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O0014 ASSESMENT OF DISEASE-SEVERITY SCORING SYSTEMS FOR SEPTIC PATIENTS IN DEPARTMENTS OF INTERNAL MEDICINE
S6
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
Table 1. Correlation between D-Dimer cut-off of 1.0 and imaging results D-Dimer ≥1 <1
(+) Imaging
(–) Imaging
19 1
41 37
Methods: In our study we collected prospectively computerized data for septic patients admitted to Department of Internal Medicine at our hospital. For this purpose we developed a module that was incorporated into the Electronic Medical Record (EMR) system. The module identified patient with suspected infection that fulfilled criteria of systemic inflammatory response syndrome (SIRS) and automatically imposed a shift to computerized questionnaire that included structured forms and automatic data gathering. At the end of data recording the computer calculated for every patient the four different scores. Later, we followed survival up to 60 days. Using a logistic regression procedure we calculated the specificity and sensitivity, so we could draw the ROC curves for every scoring system. Results: Between February,1,2008 to June,30,2008 we gathered a computerized data of 353 patients admitted to Departments of Internal Medicine fulfilling sepsis criteria on admission. Mean age was 71.6 years. 51.3% were males. Mortality rate through the follow up period was 28.6%, 80% died in hospital. 28 day mortality was 22.1%. For every scoring systems assessed in our study we calculate the AUC (area under ROC curve) for the different four outcomes (in hospital mortality, 28 day in hospital mortality, 30 day mortality, 60 day mortality). For MEW score AUC was 0.67 to 0.71. REMS score AUC was 0.74 to 0.76. MEDS score AUC was 0.79 to 0.81 and that of Simple Clinical Score was 0.8 to 0.82. Summary/Conclusions: Ideal disease-severity scoring systems for septic patients admitted to a Department of Internal Medicine are not available yet. From the currently available scoring systems, the most appropriate for our study group were the Simple Clinical Score and the MEDS score with AUC of 0.8 and 0.82.
Figure 3. Sensitivity of D-Dimer in diagnosing DVT in risk stratified
O0015 ultrasound. Only 22.5% of patients sent for imaging were positive for DVT. In low risk patients who had been sent for imaging (n=97), a D-Dimer threshold of 1.0 (Table 1) yielded a sensitivity of 95%, specificity of 47.4%, positive predictive value of 32% and negative predictive value of 97.4% for DVT. By adjusting D-Dimer thresholds in the low risk population, the projected sensitivities were calculated (Figure 2). Increasing D-Dimer thresholds up to 2.2 did not compromise sensitivity, but reduced the number of patients sent for imaging by 29%. In the high or indeterminate risk group, a D-Dimer level of 1 yielded sensitivities of 78.9% and 86.4% respectively (Figure 3). Throughout the 6 month period, no patients returned with a missed case of DVT. Discussion and conclusion: In high or unknown risk patients, a low D-Dimer level alone is insufficient to exclude DVT. In low risk patients, D-Dimer thresholds of 1.0, even up to 2.2, offers sufficient sensitivity (95%) to discharge patients without the need for imaging. Longer term data is required before a higher cut-off can be determined and safely applied. Our results highlight the importance of risk stratification in DVT assessment and suggest that our algorithm is a safe and effective method in reducing the number of patients sent for imaging. Keywords: Deep vein thrombosis, DVT, D-Dimer, risk stratification
O0014 ASSESMENT OF DISEASE-SEVERITY SCORING SYSTEMS FOR SEPTIC PATIENTS IN DEPARTMENTS OF INTERNAL MEDICINE
Nesrin Ghanem-Zoabi, Arie Laor, Gabriel Weber, Moshe Vardi, Natalia Binderis, Haim Bitterman. Carmel Medical Center, Haifa, Israel. The Ruth and Bruce Rappaport Faculty of Medicine. Technion - Israel Institute of Technology Background: Sepsis is a major health issue. Elderly people are more prone to infections. As the population is getting older, patients with sepsis represent a growing percentage of the patients. Most of these patients are admitted to the Department of Internal Medicine. It is increasingly recognized that simple categorical descriptions of sepsis patients do not adequately characterize their illness severity and do not accurately define their mortality risk. Accurate identification of pretreatment severity of illness may improve precision in the evaluation of new therapies, and may assist in monitoring their utilization and refining their indications by identifying levels of severity for those clinical situations where certain therapies appear to be efficacious. Most of disease severity scoring systems were developed for ICU patients, out of which, many are post-surgical. Aims: To assess the suitability of four different scoring systems for septic patients hospitalized in Departments of Internal Medicine. The scoring systems examined in this study were MEW score, Simple Clinical Score, MEDS score and REMS score.
