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ABSTRACT BACKGROUND: Gastrointestinal (GI) bleeding is an important cause of mortality and morbidity among geriatric patients. OBJECTIVE: To investigate whether the shock index and other scoring systems are effective predictors of mortality and prognosis among geriatric patients presenting to the emergency department with complaints of upper GI bleeding. DESIGN AND SETTING: Prospective cohort study in an emergency department in Bursa, Turkey. METHODS: Patients over 65 years admitted to a single-center, tertiary emergency service between May 8, 2019, and April 30, 2020, and diagnosed with upper GI bleeding were analyzed. 30, 180 and 360-day mortality prediction performances of the shock index and the Rockall, Glasgow-Blatchford and AIMS-65 scores were evaluated. RESULTS: A total of 111 patients who met the criteria were included in the study. The shock index (P < 0.001) and AIMS-65 score (P < 0.05) of the patients who died within the 30-day period were found to be significantly different, while the shock index (P < 0.001), Rockall score (P < 0.001) and AIMS-65 score (P < 0.05) of patients who died within the 180-day and 360-day periods were statistically different. In the receiver operating characteristic (ROC) analysis for predicting 360-day mortality, the area under the curve (AUC) value was found to be 0.988 (95% confidence interval, CI, 0.971-1.000; P < 0.001). CONCLUSION: The shock index measured among geriatric patients with upper GI bleeding at admission seems to be a more effective predictor of prognosis than other scoring systems.
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ABSTRACT BACKGROUND: Many scoring systems for predicting mortality, rebleeding and transfusion needs among patients with upper gastrointestinal bleeding (UGIB) have been developed. However, no scoring system can predict all these outcomes. OBJECTIVE: To show whether the perfusion index (PI), compared with the Rockall score (RS), helps predict transfusion needs and prognoses among patients presenting with UGIB in emergency departments. In this way, critical patients with transfusion needs can be identified at an early stage. DESIGN AND SETTING: Prospective cohort study in an emergency department in Turkey, conducted between June 2018 and June 2019. METHODS: Patients' demographic parameters, PI, RS, transfusion needs and prognosis were recorded. RESULTS: A total of 219 patients were included. Blood transfusion was performed in 174 patients (79.4%). The PI cutoff value for prediction of the need for blood transfusion was 1.17, and the RS cutoff value was 5. The area under the curve (AUC) value for PI (AUC: 0.772; 95% confidence interval, CI: 0.705-0.838; P < 0.001) was higher than for RS (AUC: 0.648; 95% CI: 0.554-0.741; P = 0.002). 185 patients (84.5%) were discharged, and 34 patients (15.5%) died. The PI cutoff value for predicting mortality was 1.1, and the RS cutoff value was 7. The AUC value for PI (AUC: 0.743; 95% CI: 0.649-0.837; P < 0.001) was higher than for RS (AUC: 0.725; 95% CI: 0.639-0.811; P < 0.001). CONCLUSION: PI values for patients admitted to emergency departments with UGIB on admission can help predict their need for transfusion and mortality risk.
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Humanos , Triagem , Índice de Perfusão , Prognóstico , Índice de Gravidade de Doença , Estudos Prospectivos , Curva ROC , Medição de Risco , Serviço Hospitalar de Emergência , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/terapiaRESUMO
ABSTRACT BACKGROUND: Traditionally peptic ulcer disease was the most common cause of upper gastrointestinal (UGI) bleed but with the changing epidemiology; other etiologies of UGI bleed are emerging. Many scores have been described for predicting outcomes and the need for intervention in UGI bleed but prospective comparison among them is scarce. OBJECTIVE: This study was planned to determine the etiological pattern of UGI bleed and to compare Glasgow Blatchford score, Pre-Endoscopy Rockall score, AIMS65, and Modified Early Warning Score (MEWS) as predictors of outcome. METHODS: In this prospective cohort study 268 patients of UGI bleed were enrolled and followed up for 8 weeks. Glasgow Blatchford score, Endoscopy Rockall score, AIMS65, and MEWS were calculated for each patient, and the area under the receiver operating characteristic (AUC-ROC) curve for each score was compared. RESULTS: The most common etiology for UGI bleed were gastroesophageal varices 150 (63.55%) followed by peptic ulcer disease 29 (12.28%) and mucosal erosive disease 27 (11.44%). Total 38 (15.26%) patients had re-bleed and 71 (28.5%) patients died. Overall, 126 (47%) patients required blood component transfusion, 25 (9.3%) patients required mechanical ventilation and 2 (0.74%) patients required surgical intervention. Glasgow Blatchford score was the best in predicting the need for transfusion (cut off - 10, AUC-ROC= 0.678). Whereas AIMS65 with a score of ≥2 was best in predicting re-bleed (AUC-ROC=0.626) and mortality (AUC-ROC=0.725). CONCLUSION: Gastrointestinal bleed was most commonly of variceal origin at our tertiary referral center in Northern India. AIMS65 was the best & simplest score with a score of ≥2 for predicting re-bleed and mortality.
