Incidence of Inflammatory Bowel Disease in New Zealand Remains High, Findings in the Manawatu Region.

BACKGROUND: New Zealand (NZ) has one of the world's highest rates of inflammatory bowel diseases (IBD), however available data are limited to southern, urban regions. AIMS: To determine the incidence and prevalence of IBD in the Manawatu region of NZ. METHODS: Patients in the Manawatu region, with a diagnosis of IBD made between 2011 and 2015 were identified. Demographic, diagnostic and disease data were collected, fulfilment of diagnostic criteria was assessed, and incidence rates were calculated. Comparison of disease phenotype and observed diagnostic criteria was made between diagnosis and 12-months following diagnosis. All resident patients with a diagnosis of IBD current on 5 March 2013 were identified, and prevalence rates were calculated. RESULTS: The mean annual age-standardised incidence rates of UC, CD, and IBD were 10.2, 17.0, and 27.2 per 100,000. IBD incidence was highest among those of European ethnicity (24.8 per 100,000), followed by Asian (1.4), and Maori (1.1). IBD incidence in the urban population was 34.0 per 100,000 (95% CI 24.1-46.0) compared to the rural population of 5.6 (95% CI 0.4-22.4). The age-standardised point prevalence of UC, CD, and IBD on 5 March 2013 was 157.7, 231.8, and 397.9 per 100,000, respectively. CONCLUSIONS: The incidence and prevalence of IBD in the Manawatu region are comparable to those reported in other Australasian studies. Incidence was lower in Maori, and in the rural population. Follow-up is required to identify any changes in incidence and phenotype, and whether rural residence remains protective.

A Method Using Longitudinal Laboratory Data to Predict Future Intestinal Complication in Patients with Crohn's Disease.

BACKGROUND: Stenosis, fistulization, and perforation of the bowel are severe outcomes which can occur in patients with Crohn's disease. Accurate prediction of these events may enable clinicians to alter treatment strategies and avoid these outcomes. AIMS: To study the correlation between longitudinal laboratory testing and subsequent intestinal complications in patients with Crohn's disease. METHODS: An observational cohort of patients with Crohn's disease at a single center were analyzed between 01/01/1994 and 06/30/2016. A complication was defined as the development of an intestinal fistula, stenosis, or perforation. Exploratory analysis using Cox regression was performed to select the best statistical method to represent longitudinal laboratory data. Cox regression was used to identify laboratory variables independently associated with the development of a subsequent complication. A clinical scoring tool was designed. RESULTS: In 246 patients observed over a median of 5.72 years, 134 complications occurred. Minimum or maximum value in a preceding window period of one year was most strongly associated with subsequent complication. A Longitudinal Laboratory score of ≥ 2 (maximum albumin level < 39 g/L = 1, maximum mean cell volume < 88 fL = 1, minimum platelet count > 355 × 109/L = 1, minimum C reactive protein > 5 mg/L = 1) was 62% sensitive and 91% specific in identifying patients who develop a subsequent complication. CONCLUSION: A consistent reduction in serum albumin and mean cell volume, and a consistent increase in platelet count and C reactive protein were associated with a subsequent complication in patients with Crohn's disease. Longitudinal laboratory tests may be used as described in this paper to provide a rational for earlier escalation of therapy.

Clostridioides difficile infection in a rural New Zealand secondary care centre: an incidence case-control study.

BACKGROUND: Clostridioides difficile infection (CDI) is a form of antibiotic-associated infectious diarrhoea resulting in significant morbidity and mortality. Community-acquired disease in low-risk individuals is increasingly recognised. There are limited New Zealand data published. AIM: To determine the incidence and location of onset of CDI cases in the Manawatu region, and further describe the demographics, risk factors and prevalent C. difficile ribotypes of the population. METHODS: We performed an incidence case-control study of CDI in the Manawatu region between September 2018 and September 2019. Cases were matched to controls with a negative test for C. difficile. Demographic and comorbidity data, location of onset, drug exposure, disease recurrence and 30-day mortality were collected. Ribotype analysis was performed on C. difficile isolates. RESULTS: Thirty-two specimens tested toxin positive over 12 months, yielding an incidence of 18.3 cases per 100 000 person-years. Twenty-five percent of cases had community onset disease. Cases were more likely to have had amoxicillin/clavulanate or ceftriaxone prescribed. Elevated blood white cell count and lower HbA1c were significantly associated with CDI. The dominant ribotype was 014/020. Two cases were RT 023. CONCLUSION: Our data are similar to previous national data. RT 023 has not been previously reported in New Zealand and has been associated with severe colitis. We demonstrated a significant proportion of community-acquired cases and the true incidence might be higher. Vigilance for community onset disease is required. These data may allow observation of temporal changes in incidence and infection patterns of CDI in New Zealand.

