Novel Nasogastric Tube-Related Criteria for Urgent Endoscopy in Nonvariceal Upper Gastrointestinal Bleeding

Background

Patients with active upper gastrointestinal bleeding (UGIB) require urgent endoscopy, but appropriate criteria for urgent endoscopy in these patients have not yet been established.

Aims

The goal of this study is to establish a simple system for the selection of UGIB patients who may benefit from urgent endoscopy.

Methods

Of the 335 patients who required emergency hospitalization for UGIB from May 2010 to March 2012 at Nagoya Daini Red Cross Hospital, 166 patients who underwent placement of a nasogastric tube (NGT) were retrospectively identified. Active bleeding on the endoscopic image was used as an endpoint that reflected the need for urgent endoscopy.

Results

The ratio of the heart rate to the systolic blood pressure (HR/SBP ratio) and aspiration of fresh or dark red fluid from the NGT [NGT(+)] were significant predictors of active bleeding in the univariate analysis [HR/SBP ratio, P = 0.016; NGT(+), P < 0.001]. The HR/SBP ratio [odds ratio (OR) 8.118; 95 % confidence intervals (CI) 1.696–38.850; P = 0.009] and NGT(+) (OR 4.630; 95 % CI 2.092–10.204; P < 0.001) were also significantly associated with active bleeding in the multivariate analysis. Moreover, receiver operating characteristic analysis revealed a setting with HR/SBP ratio >1.4 or NGT(+) to be optimal criteria to predict active bleeding. These criteria were associated with a sensitivity of 64.9 % (24/37) and a specificity of 76.7 % (99/129) for the prediction of active bleeding; consequently, they are superior to the sensitivity and specificity of previously proposed criteria.

Conclusions

A novel and simple criteria system using NGT(+) and HR/SBP is a good predictor of the need for urgent endoscopy in patients with nonvariceal UGIB.     

Defining Appropriate Use of Proton-Pump Inhibitors Among Medical Inpatients

BACKGROUND

Proton-pump inhibitors (PPIs) are commonly used among medical inpatients, both for prophylaxis against upper gastrointestinal bleeding (UGIB) and continuation of outpatient use. While PPIs reduce the risk of UGIB, they also appear to increase the risk of hospital-acquired pneumonia (HAP) and Clostridium difficile infection (CDI). Depending upon the underlying risks of these conditions and the changes in those risks with PPIs, use of proton-pump inhibitors may lead to a net benefit or net harm among medical inpatients.

OBJECTIVE

We aimed to determine the net impact of PPIs on hospital mortality among medical inpatients.

DESIGN

A microsimulation model, using literature-derived estimates of the risks of UGIB, HAP, and CDI among medical inpatients, along with the changes in risk associated with PPI use for each of these outcomes. The primary outcome was change in inpatient mortality.

PARTICIPANTS

Simulated general medical inpatients outside the intensive care unit (ICU).

MAIN MEASURE

Change in overall mortality during hospitalization.

KEY RESULTS

New initiation of PPI therapy led to an increase in hospital mortality in about 90 % of simulated patients. Continuation of outpatient PPI therapy on admission led to net increase in hospital mortality in 79 % of simulated patients. Results were robust to both one-way and multivariate sensitivity analyses, with net harm occurring in at least two-thirds of patients in all scenarios.

CONCLUSIONS

For the majority of medical inpatients outside the ICU, use of PPIs likely leads to a net increase in hospital mortality. Even in patients at particularly high risk of UGIB, only those at the very lowest risk of HCAP and CDI should be considered for prophylactic PPI use. Continuation of outpatient PPIs may also increase expected hospital mortality. Apart from patients with active UGIB, use of PPIs in hospitalized patients should be discouraged.

     

Increase in colonic diverticulosis and diverticular hemorrhage in an aging society: lessons from a 9-year colonoscopic study of 28,192 patients in Japan

Purposes

Colonoscopic evidence of epidemiological trends in diverticulosis and diverticular bleeding is scarce. We evaluated trends in diverticular disease and associated factors over 9 years.

Methods

Twenty-eight thousand one hundred ninety-two patients who underwent colonoscopy at an emergency hospital were reviewed from an electronic endoscopy database. Diverticula were classified as right-sided, left-sided, and bilateral types, and time trends in the proportion in diverticulosis, type, and diverticular bleeding were determined. Associations of age (≤39, 40–59, and ≥60 years), sex, and year increase with disease and odds ratios were estimated using logistic regression.

