Israel Medical Association Journal

Background: Current treatment options for acute calculous cholecystitis include either early cholecystectomy, or conservative treatment consisting of intravenous antibiotics and an interval cholecystectomy several weeks later. Percutaneous drainage is reserved for patients in whom conservative therapy failed or as a salvage procedure for high risk patients.

Objective: To identify clinical and radiographic factors leading to failure of conservative treatment.

Methods: We prospectively collected data on consecutive patients admitted with the diagnosis of acute cholecystitis. Parameters were compared between patients who were successfully treated conservatively and those who required percutaneous cholecystostomy. Logistic regression analysis was performed to identify predictors for failure of conservative treatment. 

Results: The study population comprised 103 patients with a median age of 60 who were treated for acute cholecystitis. Twenty-seven patients (26.2%) required PC[1]. On univariate analysis, age above 70 years, diabetes, elevated white blood cell count, tachycardia (> 100 beats/min) at admission, and a distended gallbladder (> 5 cm transverse diameter) were found to be significantly more common in the PC group (P < 0.001). WBC[2] was higher in the PC group throughout the initial 48 hours. On multivariate analysis, age above 70 (odds ratio 3.6), diabetes (OR[3] 9.4), tachycardia at admission (OR 5.6), and a distended gallbladder (OR 8.5) were predictors for cholecystostomy (P < 0.001). Age above 70 (OR 5.2) and WBC > 15,000 (OR 13.7) were predictors for failure of conservative treatment after 24 and 48 hours (P < 0.001). 

Conclusions: Age above 70, diabetes, and a distended gallbladder are predictors for failure of conservative treatment and such patients should be considered for early cholecystostomy. Persistently elevated WBC (> 15,000) suggests refractory disease and should play a central role in the clinical follow-up and decision-making process for elderly patients with acute cholecystitis.

Background: Non-operative management of blunt splenic trauma is the preferred option in hemodynamically stable patients.

Objectives: To identify predictors for the successful non-operative management of patients with blunt splenic trauma.

Methods: The study group comprised consecutive patients admitted with the diagnosis of blunt splenic trauma to the Department of Surgery, Hadassah-Hebrew University Medical Center in Jerusalem over a 3 year period. Prospectively recorded were hemodynamic status, computed tomography grade of splenic tear, presence and extent of extra-abdominal injury, number of red blood cell units transfused, and outcome. Hemodynamic instability and the severity of associated injuries were used to determine the need for splenectomy. Hemodynamically stable patients without an indication for laparotomy were admitted to the Intensive Care Unit and monitored.

Results: There were 64 adults (45 males, mean age 30.2 years) who met the inclusion criteria. On univariate analysis the 13 patients (20.3%) who underwent immediate splenectomy were more likely to have lower admission systolic blood pressure (P = 0.001), Glasgow Coma Scale < 8 (P = 0.02), and injury to at least three extra-abdominal regions (P = 0.06). Nine of the 52 patients (17.3%) who were successfully treated non-operatively suffered from grade ≥4 splenic tear. Multivariate analysis identified admission systolic BP[1] (odds ratio 1.04) and associated injury to less than three extra-abdominal regions (OD[2] 8.03) as predictors for the success of non-operative management, while the need for blood transfusion was a strong predictor (OR 66.67) for splenectomy.

Conclusions: Admission systolic blood pressure and limited extra-abdominal injury can be used to identify patients with blunt splenic trauma who do not require splenectomy and can be safely monitored outside an ICU[3] environment. 

Background: Infective endocarditis is a common disease with significant morbidity and mortality.

Objectives: To define clinical and echocardiographic parameters predicting morbidity and in-hospital mortality in patients with infective endocarditis hospitalized in a tertiary hospital from 1991 to 2000.

Methods: All patients with definite IE diagnosed according to the Duke criteria were included. We examined relevant clinical features that might influence outcome.

Results: The study group comprised 100 consecutive patients, 77 with native valve and 23 with prosthetic valve endocarditis. The overall in-hospital mortality rate was 8%. There was a higher mortality in the PVE[1] group compared to the NVE[2] group (13% vs. 7%, P = 0.07). The mortality rate in each group, with or without surgery, was not significantly different. Clinical predictors of mortality were older age and hospital-acquired endocarditis. The presence of vegetations and their size were significant predictors of major embolic events and mortality. Staphylococcus aureus was a predictor of mortality (25% vs. 5%, P < 0.005) and abscess formation. Multivariate logistic analysis identified vegetation size and S. aureus as independent predictors of mortality.

