The effect of mechanical bowel preparation on postoperative complications in laparoscopic right colectomy: a retrospective propensity score matching analysis.

PURPOSE: To assess whether full bowel preparation affects 30-day surgical outcomes in laparoscopic right colectomy for colon cancer. METHODS: A retrospective chart review of all elective laparoscopic right colectomies performed for colonic adenocarcinoma between Jan 2011 and Dec 2021. The cohort was divided into two groups-no bowel preparation (NP) group and patients who received full bowel preparation (FP), including oral and mechanical cathartic bowel preparation. All anastomoses were extracorporeal stapled side-to-side. The two groups were compared at baseline and then were matched using propensity score based on demographic and clinical parameters. The primary outcome was 30-day postoperative complication rate, mainly anastomotic leak (AL) and surgical site infection (SSI) rate. RESULTS: The original cohort included 238 patients with a median age of 68 (SD 13) and equal M:F ratio. Following propensity score matching, 93 matched patients were included in each group. Analysis of the matched cohort showed a significantly higher overall complication rate in the FP group (28 vs 11.8%, p = 0.005) which was mostly due to minor type II complications. There were no differences in major complication rates, SSI, ileus, or AL rate. Although operative time was significantly longer in the FP group (119 vs 100 min, p ≤ 0.001), length of stay was significantly shorter in the FP group (5 vs 6 days, p = 0.001). CONCLUSIONS: Aside from a shorter hospital stay, full mechanical bowel preparation for laparoscopic right colectomy does not seem to have any benefit and may be associated with a higher overall complication rate.

A deep look into the storm: Israeli multi-center experience of coronavirus disease 2019 (COVID-19) in patients with autoimmune inflammatory rheumatic diseases before and after vaccinations.

Objective: We aimed to characterize the course of COVID-19 in autoimmune inflammatory rheumatic disease (AIIRD) patients in Israel, taking into consideration several remarkable aspects, including the outcomes of the different outbreaks, the effect of vaccination campaigns, and AIIRD activity post-recovery. Methods: We established a national registry of AIIRD patients diagnosed with COVID-19, including demographic data, AIIRD diagnosis, duration and systemic involvement, comorbidities, date of COVID-19 diagnosis, clinical course, and dates of vaccinations. COVID-19 was diagnosed by a positive SARS-CoV-2 polymerase chain reaction. Results: Israel experienced 4 outbreaks of COVID-19 until 30.11.2021. The first three outbreaks (1.3.2020 - 30.4.2021) comprised 298 AIIRD patients. 64.9% had a mild disease and 24.2% had a severe course; 161 (53.3%) patients were hospitalized, 27 (8.9%) died. The 4th outbreak (delta variant), starting 6 months after the beginning of the vaccination campaign comprised 110 patients. Despite similar demographic and clinical characteristics, a smaller proportion of AIIRD patients had negative outcomes as compared to the first 3 outbreaks, with regards to severity (16 patients,14.5%), hospitalization (29 patients, 26.4%) and death (7 patients, 6.4%). COVID-19 did not seem to influence the AIIRD activity 1-3 months post-recovery. Conclusions: COVID-19 is more severe and has an increased mortality in active AIIRD patients with systemic involvement, older age and comorbidities. Vaccination with 3 doses of the mRNA vaccine against SARS-CoV-2 protected from severe COVID-19, hospitalization and death during the 4th outbreak. The pattern of spread of COVID-19 in AIIRD patients was similar to the general population.

Unilateral Increase of Gustatory Thresholds in Acute Otitis Media: A Pilot Study.