Results

Diverticulosis was identified in 6,150 patients (20.3 %; mean age, 67.6 years) and was predominantly right-sided (48.0 %). Diverticular bleeding was found in 427 (1.5 %; mean age, 69.7 years) and was predominantly bilateral (47.0 %). Proportion of colonic diverticulosis increased significantly (P?<?0.01 for trend) from 66.0 % (1,424/2,157) in 2003 to 70.1 % (2,914/4,159) in 2011 and was associated (P?<?0.01) with an increased number of patients aged ≥60 years. Proportion of diverticular bleeding increased significantly (P?<?0.01 for trend) from 1.02 % (22/2,157) in 2003 to 1.67 % (69/4,159) in 2011 and was associated (P?=?0.04) with an increased number of patients aged 40–59 years. Diverticulosis, right and bilateral type, and diverticular bleeding were independently associated with the 9-year trend after adjustment by age and sex.

Conclusions

Colonic diverticulosis and diverticular bleeding are prevalent and increasing in Japan. Given the significant association of age with this trend, both diseases can be expected to increase for decades to come.     

External validation of scoring systems in risk stratification of upper gastrointestinal bleeding

Aim

The aim of this study was to externally validate the four commonly used scoring systems in the risk stratification of patients with upper gastrointestinal bleed (UGIB).

Methods

Patients of UGIB who underwent endoscopy within 24 h of presentation were stratified prospectively using the pre-endoscopy Rockall score (PRS) >0, complete Rockall score (CRS) >2, Glasgow Blatchford bleeding scores (GBS) >3, and modified GBS (m-GBS) >3 scores. Patients were followed up to 30 days. Prognostic accuracy of the scores was done by comparing areas under curve (AUC) in terms of overall risk stratification, re-bleeding, mortality, need for intervention, and length of hospitalization.

Results

One hundred and seventy-five patients were studied. All four scores performed better in the overall risk stratification on AUC [PRS?=?0.566 (CI: 0.481–0.651; p-0.043)/CRS?=?0.712 (CI: 0.634–0.790); p<0.001)/GBS?=?0.810 (CI: 0.744–0.877; p->0.001); m-GBS?=?0.802 (CI: 0.734–0.871; p<0.001)], whereas only CRS achieved significance in identifying re-bleed [AUC—0.679 (CI: 0.579–0.780; p = 0.003)]. All the scoring systems except PRS were found to be significantly better in detecting 30-day mortality with a high AUC (CRS = 0.798; p-0.042)/GBS = 0.833; p-0.023); m-GBS = 0.816; p-0.031). All four scores demonstrated significant accuracy in the risk stratification of non-variceal patients; however, only GBS and m-GBS were significant in variceal etiology. Higher cutoff scores achieved better sensitivity/specificity [RS > 0 (50/60.8), CRS > 1 (87.5/50.6), GBS > 7 (88.5/63.3), m-GBS > 7(82.3/72.6)] in the risk stratification.

Conclusion

GBS and m-GBS appear to be more valid in risk stratification of UGIB patients in this region. Higher cutoff values achieved better predictive accuracy.

     

Bleeding of New Oral Anticoagulants for Stroke Prevention in Atrial Fibrillation: A Meta-Analysis of Randomized Controlled Trials

Purpose

Oral direct factor Xa inhibitors and oral direct thrombin inhibitors are new oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation (AF). We systematically reviewed their risk of major bleeding and efficacy in thromboembolism reduction in AF.

Methods

Eligible randomized controlled trials evaluating NOACs for stroke prevention in AF patients were identified from a systematic search of MEDLINE, EMBASE and the Cochrane database. Risk ratios (RRs) and 95 % confidence intervals (CIs) were calculated using a Mantel-Haenzel random-effects model.

