Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018




Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."



Prof. Somashekhar Nimbalkar
Head, Department of Pediatrics, Pramukhswami Medical College, Karamsad
Chairman, Research Group, Charutar Arogya Mandal, Karamsad
National Joint Coordinator - Advanced IAP NNF NRP Program
Ex-Member, Governing Body, National Neonatology Forum, New Delhi
Ex-President - National Neonatology Forum Gujarat State Chapter
Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018




Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018




Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
Lucknow
On Sep 2018




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"My sincere attachment with JCDR as an author as well as reviewer is a learning experience . Their systematic approach in publication of article in various categories is really praiseworthy.
Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."



Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
Department of Pharmacology
Calcutta National Medical College & Hospital , Kolkata




Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
Associate Professor of Anatomy,
Muzaffarnagar Medical College,
Muzaffarnagar.
On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".



Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : PC07 - PC11 Full Version

PULP Score vs AAST EGS Grading System in Prediction of Outcome of Perforated Peptic Ulcer Disease: A Retrospective Study


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52227.16345
B Bharath, Gade Sagar Reddy, John M Francis

1. Associate Professor, Department of General Surgery, Rajarajeswari Medical College and Hospital, Bengaluru, Karnataka, India. 2. Resident, Department of General Surgery, PES institute of Medical Science, Kuppam, Andhra Pradesh, India. 3. Assistant Professor, General Surgery, PES institute of Medical Science, Kuppam, Andhra Pradesh, India.

Correspondence Address :
B Bharath,
S171 Dwarakavasa Road, Bharathnagar, 2nd Stage, BEL Layout, Bengaluru, Karnataka, India.
E-mail: bharathbasavraj@gmail.com

Abstract

Introduction: Peptic Ulcer Disease (PUD) is the most common diagnosis for upper abdomen pain, and it includes ulcerations and erosion in the Stomach and Duodenum. Complication such as Perforated PUD (PPUD) is only second to bleeding and remains a life-threatening emergency.

Aim: To compare the American Association for the Surgery of Trauma– Emergency General Surgery (AAST EGS) scoring system with a widely accepted Peptic Ulcer Perforation (PULP) scoring system for PULP to determine the discriminative capacity and pairwise comparison of both scoring systems.

Materials and Methods: This was a retrospective study conducted from September 2018 to August 2020 at Department of General Surgery, PES institute of Medical Science, Kuppam, Andhra Pradesh, India. All the adults diagnosed with perforated PUD were included. Preoperative, Intraoperative, and postoperative data were collected. The scores were generated for PULP and AAST EGS grades and analysed using Statistical Package for Social Sciences (SPSS) version 17.0. Spearman’s rho test evaluated a comparison of each variable with the AAST EGS grade. The pairwise comparison was performed for complication development, patient duration of stay, mortality and described using the Area Under the Receiver Operating Characteristic (AUROC) with 95% confidence intervals.

Results: This study included 165 patients in this 87% male with a mean age of 56.89±16.79 years. All the total patients were divided into those <=50 years (n=56,mean age:36.8±9.04 years) and >50 years (n=109,mean age: 67.2±8.4 years) and comparative analysis was performed accordingly. Overall, the patients were categorised into the following AAST EGS grade I (9, 5.5%), grade II (99, 60%), grade III (42, 25.45%), grade IV (15, 9%), there were no patients with grade 5 AAST EGS. The AAST EGS grade was comparatively better them PULP score for postoperative complications, but there is not much difference between the PULP score and AAST EGS score for the patient's duration of stay. AAST EGS grade and the PULP discriminated, patient 30-day mortality similarly, but if Area Under Curve (AUC) >0.8, it is a good predictor.

Conclusion: The AAST EGS scoring system and the PULP scoring system do similarly predict mortality and complication. But the presence of many variables with points and tabulation which requires laboratory investigation makes PULP scoring system inconvieninent at bedside.