BACKGROUND: To evaluate chorda tympani nerve function as measured by unilateral increases of gustatory thresholds in the presence of ipsilateral acute otitis media. METHODS: Prospective clinical study comparing electrogustometric measurements was conducted to evaluate the taste thresholds of each side of the tongue in a patient during an acute episode of unilateral acute otitis media. Included were patients aged 12-40 who presented to the emergency department and outpatient ear, nose, and throat clinic of a university-affiliate tertiary medical center with unilateral acute otitis media between January 2019 and January 2020 and consented to the study. RESULTS: Eleven patients were initially recruited into the study, and 10 patients aged (mean ± standard deviation) 26.1 ± 11.2 years comprised the final study group. Taste thresholds were significantly elevated on the side ipsilateral to the ear affected by acute otitis media (P < .05). CONCLUSION: Chorda tympani nerve conductance is impaired during the acute stage of acute otitis media. This may have implications in the understanding of peripheral neural properties during acute middle ear inflammatory conditions and on the diagnosis of acute otitis media.

Hospitalized patients with positive antiphospholipid antibodies who have low complement levels are at increased risk for death-a retrospective cohort study.

PURPOSE: To investigate whether low complement levels can predict worse outcomes in patients hospitalized with positive anti-phospholipid antibodies. METHODS: This was a retrospective cohort study. We obtained demographics, laboratory, and prognostic data of all consecutive patients hospitalized between 2007 and 2021, for whatever reason, with at least one positively abnormal anti-phospholipid antibody, who were also tested for complement levels (C3 or C4). We then compared the rates of long-term mortality, 1-year mortality, deep vein thrombosis, and pulmonary emboli between groups of low complement and normal complement levels. Multivariate analysis was used to control for levels of clinical and laboratory confounders. RESULTS: We identified 32,286 patients tested for anti-phospholipid antibodies. Of those patients, 6800 tested positive for at least one anti-phospholipid antibody and had a documented complement level. Significant higher mortality rates were found in the low complement group, with an odds ratio for mortality (OR 1.93 CI 1.63-2.27 p < .001). Deep vein thrombosis and pulmonary emboli rates were similar. Multivariate analysis confirmed that low complement was an independent predictor for mortality after controlling for age, sex, dyslipidemia, chronic heart failure (CHF), chronic kidney disease (CKD), and anemia. CONCLUSIONS: Our study results indicate that low complement is associated with significantly higher mortality rates in admitted patients with elevated levels of anti-phospholipid antibodies. This finding correlates with recent literature suggesting a vital role for complement activation in anti-phospholipid syndrome.

Aortic thoracic neuromodulation in heart failure with preserved ejection fraction.

The inadequacy of medical therapies for heart failure with preserved ejection fraction (HFpEF) is driving the development of device-based solutions targeting underlying pathophysiologic abnormalities. The maladaptive autonomic imbalance with a reduction in vagal parasympathetic activity and increased sympathetic signalling contributes to the deterioration of cardiac performance, patient fitness, and the increased overall morbidity and mortality. Thoracic aortic vagal afferents mediate parasympathetic signalling, and their stimulation has been postulated to restore autonomic balance. In this first-in-man experience with chronic stimulation of aortic vagal afferents (Harmony™ System, Enopace, Israel), we demonstrate improved left atrial remodelling and function parallel with improved left ventricular performance. The observed favourable structural and functional cardiac changes remained stable throughout the 1 year follow-up and were associated with improved symptoms and physical fitness. The current experience warrants further validation of the endovascular stimulation of aortic thoracic afferents as a new interventional approach for device-based treatment in HFpEF.

Anorectal Malignancies Presenting as a Perianal Abscess or Fistula.

BACKGROUND: Acute anorectal abscess and fistula are common conditions that usually presents as a painful lump close to the anal margin. Tumors in the distal rectum and in the perianal region may mimic the symptoms and signs of anorectal sepsis, thereby leading to a delay in diagnosis and management. The purpose of this study was to describe patients presenting with acute perianal abscess or fistula who were subsequently diagnosed with anorectal cancer. METHODS: We performed a retrospective, review of all cases presenting with acute perianal abscess or fistula who were subsequently found to have anorectal carcinoma on biopsy in two tertiary centers. We analyzed the data focusing on the clinical features, laboratory values, clinical staging of the tumors, the subsequent management, the pathological staging, and the outcome of each patient. RESULTS: Overall, 3219 patients presenting with anorectal abscess or fistula were reviewed. Cancer was diagnosed in 16 (.5%) patients, 12 with adenocarcinoma of the rectum and 4 with squamous cell carcinoma of the anus. In 5 patients (31.2%), cancer was diagnosed in the setting of chronic perianal fistula, 4 of them had Crohn's disease. In 10 patients (62.5%), cancer was not diagnosed during the initial evaluation of the acute symptoms. CONCLUSIONS: A high index of suspicion is required to make the diagnosis of perianal tumors when assessing patients presenting with perianal sepsis, particularly those with Crohn's disease, a long history of persistent perianal disease, and an advanced age. In most cases, proper drainage followed by proximal diversion are the surgical treatment of choice in the acute setting.

