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STATE SEVERITY ASSESSMENT IN PATIENTS WITH OBSTRUCTIVE
JAUNDICE USING PMGMU2018H SCALE ADAPTED TO THE
RUSSIAN MEDICAL AND ECONOMIC STANDARDS
Rustamov Zoxidjon Vaxidjon o'g'li
Karimova Xurliqo Elmurodovna
Azimova Aziza Azimovna
SAMARKAND STATE MEDICAL UNIVERSITY
https://doi.org/10.5281/zenodo.13767552
The aim of the study was to assess the effectivity of PMGMU2018h scale for
evaluation of the state severity degree of patients suffering from obstructive
jaundice relative to other common assessment scales.
Key words
: formula of the severity degree for patients with jaundice;
indicators of obstructive jaundice;
Materials and Methods
Thirty physical and laboratory indicators have been studied in 258 patients
with obstructive jaundice treated in three medical settings: N.V. Sklifosovsky
Research Institute of Emergency Care, Clinical Center of I.M. Sechenov First
Moscow State Medical University (Sechenov University), and Pushkino District
Hospital named after Prof. V.N. Rozanova from 1996 to 2014.
Statistical data processing. To quantify the severity degree of a patient at any
time with the help of the multivariate linear regression analysis using a universal
statistical program package StatSoft Statistica 10.0 for MS Exel, a mathematical
relation has been established between the clinical quantitative parameters and
the probability of a lethal outcome or recovery. The principle and methodology
of calculations have been reported by the authors in detail in their previous
works [13, 14]. As a result, 9 factors significant for the quantitative definition of
the patient’s state severity have been determined.
Results and Discussion
Due to the subjective factor in determining the state severity by a surgeon,
there are always doubts in the identity of this definition not only by the specialists
of various clinics but physicians within the same unit as well. However, the
objective assessment of the patient’s state severity in a surgical pathology of the
abdominal cavity and determination of the unfavorable outcome probability
present some difficulties.
One of the most common integral systems for severity evaluation is APACHE
II which assesses acute physiological disorders and chronic health conditions. A
distinct feature of this scale is that the estimates which use the specific
parameters of organ systems dysfunction are limited by the diseases of these
systems, whereas the evaluation of the systems which might provide wider
information about a patient’s state requires an extensive invasive monitoring. A
drawback of the given scale is the possibility to employ it only for the seriously ill
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patients in the intensive care units for fear of overestimating the severity degree
in other patients [1, 12, 15, 16].
The next to appear was a no less significant scale SAPS, which was based on
the simplified APACHE II. Some evaluation parameters were removed and the
most available and easily measured were preserved: there was no need to record
and calculate the average AP, the parameters of blood gas content and blood
creatinine concentration were excluded; “corrections” for comorbid diseases
were eliminated. This scale is non-applicable as a probable tool of lethality
prediction in a specific patient as its use is restricted by the lethality prediction
in stratified groups of patients without taking into account the selected “main”
diagnosis [1, 12, 17, 18].
The next scale to be considered is MODS. For this scale, optimal values of
variables for each of the six vital systems (central nervous system, cardiovascular
and respiratory systems, functions of the kidneys, liver, and hemocoagulation
system) were defined. Besides, great attention was paid to the Glasgow coma
scale. MODS is utilized to assess complications rather than the risk of lethal
outcome like the previous scales. It may be suitable for dynamic patient
observation and evaluation of a dysfunction/failure degree of separate systems
and organs [1, 19].
An integral SOFA system was developed on the basis of MODS. This scale also
uses six main parameters and the same variables excluding cardiovascular
system. Its insufficiency was defined by a different parameter (which appeared
to be more important in the assessment of multiple organ failure and may serve
as an indicator of the efficacy of the conducted treatment in some diseases). This
scale was designed for a fast scoring and description of a number of complications
and treatment rather than for the prediction of the disease outcome [1, 12, 15,
17].
All considered scales have some disadvantages in
common: insufficient prognostic capability of an outcome for a specific
patient but a relatively exact prognosis of the lethal outcome probability for a
group of patients, low sensitivity at a sufficiently high specificity. This allows for
a more or less accurate prediction of a lethal outcome probability but makes the
evaluation of the patient’s state in dynamics difficult, which is critical for the
practicing physician. We think that it is the probability of the lethal outcome
defined quantitatively (by a number) that serves as an indicator of the patient’s
severity degree. The higher the probability of the lethal outcome, the higher the
severity degree, and vice versa, the lower the probability, the lower the patient’s
severity degree. This approach to the application of the prognostic techniques
makes the scales suitable for dynamic control of the patient’s condition and
making decisions on the treatment tactics for each concrete patient [4, 5, 10, 20].