Short-term colectomy is avoided in over half of regional patients failing medical therapy for acute severe ulcerative colitis with co-ordinated transfer and tertiary care.

BACKGROUND AND AIMS: Many patients presenting with an acute severe ulcerative colitis to a regional hospital are transferred to a metropolitan hospital for specialised care. This study aimed to evaluate the outcomes and characteristics of these patients. METHOD: A retrospective observational cohort study was conducted to examine the 30-day colectomy rate using prospectively collected data on 69 consecutive index cases of acute severe ulcerative colitis transferred from regional hospitals to our metropolitan hospital meeting Truelove and Witts criteria. Those that avoided colectomy were followed out to 1 year to examine outcomes. RESULTS: The 30-day colectomy rate was 46.4% (32/69) in regional transfer patients. Rescue therapy was administered to 65% (45/69) of patients after transfer to our metropolitan hospital. Colectomy was avoided in 55% of these patients at 30 days. Colectomy free status was maintained in 78% (29/39) of these patients. Mortality was 0% at 30 days and 1 year. CONCLUSION: Over 50% of the patients failing therapy in a regional centre and requiring transfer avoided short term colectomy with co-ordinated referral for rescue therapy in a tertiary metropolitan inflammatory bowel disease unit. These patients would have ultimately required colectomy in their regional hospital without intervention.

Detectable Laboratory Abnormality Is Present up to 12 Months Prior to Diagnosis in Patients with Crohn's Disease.

BACKGROUND AND AIMS: Patients with inflammatory bowel disease (IBD) often have subjective symptoms for months or years prior to their diagnosis. Blood tests taken prior to diagnosis may provide objective evidence of duration of pre-diagnosis disease. We aim to describe the pre-diagnosis laboratory pattern of patients with IBD. METHODS: A total of 838 patients diagnosed with IBD between 01/01/1996 and 01/03/2014, with pre-diagnosis laboratory testing available, contributed data for analysis. C-reactive protein, erythrocyte sedimentation rate, hemoglobin level, mean cell volume (MCV) platelet count, white blood cell count, neutrophil count, albumin level, ferritin level, serum iron level, alanine transaminase level, and fecal calprotectin were examined in the 24 months leading up to diagnosis and compared to baseline data taken between 24 and 36 months prior to diagnosis. RESULTS: For patients with Crohn's disease, a significant drop in serum albumin and MCV levels and a significant rise in platelet count were observed between 115 and 385 days prior to diagnosis (p < 0.01, two-tailed t test). For patients with ulcerative colitis, a significant change in albumin level, MCV, hemoglobin level, platelet count, and serum iron level was observed at diagnosis (p < 0.01, two-tailed t test) but was not detectable before. CONCLUSIONS: These data provide objective evidence of duration of delay between disease onset and diagnosis in a cohort of patients with IBD. Expediting diagnostic testing in patients presenting with symptoms consistent with IBD, who also have abnormal laboratory results, may reduce diagnostic delay, speed access to therapy, and improve clinical outcomes.

Prevalence, timing, and impact of early recurrence of atrial tachyarrhythmias after pulsed field ablation: A secondary analysis of the PULSED AF trial.

