A prospective comparison of 3 scoring systems in upper gastrointestinal bleeding.

BACKGROUND: The clinical severities of upper gastrointestinal bleeding (UGIB) are of a wide variety, ranging from insignificant bleeds to fatal outcomes. Several scoring systems have been designed to identify UGIB high- and low-risk patients. The aim of our study was to compare the Glasgow-Blatchford score (GBS) with the preendoscopic Rockall score (PRS) and the complete Rockall score (CRS) in their utilities in predicting clinical outcomes in patients with UGIB. METHODS: We designed a prospective study to compare the performance of the GBS, PRS, and CRS in predicting primary and secondary outcomes in UGIB patients. The primary outcome included the need for blood transfusion, endoscopic therapy, or surgical intervention and was labeled as high risk. The secondary outcomes included rebleeding and 30-day mortality. The area under the receiver operating characteristic curve (AUC), sensitivity, specificity, and positive and negative predictive values for each system were analyzed. A total of 303 consecutive patients admitted with UGIB during a 1-year period were enrolled. RESULTS: For prediction of high-risk group, AUC was obtained for GBS (0.808), PRS (0.604), and CRS (0.767). For prediction of rebleeding, AUC was obtained for GBS (0.674), PRS (0.602), and CRS (0.621). For prediction of mortality, AUC was obtained for GBS (0.513), PRS (0.703), and CRS (0.620). CONCLUSIONS: In detecting high-risk patients with acute UGIB, GBS may be a useful risk stratification tool. However, none of the 3 score systems has good performance in predicting rebleeding and 30-day mortality because of low AUCs.

Hypokalemia and hypothermia are associated with 30-day mortality in patients with acute paraquat poisoning.

BACKGROUND: Clinical predictors associated with acute paraquat (PQ) poisoning have not been systematically studied. OBJECTIVE: To identify independent predictors of death in patients with acute PQ poisoning. METHODS: This is a retrospective study executed in the emergency department of a university hospital. One hundred three consecutive patients poisoned with PQ between January 1999 and December 2004 were enrolled. Urine PQ concentration, electrolyte and renal function, detailed history, and Acute Physiology and Chronic Health Evaluation II were extracted from medical records. The outcome measure was 30-day mortality. Multivariate analysis was done by Cox-proportional hazard regression model. Receiver operating characteristics area under the curve was calculated for selected predictors. RESULTS: The crude 30-day mortality was 67.9% (70 of 103). Independent predictors of death were acute renal failure (hazard ratio, 3.53; 95% confidence interval, 1.97-6.32), hypokalemia (2.07, 1.21-3.51), hypothermia (2.91, 1.67-5.07), suicide (2.11, 1.04-4.29), and self-reported ingested dose (2.06, 1.38-3.06). The receiver operating characteristics area under the curve of serum potassium concentrations, maximal urine PQ concentrations, and Acute Physiology and Chronic Health Evaluation II scores were 0.75 (95% confidence interval, 0.60-0.81), 0.71 (0.66-0.84), and 0.80 (0.71-0.88), respectively. Under the cutoff value of 3.6 mEq/L, hypokalemia had a sensitivity of 75% and specificity of 54% in predicting mortality. CONCLUSION: The identified risk factors may allow better identification of those at greater mortality risk. Future development of a tailored clinical scoring system incorporating the identified risk factors for acute PQ poisoning may be of great help.

Acute appendicitis in the octogenarians and beyond: a comparison with younger geriatric patients.

BACKGROUND: Difference of the clinical characteristics and outcome of acute appendicitis (AA) between young old (age 60 to 79 years) and octogenarian patients (age 80) is unknown. We hypothesized that octogenarian patients would have more atypical presentation and worse outcomes. METHODS: Our study was a 10-year retrospective analysis of a hospital based database. All patients with histopathologically confirmed AA from 1995 to 2005 registered in this database were selected for study. Demographic data, preexisting conditions, clinical manifestations, Alvarado score, delay in surgery, complications, and mortality were compared between the octogenarians and young old. Independent effect of age on outcomes was examined by logistic regression model controlling for sex, comorbidities, and time delayed for surgery. RESULTS: Octogenarian patients constituted 93 (14.8%) of 628 geriatric patients with AA. On clinical manifestations, migrating pain and localized iliac fossa tenderness were less common in the octogenarians. Low sensitivity of Alvarado score in diagnosing AA was noted in both young old (50.7%) and octogenarian (44.1%) patients. Compared with young old patients, octogenarians had a longer delay in surgery and worse outcomes. Octogenarians had a significantly higher perforation rate (65.6% vs 49.5%, P < 0.001), postoperative morbidity rate (18.3% vs 10.1%, P < 0.001), and mortality rate (6.5 % vs 1.5 %, P < 0.001). Octogenarian age was independently associated with appendiceal perforation (OR, 95% CI; 1.94, 1.23 approximately 3.08), postoperative morbidity (2.0, 1.10 approximately 3.62), and mortality (4.5, 1.54 approximately 13.41). CONCLUSIONS: The clinical presentation of AA in octogenarian patients is atypical and the outcomes are worse than young old patients.