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A PMGMU2018h scale was developed to assess the state severity of patients
with obstructive jaundice at any time and, consequently, to assess the efficacy of
the treatment. The state severity is defined by calculations using the original
mathematical formula developed by the authors where data obtained during
physical examination and laboratory findings are employed.
As mentioned above, the methodology of calculating statistical dependence
underlying the developed formula has been previously described by the authors
in their works [13, 14]. The formula integrates 9 significant indicators: jaundice
duration in days, blood bilirubin, div temperature, blood leukocytosis, heart
rate, patient’s age, blood creatinine, blood lymphocytes, respiration rate.
As a result of the calculation using a multivariate linear regression analysis
and the subsequent expert appraisal of the data, a relation adequately reflecting
the severity degree of the patient’s state at a definite time has been found. The
detected mathematical dependence is presented by the following formula:
G
= [0.002 (
d
·
b
) + 1.2 (
t
– 36.6) + 0.001 (
Hr
·
a
) + 0.322 (
L
) + + 0.22 (16 –
Lym
) + 0.0085 (
Cr
– 60) + 0.165 (
Rr
– 20)] – 6.0, where
G
is the severity degree;
d
— disease duration (days);
b
— blood bilirubin (μmol/L);
t
— div temperature
(°С);
Hr
— heart rate per minute;
a
— patient’s age (years);
L
— blood leukocytes
in the SI units (10
9
/L);
Lym
— blood lymphocytes (%) in the clinical blood test;
Cr
— blood creatinine in the SI units (μmol/L);
Rr
— respiratory rate per minute.
This formula is available in the MS Excel program minimizing the labor
efforts of the medical personnel for calculations (Table 1).
The severity degree value (
G
) was determined for a definite patient by the
given formula. To facilitate the calculation of the severity degree of a patient with
obstructive jaundice, several tables were made up in the MS Excel program with
the nested design equations (Tables 2–6). Data of patient K. treated in one of the
mentioned clinics were used as a clinical
CLINICAL SUPPLEMENTS
T a b l e 1
Calculation of patient’s state severity degree using PMGMU2018h scale
Indicators
Observation day
1st
4th
10th
Patient’s
age
—
a
(years)
65
65
65
Disease
duration —
d
(days)
1
4
10
Bilirubin —
b
(μmol/L)
190
190
100
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Body
temperature
—
t
(°С)
37.3
38
37
Blood
leukocytes —
L
(10
9
/L)
12·10
9
13.5·10
9
9·10
9
Heart rate
per min —
Hr
100
95
90
Blood
creatinine —
Cr
(μmol/L)
120
105
100
Blood
lymphocytes
—
Lym
(%)
18
15
21
Respiratory
rate per min
—
Rr
21
20
18
Severity
degree —
G
6.7
8.3
4.9
T a b l e 2
Indicators revealed on physical examination
Observation day
Indicators
st
4
th
10
th
1
Inclusion
in MES
Patient’s
age
(years)
65
65
65
Yes
Disease
duration
(days)
1
4
10
Yes
Body
temperature
(°С) 37.3
38
37
Yes
Rectal
temperature
(°С) 38.3
39
38
Yes
Systolic BP
165
155
155
Yes
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Average BP
[(diast. · 2 +
syst.)/3]
132
125
118
Yes
Central
venous
pressure
40
40
40
No
Heart rate
per
min
100
95
90
Yes
Respiratory
rate per min
21
20
18
Yes
Chronic disease 5
points
(hepatic failure)
Yes
T a b l e 3
Indicators of patient’s biochemical blood test
Observation day
Indicators
1st
4th
10th
Inclusion
in MES
Na
+
of the
blood serum
(mmol/L)
152
150
149
No
К
+
of the
blood serum
(mmol/L)
3.2
3.6
3.7
No
Bilirubin
(μmol/L)
190
190
100
Yes
Creatinine
(μmol/L)
120
105
100
Yes
Blood
urea
7.3
6
Yes
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(mmol/L)
8
Serum
glucose
(mmol/L)
8.1
8.3
7.6
Yes
CLINICAL SUPPLEMENTS
T a b l e 4
Indicators of patient’s general blood and urine tests
Observation day
Indicators
1st
4th
10th
Inclusion
in MES
Hematocrit (%) 40
42
39
Yes
Leukocytes
(10
9
/L)
12·10
9
13.5·10
9
9·10
9
Yes
Thrombocytes (10
9
/L) 180
180 200
Yes
Blood lymphocytes (%) 18
15
21
Yes
T a b l e 5
Patient’s indicators for calculation of Glasgow coma scale
Indicators
Observation day
1st
4th
10th
Glasgow
scale (score)
15
Eye opening
1 point (spontaneous)
Motor
response
1
point
(obeys
commands)
Verbal
reaction
1
point
(oriented,
maintains
the
conversation)
T a b l e 6
Patient’s indicators determined in the gas analyzer
Observation day
Indicators
1st
4th
10th
Inclusion
in MES
Oxygenation
index,
350
375
370
No
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Pa/O
2
/FiO
2
(mm Hg)
Oxygenation
PaO
2
(mm Hg)
No
Arterial
blood
(pH)
7.39
No
Serum НСO
3
(mmol/L)
25
27
27
No
example. All indicators necessary for computing the severity degree in all
considered scales were tabulated. A separate column was introduced to indicate
the inclusion of a given indicator into the obstructive jaundice-related MES RF (in
bold are shown those indicators that are not included in MES).
