Anne C. Travis

A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding

BACKGROUND Although the early use of a risk stratification score in upper GI bleeding is recommended, existing risk scores are not widely used in clinical practice. OBJECTIVE We sought to develop and validate an easily calculated bedside risk score, AIMS65, by using data routinely available at initial evaluation. DESIGN Data from patients admitted from the emergency department with acute upper GI bleeding were extracted from a database containing information from 187 U.S. hospitals. Recursive partitioning was applied to derive a risk score for in-hospital mortality by using data from 2004 to 2005 in 29,222 patients. The score was validated by using data from 2006 to 2007 in 32,504 patients. Accuracy to predict mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. MAIN OUTCOME MEASUREMENTS Mortality, length of stay (LOS), and cost of admission. RESULTS The 5 factors present at admission with the best discrimination were albumin less than 3.0 g/dL, international normalized ratio greater than 1.5, altered mental status, systolic blood pressure 90 mm Hg or lower, and age older than 65 years. For those with no risk factors, the mortality rate was 0.3% compared with 31.8% in patients with all 5 (P < .001). The model had a high predictive accuracy (AUROC = 0.80; 95% CI, 0.78-0.81), which was confirmed in the validation cohort (AUROC = 0.77, 95% CI, 0.75-0.79). Longer LOS and increased costs were seen with higher scores (P < .001). LIMITATIONS Database data used does not include outcomes such as rebleeding. CONCLUSIONS AIMS65 is a simple, accurate risk score that predicts in-hospital mortality, LOS, and cost in patients with acute upper GI bleeding.

The AIMS65 score compared with the Glasgow-Blatchford score in predicting outcomes in upper GI bleeding

INTRODUCTION We previously derived and validated the AIMS65 score, a mortality prognostic scale for upper GI bleeding (UGIB). OBJECTIVE To validate the AIMS65 score in a different patient population and compare it with the Glasgow-Blatchford risk score (GBRS). DESIGN Retrospective cohort study. PATIENTS Adults with a primary diagnosis of UGIB. MAIN OUTCOME MEASUREMENTS PRIMARY OUTCOME inpatient mortality. SECONDARY OUTCOMES composite clinical endpoint of inpatient mortality, rebleeding, and endoscopic, radiologic or surgical intervention; blood transfusion; intensive care unit admission; rebleeding; length of stay; timing of endoscopy. The area under the receiver-operating characteristic curve (AUROC) was calculated for each score. RESULTS Of the 278 study patients, 6.5% died and 35% experienced the composite clinical endpoint. The AIMS65 score was superior in predicting inpatient mortality (AUROC, 0.93 vs 0.68; P < .001), whereas the GBRS was superior in predicting blood transfusions (AUROC, 0.85 vs 0.65; P < .01) The 2 scores were similar in predicting the composite clinical endpoint (AUROC, 0.62 vs 0.68; P = .13) as well as the secondary outcomes. A GBRS of 10 and 12 or more maximized the sum of the sensitivity and specificity for inpatient mortality and rebleeding, respectively. The cutoff was 2 or more for the AIMS65 score for both outcomes. LIMITATIONS Retrospective, single-center study. CONCLUSION The AIMS65 score is superior to the GBRS in predicting inpatient mortality from UGIB, whereas the GBRS is superior for predicting blood transfusion. Both scores are similar in predicting the composite clinical endpoint and other outcomes in clinical care and resource use.

Endoscopy in the Elderly

With increasing age, the incidence of both benign and malignant gastrointestinal (GI) disease rises. Endoscopic procedures are commonly performed in elderly and very elderly patients to diagnose and treat GI disorders. There are a number of issues to contemplate when considering performing an endoscopic procedure in an elderly patient, including the anticipated benefits of endoscopy as well as the increased risks associated with procedural sedation and some endoscopic procedures. This review will focus on the yield and safety of endoscopic procedures in older adults.

Diagnostic yield of dual-phase computed tomography enterography in patients with obscure gastrointestinal bleeding and a non-diagnostic capsule endoscopy

Background and Aim:  In patients with obscure gastrointestinal (GI) bleeding, capsule endoscopy is widely used to determine the source of bleeding. However, there is currently no consensus on how to further evaluate patients with obscure GI bleeding with a non‐diagnostic capsule endoscopy examination. This study aims to determine the diagnostic yield of dual‐phase computed tomographic enterography (CTE) in patients with obscure GI bleeding and a non‐diagnostic capsule endoscopy.