Conclusions: Mortality is higher in older hospitalized patients. S. aureus is associated with a poor outcome. Vegetation size is an independent predictor of embolic events and of a higher mortality.

Background: Echocardiographic ventricular function predicts prognosis and guides management in patients with acute coronary syndromes. In elderly patients, interpretation of echocardiographic measurements may be difficult, especially regarding assessment of diastolic left ventricular function.

Objectives: To examine the usefulness of echocardiographic systolic and echocardiographic diastolic LV[1] function measurements as predictors of long-term outcome in elderly patients with ACS[2].

Methods: We studied 142 consecutive elderly patients (≥ 70 years old, mean age 80 ± 6 years) with ACS who had an echocardiogram at index hospitalization and were in sinus rhythm. LV ejection fraction and diastolic mitral inflow pattern were examined as predictors of survival and repeat hospitalization over a period of 18–24 months.

Results: During the 2 year mean follow-up period 35/142 patients died (25%). Survival was lower in patients with EF[3] < 40% (n=42) as compared to EF ≥ 40% (n=100) (2 year survival rate 61% vs. 81%, P = 0.038). Patients with severe diastolic dysfunction (a restrictive LV filling pattern, n=7) had a lower survival rate than those without (43 vs. 76%, P = 0.009). The most powerful independent predictor of mortality was a restrictive filling pattern (hazard ratio 4.6, 95% confidence interval 1.6–13.5), followed by a clinical diagnosis of heart failure on admission and older age. Rate of survival free of repeat hospitalization was low (33% at 18 months) but repeat hospitalization was not predicted either by EF or by a restrictive filling pattern.

Conclusions: As in the young, echocardiographic measurements of systolic and diastolic LV function predicted long-term survival in elderly patients with ACS. A restrictive filling pattern was the strongest independent predictor of mortality.

Background: The degree of left ventricular dysfunction determines the prognostic outcome of patients with acute myocardial infarction.

Objectives: To define the clinical, angiographic and procedural variables related to LV[1][1] dysfunction in patients with  with anterior wall AMI[1][2] referred for primary percutaneous coronary intervention.

Methods: The sample included 168 patients treated by primary PCI[1][3] for first anterior wall AMI. Clinical, demographic and medical data were collected prospectively into a computerized registry, and clinical outcome (death, reinfarction, major cardiovascular event) were evaluated during hospitalization and 30 days after discharge. Patients were divided into three groups by degree of LV dysfunction (mild, moderate, severe) and compared for clinical, angiographic and procedural variables.

Results: LV dysfunction was associated with pre-PCI renal failure (serum creatinine > 1.4 mg/dl), peripheral vascular disease, high peak creatine kinase level, longer door to balloon time, low TIMI flow grade before and after PCI, and use of an intraaortic balloon pump. On multivariate analysis adjusted for baseline differences, peak creatine kinase level (r = 0.3, P = 0.0001) and door to needle time (r = 0.2, P = 0.008) were the most significant independent predictors of moderate or severe LV dysfunction after anterior AMI.

Conclusion: Abnormal LV function after first anterior AMI can be predicted by door to balloon time and the size of the infarction as assessed by creatine kinase levels. Major efforts should be made to decrease the time to myocardial reperfusion.

[1][1] LV = left ventricular

[1][2] AMI = acute myocardial infarction

[1][3] PCI = percutaneous coronary intervention 

Objectives: To test whether an early change in neurohormonal and inflammatory markers after implantation can predict the clinical response to CRT.

Methods: The study group included 32 patients with advanced symptomatic systolic heart failure and a prolonged QRS complex and who were assigned to undergo CRT. Baseline plasma levels of B-type natriuretic peptide and high sensitivity C-reactive protein were determined in the peripheral venous blood and coronary sinus. Post-implantation levels were determined 2 weeks post-procedure in the PVB[2]. Baseline levels and their change in 2 weeks were correlated with all-cause mortality and hospitalization for congestive heart failure.