Using
APACHE II,
SAPS,
SOFA,
MODS,
PMGMU2018h scales, the scores were calculated on the basis of the data
given in the tables. The severity degree utilizing the given scales was estimated
according to the previously described techniques [1, 12, 17–19]. It is clearly seen
that the PMGMU2018h scale is closer to MODS than the other scales in the
assessment of this parameter. Having analyzed indicators which are determined
in the medical settings in Russia in compliance with MES, we have found that all
scales, except PMGMU2018h, utilize indicators which are not specified by MES.
A maximal score in each scale is taken as 100%. When the severity degree is
estimated according to the original techniques [1, 12, 17–19], the score which
may be obtained for one and the same patient using various scales will be
different. The score of the real severity degree according to the APACHE II, SAPS,
SOFA, MODS, PMGMU2018h scales will be expressed by different figures: up to
20 by SOFA, MODS, PMGMU2018h scales, up to 40 — by the APACHE II scale. But
to compare the values of the severity degree obtained by different techniques,
these results must be brought to a single measurement system.
Orienting in each case to a maximal possible value of the severity degree and
calculating with the help of a concrete scale we expressed all found indicators in
percentage of its value. The scores taken by us as maximally possible were those
obtained during calculation with the substitution in the computation tables and
formulas of the parameters with a maximal deviation from the norm towards the
increase in the analyzed
T a b l e 7
Patient’s state severity according to APACHE II, SAPS, SOFA, MODS,
PMGMU2018h scales in percentage of the maximal possible value
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Severity
degree (%)
Observation
day
1st
4th
10th
APACHE
II,
max=40
10
–2.5
–7.5
SAPS, max=30
30
13.3
13.3
SOFA, max=20
25
20
25
PMGMU2018h,
max=20
33.5
41.5
24.5
MODS,
max=20
35
35
30
Severity of the patient’s state according to all examined scales in percentage
of the maximal possible value
group of patients (n=258). This enabled us to compare the results of
calculation in the same measuring scale.
The severity degree of a given patient calculated in percentage terms on each
observation day is presented in summary Table 7.
It is clearly seen from the Figure that the PMGMU2018h scale is close to the
most extent to MODS by its assessment of the severity degree, beside only
PMGMU2018h meets MES RF. The SAPS and
SOFA scales have similar dynamics but their indicators of the severity degree
are insignificantly lower than those of PMGMU2018h and MODS. APACHE II
significantly underestimates the severity in comparison with other scales and
cannot be recommended for use in patients with obstructive jaundice.
Conclusion
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The PMGMU2018h scale proposed by us reflects adequately the state
severity degree of a patient with obstructive jaundice.
The PMGMU2018h scale provides the possibility to track minimal changes
in the patient’s condition and evaluate the effect of separate treatment elements
on the disease course. The proposed technique of the severity definition is
completely devoid of any subjectivity and does not depend on surgeon’s
qualifications.
The PMGMU2018h scale corresponds most closely to MODS. The developed
scale uses only those indicators that are included in MES RF.
Research funding. The work was not supported by any financial source.
Conflicts of interest. The authors have no conflicts of interest to declare.
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