Results

A total of 13 studies (n?=?61,406) were included. Oral direct factor Xa inhibitors were more effective in reducing stroke and systemic embolism compared to controls (RR 0.71, 95 % CI 0.54–0.92, P?=?0.009) or vitamin K antagonists (VKAs) (RR 0.84, 95 % CI 0.74–0.94, P?=?0.002), with no significant difference in major and clinically relevant non-major (CRNM) bleeding (against controls: RR 0.94, 95 % CI 0.75–1.18, P?=?0.60; against VKAs: RR 0.90, 95 % 0.69–1.17, P?=?0.44). Oral direct thrombin inhibitors were associated with an improved major and CRNM bleeding profile (both comparisons: RR 0.88, 95 % CI 0.78–0.98, P?=?0.02) and a significant reduction in stroke and systemic embolism (against controls: RR 0.79, 95 % CI 0.66–0.93, P?=?0.006; against VKAs: RR 0.78, 95 % CI 0.66–0.93, P?=?0.006).

Conclusions

Oral direct factor Xa inhibitors and oral direct thrombin inhibitors are more effective in reducing stroke and systemic embolism without increasing the risk of major bleeding compared to traditional oral anticoagulants. This favorable risk-benefit balance should be further confirmed by long-term, large-scale safety studies.     

The introduction of a simple maneuver to reduce the risk of postoperative bleeding after major hepatectomies

Background/Purpose

In major hepatectomies, postoperative increases in central venous pressure (CVP) may cause suture failure and massive bleeding. The aim of our study is to test the application of an intraoperative maneuver to reduce the risk of postoperative bleeding.

Methods

Our study included 172 consecutive patients who had major liver resection with selective hepatic vascular exclusion and sharp transection of the liver parenchyma. An intraoperative maneuver (5 s occlusion of the hepatic vein) was applied in an alternating way, and the patients were assigned to two groups: Cohort A (n = 86), that was granted the maneuver, and Cohort B (n = 86), that was used as a control group.

Results

In Cohort A, application of the maneuver was successful in demonstrating bleeders under low CVP levels. Cohort A had lower rate of massive bleeding requiring emergency reoperation (2.3 vs 5.8%, P = 0.049), less postoperative blood transfusions (13 vs 24%, P = 0.042), lower morbidity (20 vs 35%, P < 0.045) and shorter hospital stay compared to Cohort B.

Conclusions

Hepatectomies conducted under low CVP are prone to postoperative hemorrhage which can be prevented if the final bleeding control is performed under high pressure in the hepatic veins. Application of our testing maneuver effectively unmasked previously undetectable bleeding veins.     

Risk model for right hemicolectomy based on 19,070 Japanese patients in the National Clinical Database

Background

Right hemicolectomy is a very common procedure throughout the world, although this procedure is known to carry substantial surgical risks. The present study aimed to develop a risk model for right hemicolectomy outcomes based on a nationwide internet-based database.

Methods

The National Clinical Database (NCD) collected records on over 1,200,000 surgical cases from 3,500 Japanese hospitals in 2011. After data cleanup, we analyzed 19,070 records regarding right hemicolectomy performed between January 2011 and December 2011.

Results

The 30-day and operative mortality rates were 1.1 and 2.3 %, respectively. The 30-day mortality rates of patients after elective and emergency surgery were 0.7 and 6.0 %, respectively (P < 0.001). The odds ratios of preoperative risk factors for 30-day mortality were: platelet <50,000/μl, 5.6; ASA grade 4 or 5, 4.0; acute renal failure, 3.2; total bilirubin over 3 mg/dl, 3.1; and AST over 35 U/l, 3.1. The odds ratios for operative mortality were: previous peripheral vascular disease, 3.1; cancer with multiple metastases, 3.1; and ASA grade 4 or 5, 2.9. Sixteen and 26 factors were selected for risk models of 30-day and operative mortality, respectively. The c-index of both models was 0.903 [95 % confidence interval (CI) 0.877–0.928; P < 0.001] and 0.891 (95 % CI 0.873–0.908; P < 0.001), respectively.

Conclusion

We performed the first reported risk stratification study for right hemicolectomy based on a nationwide internet-based database. The outcomes of right hemicolectomy in the nationwide population were satisfactory. The risk models developed in this study will help to improve the quality of surgical practice.     

Risk factors for bacteriuria with carbapenem-resistant Klebsiella pneumoniae and its impact on mortality: a case–control study

Background

The objective of this study was to evaluate the mortality of and risk factors for bacteriuria due to carbapenem-resistant Klebsiella pneumoniae (CRKp) versus carbapenem-susceptible K. pneumoniae (CSKp) producing extended spectrum β lactamase (ESBL).