ROLE OF VAGAL NERVE INJURY ON INFLAMMATORY LUNG DISEASE DEVELOPMENT IN SUBARACHNOID HEMORRHAGE: EXPERIMENTAL STUDY
Mehmet Dumlu Aydin 1 , Mehmet Bilici 2 , Attila Eroglu 3 , Attila Turkyılmaz 3 , Cemal Gundogdu 4 . 1 Department of Neurosurgery, 2 Department of Medical Oncology, 3 Department of Lung Surgery, 4 Department of Pathology, Medical Faculty of Ataturk University, Erzurum, Turkey Background: Vagal sensory neurons relay information from the lungs’ chemoreceptor, baroreceptor pulmonary reflexes and breath rhtym. Autonomic denervation of vagal nerve cause pulmonary edema. The interruption of the nerve supply to the lungs may initiate fibroproliferative responses in the airway walls. Subarachnoid hemorrhage may cause neurogenic pulmonary edema and systemic fat embolism. Pulmonary contusion is a more important etiology in cerebral fat embolism and bacterial dissemination. Because chylomicrons and lymphatic fluid are transported into lungs via thoracic duct (1). Lungs have important role in immune functions (2). Alveolar epithelial macrophages, pulmonary T cells and immunomodulatory molecules secreted by lungs have an important roles in inflammatory processes. We aimed to investigate whether the effect of vagal nerve injury the development of fatty degeration of lungs in subarachnoid hemorrhage. Methods: This study has been conducted on 24 rabbits. Experimental SAH has been applied to half of the animals by injecting homologous blood into the cisterna magna, and the remaining half was applied only isotonic saline solution in the same manner under general anesthesia. After 20 days, all animals were killed. Their lungs, vagal nerves and brains were examined histopathologically. The results analysed with Mann-witney-U test Results: Eight animals died of SAH group and two animals of the control group between first days and 20 days. In the massive vagal nerve lesions (Figure 1) developed animals, subpleural hemorrhage (Figure 2) and pulmonary infiltrations focuses were observed. In histopathological analysis, intra-alveolar hemorrhage, lung edema, perivascular-peribronchial infiltarative changes were observed (Figure 3). But, minimal histopathological changes were found in the lungs of aniamals with have intact vagal nerves. Conclusions: In massive subaracnoid hemorrhage, intracranial parts of vagal neves may be injured due to mechanical compression and-or ischemic processes. Because vagal nerve functions block sympathetic hyperactivity, vagal nerve injuries may cause sympathetic overstimulation on the lungs. So, increased sympathetic hyperactivity may cause neurogenic lung edema, lung tissue destruction, fatty degeneration and fat embolism. In serious subarahnoid hemorrhage cases, vagal nerve injuries should be considered as respiration difficulties and lung pathologies. Literature: 1. Aydin MD, Akçay F, Aydin N, Gündogdu C.Cerebral fat embolism: pulmonary contusion is a more important etiology than long bone fractures. Clin Neuropathol. 2005 Mar-Apr;24(2):86-90.
Abstracts from 8th Congress of the European Federation of Internal Medicine / European Journal of Internal Medicine 20S (2009), S1–S283
Table 1. Correlation between D-Dimer cut-off of 1.0 and imaging results D-Dimer ≥1 <1
(+) Imaging
(–) Imaging
19 1
41 37
Methods: In our study we collected prospectively computerized data for septic patients admitted to Department of Internal Medicine at our hospital. For this purpose we developed a module that was incorporated into the Electronic Medical Record (EMR) system. The module identified patient with suspected infection that fulfilled criteria of systemic inflammatory response syndrome (SIRS) and automatically imposed a shift to computerized questionnaire that included structured forms and automatic data gathering. At the end of data recording the computer calculated for every patient the four different scores. Later, we followed survival up to 60 days. Using a logistic regression procedure we calculated the specificity and sensitivity, so we could draw the ROC curves for every scoring system. Results: Between February,1,2008 to June,30,2008 we gathered a computerized data of 353 patients admitted to Departments of Internal Medicine fulfilling sepsis criteria on admission. Mean age was 71.6 years. 51.3% were males. Mortality rate through the follow up period was 28.6%, 80% died in hospital. 28 day mortality was 22.1%. For every scoring systems assessed in our study we calculate the AUC (area under ROC curve) for the different four outcomes (in hospital mortality, 28 day in hospital mortality, 30 day mortality, 60 day mortality). For MEW score AUC was 0.67 to 0.71. REMS score AUC was 0.74 to 0.76. MEDS score AUC was 0.79 to 0.81 and that of Simple Clinical Score was 0.8 to 0.82. Summary/Conclusions: Ideal disease-severity scoring systems for septic patients admitted to a Department of Internal Medicine are not available yet. From the currently available scoring systems, the most appropriate for our study group were the Simple Clinical Score and the MEDS score with AUC of 0.8 and 0.82.