Pyogenic Liver Abscess: Contemporary Trends in a Tertiary Institute.

Background: Pyogenic liver abscess (PLA) is an uncommon but potentially life-threatening condition. In recent years, advances in diagnostics and management have led to early diagnosis and treatment and decreased mortality. We present recent data from a large series of patients with PLA and examine the trends in the management of PLA over a period of 50 years. Methods: The medical records of all patients admitted to the Shaare Zedek Medical Center, Israel, between January 2011 and December 2021 with a primary or secondary diagnosis of PLA were reviewed retrospectively. Results: : Ninety-five patients with PLA were identified. Thirty-eight (40%) were female. The median patient age was 66 years (range 18-93). The diagnosis of PLA in all patients was confirmed with abdominal computed tomography (CT). In twenty patients (21.1%), PLA was not diagnosed by the initial abdominal US. Most abscesses were right-sided. Biliary tract origin was the most common underlying cause of PLA (n = 57, 60%), followed by cryptogenic etiology (n = 28, 30%). Escherichia coli, Klebsiella pneumoniae, and Streptococcus species were most commonly identified. The most common primary treatment modality was percutaneous drainage (PD), which was performed in 81 patients (85.3%). Fourteen patients (14.7%) were treated medically without intervention, and two patients (2.1%) were treated surgically following a failure of PD. Four patients died as a direct result of PLA. Conclusions: Patients diagnosed with PLA are older, the male predominance is less pronounced, and the offending pathogens are likely to originate from the biliary tract. This study questions the utility of abdominal US as the initial diagnostic imaging in patients with suspected PLA (versus CT) and demonstrates improved outcomes for patients with PLA over the years.

Small Bowel Obstruction in Patients without Prior Abdominal Surgery: To Operate or Not?

INTRODUCTION: Surgical exploration is still considered mandatory in the setting of small bowel obstruction (SBO) in patients without prior intra-abdominal surgery. However, recent studies have challenged this 'classic' approach describing success with conservative non-surgical treatment. The aim of this study is to identify clinical, radiological and biochemical variables that may be associated with the absence of intra-abdominal pathology in patients with SBO who have not undergone previous surgery. METHODS: This is a retrospective cohort study of prospectively recorded data. Patients with SBO without prior abdominal surgery who presented to a single tertiary referral medical center between 2009 and 2019 were included. RESULTS: Eighty-seven patients were included of whom 61(70.0%) were allocated to the 'therapeutic exploration' group and 26 (30.0%) to the 'non-therapeutic exploration' group. Forty-eight patients (55.0%) had adhesions, 17.2% had closed-loop obstruction, 10.0% had an internal hernia, 27.6% had bowel ischemia and 5.7% had bowel necrosis. Although multiple clinical, laboratory, radiological and preoperative factors were examined, none were significantly associated with pathological findings during surgical exploration. There was no statistically significant difference in the incidence of complications when comparing between those groups. CONCLUSIONS: In this series, no variables were associated with intra-abdominal pathology in patients who underwent surgery for SBO with no history of prior abdominal surgery. However, the fact that 27.0% had ischemic bowel upon surgical exploration suggests that this approach is still mandatory for this specific group of patients. Furthermore, clinicians and patients should be aware that negative exploration may be expected in up to 30.0%.

Ex-vivo activation of a liposomal prodrug of mitomycin C by human tumors.

