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Background: Mortality and morbidity are considerable after treatment for perforated peptic ulcer (PPU). Since 2003, a Danish nationwide quality-of-care (QOC) improvement initiative has focused on reducing preoperative delay, and improving perioperative monitoring and care for patients with PPU. The present study reports the results of this initiative., Methods: This was a nationwide cohort study based on prospectively collected data, involving all hospitals caring for patients with PPU in Denmark. Details of patients treated surgically for PPU between September 2004 and August 2011 were reported to the Danish Clinical Register of Emergency Surgery. Changes in baseline patient characteristics and in seven QOC indicators are presented, including relative risks (RRs) for achievement of the indicators., Results: The study included 2989 patients. An increasing number fulfilled the following four QOC indicators in 2010-2011 compared with the first 2 years of monitoring: preoperative delay no more than 6 h (59·0 versus 54·0 per cent; P = 0·030), daily monitoring of bodyweight (48·0 versus 29·0 per cent; P < 0·001), daily monitoring of fluid balance (79·0 versus 74·0 per cent; P = 0·010) and daily monitoring of vital signs (80·0 versus 68·0 per cent; P < 0·001). A lower proportion of patients had discontinuation of routine prophylactic antibiotics (82·0 versus 90·0 per cent; P < 0·001). Adjusted 30-day mortality decreased non-significantly from 2005-2006 to 2010-2011 (adjusted RR 0·87, 95 per cent confidence interval 0·76 to 1·00), whereas the rate of reoperative surgery remained unchanged (adjusted RR 0·98, 0·78 to 1·23)., Conclusion: This nationwide quality improvement initiative was associated with reduced preoperative delay and improved perioperative monitoring in patients with PPU. A non-significant improvement was seen in 30-day mortality., (Copyright © 2013 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Accurate and early identification of high-risk surgical patients with perforated peptic ulcer (PPU) is important for triage and risk stratification. The objective of the present study was to develop a new and improved clinical rule to predict mortality in patients following surgical treatment for PPU., Design: nationwide cohort study based on prospectively collected data., Setting: thirty-five hospitals in Denmark., Patients: a total of 2668 patients surgically treated for gastric or duodenal PPU between 1 February 2003 and 31 August 2009., Outcome Measure: 30-day mortality., Results: We derived a new clinical prediction rule for 30-day mortality and evaluated and compared its prognostic performance with the American Society of Anaesthesiologists (ASA) and Boey scores. A total of 708 patients (27%) died within 30 days of surgery. The Peptic Ulcer Perforation (PULP) score - comprised eight variables with an adjusted odds ratio of more than 1.28: 1) age > 65 years, 2) active malignant disease or AIDS, 3) liver cirrhosis, 4) steroid use, 5) time from perforation to admission > 24 h, 6) pre-operative shock, 7) serum creatinine > 130 μM, and 8) the four levels of the ASA score (from 2 to 5). The score predicted mortality well (area under receiver operating characteristics curve (AUC) 0.83). It performed considerably better than the Boey score (AUC 0.70) and better than the ASA score alone (AUC 0.78)., Conclusion: The PULP score accurately predicts 30-day mortality in patients operated for PPU and can assist in risk stratification and triage., (© 2011 The Authors Acta Anaesthesiologica Scandinavica © 2011 The Acta Anaesthesiologica Scandinavica Foundation.)

Background: Morbidity and mortality rates in patients with perforated peptic ulcer (PPU) remain substantial. The aim of the present study was to evaluate the effect of a multimodal and multidisciplinary perioperative care protocol on mortality in patients with PPU., Methods: This was an externally controlled multicentre trial set in seven gastrointestinal departments in Denmark. Consecutive patients who underwent surgery for gastric or duodenal PPU between 1 January 2008 and 31 December 2009 were treated according to a multimodal and multidisciplinary evidence-based perioperative care protocol. The 30-day mortality rate in this group was compared with rates in historical and concurrent national controls., Results: The 30-day mortality rate following PPU was 17·1 per cent in the intervention group, compared with 27·0 per cent in the three control groups (P = 0·005). This corresponded to a relative risk of 0·63 (95 per cent confidence interval 0·41 to 0·97), a relative risk reduction of 37 (5 to 58) per cent and a number needed to treat of 10 (6 to 38)., Conclusion: The 30-day mortality rate in patients with PPU was reduced by more than one-third after the implementation of a multimodal and multidisciplinary perioperative care protocol, compared with conventional treatment., Registration Number: NCT00624169 (http://www.clinicaltrials.gov)., (Copyright © 2011 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.)

