Use of the Complete Rockall Score and the Forrest Classification to Assess Outcome in Patients with Non-variceal Upper Gastrointestinal Bleeding Subject to After-hours Endoscopy: A Retrospective Cohort Study.

OBJECTIVES: To evaluate the usefulness of the Forrest classification and the complete Rockall score with customary cut-off values for assessing the risk of adverse events in patients with upper gastrointestinal bleeding (UGI-B) subject to after-hours emergency oesophago-gastro-duodenoscopy (E-EGD) within six hours after admission. METHODS: The medical records of patients with non-variceal UGI-B proven by after-hours endoscopy were analysed. For 'high risk' situations (Forrest stage Ia-IIb/complete Rockall score > 2), univariate analysis was conducted to evaluate odds ratio for reaching the study endpoints (30-day and one-year mortality, re-bleeding, hospital stay ≥ 3 days). RESULTS: During the study period (75 months), 86 cases (85 patients) met the inclusion criteria. Patients' age was 66.36 ± 14.38 years; 60.5% were male. Mean duration of hospital stay was 15.21 ± 19.24 days. Mortality rate was 16.7% (30 days) and 32.9% (one year); 14% of patients re-bled. Univariate analysis of post-endoscopic Rockall score ≥ 2 showed an odds ratio of 6.09 for death within 30 days (p = 0.04). No other significant correlations were found. CONCLUSION: In patients with UGI-B subject to after-hours endoscopy, a 'high-risk' Rockall score permits an estimation of the risk of death within 30 days but not of re-bleeding. A 'high-risk' Forrest score is not significantly associated with the study endpoints.

[Pre-endoscopic assessment to predict outcome of acute upper gastrointestinal bleeding--a retrospective study in patients subject to emergency endoscopy outside regular working hours]. / Sind prä-endoskopische Scores als prognostische Instrumente bei oberen gastrointestinalen Blutungen geeignet? Retrospektive Untersuchung bei Patienten, die außerhalb der regulären Dienstzeiten notfallmäßig endoskopiert wurden.

BACKGROUND AND OBJECTIVES: To evaluate the predictive value of pre-endoscopic risk scores in patients with upper gastrointestinal bleeding (UGI-B). PATIENTS AND METHODS: The medical records of patients evaluated by emergency esophago-gastro-duodenoscopy (E-EGD) for suspected UGI-B outside regular working hours were retrospectively analysed. RESULTS: During the 75 months of the study period 112 E-EGDs met the inclusion criteria. Mean age was 65.5 ± 14.7 years. 38.4 % of patients were female. Endoscopy revealed 41 gastro-duodenal ulcers, 16 Mallory-Weiss, 13 varices, 4 neoplasia. 72 patients received transfusions, 39 had endoscopic interventions. 2 patients were surgically treated, 16 had recurrent bleeding. 16 of the 110 patients died during hospitalisation. The following sensitivities were found for the Blatchford score (cut-off > 1), the clinical Rockall score (cut-off > 0) and the Adamopoulos score (cut-off > 2) in predicting need for clinical intervention (endoscopic or surgical intervention or transfusion): 100/97.7/93%, recurrent bleeding: 100/100/93.8%, in-hospital mortality: 100/93.8/93.8%, respectively. CONCLUSIONS: The Blatchford score is a suitable tool in determining the need for clinical intervention and the risk of recurrent bleeding and death in patients with UGI-B. The clinical Rockall score and the Adamopoulos score (the latter had originally been developed to predict active UGI-B at endoscopy and was used with a lower cut-off in our study) are inferior alternatives.

[Demands for endoscopy service outside of regular hours: a retrospective study and literature analysis]. / Inanspruchnahme des Endoskopie-Hintergrunddienstes ausserhalb der regulären Dienstzeiten: Eine retrospektive Studie und Literaturanalyse.