Keywords

American association for the surgery of trauma, Emergency general surgery, Laparatomy, Peptic ulcer perforation

The PUD is used to include ulcerations and erosion in the stomach, and Duodenum, the risk factors of PUD are Helicobacter Pylori infection, non steroidal anti-inflammatory use, Zollinger Ellison Syndrome, and idiopathic (1). PPUD is only second to bleeding, has reported incidences of 4 to 14 per 100,000 individuals (2). Many scoring systems such as Boey's score, the PULP, or the American Society of Anesthesiologists scores (ASA) are used to estimate PPUD severity and mortality (3),(4). Perforation of the ulcer in both the Duodenum and stomach is an emergency surgical condition. It is a life-threatening emergency with 20–50% morbidity rates and 3–40% mortality rates in surgically treated Perforated Peptic Ulcer (PPU) patients (5). A recent comparison of PULP scoring system indicated the inability to assess patient risk of mortality and suggested that a particular combination of clinical variables predicted mortality with better results (5). Based on this, the AAST developed the AAST EGS grading system, which was based on a group of standard definitions based on the severity of the disease (6). This new scoring system was validated by Hernandez MC et al., (7). This study aimed to determine the discriminative power and compare it with the PULP scoring system with respect to the complication, duration of stay, morbidity, and mortality.

Material and Methods

This retrospective study was undertaken at the Department of General Surgery, PES institute of Medical Science, Kuppam, Andhra Pradesh, India, i.e. situated in a rural part of the tri-state junction of south India from September. PES Medical Research Centre approved the study (#PESIMSR/IHEC/25/2018).

Inclusion criteria: All patients who presented with PPUD who were willing to undergo surgery in the institute were included in the study.

Exclusion criteria: Those patients who refused treatment, biopsy-proven malignant perforation, patient death before the surgery, and conservatively managed PPUD were excluded from the study.

Procedure

Most of the patients who presented to the Emergency (ER) Department with severe abdominal pain were evaluated by ER consultants. If there is suspicion of perforation, the patient is resuscitated in an ER, upright chest x-ray (CXR) is done to detect air under the diaphragm, and the patient is seen by a surgeon within a maximum of 30 minutes. Once the diagnosis of perforated viscus is confirmed, the patient is operated on within 60–90 minutes postoperatively if needed, and patients are shifted to Intensive Care Unit (ICU) for further management.

The following data were collected: Baseline patient personal information, vital signs such as Heart Rate (HR) (beats per min), Systolic Blood Pressure (SBP) (mm hg), Respiratory Rate (RR) (breaths per min), and temperature (°C). Haemoglobin (mg/dL), albumin (mg/dL), leukocytosis (cell/l), intraoperative findings, types of complications, relaparotomy rate, histopathological report, duration of stay in the hospital including intensive care, and 30-day mortality.

The initial evaluation tabulated the score using the AAST EGS score for PPUD consists of five grades (I-V) that correlate with disease severity to clinical features, imaging reports, operative findings, and histopathological findings (Table/Fig 1) and the PULP score (Table/Fig 2). Patients assigned AAST EGS scores for operative and pathological criteria since all the other criteria are interrelated.

The comparison of both the scoring systems was done based on duration of stay,clavien dindo classification of complication (8) and complications.

Statistical Analysis

The data collected were analysed with Statistical Package for Social Sciences (SPSS) version 17.0. All the data is delineated using the mean with Standard Deviations (SD). The p-values <0.05 were considered statistically significant. Spearman’s rho test evaluated a comparison of each variable with the AAST EGS grade. The pairwise comparison was performed for complication development, patient duration of stay, mortality and described using the AUROC with 95% confidence intervals.

Results

In this study, a total of 165 patients with a mean age of 56±17 years were analysed. Out of these 165 patients, 87.27% (n=144) patients were males, and 12.72% (n=21) were female. And the majority of the patients belong to the age group >50 years. Two groups have been done to easily understand the severity of the disease and its complication, the first group is patients ≤50 years and the other >50 years.