Results: At baseline, coronary sinus levels of BNP[3] but not hsCRP[4] were significanly elevated compared to the PVB. Compared to baseline levels, BNP and hsCRP decreased significantly within 2 weeks after the implantation (BNP mean difference 229.1 ± 102.5 pg/ml, 95% confidence interval 24.2–434, P < 0.0001; hsCRP mean difference 5.2 ± 2.4 mg/dl, 95% CI[5] 0.3–10.1, P = 0.001). During a mean follow-up of 17.7 ± 8.2 months 6 patients died (18.7%) and 12 (37.5%) were hospitalized due to exacerbation of CHF[6]. Baseline New York Heart Association and CS[7] BNP levels predicted CHF-related hospitalizations. HsCRP levels or their change over 2 weeks did not predict all-cause mortality or hospitalizations.

Conclusions: BNP levels in the CS and peripheral venous blood during biventricular implantation and 2 weeks afterwards predict cilinical response and may guide patient management.

Background: Acute pharyngitis in children is one of the most frequent illnesses for which primary care physicians are consulted. It is caused more frequently by viruses than by bacteria, but it is difficult to differentiate the causative agent by clinical signs alone. Group A Streptococcus accounts for 30% of children with a sore throat, and only in these cases is antibiotic therapy definitely indicated. However, the frequency and symptomatology of streptococcal pharyngitis in adults is not well established.

Objectives: To examine the clinical features that could distinguish sore throat caused by b-hemolytic group A Streptococcus in adults.

Methods: Patients aged over 16 years old (n=207) who presented with a sore throat to community clinics were examined and throat cultures were taken. The microbiologic confirmation of Group A Streptococcus was correlated with symptoms and clinical signs by univariate analysis.

Results: About 24% of the patients with positive cultures were younger individuals. Chills, absence of cough, pain in swallowing, absence of rhinitis, headache, vomiting, tonsillar exudate, oral malodor, fever >38°C and sweats had high sensitivity but low specificity for streptococcal pharyngitis. Univariate analysis suggested that chills and pharyngeal exudate had the greatest predictive value for streptococcal pharyngitis (P = 0.044, odds ratio 2.45; P = 0.001, OR[1] 5.49, respectively). When compared with a published scoring method (Centor criteria), large inconsistencies were found.

Conclusion: Our adult population had a relatively high prevalence of group A Streptococcus, and their presentation differed from that of pediatric patients. In primary care, a throat swab culture is not necessary in adults with a low score (0–1 points).

Background: Domestic violence is considered a major risk factor in pregnancy.

Objectives: To assess the prevalence of different kinds of abuse (physical, psychological, sexual) of pregnant as compared to non-pregnant women, and to identify demographic risk factors for physical abuse that characterize the woman and her partner.

Methods: A cross-sectional survey was conducted in 270 women seeking gynecologic care at women health centers in northern Israel. Information was collected by means of a standardized questionnaire administered via phone, and addressed demographic data, interaction with the partner, and reporting of physical abuse. All information was obtained from the respondents (including information about her partner).

Results: Four abuse scores were computed: severe physical attack, minor physical attack, psychological abuse, and sexual coercion. Psychological abuse was found to be the most prevalent (24%), followed by minor and severe physical attack (17% and 8.1%, respectively), and sexual coercion (5.6%). Physical attacks related to pregnancy (directed at the abdomen) occurred in 5.4% of the pregnant women. There was no significant difference in the prevalence of the different types of abuse between pregnant and non-pregnant women. Physical attack was associated with socioeconomic status, work status, and degree of religiosity.

Conclusion: Pregnant women were at a similar risk for abuse as non-pregnant women in all abuse categories. Predictors for abuse – socioeconomic status and religiosity – are reviewed primarily in a cultural context.

Background: Patient feedback is increasingly being used to assess the quality of healthcare.

Objective: To identify modifiable independent determinants of patient dissatisfaction with hospital emergency care.

Methods: The study group comprised a random sample of 3,152 of the 65,966 adult Israeli citizens discharged during November 1999 from emergency departments in 17 of the 32 acute care hospitals in Israel. A total of 2,543 (81%) responded to a telephone survey tht used a structured questionnaire. The ndependent variables included: hospital characteristics, patient demographic variables, patient perception of care, self-rated health status, problem severity, and outcome of care. The dependent variable was dissatisfaction with overall ED[1] experience on a 1–5 Likert-type scale dichotomized into not satisfied (4 and 5) and satisfied (1,2 and 3).

