Israel Medical Association Journal

Background: It is important to predict acute cholecystitis (AC) before a laparoscopic cholecystectomy because inflammation of the gallbladder predicts the need for open conversion and subsequent morbidity after a laparoscopic cholecystectomy.

Objectives: To create an index based on clinical, laboratory, and ultrasound criteria on admission that will predict AC on pathological examination in patients presenting acutely.

Methods: We retrospectively reviewed consecutive cases of emergency laparoscopic cholecystectomies conducted by three experienced surgeons between 1 October 2014 and 31 January 2018. Independent variables were age, sex, presenting symptoms, admission laboratory tests, and ultrasound findings. The outcome variable was AC on histological examination. An index was created from all variables that added significantly to the logistic regression analysis.

Results: Eight variables that contributed significantly to the model, included age, male sex, vomiting on admission, an increased proportion of neutrophils, a normal aspartate aminotransferase test, a normal serum amylase test result, a thick gall bladder wall, and pericholecystic fluid. An index of ≤ 2 to ≥ 8 created from those variables had a graded risk for AC of 1.8% to 92.0% with a c-statistic of 0.86 (95% confidence interval 0.81–0.91). Operating time and bleeding increased in those with a higher index.

Conclusions: An index including age, sex, symptoms, and selected laboratory results as well as ultrasound characteristics had an excellent graded risk in the prediction of histological AC that was associated with operating time and an increased risk of bleeding during the operation.

Background: Recommendations for a head computed tomography (CT) scan in elderly patients without a loss of consciousness after a traumatic brain injury and without neurological findings on admission and who are not taking oral anticoagulant therapy, are discordant.

Objectives: To determine variables associated with intracranial hemorrhage (ICH) and the need for neurosurgery in elderly patients after low velocity head trauma

Methods: In a regional hospital, we retrospectively selected 206 consecutive patients aged ≥ 65 years with head CT scans ordered in the emergency department because of low velocity head trauma. Outcome variables were an ICH and neurological surgery. Independent variables included age, sex, disability, neurological findings, facial fractures, mental status, headache, head sutures, loss of consciousness, and anticoagulation therapy.

Results: Fourteen patients presented with ICH (6.8%, 3.8–11.1%) and three (1.5%, 0.3–4.2%) with a neurosurgical procedure. One patient with a coma (0.5, 0.0–2.7) died 2 hours after presentation. All patients who required surgery or died had neurological findings. Reducing head CT scans by 97.1% (93.8–98.9%) would not have missed any patient with possible surgical utility. Twelve of the 14 patients (85.7%) with an ICH had neurological findings, post-trauma loss of consciousness or a facial fracture were not present in 83.5% (95% confidence interval 77.7–88.3) of the cohort.

Conclusions: None of our patients with neurological findings required neurosurgery. Careful palpation of the facial bones to identify facial fractures might aid in the decision whether to perform a head CT scan.

Background: It is not entirely clear when and how steroids should be used to treat trichinellosis.

Objectives: To describe the course of consecutive patients with trichinellosis treated with antihelminthic drugs with and without the addition of prednisone.

Methods: We extracted data from the hospital records of 30 patients hospitalized for trichinellosis contracted after eating poorly cooked pork that came from two pigs killed in the Golan Heights, and contacted them for follow-up 5–6 weeks and 6 months after hospital discharge.

Results: All the patients who attended a party and ingested the infected pork (100% attack rate) were hospitalized after 2–16 days (median 9 days); 29 were symptomatic and 1 patient without symptoms had creatine phosphokinase levels 17.9 times above the upper limit of normal. Twelve of 23 patients (52%) treated with antihelminthic drugs without prednisone were rehospitalized with worsening fever, increased peripheral blood eosinophil counts, but decreasing CPK[1] values. These patients and another seven at the time of admission were treated with prednisone 40 mg/day for 5 days in addition to antihelminthic drugs for at least 14 days. All became asymptomatic within 24 hours and were asymptomatic 6 weeks and 6 months later.

Conclusions: Worsening symptoms in patients treated with antihelminthic drugs alone is common. A short course of prednisone is safe and alleviates symptoms due to tissue larvae in patients with trichinellosis.

Background: Pseudomembranous colitis is a well-recognized cause of diarrhea in patients receiving antibiotics and has significant consequences in terms of morbidity, mortality and cost. Clostridium difficile infection is the single most important infectious cause of PMC[1]. PMC is frequently nosocomial, with an increased risk of spread among institutionalized patients, both in hospitals and nursing homes.

Objective: To investigate the demographic, clinical and laboratory characteristics of PMC patients in an Israeli elderly population.

Methods: We studied 72 hospitalized patients with endoscopically proven PMC. The medical records of all patients including clinical history and laboratory data were reviewed, such as: age, pre-hospitalization status (dependency or not, in the community as compared to the nursing home), background medical history, presenting symptoms, antibiotic history, physical examination on admission, hematologic and biochemical parameters, treatment, duration of hospitalization, complications, mortality and recurrence of disease.

Results: Of the 72 patients (34 males and 38 females, mean age 77 years) 47% were nursing home residents. Pre-hospitalization antibiotic treatment was given to 91.4% for infections of the upper respiratory tract (45%) and urinary tract (45%). The most common antibiotics were cephalosporin (64%), penicillins (42%) and quinolones (28%). Sixty-four percent of the patients were treated with more than one antibiotic, 26% of patients received anti-acid therapy and 36% had been fed with a nasogastric tube. On admission, leukocytosis was found in 79% of patients, >20,000/mm³ in half of them; 60% were anemic, 60% had elevated erythrocyte sedimentation rate, and 78% had hypoalbuminemia. Treatment consisted of metronidazole (41%) or a combination of metronidazole and vancomycin (56%). Overall, 31% of patients recovered without complications, 29% died within 30 days of hospitalization, and 24% were re-hospitalized due to recurrence of PMC.

Conclusion: The most common antibiotics implicated in PMC are cephalosporin, penicillins and quinolones. The disease is associated with high mortality and recurrence rates.