AAST EGS grading: Overall, the AAST EGS patient grades were divided based on the age as equal or below 50 years and greater than 50 years basically to categorise the severity based on the age of the patient and it included (n,%) grade: I (9, 5.5%) there was no patients in grade I category above age 50, II (99, 60%) with total patients ≤50 year was 40 patients and >50 years was 59 patients, III (42, 25.45%) with total patients ≤50 year was 3 patients and >50 years was 39 patients, IV (15, 9%) with total patients ≤50 year was 4 patients and >50 years was 11 patients, there were no patients with grade 5 AAST EGS in the present study (Table/Fig 3).

The risk factors which patients presented (more than one possibility for each patient) for ulcers: 62 patients were diagnosed with Helicobacter pylori which accounted for 38% of the total patients, smoker 115 (69.7%), 9 patients were diagnosed to be retropositive, and the majority of these patients were aged ≤50 years (7 patients) and in this, 6 patients were categorised in grades 3 and 4. There was a significant association between smoking tobacco, tobacco chewing, chronic alcohol consumption (Table/Fig 4).

The patient demographics stratified based on AAST EGS grade (Table/Fig 3) with an overall mean age of 56.89±16.79 years, and the majority of the patient <50 years belong to 36.8±9.04 years and >50 years was 67.2±8.4 years. Overall the significant finding is that majority of the patient were aged >50 years, and as the grade increases; tachycardia and low blood pressure are noted, White Blood Cell (WBC) count too raised similarly (Table/Fig 3).

The postoperative outcome tabulated using the AAST EGS grades is presented in (Table/Fig 5). Postoperative complications such as mortality rates, acute kidney injury (AKI) are associated with increasing AAST EGS grade. The duration of hospital stay was not associated with AAST EGS grade and was statistically non-significant; the average number of days stayed was 10.1±1.01 days.

On Laparotomy, the site of perforation, the majority was pre pyloric perforation which was 119 (72.12%), and duodenal perforation 46 (27.87%). A 10.30% (n=17) of the patients were suffering from ischemic heart disease, 44.24% (n=73) were suffering from Chronic Obstructive Pulmonary Disease (COPD). A total of 54 patients (33%) needed inotropic support and presented with preoperative shock to emergency. A total of 147 (89.09%) patients had a history of PUD previously, 41 (24.84%) were diabetics, 9 (5.45%) were suffering from AIDS.
Out of 165 patients who presented with PPUD, all were treated by Graham omental patch procedure, and 2 patients developed acute wound dehiscence (burst abdomen). A 21% (n=34) of patients had postoperative pneumonia, 22.4% (n=37) had AKI, and 8.48% (n=14) died due to complications. Patients with the increased co-morbid condition had increased AAST EGS grades.

Pairwise comparison of PULP SCORE and AAST EGS: Pairwise comparisons of the PULP scores and the AAST EGS grade for the selected outcomes of 30-day mortality, duration of hospital stay, postoperative complication, and complication are demonstrated in (Table/Fig 7). The AAST EGS grade was comparatively better than the PULP score for postoperative complications. For the patient duration of stay, there is not much difference between the PULP score and AAST EGS score. AAST EGS grade and the PULP discriminated patient 30-day mortality similarly, but if AUC >0.8, it is a good predictor.