BACKGROUND AND OBJECTIVE: Many acute care hospitals provide round-the-clock emergency endoscopy to guarantee immediate diagnosis and treatment of acute conditions of the gastrointestinal tract. This study is the first one to assess the demand for emergency endoscopy outside usual working hours. PATIENTS AND METHODS: This study evaluated retrospectively 315 consecutive emergency endoscopies done at an acute care hospital (575 beds; catchment population 100,000, in the Ruhr area of Germany) between 26.7.2003 and 01.11.2009 (6 years and 3 months) outside usual working hours (i.e. during the weekend and from 6 pm to 8 am during weekdays). This represents 50 emergency endoscopies outside working hours per 100,000 people per year. RESULTS: 56.8 % of the examinations took place during the weekend (Saturday or Sunday), 26.7 % during the night (10 pm - 8 am). The distribution of the different endoscopic modalities was: 228 EGD (72.4 %), 42 incomplete colonoscopies or recto-sigmoidoscopies (13.3 %), 28 retrograde cholangio- or cholangiopancreatographies (8.9 %), 16 complete colonoscopies (5.2 %) and one oral enteroscopy. 208 (66%) of endoscopic procedures were purely diagnostic without any therapeutic intervention. The indication for endoscopy was documented in 243 of the 315 procedures. In 76.5 % of those cases the suspicion of a gastrointestinal bleeding was the indication for endoscopy. CONCLUSION: In an acute care hospital in Germany 50 emergency endoscopies outside working hours were performed per 100,000 population per year. This rate exceeds that reported in other European countries (Great Britain: 26.7, Norway: 24). Further studies are needed to evaluate the impact of different emergency endoscopic strategies on patient outcome and treatment costs.

[Familial Mediterranean fever. Rare manifestation without fever and with inconspicuous family case history]. / Familiäres Mittelmeerfieber. Seltene Manifestation ohne Fieber und mit unauffälliger Familienanamnese.

HISTORY AND ADMISSION FINDINGS: A 33-year-old man of Turkish descent had suffered from recurrent diffuse abdominal pain and shoulder pain since 13 years. Repeatedly performed investigations in the past had produced numerous diagnoses. The symptoms had been recurring quarterly to weekly, lasted three days on average and resolved spontaneously. He never had fever and the family history was unremarkable. DIAGNOSIS, TREATMENT, AND COURSE: Blood tests demonstrated increased parameters for systemic inflammation and mild normochromic normocytic anemia. In addition to splemomegaly the abdominal computed tomography revealed signs of sacroiliitis. There was no arthritis of the shoulder radiologically. Despite lack of familial history and fever genetic analysis of the Mediterranean fever gene (MEFV) revealed two heterozygous mutations in this MEFV gene for M694 and V726A. The patient was treated with colchicine and has now remained free of symptoms for meanwhile 10 months. There had been no comparable symptom-free period during the last 10 years. CONCLUSION: Sometimes the name "Familial Mediterranean Fever" (FMF) is misleading because this disease may, although rarely, occur without both, fever and familial history. Because of the increasing number of immigrants FMF should be considered in the initial differential diagnosis of patients of Mediterranean origin presenting with abdominal pain. Genetic analysis of the MEFV-gene as well as a therapeutic trial with colchicine, may help to detect FMF.

[Renal resistance index in patients with obstructive sleep apnea]. / Renaler Widerstandsindex bei obstruktiver Schlafapnoe.

BACKGROUND AND OBJECTIVE: Previous studies have demonstrated renal dysfunction in patients with obstructive sleep apnea (OSA). The renal resistance index (RI) measured by renal duplexsonography (RI = 1-[enddiastolic velocity/peak systolic velocity]) is at the same time a marker of parenchymal renal damage and predictor of the progression of renal dysfunction. It was the aim of this study to test the influence of OSA on RI. PATIENTS AND METHODS: RI was compared between patients with (n = 97) and those without OSA (n = 61). The impact of OSA on the RI was analysed by adjusting for age. Thus, the difference between the measured RI and the age-based RI was expressed as a percentage of the normal age-adjusted value (RI (%)). RESULTS: OSA patients showed a trend towards an increase in RI (69.1+/-8.8 vs. 66.5+/-8.3 %, p = 0.068) and RI (%) (10.2+/-12.9 vs. 6.4+/-11.4 %, p = 0.060), respectively. In patients with mild or moderate OSA (apnea-hypopnea-index [AHI] 5 - 30/h) this difference was significant (RI: 70.5+/-9.1 vs. 66.5+/-8.2, p = 0.012; RI (%): 12.1+/-13,4 vs. 6.5+/-11.4 %, p = 0.012). RI of patients with severe OSA did not significantly differ from those without OSA. In patients with mild and moderate OSA there was a significant linear association between AHI and RI or RI (%). This association was independent of hypertension or diabetes. CONCLUSION: An impairment of renal perfusion and renal parenchymal damage due to increased sympathetic activity may promote renal dysfunction in patients with obstructive sleep apnea.