BACKGROUND: Early recurrence of atrial tachyarrhythmias (ERAT) within 3 months of thermal ablation for atrial fibrillation (AF) is common and often considered transient. Pulsed field ablation (PFA) is a nonthermal energy source in which ERAT is not well described. OBJECTIVE: The purpose of this study was to analyze ERAT in patients with AF undergoing PFA in the Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF (PULSED AF) trial. METHODS: This analysis included 294 patients (154 paroxysmal AF and 140 persistent AF) who had ≥10 rhythm assessments during the 90-day blanking period. ERAT was defined as any instance of ≥30 seconds of AF, atrial flutter, or atrial tachycardia on transtelephonic monitoring (weekly and symptomatic) or ≥10 seconds on electrocardiography (at 3 months), both within 90 days. Late recurrence of atrial tachyarrhythmias (LRAT) was defined as observed atrial tachyarrhythmias between 90 days and 12 months. RESULTS: The overall prevalence of ERAT was 27.1% in patients with paroxysmal AF and 31.6% in patients with persistent AF. In patients with ERAT, 73% had ERAT onset within the first month of the procedure. The presence of ERAT was associated with LRAT in patients with paroxysmal AF (hazard ratio 6.4; 95% confidence interval 3.6-11.3) and patients with persistent AF (hazard ratio 3.8; 95% confidence interval 2.2-6.6). Yet, in 29.4% of patients with paroxysmal AF and 34.3% of patients with persistent AF with ERAT, LRAT was not observed. LRAT was positively correlated with the number of ERAT observations. CONCLUSION: ERAT after PFA predicted LRAT in patients with paroxysmal and persistent AF. However, the concept of a blanking period after PFA is still valid, as approximately one-third of patients with ERAT did not continue to have LRAT during follow-up and may not need reablation.

Influence of monitoring and atrial arrhythmia burden on quality of life and health care utilization in patients undergoing pulsed field ablation: A secondary analysis of the PULSED AF trial.

BACKGROUND: Freedom from atrial arrhythmia (AA) recurrence ≥30 seconds after pulsed field ablation (PFA) in patients with atrial fibrillation (AF) was reported in PULSED AF (Pulsed Field Ablation to Irreversibly Electroporate Tissue and Treat AF; ClinialTrials.gov Identifier: NCT04198701). AA burden may be a more clinically meaningful endpoint. OBJECTIVE: The purpose of this study was to determine the influence of monitoring strategies on AA detection and AA burden association with quality of life (QoL) and health care utilization (HCU) after PFA. METHODS: Patients underwent 24-hour Holter monitoring at 6 and 12 months and weekly, and symptomatic transtelephonic monitoring (TTM). AA burden post-blanking was calculated as the greater of (1) percentage of AA on total Holter time; or (2) percentage of weeks with ≥1 TTM with AA out of all weeks with ≥1 TTM. RESULTS: Freedom from all AAs varied by >20% when differing monitoring strategies were used. PFA resulted in zero burden in 69.4% of paroxysmal atrial fibrillation (PAF) and 62.2% of persistent atrial fibrillation (PsAF) patients. Median burden was low (<9%). Most PAF and PsAF patients had ≤1 week of AA detection on TTM (82.6% and 75.4%) and <30 minutes of AA per day of Holter monitoring (96.5% and 89.6%), respectively. Only PAF patients with <10% AA burden averaged a clinically meaningful (>19 point) QoL improvement. PsAF patients experienced clinically meaningful QoL improvements irrespective of burden. Repeat ablations and cardioversions significantly increased with higher AA burden (P <.01). CONCLUSION: The ≥30-second AA endpoint is dependent on the monitoring protocol used. PFA resulted in low AA burden for most patients, which was associated with clinically relevant improvement in QoL and reduced AA-related HCU.

An elemental diet is effective in the management of diversion colitis.

The use of an elemental diet in the management of inflammatory gastroenterological diseases has long been accepted as standard management and has shown to both induce and maintain remission in Crohn's disease, but the evidence is lacking for its use in diversion colitis. An elemental diet is one which provides all the required nutrition in a more easily absorbed and hypoallergenic form. In this case report, we present a patient who had a flare of diversion colitis treated with diet alone. She had a significant improvement in her symptoms with a decrease in bowel motions, rectal discharge and pain. This case suggests that there may be some role for the use of an elemental diet in the management of diversion colitis. We also examine some potential mechanisms which may lead to the benefit observed.