Methods

This was a retrospective case–control study in which 135 case-patients with bacteriuria due to CRKp were compared with 127 control patients with CSKp producing ESBL. In a first step, multivariate Cox regression and Kaplan–Meier survival analysis models were used to determine the difference in mortality between the two groups and risk factors for mortality. In a second step, a univariate analysis was used to identify risk factors for CRKp colonization.

Results

There were no significant demographic or clinical differences between the groups. In-hospital mortality in the study and control groups was 29 and 25 %, respectively (non-significant difference). Multivariate analysis revealed that the most important risk factor for mortality in both groups was being bed ridden [hazard ratio 2.2, 95 % confidence interval (CI) 1.23–3.93; P = 0.008]. Patients with CRKp bacteriuria had a longer hospitalization time with a mean ± standard deviation of 28 ± 33 days compared to 22 ± 28 days in the control group (P < 0.05). Several univariate risk factors for acquiring CRKp bacteriuria were identified: antibiotic use [odds ratio (OR) 1.93, 95 % CI 1.18–3.17, p = 0.008], especially colistin (OR 2.04, 95 % CI 1.04–4.02; P = 0.036), presence of a urinary catheter (OR 2.09, 95 % CI 1.2–3.63; P = 0.008), surgery (OR 3.94, 95 % CI 1.85–8.37; P = 0.0002), invasive procedures (OR 3.06, 95 % CI 1.61–5.8; P = 0.0004), and intensive care unit admission (OR 2.49, 95 % CI 1.18–5.37; P = 0.015).

Conclusion

Bacteriuria caused by CRKp as compared that caused by CSKp was not found to be a risk factor for death.     

Thrombocytopenia and Bleeding in Veterans with Non-hepatitis C-related Chronic Liver Disease

Background

Thrombocytopenia in chronic liver disease (CLD) typically reflects disease severity and may indicate an increased risk for bleeding.

Aims

To describe the longitudinal course of thrombocytopenia and risks for bleeding in veteran patients with non-hepatitis C-related CLD.

Methods

We identified 2,349 patients with non-hepatitis C-related CLD from databases of the New England Veterans Healthcare System between 1999 and 2008. The cohort was stratified by baseline platelet counts of <50,000, 50–100,000, > 100,000–150,000, and >150,000/μl. Primary outcomes were the incidence and hazard rates for bleeding episodes requiring hospitalization and incident severe thrombocytopenia (<50,000/μl).

Results

Over a median follow-up of 3.3 years (IQR 1.2, 6.3), incident major bleeds, predominantly gastrointestinal, occurred in 254 patients (10.8 % of the cohort) and in 19.9 % of those with baseline platelets <50,000/μl. Incident severe thrombocytopenia occurred in 315 patients (13.4 % of cohort) and in 40.7 % of those with baseline platelet counts between 50,000 and 100,000/μl. Baseline platelet counts between 50,000 and 100,000/μl independently predicted bleeding [adjusted HR 2.89 (1.76, 4.73) p < 0.001] as did esophageal varices, hemoglobin ≤9.9 g %, and INR 1.4–2.0. Incident severe thrombocytopenia and minimum platelet counts <25,000/μl each associated with bleeding episodes, but the average of minimum platelet counts recorded for those who bled was 76,000/μl.

Conclusions

Among veteran patients with non-hepatitis C-related CLD, baseline platelet counts of 50,000 to 100,000/μl increased subsequent risks for both incident severe thrombocytopenia and major bleeding events. Whereas associations between severe thrombocytopenia and bleeding most likely reflect CLD severity, liver-related coagulopathies, and co-morbid bleeding risks, interventions to enhance platelet production may be beneficial for such patients.     

Rarity of Severe Bleeding and Perforation in Endoscopic Ultrasound-Guided Fine Needle Aspiration for Submucosal Tumors

Background

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is an established procedure for the pathological diagnosis of gastrointestinal submucosal tumors (SMTs). Although bleeding and perforation are potentially severe complications of EUS-FNA, the incidences and severities of these complications have not yet been fully evaluated because of their relative rarity.

Aim

The purpose of this study was to evaluate the incidences and mortality of severe bleeding and perforation in patients who underwent EUS-FNA for SMTs.

Methods

The records of 1,135 consecutive patients who underwent EUS-FNA for SMTs at 219 hospitals, with low- to high-volume, were reviewed using a Japanese nationwide administrative database.