Background: Peptic ulcer perforation is a serious surgical emergency with a substantial short-term mortality, but the influence of antipsychotic drug use on the prognosis remains unknown., Aim: To examine the association between antipsychotic drug use and 30-day mortality following peptic ulcer perforation., Methods: This cohort study comprised 2033 patients with a first-time hospitalization with peptic ulcer perforation, in Northern Denmark, between 1991 and 2004. Data on preadmission use of antipsychotics and other medications, psychiatric disease, other comorbidities and mortality were obtained through population-based medical databases. We used Cox regression analyses to compute adjusted mortality rate ratios (MRRs)., Results: One hundred and sixteen (5.7%) patients with peptic ulcer perforation were current users of antipsychotic drugs at the time of hospital admission and 205 (10.1%) were former users. The overall 30-day mortality was 27%. Among current users of antipsychotics 30-day mortality was 39%. The adjusted 30-day MRR for current users of antipsychotic drugs compared with non-users was 1.7 (95% CI: 1.2-2.3). Former use was not a predictor of mortality. The increase in mortality was equal in users of conventional and atypical antipsychotics., Conclusion: Use of antipsychotic drugs is associated with substantially increased mortality following peptic ulcer perforation.

Background: Limited data exist on the impact of the introduction of newer selective cyclo-oxygenase-2 inhibitors into clinical practice in 1999 on overall non-steroidal anti-inflammatory drug use and hospitalization rates of complicated peptic ulcer disease at the population level., Aim: To examine these issues, we conducted a population-based study in western Denmark, within a population of 1.2 million., Methods: All patients with perforated (n = 1488) or bleeding peptic ulcer (n = 6017) between 1996 and 2004 were identified in hospital discharge registries. We computed standardized annual hospitalization rates and hospitalization rate ratios using Poisson regression. Data on annual number of prescriptions for non-steroidal anti-inflammatory drugs were obtained through population-based prescription databases. Results Introduction of newer selective cyclo-oxygenase-2 inhibitors was followed by a 44% increase in the annual number of prescriptions for non-steroidal anti-inflammatory drugs--almost entirely due to increased use of newer selective cyclo-oxygenase-2 inhibitors. Annual standardized hospitalization rates for bleeding peptic ulcer remained stable. Standardized hospitalization rates for perforated peptic ulcer decreased from 17 per 100,000 person-years in 1996 to 12 per 100,000 person-years in 2004 (HRR 0.71; 95% CI: 0.57-0.88). Conclusion Introduction of newer selective cyclo-oxygenase-2 inhibitors was followed by substantial increase in overall non-steroidal anti-inflammatory drug use and coincided with stable and decreasing hospitalization rates for bleeding and perforated peptic ulcer, respectively.

Background: Despite evidence that use of glucocorticoids increases the risk of complicated peptic ulcer disease, limited data exist on how use of oral glucocorticoids affects outcome for patients with peptic ulcer perforation., Aim: To examine 30-day mortality from peptic ulcer perforation among pre-admission oral glucocorticoid users compared with non-users., Methods: We identified 2061 patients with a first-time hospital discharge diagnosis of perforated peptic ulcer, using population-based discharge registries in three Danish counties. Data on use of glucocorticoids and other ulcer-related drugs, previous hospitalizations for uncomplicated peptic ulcer disease, and comorbidity were obtained from discharge registries and prescription databases. Follow-up data on mortality were provided by the Danish Civil Registry System., Results: A total of 228 patients (11.1%) were exposed to glucocorticoids within 60 days of admission. Overall 30-day mortality rate was 25.2%, the corresponding rate among current glucocorticoid users was 39.4%. Compared with 'never users', the adjusted mortality ratio among current users of oral glucocorticoids alone was 2.1 (95% CI: 1.5-3.1). Among current users of oral glucocorticoids in combination with other ulcer-related drugs the mortality ratio was 1.5 (95% CI: 1.1-2.1)., Conclusion: Pre-admission use of oral glucocorticoids is associated with up to a twofold increase in 30-day mortality among patients hospitalized with perforated peptic ulcer.