Is acute appendicitis more severe in foreign workers of northern Israel? A retrospective cohort study.

BACKGROUND: Acute appendicitis (AA) is one of the most common surgical emergencies worldwide. It's classified into simple or complicated disease. Due to the high prevalence of the disease, AA has been studied as a marker to assess the quality of care afforded to minority groups. The purpose of this study was to compare AA outcomes in foreign workers (FW) to the general population in northern Israel. METHODS: This is a retrospective cohort study. We identified all patients aged 18-50 who were admitted to our institution between January 1st, 2013 and October 31st, 2018, with the diagnosis of acute appendicitis. The study group included all FW and the control group included citizens of Israel. Study patients were matched based on age, sex, and co-morbidities. We compared time to presentation, admission parameters and disease outcomes. Our study outcomes were disease severity and length of hospital stay. RESULTS: We identified 20 FW and 97 matched local patients. FW presented with significantly higher heart rate, temperature, and white blood cell count (WBC). Duration of symptoms was comparable between the two groups. The rates of complicated disease were significantly higher among FW (45 vs 17.5%, p < 0.0001). Length of hospitalization was significantly longer in the FW group (4.8 vs. 3.9 days, p = 0.01). The odds ratio of FWs for having a complicated disease was OR = 3.85 [95% CI: 1.38, 10.72], p = 0.01. Multivariate analysis identified FW and duration of symptoms as significantly contributing to a complicated disease outcome. CONCLUSIONS: Although duration of symptoms was comparable to the local population, FW in northern Israel are at increased risk for a complicated disease which resulted in longer hospital stay. Further studies may enlighten the reason for this disparity.

High rates of recurrence of gallstone associated episodes following acute cholecystitis during long term follow-up: a retrospective comparative study of patients who did not receive surgery.

INTRODUCTION: Patients who are admitted with acute cholecystitis (AC) and do not undergo urgent cholecystectomy, are usually referred for interval cholecystectomy. Many do not have surgery for various reasons, and some of those do not suffer from any recurrent symptoms. The primary objective of this study was to assess the rate and nature of recurrent gallstone-related events in this population over a long period, and its association with demographic and clinical parameters. A secondary objective was to assess the reasons for not undergoing surgery. METHODS: This is a retrospective cohort study, where the study group were adult patients admitted with AC. Patients that have suffered recurrent episodes were compared with those who did not. A control group of patients that had undergone cholecystectomy following an admission with AC was used for comparison. Demographic and clinical parameters were recorded for all patients, and the association with a recurrent episode was analyzed using univariate analysis. RESULTS: The study population was 197 patients. The group of patients who did not undergo surgery were significantly older (68.7 vs 54.2) and sicker (ASA > 3 50% vs 19%). The rate of recurrent episodes in the study group was 38.5%, and it was not found to be associated with the studied parameters. There was a trend towards higher gallstone disease specific mortality in the study group (5.5% vs 1.45% p = 0.062). CONCLUSIONS: This is a study of long-term follow-up of patients following an episode of AC we showed that the rate of recurrent episodes is quite high and involves severe inflammatory diseases, such as obstructive jaundice and pancreatitis.

The Bacteriology of Acute Cholecystitis: Comparison of Bile Cultures and Clinical Outcomes in Diabetic and Non-Diabetic Patients.

BACKGROUND: Acute cholecystitis is one of the most common acute surgical diseases. Diabetic patients have been shown to have an increased risk for gallbladder disease, but the correlation between the severity of gallstone disease and diabetes is still debated. The aim of this study is to examine the possible difference in the disease process between patients with diabetes mellitus (DM) and those without. PATIENTS AND METHODS: A retrospective study was conducted of all patients who underwent percutaneous cholecystostomy between 2005 and 2015 at Emek Medical Center, Afula, Israel. Demographic and medical history including data on bile and blood culture results, antimicrobial susceptibility, and clinical outcomes were retrieved from patient files. RESULTS: The cohort included 272 patients. Mean age was 68 years old, 50.74% were male and 43.75% had diabetes mellitus. Bile cultures were obtained from 252 (92.64%) patients and were positive in 134 (53.2%) patients. In 11 patients (4%) two pathogens were isolated. Blood cultures obtained from 231 patients and were positive in 35 (15.2%). Escherichia coli was the most common isolate, and was seen in 22.3% of positive bile cultures and 40% of blood cultures. Although diabetic patients had significantly more positive bile cultures, the severity of the disease, according to the Tokyo guidelines, was not higher. CONCLUSIONS: Acute cholecystitis was neither more severe nor had significant difference in bacteriological properties when comparing diabetic patients to non-diabetic ones.

Primary small cell type of non-Hodgkin lymphoma of the colon: a case report.