Results

Of the targeted lesions 73.5 % were located in the stomach, 13.4 % in the esophagus, 8.2 % in the duodenum, and 4.9 % at other sites. Five patients (0.44 %) experienced severe bleeding requiring red blood cell transfusion or endoscopic treatment, with none experiencing perforation. Only one patient (0.09 %) died in-hospital within 30 days of EUS-FNA (0.09 %), with death not associated with bleeding or perforation.

Conclusions

EUS-FNA is safe in evaluating SMTs, with low risks of bleeding and perforation.     

Surgery for ischemic colitis: outcome and risk factors for in-hospital mortality

Purpose

Surgery for ischemic colitis is associated with high perioperative morbidity and mortality, but the risk factors for mortality and major surgical complications are unclear.

Methods

In this retrospective single institution cohort study of all patients undergoing colorectal surgery for histologically proven ischemic colitis between 2004 and 2010, we evaluated surgical outcomes and risk factors for in-hospital mortality and major surgical complications.

Results

For the 100 patients included in the study, in-hospital mortality was 54 %; major surgical complications, defined as anastomotic leakage or rectal stump and stoma complications, occurred in 16 %. In the multivariable analysis, hospital death was more likely in patients with right-sided (odds ratio [OR] 3.8; 95 % confidence interval [CI] 1.2, 12; P?=?0.022) or pan-colonic ischemia (OR 11; 95 % CI 2.8, 39; P?<?0.001), both relative to left-sided ischemia. Decreased preoperative pH level (OR 2.5 per 0.1 decrease; 95 % CI 1.5, 4.1; P?<?0.001) and prior cardiac or aortic surgery (OR 2.4; 95 % CI 0.82, 6.8; P?=?0.109) were further important risk factors for in-hospital mortality. Major postoperative surgical complications were more likely in patients with ischemic alterations at the resection margin of the histological specimen (OR 3.7; 95 % CI 1.2, 11; P?=?0.022).

Conclusions

Colonic resection for ischemic colitis is associated with high in-hospital mortality, especially in patients with right-sided or pan-colonic ischemia. In patients developing acidosis, early laparotomy is essential. Since resection margins’ affection seems to be underestimated upon surgery, resections should be performed wide enough within healthy tissue.     

Risk of recurrence and long-term outcomes after colonic diverticular bleeding

Purpose

Diverticular disease is one of the most common causes of acute lower gastrointestinal bleeding. We aimed to evaluate the natural history, follow-up, and risk factors associated with re-bleeding (recurrence) in patients with colonic diverticular bleeding.

Methods

We reviewed patients with proven colonic diverticular hemorrhage from September 1993 to June 2012 at our institution. Recurrence was the main outcome measure.

Results

We identified 78 out of 95 patients with proven diverticular bleed who were treated non-operatively and were followed up for a median of 57.1 months. Thirty-seven (47 %) of these patients with a median age of 67 years developed recurrent diverticular bleed after a median time of 8.1 months. The bleeding originated from the left colon in 78 (83 %) out of 95 patients in the first bleeding episode and 31(84 %) out of 37 patients during the recurrent bleeding episode. Thirty-six patients (97 %) with recurrent diverticular bleed required surgical intervention. Old age at the time of initial bleeding was associated with recurrence (p?=?0.001). Patients with diverticulitis (p?<?0.0001), peripheral vascular (p?=?0.01), and chronic renal diseases (p?=?0.047) were found to have an increased risk for recurrent colonic diverticular bleed. We only had one perioperative mortality due to postoperative sepsis. All other mortalities were not directly associated with surgery.

Conclusion

Patients with a history of colonic diverticular bleed are prone to recur shortly thereafter. Certain risk factors including increased age, documented diverticulitis, history of peripheral vascular disease, and chronic renal failure may predispose to recurrence.     

Comparison of Severe Healthcare-Associated Pneumonia with Severe Community-Acquired Pneumonia

Background

We compared the demographic characteristics and outcomes of patients with severe healthcare-associated pneumonia (HCAP) to those with severe community-acquired pneumonia (CAP).

Methods

This was a retrospective study of prospectively collected data from all consecutive patients with severe pneumonia who were admitted to the hospital through the emergency department between January 2008 and December 2010.

