Lower Endoscopic Diagnostic Yields Observed in Non-hematemesis Gastrointestinal Bleeding Patients.

BACKGROUND: Location of bleeding can present a diagnostic challenge in patients without hematemesis more so than those with hematemesis. AIM: To describe endoscopic diagnostic yields in both hematemesis and non-hematemesis gastrointestinal bleeding patient populations. METHODS: A retrospective analysis on a cohort of 343 consecutively identified gastrointestinal bleeding patients admitted to a tertiary care center emergency department with hematemesis and non-hematemesis over a 12-month period. Data obtained included presenting symptoms, diagnostic lesions, procedure types with diagnostic yields, and hours to diagnosis. RESULTS: The hematemesis group (n = 105) took on average 15.6 h to reach a diagnosis versus 30.0 h in the non-hematemesis group (n = 231), (p = 0.005). In the non-hematemesis group, the first procedure was diagnostic only 53% of the time versus 71% in the hematemesis group (p = 0.02). 25% of patients in the non-hematemesis group required multiple procedures versus 10% in the hematemesis group (p = 0.004). Diagnostic yield for a primary esophagogastroduodenoscopy was 71% for the hematemesis group versus 50% for the non-hematemesis group (p = 0.01). Primary colonoscopies were diagnostic in 54% of patients and 12.5% as a secondary procedure in the non-hematemesis group. A primary video capsule endoscopy yielded a diagnosis in 79% of non-hematemesis patients (n = 14) and had a 70% overall diagnostic rate (n = 33). CONCLUSION: Non-hematemesis gastrointestinal bleeding patients undergo multiple non-diagnostic tests and have longer times to diagnosis and then compared those with hematemesis. The high yield of video capsule endoscopy in the non-hematemesis group suggests a role for this device in this context and warrants further investigation.

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.

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. 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.

Further evidence of the association between periodontal conditions and coronary artery disease.

BACKGROUND: There is increasing evidence that chronic infections, such as periodontal diseases, could play a role in the initiation and development of coronary artery disease (CAD). The present study was intended to test for a possible association between presence and severity of periodontitis and coronary artery disease in a Belgian population. METHODS: A total of 108 CAD patients (mean age 59.2 +/- 11 years) and 62 presumably healthy controls (mean age 57.7 +/- 9 years) were enrolled in the study. Probing depth, periodontal pocket bleeding index (PPBI), plaque index, furcation involvements, and tooth mobility were evaluated to compare periodontal health in both groups. The subjects were also ranked according to a novel index of periodontitis severity, the periodontal index for risk of infectiousness (PIRI), aimed at quantifying the risk of release of proinflammatory mediators from the periodontal sites. RESULTS: Periodontitis was significantly more frequent in CAD patients than in controls (CAD patients: 91%; controls: 66%). The mean number of pockets was 18 +/- 17.1 in cardiac patients versus 7.6 +/- 12.7 in controls (P < 0.0001), despite the fact that the mean number of missing teeth was significantly greater in cases than in controls (14 +/- 7.1 versus 9 +/- 5.2; P < 0.0001). Furthermore, proportions of mobile teeth, bleeding sites, periodontal pockets, and involved furcations were significantly higher in CAD patients than in controls. In addition, the extent of the periodontal disease present was also greater in cases than in controls. A logistic model, adjusted for known cardiovascular risk factors, showed a strong association between CAD and periodontitis (odds ratio [OR] = 6.5). Moreover, there was a significant dose-response relationship between increasing scores of the periodontal risk of infectiousness and the presence of CAD (adjusted OR = 1.3 per PIRI unit). CONCLUSION: In the present study, periodontitis was revealed to be a significant risk factor for CAD after adjusting for other confounding factors, with the level of association increasing with the individual extent of the periodontal lesions.

Experimental comparison of cavity sealing ability of five dental adhesive systems after thermocycling.

PURPOSE: To evaluate the cavity sealing obtained after thermocycling with five adhesive systems in which one all-in-one adhesive was compared to three one-bottle adhesives, and to observe the effect of a low-charged resin layer added to a one-bottle adhesive. MATERIALS AND METHODS: Twenty-five recently extracted teeth were randomly allocated to five experimental adhesive systems (n = 5 each): Optibond Solo (OS), Scotchbond 1 (SB1), PQ 1, Prompt-L-Pop (PLP), SB1+Revolution (R). On each tooth, two rectangular cavities at the cementoenamel junction were filled with a microhybrid composite (Z100) and the tested adhesives. Teeth were thermocycled and stained with AgNO3 + vitamin C. Leakage was evaluated on a 6-point (0-5) severity scale and the highest score was selected for each restoration. Results were treated by ordinal logistic regression and considered to be significant at p < 0.05. RESULTS: No significant difference was found between leakage values for enamel and dentin interfaces. Leakage scores never exceeded 2 for OS, SB1 and SB1+R, while they reached a maximum of 5 in 20% of PLP cases. OS was significantly better than the other adhesive systems, which were statistically equivalent. The addition of a flowable composite layer on SB1 did not yield a significant difference, but tended to give better results mainly at the dentin interface. CONCLUSION: The all-in-one adhesive PLP, because of quite variable results, seems less reliable than the one-bottle adhesives, of which OS provides significantly the best results. Addition of a flowable composite on SB1 appears to yield slightly better results.

Systemic release of endotoxins induced by gentle mastication: association with periodontitis severity.

BACKGROUND: Periodontitis has recently been identified as a potential risk factor for systemic pathologies such as cardiovascular disease, the hypothesis being that periodontal pockets could release pro-inflammatory bacterial components, for instance endotoxins, into the bloodstream. It is known that the oral cavity can be a source of circulating bacteria, but this has never been shown for bacterial endotoxins, and no evidence exists so far that the risk of systemic injury is related to the severity of periodontitis. The aim of the present study was to test the influence of gentle mastication on the occurrence of endotoxemia in patients with or without periodontal disease. METHODS: A total of 67 subjects were periodontally examined and grouped according to their periodontal status. This classification was based on an original index of severity of periodontal disease (periodontal index for risk of infectiousness, PIRI) aimed at reflecting the individual risk of systemic injury from the periodontal niches. Thus, the patients were classified into 3 risk groups: low, PIRI = 0; n = 25; moderate, 1 < or = PIRI < or = 5, n = 27; and high 6 < or = PIRI < or = 10, n = 15. Blood samples were collected before and 5 to 10 minutes after a standardized session of gentle mastication for detection of circulating endotoxins. Blood samples were tested with a chromogenic limulus amoebocyte lysate assay. RESULTS: Overall, blood levels of endotoxin after mastication were found to be significantly higher than before mastication (0.89 +/- 3.3 pg/ml versus 3.0 +/- 5.8 pg/ml; P= 0.0002). Likewise, the incidence of positive endotoxemia rose from 6% before mastication to 24% after mastication (P = 0.001). When accounting for the PIRI index, endotoxin levels and positive endotoxemia proved to be significantly higher in patients with severe periodontal disease than in the subjects with low or moderate periodontitis. CONCLUSIONS: Gentle mastication is able to induce the release of bacterial endotoxins from oral origin into the bloodstream, especially when patients have severe periodontal disease. This finding suggests that a diseased periodontium can be a major and underestimated source of chronic, or even permanent, release of bacterial pro-inflammatory components into the bloodstream.