Variables related to high mortality and morbidity in the present study are treatment delay >24 hours, shock on admission, high ASA score, age >65 years. The sensitivity of the PULP SCORE in predicting mortality was 83.33%, whereas the specificity was 87.27%. with Positive Predictive Value (PPV) of 15.33% (Confidence Interval (CI): 12.69%-1 8.41%) and Negative Predictive Value (NPV) 40% (CI: 20.36%-63.48%), and the sensitivity of the AAST EGS scoring system in predicting mortality was 82.1%, whereas the specificity was 79.26%. with PPV of 63.16% (CI: 56.37%-69.46%) and NPV 43% (CI: 32.36%-63.48%), PULP score is better then AAST EGS in predicting mortality. The sensitivity of the PULP score in predicting complication was 83.2%, whereas the specificity was 73.06%. with PPV of 5.33% (CI: 3.29%- 8.54%) and NPV 40% (CI: 21.28%-62.18%) and the sensitivity of the AAST EGS scoring system in predicting complication was 96.8% whereas the specificity was 75.36%, with PPV of 24.56% (CI: 20.18%-29.54%) and NPV 100%. AAST EGS in predicting complications was better than the PULP score (Table/Fig 7).

Discussion

There are numerous studies about the PULP scoring system in predicting 30-day mortality of the PPU (5). In this study, numerous clinical factors predict 30-day mortality, such as increased age, delay in presentation to the hospital, including delayed surgery, high ASA score, and shock on admission. The AUC for both the PULP and AAST EGS scores is similar, i.e., 0.56, which is comparatively less than the study done by Møller MH et al., which is 0.83, Thorsen K et al., which is 0.75, and study done by Patel S et al., which is 0.804 (4),(5),(9). AUC in predicting mortality by Menekse E et al., 0.955, by Anbalakan K et al., is 0.75 (10),(11).

The sensitivity of the PULP score in predicting mortality in this study is 83.33% (Table/Fig 9), which is high when compared to study done by Patel S et al., which is 75%, Anbalakan K et al., is 62.5% but lower when compared to study done by Thorsen K et al., is 92.9% (5),(9),(11). The specificity of the PULP Score in predicting mortality was 87.27% which is similar to a study done by Patel S et al., which is 85.71%, Anbalakan K et al., is 87.3%, while it was lower in a study done by Thorsen K et al., is 58.3% (5),(8),(10). The PPV of PULP Score in predicting mortality was 15.33% (CI: 12.69%-1 8.41%) which was less than the study done by Patel S et al., which is 36.8%, Anbalakan K et al., is 27.8% (9),(11). The NPV of PULP Score in predicting mortality was 40% (CI: 20.36%- 63.48%) which was less than the study done by Patel S et al., which is 96.9%, Anbalakan K et al., is 96.8% (9),(11).

The sensitivity for predicting mortality of the AAST EGS scoring system is 82.1%, whereas the specificity was 79.26%. with PPV of 63.16 %(CI: 56.37%- 69.46%) and NPV 43% (CI: 32.36%- 63.48%) and the sensitivity of the AAST EGS scoring system in predicting mortality was 96.8% whereas the specificity was 75.36%,with PPV of 24.56%(CI: 20.18%-29.54%) and NPV 100%. While the study done by Hernandez MC et al., doesn’t mention specificity, sensitivity. AUC, PPV, NPV (7). But do mention that there is similar discrimination in predicting 30-day mortality and complication similar to the PULP score. This is the first study which has analysed these results and hence further more studies are required to validate the scoring system and its result.

The 30-day post PPU repair mortality (8.48%) of the current study was comparable to the PPU repair mortality reported in Thailand (9%), Singapore (7.2%), Norway (16.3%), and Denmark (17%) (5),(10),(11),(12), but still on a higher side when compared to the recent study done by Saafan T et al., which was 0.7% (14). Kocer B et al., stated that mortality was 37.3% above 65 years and 1.4% below 65 years (15). Testini M et al., and Agarwal A et al., also revealed similar results (16),(17).