Results

During the study period, 247 patients had severe pneumonia; of these, 107 had severe CAP and 140 had severe HCAP. There was no significant difference in demographic characteristics between the two groups, except for comorbidities. Although the incidence of potentially drug-resistant pathogens was higher in patients with severe HCAP than in those with severe CAP (34 vs. 6 %, P = 0.004), there was no statistically significant difference in the rate of inappropriate antibiotic treatment (16 vs. 3 %, P = 0.143). Finally, clinical outcomes, such as intensive care unit admission, length of hospital stay, and in-hospital mortality, were not different between the two groups. In a multiple logistic regression analysis, a higher PSI score (adjusted OR 1.01; 95 % CI 1.00–1.02; P = 0.024) and the need for mechanical ventilation (adjusted OR 2.62; 95 % CI 1.37–5.00; P = 0.004) were independently associated with in-hospital mortality. However, the type of pneumonia was not associated with in-hospital mortality after adjusting for potential confounding factors.

Conclusions

The severity of illness rather than the type of pneumonia might be associated with in-hospital mortality in patients with severe pneumonia.     

Effects of modified splenocaval shunt plus devascularization on esophagogastric variceal bleeding: a comparative study of this treatment and devascularization only in cirrhotic portal hypertension

Background

Pericardial devascularization (PCDV) and portosystemic shunt were reported to have favorable results for the management of portal hypertension in cirrhotic patients in China and the West, respectively. This study was undertaken to investigate the effects of a modified proximal splenocaval shunt plus PCDV on variceal bleeding in patients with portal hypertension.

Methods

From January 1997 to December 2007, 168 patients with portal hypertension of cirrhotic origin received an operation for gastroesophageal variceal bleeding. Of these, 90 patients received a splenocaval shunt plus a PCDV procedure (Combined Group) and the other 78 patients received a PCDV procedure only (PCDV Group). The procedure-related morbidity and mortality, rebleeding, encephalopathy, and survival rates were analyzed.

Results

Postoperative mortality was 3.3% in the combined group and 5.1% in the PCDV group (P > 0.05). Overall morbidity was 13.3% in the combined group and 15.4% in the PCDV group (P > 0.05). The rate for rebleeding, including variceal bleeding and gastropathy, was 5.1% in the combined group, which was significantly lower than that in the PCDV group, at 16.7% (P < 0.05). The incidence of encephalopathy was 6.63% in the combined group and 6.67% in the PCDV group (P > 0.05). The 1-, 3-, 5- and 10-year survival rates were 97.4, 91.7, 80.0, and 60.0% in the combined group and 96.7, 83.3, 73.3, and 53.3% in the PCDV group (P > 0.05).

Conclusions

The modified splenocaval shunt plus PCDV is a safe and effective procedure for the long-term control of variceal bleeding; the procedure may not only maintain the portal flow to the liver, but may also protect the liver function in cirrhotic patients. The better clinical outcome means that the procedure may be one of the best choices for treating portal hypertension of cirrhotic origin.     

False Negative Fecal Occult Blood Test May Be Associated with Increased Mortality from Colorectal Cancer

Background

Fecal Occult Blood Test (FOBT) is an accepted screening test for colorectal cancer (CRC). It has been shown to decrease mortality by up to 30 %. The outcome of screening failures has not been adequately studied.

Aims

The purpose of this study was to assess the outcome of patients who were diagnosed with CRC after a false negative FOBT.

Methods

We identified all consecutive CRCs from pathology reports between 2005 and 2010. Patients were divided according to their FOBT result. Those who became positive were compared to patients who remained negative.

Results

Altogether 401 CRCs were identified. Of those, 202 never performed a FOBT. At least one negative FOBT was performed by 133 individuals (67 %). Of these, 76 remained negative (false negatives, FN) and 57 became positive (positive conversion, PC, controls). The prevalence of metastatic disease was threefold higher among the FNs as compared to the PC group (16 [22.2 %] vs. 4 [7.5 %], P = 0.022). All-cause mortality was also significantly higher among FNs versus PCs (24 [31.6 %] vs. 5 [8.8 %], P = 0.001); in Cox regression analysis of survival (covariates: FNs vs. PC, gender, age, medications and co-morbidities) FNs had increased mortality compared to the PC (HR 2.929, P = 0.033, CI 95 % 1.092–7.858). No statistically significant difference was found regarding all primary end points when comparing the FN and the “No test” group.