A validated risk stratification tool for detecting high-risk small bowel Crohn's disease.

BACKGROUND: Delays in Crohn's disease (CD) diagnosis are positively associated with ileal location and an increased risk of complications. AIM: To develop a simple risk assessment tool to enable primary care physicians to recognise potential ileal CD earlier, shortening the delay to specialist investigation METHODS: Three cohorts were acquired for this study. Cohort 1 included 61 patients retrospectively identified with ileal CD between 2000 and 2010 and 78 matched controls drawn from a cohort referred for investigation of abdominal symptoms. Cohort 2 included 42 individuals diagnosed with ileal CD and 57 controls identified prospectively. Cohort 3 included an additional 84 individuals with ileal CD and 495 without CD referred for colonoscopy. Clinical symptoms and serological biomarkers were acquired and used to develop a risk prediction algorithm. The algorithm was trained independently on each of the three cohorts and tested on the latter two cohorts. RESULTS: Altered bowel habit with abdominal pain combined with derangements in white cell count (WCC), albumin and platelet counts were important features in predicting ileal CD (AUC = 0.92, 95% CI = 0.89-0.92). This was validated in cohorts 2 (AUC = 0.96, 95% CI = 0.95-0.98) and 3 (AUC = 0.94, 95% CI = 0.92-0.96). C-reactive protein was independently associated with ileal CD but non-signficant in a multivariate model. CONCLUSION: A web-based risk stratification tool for ileal CD has been developed from objective and symptom-based criteria. This tool enables primary care physicians to more confidently request urgent specialist assessment for patients identified as at high risk for ileal CD.

IL23R-Protective Coding Variant Promotes Beneficial Bacteria and Diversity in the Ileal Microbiome in Healthy Individuals Without Inflammatory Bowel Disease.

BACKGROUND AND AIMS: This study aimed to characterize the mucosa-associated microbiota in ileal Crohn's disease [CD] patients and in healthy controls in terms of host genotype and inflammation status. METHODS: The mucosa-associated microbiotas of intestinal pinch biopsies from 15 ileal CD patients with mild and moderate disease and from 58 healthy controls were analysed based on 16S ribosomal sequencing to determine microbial profile differences between [1] IL23R, NOD2 and ATG16L1 genotypes in healthy subjects, [2] ileal CD patients and control subjects, and [3] inflamed and non-inflamed mucosal tissue in CD patients. RESULTS: The protective variant of the IL23R gene [rs11209026] significantly impacted the microbial composition in the ileum of healthy subjects and was associated with an increased abundance of phylotypes within the family Christensenellaceae as well as increases in diversity and richness. Comparative analysis of healthy and non-inflamed CD microbiome samples indicated a notable decrease in the abundance of Faecalibacterium prausnitzii as well as Shannon diversity and richness. Inflamed and non-inflamed ileal samples of CD subjects had high intra-individual stability and inter-individual variability, but no significant alterations in diversity, richness or taxa were identified. Calprotectin correlated positively with the abundance of Proteobacteria and negatively with diversity in the samples from healthy subjects. CONCLUSIONS: The observation of low diversity and low abundance of beneficial bacteria in healthy control subjects carrying the IL23R [rs11209026] wild-type GG genotype indicates that the gut microbiome is influenced by host genetics and is altered prior to disease diagnosis. Faecal calprotectin may be a potential non-invasive screening tool for dysbiosis in subjects without disorders of intestinal inflammation.

The Cardiopulmonary Effects of Sodium Fluoroacetate (1080) in Sprague-Dawley Rats.

