, 55 of these presented mortality data. COLLOIDS COMPARED TO CRYSTALLOIDS: Albumin or plasma protein fraction - 23 trials reported data on mortality, including a total of 7,754 patients. The pooled relative risk (RR) from these trials was 1.01 (95% confidence interval [95% CI] 0.92 to 1.10). When the trial with poor quality allocation concealment was excluded, pooled RR was 1.00 (95% CI 0.91 to 1.09). Hydroxyethyl starch - 16 trials compared hydroxyethyl starch with crystalloids, n = 637 patients. The pooled RR was 1.05 (95% CI 0.63 to 1.75). Modified gelatin - 11 trials compared modified gelatin with crystalloid, n = 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). Dextran - nine trials compared dextran with a crystalloid, n = 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). COLLOIDS IN HYPERTONIC CRYSTALLOID COMPARED TO ISOTONIC CRYSTALLOID: Eight trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1,283 randomised participants. Pooled RR was 0.88 (95% CI 0.74 to 1.05). There is no evidence from RCTs that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. As colloids are not associated with an improvement in survival, and as they are more expensive than crystalloids, it is hard to see how their continued use in these patients can be justified outside the context of RCTs.
    Cochrane database of systematic reviews (Online) 02/2007; · 5.70 Impact Factor

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