A study by Taş İ et al., reported the familiar site of perforation was in the pre-pyloric region, accounting for 68.2% and duodenum in 31.8% (18). As for patient characteristics, in terms of demography, our sample’s mean age is 56.9, which is comparable to others Menekse E et al., 50.6 years, Lohsiriwat V et al., 48 years Bojanapu S et al., 52.3 years, but higher to Saafan T et al., which was 37.41 years and Arveen S et al., which was 40-43.4 years (10),(12),(14),(19),(20). Numerous Studies in India determining the Sex ratio, such as the study by Bojanapu S et al., sex ratio (male:female) was 2.3:1 and study by Arveen S et al., is 10.5:1, which is comparable to the present study which was 6.8:1, and similarly in the African population, it is 4.8:1 (19),(20),(21) indicating more incidence of perforation in the male population. A study done in South Korea by Kim JM et al., found that female sex and age >60 years is associated with a high mortality rate (22).

In the present study, haemoglobin with a p-value of 0.12 and white blood cell count with a p-value of 0.21 was not significantly associated with 30-day morbidity. Lower haemoglobin was significantly associated with 30-day morbidity. Saafan T et al., has reported that reduced Hb is indicated too high 30-day mortality (14).

In the current study, morbidity and mortality might be due to mean age of the patient 56.89±16.79 years, and the majority of the patients were >50 year old, majority were chronic smokers and alcoholics with co-morbid conditions and predominantly male population , as was also observed in previous study (23).

In a study by Arveen S et al., done in South India, the mean hospital stay was 10.9±6.8 days, and Tas¸ I? et al., reported a mean hospital stay of 8.7±4.6 days with a maximum duration of 44 days which was similar to the present study which is 10.09 days (18),(19). In the present study, alcohol consumption was 68.48%, and smoking was 63.6%, similar to a study in a tertiary hospital in Tanzania where 85.7% consumed alcohol, and 64.3% were smokers (24). Chalya P et. al, Ekka NM and Malua S, also reported, similarly, 65.73% were chronic smokers while 42.86% of patients consumed alcohol (24),(25). But Bupicha JA et al., reported that the use of alcohol and smoking was found in 45.4 and 33% of the present study patients, respectively which was considerably lower (26). A 75.3% of the present study patients gave a history of PUD, similar to reports from Tanzania (24), where 69% had a PUD history. Still, in the study in Irrua, Nigeria, 59.6% had no history of PUD (27). The use of an ideal and widely accepted scoring system which has been validated in predicting mortality and complication of the disease, such as PULP score with AAST EGS classification, which is a relatively new scoring system that is entirely dependent on clinico- pathological and imaging and not on laboratory reports helps the clinician to predict the prognosis includes morbidity and mortality of the patient who plays a crucial part in the current scenario of counseling the family, cost-benefit and medicolegal implications.

Limitation(s)

Incorporating comorbidity status and the severity of the disease to the AAST EGS grade might improve the categorisation and early identification of the individuals at high risk. AAST EGS grade 5 was not present in the present study, which may have under-represented the extent of disease severity. Surgery for perforation was limited to Laparotomy followed by Graham omentoplasty, and procedures such as laparoscopic Grahams omentoplasty, ulcerectomy, or gastrectomy are limited.

Conclusion

PPUD is a common surgical emergency with numerous aetiologies, hence, this study found that elderly age, preoperative organ dysfunction, and late presentation are associated with the poor outcome with a more extended stay in ICU. AAST EGS scoring system and the PULP scoring system do similarly predict mortality and complication. But the presence of many variables with points and tabulation which requires laboratory investigation makes PULP scoring system inconvieninent at bedside, while AAST EGS scoring system is convenient to tabulate and predict the same result easily. Still, the lack of incorporation of co-morbid disease in AAST EGS for PPU points to the need for further more studies with a larger sample at different centres which needs to be prospectively analysed for more acceptability of this scoring system.

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DOI and Others

DOI: 10.7860/JCDR/2022/52227.16345

Date of Submission: Oct 07, 2021
Date of Peer Review: Nov 23, 2021
Date of Acceptance: Feb 11, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? NA
• For any images presented appropriate consent has been obtained from the subjects. NA

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Oct 08, 2021
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• iThenticate Software: Feb 07, 2021 (15%)

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