PURPOSE: To examine the ex- vivo ability of explanted human tumors and normal tissue to activate liposomal mitomycin C lipidic prodrug (MLP) by releasing the active free drug form, mitomycin C (MMC). METHODS: We tested conversion of MLP to MMC in an ex vivo assay using explanted tissues obtained during routine surgery to remove primary tumors or metastases. Tumor and adjacent normal tissue were obtained from freshly explanted tumors and were immediately deep frozen at - 70 °C. On test day, the fragments were thawed, homogenized and incubated in the presence of a fixed amount of liposomal MLP at 37 °C for 1 h. We measured MLP and its rate of conversion to MMC by HPLC. Controls included plasma, malignant effusions, red blood cells, tumor cell lines, mouse liver, and buffer with dithiothreitol, a potent reducing agent. RESULTS: Most patients tested (16/20) were diagnosed with colo-rectal carcinoma. The average fraction of MLP cleaved per 100-mg tumor tissue (21.1%, SEM = 1.8) was greater than per 100-mg normal tissue (16.6%, SEM = 1.3). When the tumor and normal tissue samples were paired by patient, the difference was statistically significant (p = 0.022, paired t test). Biological fluids did not activate liposomal MLP, while normal liver tissue strongly does. Interestingly, the omental fatty tissue also greatly activated MLP. CONCLUSIONS: Tumor tissue homogenates activate MLP with greater efficiency than the surrounding normal tissues, but far less than liver and adipose tissue. These observations demonstrate the bioavailability of liposomal MLP in human tumors, and its pharmacologic potential in cancer therapy.

Capillaria hepatica (syn. Calodium hepaticum) as a Cause of Asymptomatic Liver Mass.

Capillaria hepatica (syn. Calodium hepaticum) is a parasitic nematode of rodents, rarely infecting humans. An asymptomatic Israeli adult male with extensive travel history was diagnosed with a liver mass on routine post-thymectomy follow-up. Imaging and computer tomography (CT) guided biopsy were inconclusive. Surgical excision revealed an eosinophilic granuloma with fragments of a nematode suspected to be C. hepatica. Molecular methods verified the diagnosis, and the patient was treated empirically. This is the first case of hepatic capillariasis described in Israel, and the first to be diagnosed using molecular methods.

Urinary retention in diabetic older adults: mortality associated with a urinary catheter inserted during hospitalization but not removed.

PURPOSE: We have studied, in diabetic older adults with urinary retention (UR), whether a urinary catheter (UC) inserted during hospitalization but not removed is associated with 1-year mortality. METHODS: A retrospective study included 327 consecutive older adults (age ≥ 65 years; median age 83 years; 57.8% males) with UR in whom a UC was inserted during hospitalization: 139 (42.5%) diabetics and 188 (57.5%) nondiabetics. UC removal rates during hospitalization and 1-year mortality rates were studied in both groups. Cox regression analysis was used to assess whether a UC inserted during hospitalization but not removed was independently associated with 1-year mortality. RESULTS: Most diabetic and non-diabetic patients left the hospital with a UC (66.2% vs. 75.5%; p = 0.082). Overall, 54 (38.8%) diabetic patients and 52 (27.7%) nondiabetic patients died one year later (OR 1.66; 95% CI 1.04-2.65; p = 0.042). Diabetic patients with a UC at discharge day had significantly higher 1-year mortality rates relative to diabetic patients without a UC (48.9% vs. 19.1%; OR 4.04; 95% CI 1.75-9.30; p = 0.001), while in nondiabetic patients there was no significant difference in 1-year mortality rates between patients with or without a UC at discharge day (26.8% vs. 30.4%; p = 0.705). Cox regression analysis showed that only in diabetic patients a UC not removed was independently associated with 1-year mortality (HR 2.56; 95% CI 1.16-5.64; p = 0.019). CONCLUSION: A UC inserted but not removed in diabetic older adults with UR is associated with 1-year mortality. Removing a UC and its association with mortality should be studied prospectively in this population.

Can laboratory evaluation differentiate between coronavirus disease-2019, influenza, and respiratory syncytial virus infections? A retrospective cohort study.