Risk factors associated with perforated appendicitis in elderly patients presenting with signs and symptoms of acute appendicitis.

BACKGROUND: The aim of this study was to identify factors associated with rupture in elderly patients with acute appendicitis. METHODS: The medical records of 601 consecutive patients >60 years of age with acute appendicitis between 1995 and 2005 were retrospectively reviewed. Historical, clinical and laboratory factors in patients with both intact and ruptured appendices were examined with univariate and multivariate analyses by logistic regressions. RESULTS: Nine factors predicted appendiceal rupture age (odds ratio (OR) 1.05, confidence interval (CI) 1.02-1.07), male sex (OR 1.96, CI 1.35-2.06), preadmission duration of pain (OR 1.23, CI 1.11-1.36), interval of time from admission to surgery (OR 1.02, CI 1.01-1.04), fever >38 degrees C (OR 2.59, CI 1.78-3.77), left shift in leucocyte count >76% (OR 2.34, CI 1.27-4.32), anorexia (OR 2.03, CI 1.38-2.99) and a retrocaecally positioned appendix (OR 1.93, CI 1.15-3.24). CONCLUSION: The incidence of appendiceal rupture, or complications secondary to appendiceal rupture, in elderly patients may be decreased if surgery is expedited when the temperature is >38 degrees C or there is a left shift in leucocyte count >76%, especially in men with anorexia.

Predictive value of plasma brain natriuretic peptide for postoperative cardiac complications--a systemic review and meta-analysis.

BACKGROUND: We aimed to undertake a systematic review and meta-analysis of studies addressing perioperative natriuretic peptide (NP) levels to predict postoperative major adverse cardiac events (MACE) after major surgery. METHODS: We searched MEDLINE and Embase with no language restrictions up to May 2013. The end points were major cardiac complications. We summarized test performance characteristics with the use of forest plots, hierarchical summary receiver operating characteristic curves, and bivariate random effects models. RESULTS: Of the 662 retrieved articles, 24 studies satisfied the predefined eligibility criteria, including 5438 patients along with 712 (13.1%) events. After major surgery, the diagnostic odds ratio (DOR) of NP in predicting postoperative MACE was 14.3 (95% confidence interval [CI], 9.87-20.7) for overall population, 13.9 (8.43-22.8) for patients undergoing cardiac surgery, and 15.0 (8.84-25.5) for patients undergoing noncardiac surgery. The pooled sensitivity was 0.84 (95% CI, 0.79-0.88) and specificity was 0.76 (95% CI, 0.71-0.81). Postoperative measurement (DOR, 18.9; 7.68-46.3) was associated with higher predictive value than preoperative measurement (DOR, 13.6; 7.68-46.3). Results were similar for a subgroup with the composite outcome including mortality (DOR, 16.4; 10.6-25.5). B-type natriuretic peptide was associated with higher predictive accuracy (area under the summary receiver operating characteristic, 0.84; 0.81-0.87) than N-terminal pro-b-type natriuretic peptide (area under the summary receiver operating characteristic, 0.90; 0.87-0.92). CONCLUSIONS: The existing literature suggests that perioperative NP testing have reasonable accuracy and can be useful in perioperative risk stratification. Natriuretic peptide testing has high rule-out value and low rule-in value for predicting postoperative MACE. Medical decisions should be made in the context of these characteristics.

Neurogenic cardiopulmonary complications associated with spontaneous cerebellar hemorrhage.

INTRODUCTION: Neurogenic cardiopulmonary complications associated with acute brain injury other then subarachnoid hemorrhage were seldom reported, especially in the pediatric population. We report a child who developed cardiac arrhythmia, severe myocardial injury and neurogenic pulmonary edema after cerebellar hemorrhage. METHODS AND RESULTS: An 11-year-old girl had abrupt onset of spontaneous cerebellar hemorrhage presented with a fulminant picture of hypertension, supraventricular tachyarrhythmia, markedly elevated cardiac enzyme (troponin-I > 50 ng/ml), and acute pulmonary edema. The cardiopulmonary complications were deemed neurogenic because of their rapid onset after brain injury and exclusion of external blunt chest injury, resuscitative injury, and risks for underlying cardiac disease. CONCLUSIONS: In addition to SAH, severe neurogenic cardiopulmonary complications could develop in pediatric patients with cerebellar hemorrhage. Supraventricular tachycardia may be an uncommon presenting rhythm that warrants considering cerebral etiology in patients without apparent cardiac risk.