Model to predict rebleeding following endoscopic therapy for non-variceal upper gastrointestinal hemorrhage

Background and Aim:  Following endoscopic therapy, up to 20% of patients with non‐variceal upper gastrointestinal hemorrhage experience rebleeding. The aim of the present study was to determine risk factors for recurrent hemorrhage in these patients.

Mentoring in Gastroenterology

The Women in Gastroenterology Committee of the American College of Gastroenterology (ACG) conducted a survey among physician members of the ACG to examine the influence of mentoring on career satisfaction. The survey found that the overall rates of career satisfaction and mentorship are high, and that a majority of those without mentors wish that they had had one. Having a mentor who was described as either very effective or extremely effective was associated with higher career satisfaction, but was reported by only 59% of respondents. Factors associated with effective mentoring include frequent meetings, career mentoring, and mentors who are at the rank of professor. If these mentoring rates are representative of rates in the United States, approximately 170 gastroenterology fellows lack mentorship but wish they had it, and 325 more have, at best, moderately effective mentors. We should consider instituting national programs to provide trainees with effective mentorship.

A Prospective, Multicenter Study of the AIMS65 Score Compared With the Glasgow-Blatchford Score in Predicting Upper Gastrointestinal Hemorrhage Outcomes.

Background: The AIMS65 score and the Glasgow-Blatchford risk score (GBRS) are validated preendoscopic risk scores for upper gastrointestinal hemorrhage (UGIH). Goals: To compare the 2 scores’ performance in predicting important outcomes in UGIH. Study: A prospective cohort study in 2 tertiary referral centers and 1 community teaching hospital. Adults with UGIH were included. The AIMS65 score and GBRS were calculated for each patient. The primary outcome was inpatient mortality. Secondary outcomes were 30-day mortality, in-hospital rebleeding, 30-day rebleeding, length of stay, and a composite endpoint of in-hospital mortality, transfusions, or need for intervention (endoscopic, radiologic, or surgical treatment). The area under the receiver operating characteristic curve (AUROC) was calculated for each score and outcome. Results: A total of 298 patients were enrolled. The AIMS65 score was superior to the GBRS in predicting in-hospital mortality (AUROC, 0.85 vs. 0.66; P<0.01) and length of stay (Somer’s D, 0.21 vs. 0.13; P=0.04). The scores were similar in predicting 30-day mortality (AUROC, 0.74 vs. 0.65; P=0.16), in-hospital rebleeding (AUROC, 0.69 vs. 0.62; P=0.19), 30-day rebleeding (AUROC, 0.63 vs. 0.63; P=0.90), and the composite outcome (AUROC, 0.57 vs. 0.59; P=0.49). The optimal cutoffs for predicting in-hospital mortality were an AIMS65 score of 3 and a GBRS score of 10. For predicting rebleeding, the optimal cutoffs were 2 and 10, respectively. Conclusions: The AIMS65 score is superior to the GBRS for predicting in-hospital mortality and hospital length of stay for patients with UGIH. The AIMS65 score and GBRS are similar in predicting 30-day mortality, rebleeding, and a composite endpoint.

Initial management and timing of endoscopy in nonvariceal upper GI bleeding.

Upper GI bleeding (UGIB) from a nonvariceal source is a common cause of hospital admission, accounting for nearly 300,000 hospitalizations per year in the United States alone. The costs to manage patients with UGIB are rising, with in-hospital nationwide expenditures increasing from

Initial Assessment and Resuscitation in Nonvariceal Upper Gastrointestinal Bleeding

3.3 billion in 1989 to

Denial: What Is It, How Do We Recognize It, and What Should We Do About It?

7.6 billion in 2009. Although the estimated mortality rate has been widely reported to be 5% to 14%, recent evidence suggests that in-hospital mortality has decreased to approximately 2%, most likely because of advances in both medical and endoscopic therapies. The initial management of patients with nonvariceal UGIB includes resuscitation, close hemodynamic monitoring, treatment with a proton pump inhibitor, management of antithrombotics, and, in some patients, blood transfusion. The next step in management is typically endoscopy. Current guidelines recommend that endoscopy be performed within 24 hours of presentation in patients with nonvariceal UGIB. However, the role of more urgent endoscopy, especially with regard to patients presenting with higher-risk bleeding episodes, remains controversial. In this article we review the existing literature on initial management of nonvariceal UGIB and on the timing of endoscopy.