RESUMO CONTEXTO: Tradicionalmente, a doença úlcera péptica era a causa mais comum de sangramento digestivo alto, mas com a mudança da epidemiologia, outras etiologias do sangramento do trato digestivo alto estão emergindo. Muitas pontuações têm sido descritas para prever resultados e a necessidade de intervenção na hemorragia gastrointestinal superior, mas a comparação prospectiva entre elas é escassa. OBJETIVO: Este estudo foi planeado para determinar o padrão etiológico de pacientes com hemorragia digestiva alta e comparar os escores de Glasgow Blatchford, o Rockall pré-endoscopia, o AIMS65 e o Early Warning modificado (MEWS) como preditores do resultado. MÉTODOS: Neste estudo prospetivo de coorte, 268 pacientes com sangramento digestivo alto foram acompanhados durante 8 semanas. Os escores Glasgow Blatchford, Rockall pré-endoscopia, AIMS65 e MEWS foram calculados para cada paciente, e a área sob a curva (AUC-ROC) para cada pontuação foi comparada. RESULTADOS: A etiologia mais comum para a hemorragia gastrointestinal alta foi varizes gastroesofágicas 150 (63,55%), seguida de úlcera péptica 29 (12,28%) e de doença erosiva de mucosa 27 (11,44%). No total, 38 (15,26%) doentes voltaram a sangrar e 71 (28,5%) doentes morreram. No total, 126 (47%) doentes necessitaram de transfusão de componentes sanguíneos, 25 (9,3%) necessitaram de ventilação mecânica e 2 (0,74%) destes doentes necessitaram de intervenção cirúrgica. O escore de Glasgow Blatchford foi o melhor na previsão da necessidade de transfusão (corte - 10, AUC-ROC =0,678). Enquanto o AIMS65 com uma pontuação de ≥2 foi o melhor na previsão de ressangramento (AUC-ROC =0,626) e mortalidade (AUC-ROC =0,725). CONCLUSÃO: O sangramento gastrointestinal alto mais comum é de origem varicosa em centro de referência terciária. O AIMS65 é o melhor escore simples, com uma pontuação de ≥2 para prever o ressangramento e a mortalidade.
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INTRODUCTION AND AIM: The role of serum albumin level in patients with non-variceal upper gastrointestinal bleeding (NVUGB) has not been extensively studied. Our aim was to evaluate the role of serum albumin on admission in terms of in-hospital mortality in patients with NVUGB. MATERIALS AND METHODS: Patients admitted with NVUGB during a 4-year period were prospectively included. Demographic, clinical, and laboratory data were collected. ROC curve analysis was used to determine the cutoff value for serum albumin on admission that made a distinction between deceased patients and survivors with respect to serum albumin on admission, as well as its overall performance compared with the Rockall score. RESULTS: 185 patients with NVUGB were evaluated. Men predominated (56.7%) and a mean age of 59.1±19.9 years was found. Mean serum albumin on admission was 2.9±0.9g/dl with hypoalbuminemia (< 3.5g/dl) detected on admission in 71.4% of cases. The ROC curve found that the best value for predicting hospital mortality was an albumin level of 3.1g/dl (AUROC 0.738). Mortality in patients with albumin ≥ 3.2g/dl was 1.2% compared with 11.2% in patients with albumin<3.2g/dl (P=.009; OR 9.7, 95%CI 1.2-76.5). There was no difference in overall performance between the albumin level (AUORC 0.738) and the Rockall score (AUROC 0.715) for identifying mortality. CONCLUSIONS: Patients with hypoalbuminemia presenting with NVUGB have a greater in-hospital mortality rate. The serum albumin level and the Rockall score perform equally in regard to identifying the mortality rate.