Figure 3. Sensitivity of D-Dimer in diagnosing DVT in risk stratified
O0015 ultrasound. Only 22.5% of patients sent for imaging were positive for DVT. In low risk patients who had been sent for imaging (n=97), a D-Dimer threshold of 1.0 (Table 1) yielded a sensitivity of 95%, specificity of 47.4%, positive predictive value of 32% and negative predictive value of 97.4% for DVT. By adjusting D-Dimer thresholds in the low risk population, the projected sensitivities were calculated (Figure 2). Increasing D-Dimer thresholds up to 2.2 did not compromise sensitivity, but reduced the number of patients sent for imaging by 29%. In the high or indeterminate risk group, a D-Dimer level of 1 yielded sensitivities of 78.9% and 86.4% respectively (Figure 3). Throughout the 6 month period, no patients returned with a missed case of DVT. Discussion and conclusion: In high or unknown risk patients, a low D-Dimer level alone is insufficient to exclude DVT. In low risk patients, D-Dimer thresholds of 1.0, even up to 2.2, offers sufficient sensitivity (95%) to discharge patients without the need for imaging. Longer term data is required before a higher cut-off can be determined and safely applied. Our results highlight the importance of risk stratification in DVT assessment and suggest that our algorithm is a safe and effective method in reducing the number of patients sent for imaging. Keywords: Deep vein thrombosis, DVT, D-Dimer, risk stratification
O0014 ASSESMENT OF DISEASE-SEVERITY SCORING SYSTEMS FOR SEPTIC PATIENTS IN DEPARTMENTS OF INTERNAL MEDICINE
Nesrin Ghanem-Zoabi, Arie Laor, Gabriel Weber, Moshe Vardi, Natalia Binderis, Haim Bitterman. Carmel Medical Center, Haifa, Israel. The Ruth and Bruce Rappaport Faculty of Medicine. Technion - Israel Institute of Technology Background: Sepsis is a major health issue. Elderly people are more prone to infections. As the population is getting older, patients with sepsis represent a growing percentage of the patients. Most of these patients are admitted to the Department of Internal Medicine. It is increasingly recognized that simple categorical descriptions of sepsis patients do not adequately characterize their illness severity and do not accurately define their mortality risk. Accurate identification of pretreatment severity of illness may improve precision in the evaluation of new therapies, and may assist in monitoring their utilization and refining their indications by identifying levels of severity for those clinical situations where certain therapies appear to be efficacious. Most of disease severity scoring systems were developed for ICU patients, out of which, many are post-surgical. Aims: To assess the suitability of four different scoring systems for septic patients hospitalized in Departments of Internal Medicine. The scoring systems examined in this study were MEW score, Simple Clinical Score, MEDS score and REMS score.
ROLE OF VAGAL NERVE INJURY ON INFLAMMATORY LUNG DISEASE DEVELOPMENT IN SUBARACHNOID HEMORRHAGE: EXPERIMENTAL STUDY
Mehmet Dumlu Aydin 1 , Mehmet Bilici 2 , Attila Eroglu 3 , Attila Turkyılmaz 3 , Cemal Gundogdu 4 . 1 Department of Neurosurgery, 2 Department of Medical Oncology, 3 Department of Lung Surgery, 4 Department of Pathology, Medical Faculty of Ataturk University, Erzurum, Turkey Background: Vagal sensory neurons relay information from the lungs’ chemoreceptor, baroreceptor pulmonary reflexes and breath rhtym. Autonomic denervation of vagal nerve cause pulmonary edema. The interruption of the nerve supply to the lungs may initiate fibroproliferative responses in the airway walls. Subarachnoid hemorrhage may cause neurogenic pulmonary edema and systemic fat embolism. Pulmonary contusion is a more important etiology in cerebral fat embolism and bacterial dissemination. Because chylomicrons and lymphatic fluid are transported into lungs via thoracic duct (1). Lungs have important role in immune functions (2). Alveolar epithelial macrophages, pulmonary T cells and immunomodulatory molecules secreted by lungs have an important roles in inflammatory processes. We aimed to investigate whether the effect of vagal nerve injury the development of fatty degeration of lungs in subarachnoid hemorrhage. Methods: This study has been conducted on 24 rabbits. Experimental SAH has been applied to half of the animals by injecting homologous blood into the cisterna magna, and the remaining half was applied only isotonic saline solution in the same manner under general anesthesia. After 20 days, all animals were killed. Their lungs, vagal nerves and brains were examined histopathologically. The results analysed with Mann-witney-U test Results: Eight animals died of SAH group and two animals of the control group between first days and 20 days. In the massive vagal nerve lesions (Figure 1) developed animals, subpleural hemorrhage (Figure 2) and pulmonary infiltrations focuses were observed. In histopathological analysis, intra-alveolar hemorrhage, lung edema, perivascular-peribronchial infiltarative changes were observed (Figure 3). But, minimal histopathological changes were found in the lungs of aniamals with have intact vagal nerves. Conclusions: In massive subaracnoid hemorrhage, intracranial parts of vagal neves may be injured due to mechanical compression and-or ischemic processes. Because vagal nerve functions block sympathetic hyperactivity, vagal nerve injuries may cause sympathetic overstimulation on the lungs. So, increased sympathetic hyperactivity may cause neurogenic lung edema, lung tissue destruction, fatty degeneration and fat embolism. In serious subarahnoid hemorrhage cases, vagal nerve injuries should be considered as respiration difficulties and lung pathologies. Literature: 1. Aydin MD, Akçay F, Aydin N, Gündogdu C.Cerebral fat embolism: pulmonary contusion is a more important etiology than long bone fractures. Clin Neuropathol. 2005 Mar-Apr;24(2):86-90.