Conclusion

These data disclose a particular risk of FOBT as a screening test. A subgroup of patients with “false” negative tests may have increased morbidity and mortality. Efforts should be made to recognize and characterize this high-risk group.     

Factors Predictive of Adverse Events Associated with Endoscopic Ultrasound-Guided Fine Needle Aspiration of Pancreatic Solid Lesions

Background

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) provides high diagnostic accuracy with a low incidence of procedural complications. However, it occasionally causes serious complications, and factors that increase the susceptibility to such adverse events remain unknown.

Aims

We aimed to examine post-procedural events and determine risk factors associated with EUS-FNA of pancreatic solid lesions.

Methods

This single-center retrospective study included 316 consecutive patients with pancreatic solid lesions who underwent 327 EUS-FNA procedures from April 2003 to September 2011. We registered all patients undergoing EUS-FNA in the database and retrospectively ascertained the presence/absence of post-procedural adverse events.

Results

The incidence of post-procedural adverse events, including moderate to mild pancreatitis, mild abdominal pain, and mild bleeding, was 3.4 %. Univariate analysis showed that the incidence of post-procedural events was significantly increased in patients with tumors less than or equal to 20 mm in diameter (P < 0.001), those with pancreatic neuroendocrine tumors (PNET) (P = 0.012), and patients who had intervening normal pancreas for accessing the lesion (P = 0.048). Multivariate analysis identified tumors measuring less than or equal to 20 mm in diameter (OR 18.48; 95 % CI 3.55–96.17) and case of PNETs (OR 36.50; 95 % CI 1.73–771.83) were an independent risk factors.

Conclusions

EUS-FNA of pancreatic solid lesions is a safe procedure. However, pancreatic lesions with small diameters and pancreatic neuroendocrine tumors are important factors associated with adverse events after EUS-FNA.     

agr dysfunction and persistent methicillin-resistant Staphylococcus aureus bacteremia in patients with removed eradicable foci

Purpose

Persistent Staphylococcus aureus bacteremia (SAB) has been observed in patients with eradicated foci, but there are few studies of the risk factors and clinical outcomes of persistent bacteremia. This study determined the risk factors for persistent methicillin-resistant S. aureus (MRSA) bacteremia in patients without retained eradicable foci, including genotypic characteristics.

Methods

All adult SAB patients were investigated between 2008 and 2010. Persistent bacteremia was defined as bacteremia lasting >7 days after treatment and patients were monitored prospectively. The study included patients without retained eradicable foci, e.g., removed prosthetic devices and intravenous catheters removed after diagnosis, and those without metastatic infections.

Results

Persistent bacteremia occurred in 36 % (31/87) SAB patients with eradicated foci. There were no significant differences in successful defervescence (2.0 vs. 2.0 days, P = 0.55) and total length of hospital stay after bacteremia in the persistent bacteremia group and resolved bacteremia group (P = 0.32). The difference in MRSA bacteremia-related 30-day mortality with persistent bacteremia and resolved bacteremia was not significant (P = 0.12). However, agr dysfunction was higher in persistent bacteremia patients (94 %) than those with resolved bacteremia (75 %, P = 0.03). Multivariate analysis using a logistic regression model found that only agr dysfunction [odds ratio (OR) 4.83, 95 % confidence interval (CI) 1.02–22.89, P = 0.04] was an independent risk factor for persistent bacteremia.

Conclusions

This study suggests that persistent bacteremia with eradicated foci might not adversely affect the outcome for MRSA bacteremia patients. agr dysfunction in S. aureus was significantly associated with persistent bacteremia.     

Value of the APASL severity score in patients with acute variceal bleeding: a single center experience

Background

Acute variceal bleeding is a severe complication in patients with cirrhosis. The Asian Pacific Association for Study of the Liver (APASL) severity score was proposed in 2011. This score is used for evaluating the severity of acute variceal bleeding. However, as this score is largely based on expert opinion, it requires validation.

Aim

To determine the value of the APASL severity score.

Methods

We retrospectively reviewed the medical records of patients treated for acute variceal bleeding at Konkuk University Hospital from 2006 to 2011. The APASL severity score, Child-Pugh score, and Model for End-Stage Liver Disease (MELD) score were calculated, and predictive values for treatment failure, rebleeding, and in-hospital mortality were compared by the area under the receiver operating curve (AUROC).