Sodium fluoroacetate (1080) is a highly toxic metabolic poison that has the potential because of its lack of defined color, odor, and taste and its high water solubility to be intentionally or unintentionally ingested through food adulteration. Although the mechanism of action for 1080 has been known since the 1950's, no known antidote exists. In an effort to better understand the cardiopulmonary impacts of 1080, we utilized whole-body plethysmography and telemeterized Sprague-Dawley rats which allowed for the real-time measurement of respiratory and cardiac parameters following exposure using a non-invasive assisted-drinking method. Overall, the animals showed marked depression of respiratory parameters over the course of 24 hours post-exposure and the development of hemorrhage in the lung tissue. Tidal volume was reduced by 30% in males and 60% in females at 24 hours post-exposure, and respiratory frequency was significantly depressed as well. In telemeterized female rats, we observed severe cardiac abnormalities, highlighted by a 50% reduction in heart rate, 75% reduction in systolic blood pressure, and a 3.5-fold lengthening of the QRS interval over the course of 24 hours. We also observed a reduction in core body temperature of nearly 15°C. Our study was able to describe the severe and pronounced effects of sodium fluoroacetate poisoning on cardiopulmonary function, the results of which indicate that both tissue specific and systemic deficits contribute to the toxicological progression of 1080 intoxication and will need to be accounted for when developing any potential countermeasure for 1080 poisoning.

The effect of pre-admission immunosuppression on colectomy rates in acute severe ulcerative colitis.

BACKGROUND: Patients on immunosuppression at the time of acute severe ulcerative colitis have been suggested to be at a higher risk of colectomy than those who are treatment-naïve. The aim of this study was to examine the effect of immunosuppressive therapy on the risk of colectomy. METHOD: We conducted a retrospective observational cohort study using prospective data examining the 30 day and 1 year colectomy rates of 200 consecutive patients with an index episode of acute severe ulcerative colitis as defined by the Truelove and Witts criteria. RESULTS: Immunosuppression on admission was shown not to increase colectomy rate at 30 days post-admission (immunomodulator: p = 0.422, oral steroids: p = 0.555). A total of 24 patients underwent colectomy between 30 days and 1 year. A three-fold higher risk of colectomy at 1 year was seen in those requiring an immunomodulator prior to the index admission compared with those started de novo during the index admission [41% versus 14% odds ratio (OR): 2.93 (1.19-7.24 p = 0.016)]. Factors most predictive of colectomy at 30 days were abdominal radiographic colonic dilation ⩾5.5 cm, first presentation of ulcerative colitis, C-reactive protein ⩾ 45 mg/l on day 3 of therapy and bowel frequency ⩾8 on day 3. CONCLUSION: The need for an immunomodulator prior to admission with acute severe ulcerative colitis increases the medium-term colectomy rate by three-fold at 1 year. Prospective studies are needed to confirm these findings and develop strategies to reduce the high risk in this subgroup of patients.

A rolling phenotype in Crohn's disease.

BACKGROUND AND AIM: The Montreal classification of disease behaviour in Crohn's disease describes progression of disease towards a stricturing and penetrating phenotype. In the present paper, we propose an alternative representation of the long-term course of Crohn's disease complications, the rolling phenotype. As is commonly observed in clinical practice, this definition allows progression to a more severe phenotype (stricturing, penetrating) but also, regression to a less severe behaviour (inflammatory, or remission) over time. METHODS: All patients diagnosed with Crohn's Disease between 01/01/1994 and 01/03/2008, managed at a single centre and observed for a minimum of 5 years, had development and resolution of all complications recorded. A rolling phenotype was defined at each time point based on all observed complications in the three years prior to the time point. Phenotype was defined as B1, B2, B3, or B23 (penetrating and stenotic). The progression over time of the rolling phenotype was compared to that of the cumulative Montreal phenotype. RESULTS: 305 patients were observed a median of 10.0 (Intraquartile range 7.3-13.7) years. Longitudinal progression of rolling phenotype demonstrated a consistent proportion of patients with B1 (70%), B2 (20%), B3 (5%) and B23 (5%) phenotypes. These proportions were observed regardless of initial phenotype. In contrast, the cumulative Montreal phenotype progressed towards a more severe phenotype with time (B1 (39%), B2 (26%), B3(35%) at 10 years). CONCLUSION: A rolling phenotype provides an alternative view of the longitudinal burden of intra-abdominal complications in Crohn's disease. From this viewpoint, 70% of patients have durable freedom from complication over time (>3 years).