INTRODUCTION: Primary lymphoma of the colon is exceedingly rare and comprises 0.2-1% of all colon tumors. The most common subtype of lymphoma in the colon is non-Hodgkin lymphoma. Symptoms are often nonspecific, and treatment varies between chemotherapy alone and a combination of surgery and chemotherapy. CASE PRESENTATION: We describe a case of a Ashkenazi Jew patient who presented in the typical way that carcinoma of the colon might present but turned out to have a very rare type of tumor in both its histology and its location. CONCLUSION: There was apparent discordance between the relative bulkiness and gross appearance of the tumor with the unrevealing result of the biopsies, demanding a high level of suspicion as to the actual presence and possible type of such a tumor in the future.

Diagnostic Value of C-Reactive Protein Levels in Postoperative Infectious Complications After Bariatric Surgery: a Systematic Review and Meta-Analysis.

BACKGROUND: Bariatric surgery involves the risk of postoperative infectious complications, in particular, anastomotic leaks and intra-abdominal abscesses. C-reactive protein (CRP) is a nonspecific marker of inflammation which has gained attention as a test to predict postoperative infectious complications. This systematic review and meta-analysis evaluated the diagnostic value of CRP to detect postoperative infectious complications after bariatric surgery. METHODS: Search of MEDLINE, EMBASE, CENTRAL, and PubMed databases were performed. Articles measuring serum CRP postoperatively in patients with obesity undergoing bariatric surgery were included. Main outcomes included diagnostic value of postoperative serum CRP (area under the curve (AUC), sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV)). Diagnostic accuracy of included studies was assessed using QUADAS-2. RESULTS: Six studies including 2770 patients met the inclusion criteria. The derived CRP cutoff values were 71.4 mg/dL, 130.3 mg/dL, and 118.7 mg/dL on postoperative days (PODs) 1, 3, and 5, respectively. Pooled AUC was similar across PODs 1, 3, and 5 with AUC being highest on POD 5 (0.88 ± 0.07). PPV was between 19 and 21%, and NPV was between 98 and 99%. CRP levels were significantly higher (P < .0001) in postoperative infectious complication group versus the no complication group on PODs 3 and 5. CONCLUSIONS: High NPV and moderately high sensitivity on PODs 1, 3, and 5 may help predict patients who are at a low risk of infectious complication following bariatric surgery. High specificity on PODs 1 and 3 also indicates that it can be useful for early diagnosis of postoperative infectious complications.

Outcome of Delayed Cholecystectomy after Percutaneous Cholecystostomy for Acute Cholecystitis.

BACKGROUND: Recent studies have suggested that urgent cholecystectomy is the preferred treatment for acute cholecystitis. However, initial conservative treatment followed by delayed elective surgery is still common practice in many medical centers. OBJECTIVES: To determine the effect of percutaneous cholecystostomy on surgical outcome in patients undergoing delayed elective cholecystectomy. METHODS: We conducted a retrospective analysis of all patients admitted to our medical center with acute cholecystitis who were treated by conservative treatment followed by delayed cholecystectomy between 2004 and 2013. Logistic regression was calculated to assess the association of percutaneous cholecystostomy with patient characteristics, planned surgical procedure, and the clinical and surgical outcomes. RESULTS: We identified 370 patients. Of these, 134 patients (36%) underwent cholecystostomy during the conservative treatment period. Patients who underwent cholecystostomy were older and at higher risk for surgery. Laparoscopic cholecystectomy was offered to 92% of all patients, yet assignment to the open surgical approach was more common in the cholecystostomy group (16% vs. 3%). Cholecystostomy was associated with significantly higher conversion rates to open approach (26% vs. 13%) but was not associated with longer operative time, hemorrhage, surgical infections, or bile duct or organ injuries. CONCLUSIONS: Treatment with cholecystostomy is associated with higher conversion rates but does not include other major operative-related complications or poorer clinical outcome.

Readmissions to medical wards: analysis of demographic and socio-medical factors.

BACKGROUND: Unplanned readmissions affect occupancy rates in medical wards and these have been constantly increasing in Israel. We examined the frequency and risk factors affecting the likelihood of 30-day emergency medical readmissions. METHODS: We compared the clinical, epidemiological, and socioeconomic characteristics of readmitted patients during 2009 to a control group matched by age, sex, and primary medical diagnosis. RESULTS: Rate of unplanned readmissions within 30 days was 12.2%. The mean time to readmission was 12.8 days. The mean length of hospital stay at index admission was 4.4 and 3.8 days for the study and control groups, respectively, and 4.99 days in the second admission (study group only). By simple univariate logistic regression, living in a nursing home, chronic kidney disease, ischemic heart disease, previous cerebrovascular accident, number of chronic medications, length of hospital stay at index admission, and hospitalization in the previous year prior to index admission were significantly associated with risk of readmission. In multivariate logistic regression model, only living in a nursing home (OR=2.94, 95%CI=1.15-7.48), presence of chronic kidney disease (OR=1.62, 95%CI=1.06-2.46), length of index admission ≥ 3 days (OR=1.53, 95%CI=1.07-2.2), and hospitalization in the previous year (OR=3.33, 95%CI=2.34-4.74) were found to be significantly associated with likelihood of readmission. CONCLUSION: Risk factors affecting 30-days readmission at our medical centre are similar to previous observations, and yet, some are perhaps unique to our region.