Results

A total of 136 patients were enrolled, and all patients were treated by endoscopic variceal ligation (EVL) and terlipressin combination therapy. Most patients were male (n = 123, 90.4 %), and the most common etiology was alcohol (n = 91, 66.9 %). Thirteen treatment failures, eight rebleedings, and seven in-hospital mortalities occurred. The AUROCs of the APASL severity score, Child-Pugh score, and MELD score were 0.760, 0.681, and 0.607 for treatment failure; 0.660, 0.714, and 0.677 for rebleeding; and 0.872, 0.847, and 0.735 for in-hospital mortality. A significant difference was only observed between the APASL severity score and MELD score for treatment failure (p = 0.0259).

Conclusion

APASL severity score was a useful method for predicting treatment failure. However, the predictive value for rebleeding and in-hospital mortality were not satisfactory.     

Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacrylate): a South European single center experience

Background

Endoscopic injection of N-butyl-2-cyanoacrylate is the current recommended treatment for gastric variceal bleeding. Despite the extensive worldwide use, there are still differences related to the technique, safety, and long term-results. We retrospectively evaluated the efficacy and safety of cyanoacrylate in patients with gastric variceal bleeding.

Patients and Methods

Between January 1998 and January 2010, 97 patients with gastric variceal bleeding underwent endoscopic treatment with a mixture of N-butyl-2-cyanoacrylate and Lipiodol^TM. Ninety-one patients had cirrhosis and 6 had non-cirrhotic portal hypertension. Child-Pugh score at presentation for cirrhotic patients was A–12.1 %; B–53.8 %; C–34.1 % and median MELD score at admission was 13 (3–26). Successful hemostasis, rebleeding rate and complications were reviewed. Median time of follow up was 19 months (0.5–126).

Results

A median mixture volume of 1.5 mL (0.6 to 5 mL), in 1 to 8 injections, was used, with immediate hemostasis rate of 95.9 % and early rebleeding rate of 14.4 %. One or more complications occurred in 17.5 % and were associated with the use of Sengstaken-Blakemore tube before cyanoacrylate and very early rebleeding (p?<?0.05). Hospital mortality rate during initial bleeding episode was 9.3 %. Very early rebleeding was a strong and independent predictor for in-hospital mortality (p?<?0.001). Long-term mortality rate was 58.8 %, in most of the cases secondary to hepatic failure.

Conclusion

N-butyl-2-cyanoacrylate is a rapid, easy and highly effective modality for immediate hemostasis of gastric variceal bleeding with an acceptable rebleeding rate. Patients with very early rebleeding are at higher risk of death.     

Serum hs-CRP was correlated with treatment response to pegylated interferon and ribavirin combination therapy in chronic hepatitis C patients

Background/aims

Serum high sensitivity C-reactive protein (hs-CRP) is a surrogate marker for cardiovascular disease risks and related mortality. However, the features of hs-CRP in chronic HCV infection (CHC) patients have not been fully addressed. This study aimed to elucidate the characteristics of hs-CRP and its correlation with clinical profiles in CHC patients.

Methods

Ninety-five CHC patients and 95 age- and sex-matched healthy controls were enrolled for serum hs-CRP level, biochemical, and metabolic profiles examinations. Sequential changes of hs-CRP levels in CHC patients receiving peginterferon/ribavirin combination therapy were also evaluated.

Results

The mean hs-CRP level of CHC patients was significantly higher than that of healthy controls (0.97 ± 0.11 vs. 0.24 ± 0.07 mg/L, P < 0.001). There was no significant correlation between hs-CRP and both virological and histological factors. CHC patients with a high LDL-C level had significantly higher mean hs-CRP (1.38 ± 0.20 mg/L) than that of patients without (0.59 ± 0.06 mg/L) (P < 0.001). Hs-CRP level was significantly decreased in 83 patients after peginterferon/ribavirin combination therapy (0.24 vs. 0.62 mg/L, P < 0.001), particularly in 68 patients achieving a sustained virological response (0.25 vs. 0.64 mg/L, P < 0.001).

Conclusion

CHC patients had a higher hs-CRP level than healthy controls which could be ameliorated after peginterferon/ribavirin combination therapy.