Neuropathological and behavioral sequelae in IL-1R1 and IL-1Ra gene knockout mice after soman (GD) exposure.

Soman (GD) exposure results in status epilepticus (SE) that leads to neurodegeneration, neuroinflammation, and behavioral consequences including learning and memory deficits. The neuroinflammatory response is characterized by the upregulation of the pro-inflammatory cytokine, interleukin-1 (IL-1), which mediates the expression of other neurotoxic cytokines induced after GD exposure. However, the specific role of IL-1 signaling has not been defined in terms of the consequences of GD-induced SE. Therefore, the purpose of this study was to regulate IL-1 signaling and study the behavioral deficits and neurodegeneration that occur after convulsion onset. Wild type (WT), IL-1 receptor (IL-1R1) knockout (KO), and IL-1 receptor antagonist (IL-1Ra) KO mice were exposed to a convulsive dose of GD, and behavior was evaluated up to 18days later. Activity was studied using the Open Field, anxiety was assessed in the Zero Maze, and spatial learning and memory were evaluated with the Barnes Maze. The animals were euthanized at 24hours and 18days to determine neuropathology in the piriform cortex, amygdala, thalamus, and CA1, CA2/3, and CA4 regions of the hippocampus. Unlike the IL-1Ra KO, the IL-1R1 KO showed less neuropathology compared to WT at 24hours, but moderate to severe injury was found in all strains at 18days. Compared to their saline controls, the exposed WT mice were significantly more active in the Open Field, and the IL-1R1 KO strain showed reduced anxiety in the Zero Maze Test. Compared to WT mice, IL-1R1 and IL-1Ra KO mice had spatial learning and memory impairments in the Barnes Maze. Therefore, the IL-1 signaling pathway affects neurodegeneration and behavior after GD-induced convulsions.

The economics of surgical laser technology in veterinary practice.

A decision to invest in and develop laser technology should only be made after a thorough investigation and comparison of the available types, vendors, available features, and purchasing options. A sound marketing program must then be used for introducing laser technology to the staff, clients, and colleagues. Without adhering to such a program, a practice will [figure: see text] not experience the necessary profitability following the purchase of a laser. Staff enthusiasm and support will dwindle, and ultimately the laser investment will be viewed unfavorably. When marketed properly, however, the investment in a surgical laser will provide outstanding profitability. The return on investment can be provided by using the support staff for client education, by offering laser technology for routine elective procedures and complex procedures, and by adhering strictly to a fee schedule. Add that to the truly remarkable results obtained using laser surgical techniques, a practice will be greatly enhanced.

Supratherapeutic anticoagulation at presentation is associated with reduced mortality in nonvariceal upper gastrointestinal hemorrhage.

INTRODUCTION: Warfarin is a widely used and easily reversible anticoagulant. Although bleeding is more likely in warfarin users, it may also be more readily treated. This retrospective observational case-control study compares the outcome of acute nonvariceal upper gastrointestinal hemorrhage in warfarin users with a supratherapeutic international normalized ratio (INR) and outcome in non - warfarin users. PATIENTS AND METHODS: Clinical and endoscopic data for patients presenting with overt upper gastrointestinal hemorrhage were collected between 23rd February 2001 and 12 October 2010. Patients with variceal hemorrhage were excluded. Warfarin users with a supratherapeutic INR (≥ 3.0) at presentation (supratherapeutic anticoagulation [SA] group) were matched to a cohort with upper gastrointestinal hemorrhage not taking warfarin at presentation (control group). Patients were matched by age, sex, Rockall score, year of endoscopy, inpatient or outpatient status, and the presence of disseminated cancer at presentation. The incidence rates of major outcomes in the two groups were compared. RESULTS: A total of 128 patients (SA group) were matched to 135 control patients. The SA group patients were less likely to die within 30 days (6.25 % vs. 15.5 %, odds ratio = 0.36, P = 0.028 by Test for Equality of Proportions). There was a trend toward more surgery in the control group (5 % vs. 2 %), and rates of blood transfusion (77 % vs. 70 %) were similar in the two groups. CONCLUSION: In patients presenting with nonvariceal upper gastrointestinal hemorrhage, a supratherapeutic INR at presentation due to warfarin use is associated with reduced mortality.

