Acute gastrointestinal bleeding cases presenting to the emergency department are associated with age, sex and seasonal and circadian factors

Vitamin-K Antagonists vs. Direct Oral Anticoagulants on Severity of Upper Gastrointestinal Bleeding: A Retrospective Analysis of Italian and UK Data

Background: Gastrointestinal bleeding (GIB) is one of most frequent and significant challenges for emergency physicians and gastroenterologists. Mortality for upper (U) GIB is high, especially in the elderly and comorbid patients. However, there is scant evidence in the literature concerning an assessment of warfarin (VKA) and direct oral anticoagulants (DOACs) in terms of upper gastrointestinal bleeding (UGIB) severity. Aims: Using data from two different settings (Italy and the UK), we aimed to compare the impact of VKA and DOACs on the severity of UGIB. Methods: Retrospective bicentric study on adult patients under VKA or DOACs admitted either to the emergency department at the Gemelli Hospital in Rome, Italy or University College Hospital in London, UK, with suspected UGIB from 01/01/2017 to 31/12/2018. Univariate analysis with Fisher’s exact test, and analysis of variance (ANOVA) were used. Results: 106 patients (62 M/44 F; mean age 71.2 ± 16.9 yrs) were enrolled and divided into the VKA group (N = 57; M: 56%, mean age: 64.9 ± 21.3 yrs) and the DOAC group (N = 49; M: 61%; mean age: 77.6 ± 12.5 yrs). At univariate analysis, the VKA group presented two endoscopic diagnoses more frequently than the DOAC group (26% vs. 8%, p < 0.05), were more frequently endoscopically treated (44% vs. 22%, p < 0.05), rescoped (12% vs. 2%, p = 0.048) and hospitalized (79% vs. 53%, p = 0.01) with a longer length of stay, LOS (VKA: 58% > 5 days vs. DOAC: 68% < 5 days, p = 0.01). There was no difference in terms of hemoglobin level on admission, however the requirement of blood transfusions was higher in the VKA group (60% vs. 41%, p = 0.041). One third of the VKA group showed a lower platelet count than the DOAC group (33% vs. 8%, p = 0.01). No statistically significant differences for in-hospital mortality were observed. For the ANOVA, the type of anticoagulant used was the only significant predictor of need to rescope (p = 0.041) and a significant co-predictor for a LOS > 5 days (p = 0.009; as well as cirrhosis, p = 0.013 and age, p = 0.005). Conclusions: Our outcomes revealed a more severe UGIB in patients on VKA, but the impact of comorbidities (i.e., more cirrhotic patients in the VKA group) cannot be disregarded. DOAC subgroup descriptive analysis, even though on a little cohort, showed higher bleeding severity for rivaroxaban.

Rhythmicity of patient flow in an acute medical unit: relationship to hospital occupancy, 7-day working and the effect of COVID-19

BACKGROUND

The Acute Medical Unit (AMU) provides care for unscheduled hospital admissions. Seven-day consultant presence and morning AMU discharges have been advocated to improve hospital bed management.

AIMS

To determine whether a later time of daily peak AMU occupancy correlates with measures of hospital stress; whether 7-day consultant presence, for COVID-19, abolished weekly periodicity of discharges.

DESIGN

Retrospective cohort analysis.

METHODS

: Anonymised AMU admission and discharge times were retrieved from the Profile Information Management System (PIMS), at a large, urban hospital from 14 April 2014 to 31 December 2018 and 20 March to 2 May 2020 (COVID-19 peak). Minute-by-minute admission and discharge times were combined to construct a running total of AMU bed occupancy. Fourier transforms were used to determine periodicity. We tested association between (i) average AMU occupancy and (ii) time of peak AMU occupancy, with measures of hospital stress (total medical bed occupancy and 'medical outliers' on non-medical wards).

RESULTS

: Daily, weekly and seasonal patterns of AMU bed occupancy were evident. Timing of AMU peak occupancy was unrelated to each measure of hospital stress: total medical inpatients (Spearman's rho, rs = 0.04, P = 0.24); number of medical outliers (rs = -0.06, P = 0.05). During COVID-19, daily bed occupancy was similar, with continuation of greater Friday and Monday discharges than the weekend.

CONCLUSIONS

: Timing of peak AMU occupancy did not alter with hospital stress. Efforts to increase morning AMU discharges are likely to have little effect on hospital performance. Seven-day consultant presence did not abolish weekly periodicity of discharges-other factors influence weekend discharges.

Seasonal variation of peptic ulcer disease, peptic ulcer bleeding, and acute pancreatitis: A nationwide population-based study using a common data model

Although gastrointestinal diseases are reported at various times throughout the year, some particular seasons are associated with a higher incidence of these diseases. This study aimed to identify the seasonal variations of peptic ulcer (PU), peptic ulcer bleeding (PUB), and acute pancreatitis (AP) in South Korea.We conducted a retrospective, observational cohort study of all subjects aged >18 years between 2012 and 2016 using the Health Insurance Review and Assessment-National Patient Samples database, previously converted to the standardized Observational Medical Outcomes Partnership-Common Data Model. We assessed the overall seasonal variations of PU, PUB, and AP and further analyzed seasonal variations according to age and sex subgroups.In total, 14,626 patients with PU, 3575 with PUB, and 9023 with AP were analyzed for 5 years. A clear seasonal variation was noted in PU, with the highest incidence rate during winter, the second highest during spring, the third highest during summer, and the lowest incidence during autumn for 5 years (P < .001). PUB also showed significant seasonal fluctuations, with winter peak for 4 years, except 1 year, which had a spring peak (P < .001). However, AP showed no clear seasonal variations (P = .090). No significant differences in the seasonal variation of PU, PUB, and AP were observed according to sex and age subgroups (<60 years vs ≥60 years).Seasonal variation of PU and PUB should be considered when determining allocation of available health care resources.

Establishment and Evaluation of a Time Series Model for Predicting the Seasonality of Acute Upper Gastrointestinal Bleeding

Objective

We aimed to establish and evaluate a time series model for predicting the seasonality of acute upper gastrointestinal bleeding (UGIB).

Methods

Patients with acute UGIB who were admitted to the Emergency Department and Gastrointestinal Endoscopy Center of Guangdong Provincial Hospital of Traditional Chinese Medicine from January 2013 to December 2019 were enrolled in the present study. The incidence trend of UGIB was analyzed by seasonal decomposition method. Then, exponential smoothing model and autoregressive integrated moving average model (ARIMA) were used to establish the model and forecast, respectively.

Results

Finally, the exponential smoothing model with better fitting and prediction effect was selected. The smooth R2 was 0.586, and the Ljung-Box Q (18) statistic value was 22.272 (P = 0.135). The incidence of UGIB had an obvious seasonal trend, with a peak in annual January and a seasonal factor of 140%. After that, the volatility had gradually declined, with a trough in August and a seasonal factor of 67.8%. Since then, it had gradually increased.

Conclusion

The prediction effect of exponential smoothing model is better, which can provide prevention and treatment strategies for UGIB, and provide objective guidance for more medical staff in Emergency Department and Gastrointestinal Endoscopy Center during the peak period of UGIB.