Results: Eleven percent of the population reported being dissatisfied with their emergency room visit. Univariate analyses revealed that dissatisfaction was significantly related to ethnic group, patient education, hospital identity and geographic location, perceived comfort of ED facilities, registration expediency, waiting times, perceived competence and attitudes of caregivers, explanations provided, self-rated health status, and resolution of the problem that led to referral to the ED. Multivariate analyses using logistic regressions indicated that the four most powerful predictors of dissatisfaction were patient perception of doctor competence and attitudes, outcomes of care, ethnicity, and self-rated health status.

Conclusions: Attempts to reduce dissatisfaction with emergency care should focus on caregiver conduct and attitudes. It may also be useful to improve caregiver communication skills, specifically with ethnic minorities and with patients who rate their health status as poor.

Background: Smoking is the most important preventable cause of chronic disease in the western world. Many smokers want to quit, but have difficulty overcoming the addictive effect of nicotine.

Objectives: To assess the quitting rate of smokers who participated in smoking cessation groups and to characterize predictors of success or failure over a 1-3 year follow-up period.

Methods: We studied 89 participants in 7 groups. Questionnaires were completed at baseline and after a follow-up period of 1 to 3 years. Smoking cessation was determined by self-report and a carbon monoxide breath test.

Results: Of the 89 participants in the support groups 76 (85%) were located. An intention-to-treat analysis was done for these participants. At follow-up 25 (33%) were non-smokers. There was a 95% agreement rate between self-report of smoking status and CO breath analysis. There were no differences between quitters and non-quitters in education level, gender, age at initiation of smoking, previous quit attempts, extent of participation in group meetings, concern about gaining weight, Fagerstrom index, or the number of close friends or relatives who smoke. Belief in one's ability to quit, satisfaction with group meetings, and spouse support were significantly associated with success (P<0.01).

Conclusions: The quit rate was 33%. Self-report is a reliable method for assessing smoking status. Smokers' belief in their ability to quit must be reinforced. Spouse participation in some group meetings may be beneficial, as may the involvement of a dietician and an expert on exercise. Follow-up "booster" meetings may also help.

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CO= carbon monoxide

* In partial fulfilment of the requirements for an MD degree.

Background: Acute respiratory distress syndrome is a well-recognized condition resulting in high permeability pulmonary edema associated with a high morbidity.

Objectives: To examine a 10 year experience of predisposing factors, describe the clinical course, and assess predictors of mortality in children with this syndrome.

Methods: The medical records of all admissions to the pediatric intensive care unit over a 10 year period were evaluated to identify children with ARDS¹. Patients were considered to have ARDS if they met all of the following criteria: acute onset of diffuse bilateral pulmonary infiltrates of non-cardiac origin and severe hypoxemia defined by <200 partial pressure of oxygen during ³6 cm H2O positive end-expiratory pressure for a minimum of 24 hours. The medical records were reviewed for demographic, clinical, and physiologic information including PaO2² /forced expiratory O2, alveolar–arterial O2 difference, and ventilation index.

Results: We identified 39 children with the adult respiratory distress syndrome. Mean age was 7.4 years (range 50 days to 16 years) and the male:female ratio was 24:15. Predisposing insults included sepsis, pneumonias, malignancy, major trauma, shock, aspiration, near drowning, burns, and envenomation. The mortality rate was 61.5%. Predictors of death included the PaO2/FIO2, ventilation index and A-aDO2³ on the second day after diagnosis. Non-survivors had significantly lower PaO2/FIO2 (116±12 vs. 175±8.3, P<0.001), and higher A-aDO2 (368±28.9 vs. 228.0±15.5, P<0.001) and ventilation index (43.3±2.9 vs. 53.1±18.0, P<0.001) than survivors.

Conclusions: Local mortality outcome for ARDS is comparable to those in tertiary referral institutions in the United States and Western Europe. The PaO2/FIO2, A-aDO2 and ventilation index are valuable for predicting outcome in ARDS by the second day of conventional therapy. The development of a local risk profile may allow early application of innovative therapies in this population. 

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¹ARDS = acute respiratory distress syndrome

² PaO2 = partial pressure of oxygen

³A-aDO2 = alveolar–arterial O2 difference