Dihydrotachysterol therapy for hypoparathyroidism: consequences of inadequate monitoring. Five cases and a review.

BACKGROUND: The half synthetic Vitamin D analogue dihydrotachysterol (DHT) is widely used for hypocalcaemic hypoparathyroidism following surgical removal of parathyroids. Such treatment generally initiated by surgeons right after surgery has to be continued in clinical practice. Unfortunately, the required careful monitoring of calcium metabolism is often lacking and as demonstrated may lead to life-threatening conditions. PATIENTS AND METHODS: Here we report on five patients referred to our nephrology unit because of unknown impairment of renal function during therapy with DHT. All patients had clinical signs of hypercalcaemia. Since most symptoms are nonspecific they were not perceived by primary care physicians. In fact DHT treatment was continued for 4 - 50 years. In all cases calcium levels were determined after inadequate long intervals ranging from 3.08 to 4.97 mmol/l. Creatinine levels ranged from 277 to 365 micromol/l. All patients suffered from symptoms of severe hypercalcaemia, three of them needing intensive care unit treatment. RESULTS: All patients were treated effectively with a regimen consisting of intravenous saline, a loop diuretic, and application of bisphosphonates. As confirmed by renal biopsy persisting alleviation of renal function was due to calcifications. After discontinuation of DHT therapy patients were safely switched to shorter acting vitamin D derivates maintaining a normal calcium level. CONCLUSIONS: In comparison to short acting vitamin-D derivates hypercalcaemic episodes with DHT appear to last longer and may therefore occur with higher incidence. A future option could be the use of synthetic parathyroid hormone (s-PTH) recently shown to be safe and effective. Nevertheless a customized therapy and careful monitoring is indispensable in any case to prevent irreversible organ damage.

[Renal function in hypertensive patients with obstructive sleep apnea]. / Nierenfunktion bei hypertensiven Patienten mit obstruktiver Schlafapnoe.

BACKGROUND: Patients with hypertension often suffer from obstructive sleep apnea (OSA). In addition to hypertension several other risk factors (hypoxemia, hyperlipidemia, and increased sympathic nerve activity) may contribute to progressive renal dysfunction in OSA patients. The aim of this study was to compare renal function in OSA-patients with and without hypertension. METHODS: 81 consecutive patients (50 males, 31 females) were screened for sleep apnea. Parameters of renal function (serum creatinine, creatinine clearance, microalbuminuria), and of lipid and glucose metabolism were correlated to polysomnographic results. RESULTS: OSA (apnea/hypopnea index [AHI] > or = 5) was found in 57 of 81 patients. Mean AHI was 26.7 +/- 26.1. Hypertension (blood pressure > or = 140/90 mmHg or use of antihypertensive drugs) occurred in 63 of 81 patients. Serum creatinine in OSA patients was significantly higher than in patients without OSA (1.11 +/- 0.15 vs. 0.91 +/- 0.12 mg/dl, p < 0.001). Serum creatinine correlated significantly with AHI. Creatinine clearance was associated with age (r = -0.314; p = 0.014) and presence of OSA (r = 0.265; p = 0.093). No correlation was shown between hypertension and serum creatinine or creatinine clearance. Microalbuminuria was not associated with OSA. CONCLUSION: Our results suggest an independent association between OSA and impaired renal function. Further prospective studies will have to be done to elucidate the pathophysiological mechanisms.