Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Oakland K, Jairath V, Uberoi R, et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. Lancet Gastroenterol Hepatol 17; published online June 3. http://dx.doi.org/1.116/s46-153(17)315-4.
Supplementary Table 1: Previously described risk scores for upper and lower gastrointestinal bleeding Score Variables Predicted Outcomes PRE-ENDOSCOPY ROCKALL 1 BLATCHFORD BLEED 3 AIMS65 4 STRATE 5 NOBLADS 6 Age On-going bleeding Albumin <3g/l HR 1 <6 SBP<1 INR>1.5 SBP 115 6-79 PT>1. Altered mental status Syncope > Erratic mental status SBP 9 Non-tender abdominal examination Shock Unstable co-morbid disease Age>65 Bleeding per rectum in first 4 hours of No shock (defined as organ presentation HR>1 and SBP>1 derangement requiring ICU Aspirin use SBP<1 admission) > active Charslon co-morbid conditions Co-morbidity Nil major CHF, IHD, any major morbidity renal failure, liver failure, metastatic cancer Urea 6.5- -1 1-5 >5 Hb M 1. F 1.-11.9 M 1.-11.9 (no F) M <1 SBP 1-19 9-99 <9 Other HR>=1 Melaena Syncope Hepatic disease Cardiac failure Death and re-bleeding Need for intervention In-hospital complications and mortality LOS and mortality Severe haemorrhage* used a surrogate marker of patients that will require substantial support and early interventions * NSAIDs No diarrhoea No abdominal tenderness SBP 1 Non-aspirin antiplatelet Albumin <3g/l > active Charslon comorbid conditions Severe haemorrhage*, transfusion, LOS, need for intervention * Severe haemorrhage defined as requirement of >= units red cells OR decrease in Hct of >=% in first 4 hours, OR additional transfusion OR further decrease in Hct >=% after 4 hours of clinical stability OR re-admission with LGIB within one week 7 1
Supplementary Table : Sources of bleeding Diverticular disease Colitis Colorectal cancer Haemorrhoids and other benign anorectal disorders Polyps Post-polypectomy Angiodysplasia Small bowel bleeding Unknown Other* Development Cohort N=336 645 (7.6) 6 (11.5) 16 (4.5) 39 (16.7) 55 (.4) 5 (.1) 3 (1.) (.3) 55 (3.5) 131 (5.6) 93 Validation Cohort N= 4 (9.) 37 (1.) 13 (4.5) 3 (13.) 7 (.4) 3 (1.) 1 (4.) 3 (1.) 6 (3.6) 6 (9.) *aortoenteric fistula, drug induced LGIB, caecal varices, arteriovenous malformation, colonic perforation, colonic endometriosis, intussusception, Meckel s diverticulum, post-endoscopic biopsy, stenting, post-trans anal endoscopic microsurgery Supplementary Table 3: The inpatient use of endoscopy and interventional radiology OGD Colonoscopy Flexible sigmoidoscopy Capsule endoscopy Endoscopic haemostasis Mesenteric angiography ± embolisation Development Cohort N=336 56 (11.) 37 9 (3.9) 46 47 (.) 44 (.3) 49 41 (1.) 153 3 (1.4) 57 Validation Cohort N= 37 (1.) 9 67 (3.3) 43 (14.9) 1 (.3) 13 (4.5) 15 (5.)
Supplementary Table 4: Final prediction model for safe discharge Predictor Coefficient Standard error P-value Intercept -5 5 574 < 1 Age - 7 34 37 Gender - 764 115 14 Previous LGIB admission - 3 1474 5 DRE findings - 497 1357 3 Heart rate - 117 33 3 Systolic blood pressure 135 5 < 1 Haemoglobin 53 6 < 1 Supplementary Table 5: Number of patients safely discharged by score Score 1 3 4 5 6 7 9 1 11 1 13 14 15 16 17 1 19 Safely discharged % (N) Development cohort 1. (1). () 1. (). (15) 3.3 (5) 1.7 (49). (75).9 (76) 4.5 (71) 79. (64) 5.1 (57) 71.6 (53) 1.5 (53) 76.5 (39) 56.5 (6) 51. (1) 5. (9) 34. (17) Validation cohort 1. (1) 1 () 1 () 91.7 (11) 6.7 (13) 5. (17) 76.5 (13) 76.5 (13) 3.3 (1) 61.5 () 73.7 (14) 3.3 (1) 47.1 () 69. (9). ().6 (4) 3
Supplementary Figure 1: Calibration plot of the final prediction model for safe discharge in the validation cohort.. 95% confidence intervals around the observed predictions (triangle) at tenths of predicted risk. Appendix References 1. Rockall TA, Logan RF, Devlin HB, et al. Risk assessment after acute upper gastrointestinal haemorrhage. Gut 1996;3(3):316-1.. Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment for uppergastrointestinal haemorrhage. Lancet (London, England) ;356(93):131-1. 3. Kollef MH, O'Brien JD, Zuckerman GR, et al. BLEED: a classification tool to predict outcomes in patients with acute upper and lower gastrointestinal hemorrhage. Critical care medicine 1997;5(7):115-3. 4. Saltzman JR, Tabak YP, Hyett BH, et al. A simple risk score accurately predicts in-hospital mortality, length of stay, and cost in acute upper GI bleeding. Gastrointest Endosc 11;74(6):115-4. 5. Strate LL, Orav EJ, Syngal S.Early predictors of severity in acute lower intestinal tract bleeding. Archives of internal medicine 3;163(7):3-43. 6. Aoki T, Nagata N, Shimbo T, et al. Development and Validation of a Risk Scoring System for Severe Acute Lower Gastrointestinal Bleeding. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 16;14(11):156-7.e. 4