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Hemorragia Gastrointestinal/complicações , Hipoalbuminemia/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia Gastrointestinal/mortalidade , Hemorragia Gastrointestinal/terapia , Mortalidade Hospitalar , Humanos , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Estudos Prospectivos , Curva ROC , Fatores de Risco , Albumina Sérica/análiseRESUMO
Introducción: la probabilidad de recidiva está presente en cerca de 80 por ciento de los pacientes que presentan episodio de hemorragia digestiva alta no varicosa (HDA-NV). Objetivo: determinar el riesgo de resangrado mediante el empleo de la Escala de Rockall completa. Material y Métodos: se realizó un estudio prospectivo de corte transversal que incluyó a todos los pacientes con episodio de HDA-NV en el período entre septiembre 2011 y marzo 2013 en el Hospital Clínico Quirúrgico Dr. Luis Díaz Soto. Se utilizó la Escala de Rockall para determinar el índice de Rockall, que permitió agrupar a los pacientes en grupos de riesgo bajo, intermedio y alto. La evaluación de la eficacia en la estimación del riesgo de resangrado se realizó mediante el análisis por curva de ROC. Resultados: la estratificación en grupos de riesgo mostró el predominio de los casos con riesgo bajo (53 pacientes, 44,9 por ciento) o intermedio (47 casos, 39,8 por ciento), mientras que solo 18 casos (15,3 por ciento) se encontraron en riesgo alto. Sin embargo, 38,8 por ciento de los que se encontraron en este grupo presentaron un nuevo episodio hemorrágico. La capacidad predictiva de la Eescala de Rockall para el resangrado fue buena (ABC: 0,821, IC 95 por ciento: 0,664-0,977). El valor de corte con mayor eficacia fue 5, con un índice de Youden de 0,53. La sensibilidad fue de 63 por ciento y la especificidad de 83 por ciento. Conclusiones: con la Escala de Rockall completa se identifican correctamente los pacientes con probabilidad de que ocurra resangrado, por lo que puede ser introducido en la práctica clínica de la institución(AU)
Introduction: the probability of recurrence is present in near of 80 percent of the patients with upper non-variceal digestive bleeding. Objective: to determine the rebleeding risk applying the complete Rockall score in patients with upper non-variceal gastrointestinal bleeding. Material and Methods: a retrospective analysis was carried out in 118 patients admitted to the emergency room and endoscopy unit of Dr. Luis Díaz Soto hospital with non-variceal upper gastrointestinal bleeding between September 2011 and March 2013.The Rockall scores were calculated and patients were divided into three risk categories: low risk, moderate risk and high risk. Receiver operating characteristic (ROC) curves were plotted for rebleeding. The discriminative accuracy of the risk scores was assessed by the area under the ROC curve. Results: high clinical Rockall scores >5 were associated with rebleeding. The accuracy of the complete Rockall score in predicting rebleeding was good (area under ROC: 0,821, IC 95 percent: 0,664-0,977). The sensitivity was of a 63 percent and the specificity of 11, 8 percent, j= 0, 53. Conclusions: the Rockall score is clinically useful, rapid and accurate in predicting rebleeding, by what it can be entered in the clinical practice of this hospital(AU)
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HumanosRESUMO
Introduction: Upper gastrointestinal bleeding (UGIB), a high morbi-mortality disease, is a medical emergency with high incidence among the population. It also represents a significant health expense and its mortality rate is 4-12 percent. There are different systems to classify the risk for these patients; one of them is the Rockall Score. This system has been previously validated as mortality predictor. Objective: To evaluate the use in our environment of the Rockall Score as a mortality predictor, the need for surgery and hemoderivative requirements. Materials and Methods: Retrospective study in adult patients subjected to emergency upper digestive endoscopy due to potential non-variceal UGIB at Hospital Militar de Santiago. Many clinical and endoscopic variables were analyzed. Validation of Rockall Score was carried out by ROC curve analysis. Results: Ninety-one patients were studied: 2/3 male; 70 percent > 60 years; 68 percent with a related disease. The most frequent endoscopic diagnosis was stomach and duodenal lesions. Mortality rate of 8.8 percent. Rockall Score indicated an acceptable discrimination ratio as a predictor of mortality, need for surgery and red blood cell transfusion. The best sensitivity and specificity correlation score was >_ 5 to determine the high-risk group. Conclusion: Rockall Score proved to be a good mortality predictor in patients with non-variceal UGIB in our environment. The identification of high-risk UGIB patients will allow for an appropiate therapeutic approach.
Introducción: Hemorragia digestiva alta (HDA), patología de alta morbimortalidad, es una emergencia médica, presenta alta incidencia poblacional y demanda alto gasto en salud. Presenta una mortalidad entre 4-12 por ciento. Existen diferentes sistemas de clasificación de riesgo para estos pacientes, uno de los cuales es la clasificación de Rockall. Este sistema ha sido previamente validado como predictor de mortalidad. Objetivo: Evaluar en nuestro medio el uso de la clasificación de Rockall, para predecir mortalidad, necesidad de cirugía y requerimientos de hemoderivados. Materiales y Métodos: Estudio restrospectivo en pacientes adultos sometidos a endoscopia digestiva alta de urgencia por sospecha de HDA no variceal en el Hospital Militar de Santiago. Se analizaron diversas variables clínicas y endoscópicas. La validación de la clasificación de Rockall se realizó con el análisis de curva ROC. Resultados: Se estudiaron 91 pacientes: 2/3 de sexo masculino; 70 por ciento > 60 años; 68 por ciento presentaban alguna enfermedad asociada. El diagnóstico endoscópico mas frecuente fue lesiones en estómago y duodeno. Tasa de mortalidad de 8,8 por ciento. La clasificación de Rockall mostró un aceptable nivel de discriminación como predictor de mortalidad, requerimiento de cirugía y tranfusión de glóbulos rojos. El puntaje de mejor correlación de sensibilidad y especificidad fue > 5 para definir el grupo de alto riesgo. Conclusión: La clasificación de Rockall resultó ser un buen predictor de mortalidad en pacientes con HDA no variceal en nuestro medio. Identificar pacientes con HDA de alto riesgo, permitiría un adecuado enfrentamiento terapéutico.