Factors at presentation predictive of a requirement for endoscopic therapy in patients presenting with overt upper gastrointestinal haemorrhage: a retrospective observational study.

INTRODUCTION: In patients with upper gastrointestinal haemorrhage (UGIH), endoscopic treatment of high-risk lesions reduces mortality. Performing out of office hours endoscopy places a strain on endoscopy services. This analysis aims to identify factors at presentation associated with lesions requiring endoscopic therapy, allowing triage of those likely to receive benefit from acute out of hours endoscopy. METHODS: Patients presenting between 17 March 2001 and 12 October 2010 with UGIH had clinical and laboratory features on presentation, endoscopic findings and administered treatment recorded. Patients with known cirrhotic liver disease were excluded. Logistic regression was performed, identifying factors at presentation associated with a requirement of endoscopic therapy (RET), which were then used to create a scoring system predictive of RET. RESULTS: In all, 1492 patients were analysed. The presence on presentation of fresh melaena (OR = 3.18, p<0.001), fresh haematemesis (OR=2.13, p<0.001), haemoglobin<130 g/L (OR=2.65, p<0.001), urea >10 mmol/L (OR=2.10, p<0.001), systolic blood pressure <100 mm  Hg (OR=1.85, p<0.001), inpatient status (OR=1.43, p=0.04), a history of peptic ulcer disease (OR=1.96, p=0.02), male sex (OR=1.45, p=0.01), presentation within 8 h of symptom onset (OR=1.48, p=0.02), coffee ground vomitus (OR=0.47, p=0.004) and warfarin use (OR=0.57, p=0.005) were associated with RET. Using a simple scoring system (fresh haematemesis=2, fresh melaena=2, haemoglobin <130=2, urea >10=1, BP <100=1, male sex=1, history of peptic ulcer disease=1), a score ≥7 was associated with RET in 45% of cases and a score ≤4 in 7%. CONCLUSIONS: Application of this scoring system when assessing patients presenting with UGIH out of office hours may help predict the likelihood of RET, and aid in the triage of endoscopy. Prospective validation of this score in an external cohort is required.

Murine typhus and leptospirosis presenting with undifferentiated symptoms of an acute febrile illness to Waikato Hospital, New Zealand, 2009-2010.

AIMS: This prospective observational study aimed to identify what proportion of patients presenting to Waikato Hospital with undifferentiated symptoms of an acute febrile illness (USFI) have leptospirosis or murine typhus infection, and to identify factors at presentation predictive of each infection. It also aimed to identify infecting rickettsial organism(s) causing murine typhus in the region. METHODS: Between 15/10/2009-15/10/2010 all adult patients presenting with USFI of greater than and equal to 72 hours with no clear diagnosis on presentation were invited to participate in the study. A structured questionnaire and examination were administered and acute and convalescent serology was performed. For patients returning positive murine typhus serology, rickettsial PCR analysis was performed on stored acute blood samples. RESULTS: Fifty-seven patients were recruited. Nine were diagnosed with leptospirosis, five with murine typhus, three with Epstein-Barr virus (EBV), two with cytomegalovirus (CMV), five with bacterial sepsis and six with other diagnoses. Twenty seven had an acute febrile illness for which no diagnosis was found. A low platelet count (p<0.001) was associated with murine typhus infection, and rural occupation (p<0.001) and a low lymphocyte count (p=0.001) with leptospiral infection. There was a trend towards rural residence being associated with murine tyhpus infection (p=0.059). Two of four patients with positive murine typhus serology returned positive PCR analysis for Rickettsia typhi. CONCLUSION: A significant proportion of patients presenting to Waikato Hospital with USFI had leptospirosis or murine typhus infection. A low platelet count and rural residence were associated with murine typhus infection, and rural occupation and a low lymphocyte count with leptospiral infection. R. typhi was identified as a rickettsial organism causing rickettsial fever in the Waikato region.