AIM: To identify clinical and laboratory parameters that can assist in the differential diagnosis of coronavirus disease 2019 (COVID-19), influenza, and respiratory syncytial virus (RSV) infections. METHODS: In this retrospective cohort study, we obtained basic demographics and laboratory data from all 685 hospitalized patients confirmed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), influenza virus, or RSV from 2018 to 2020. A multiple logistic regression was employed to investigate the relationship between COVID-19 and laboratory parameters. RESULTS: SARS-CoV-2 patients were significantly younger than RSV (P=0.001) and influenza virus (P=0.022) patients. SARS-CoV-2 patients also displayed a significant male predominance over influenza virus patients (P=0.047). They also had significantly lower white blood cell count (median 6.3×106 cells/µ) compared with influenza virus (P<0.001) and RSV (P=0.001) patients. Differences were also observed in other laboratory values but were insignificant in a multivariate analysis. CONCLUSIONS: Male sex, younger age, and low white blood cell count can assist in the diagnosis of COVID-19 over other viral infections. However, the differences between the groups were not substantial enough and would probably not suffice to distinguish between the viral illnesses in the emergency department.

Ferritin as a Marker of Severity in COVID-19 Patients: A Fatal Correlation.

BACKGROUND: Ferritin, the cellular protein storage for iron, has emerged as a key molecule in the immune system, orchestrating the cellular defense against inflammation. At the end of 2019, the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) rapidly spread throughout China and other countries around the world, resulting in a viral pandemic. OBJECTIVES: To evaluate the correlation between ferritin and disease severity in coronavirus disease-2019 (COVID-19). METHODS: In this cross-sectional study, we obtained clinical and laboratory data regarding 39 hospitalized patients with confirmed COVID-19 from two hospitals in Israel. RESULTS: A significant increase in ferritin levels was demonstrated in patients with moderate and severe disease, compared to patients with mild disease (P = 0.006 and 0.005, respectively). Severe patients had significantly higher levels of ferritin (2817.6 ng/ml) than non-severe patients (708.6 ng/ml) P = 0.02. CONCLUSIONS: In this preliminary cross-sectional study, elevated ferritin levels were shown to correlate with disease severity in 39 patients from Israel with confirmed COVID-19 infection. Our results further strengthen the hypothesis that severe COVID-19 disease might be due to an underlying dysregulated hyperimmune response. In order to identify these patients early and prioritized resources, we believe that all patients with COVID-19 should be screened for hyperferritinemia.

Hyperferritinemia in the elderly can differentiate the bad from the worst: A retrospective cohort analysis.

Both total-body iron stores and inflammation influence the concentration of ferritin in the blood. Ferritin as an inflammatory marker might serve as a prognostic marker in the elderly. Therefore, we characterized the clinical circumstances and long-term outcomes of hyperferritinemia (> 1000 µg/L) in hospitalized elderly patients.A retrospective analysis of elderly (> 70 years) inpatients with ferritin levels of > 1000 µg/L in a tertiary medical center during a 3-year period. We obtained both laboratory and clinical data, assessing the potential association of high ferritin levels with long-term mortality.Overall, 242 patients (median age 79 years; median ferritin level 1436 µg/L) met the inclusion criteria and were followed for a median time of 18.6 months. Clinical outcomes were dismal for the whole cohort: the diagnosis of solid malignancy occurred in 23.5% of cases while 31% had a severe infection (ranging from sepsis to septic shock). The median survival time of the whole cohort was 4.7 months only. Within the cohort, risk stratification was feasible: higher ferritin levels differentiate between groups of patients who had a poor prognosis (with either septic shock or solid malignancy) and those who had a relatively favorable prognosis (patients diagnosed as suffering from sepsis without shock and patients with iatrogenic causes for hyperferritinemia).Hyperferritinemia in elderly inpatients is associated with high rates of mortality. Within this group of patients, differential ferritin levels enable further risk stratification. High ferritin levels in the elderly can differentiate the bad from the worst.

Risk of bacteremia in hospitalised patients with inflammatory bowel disease: a 9-year cohort study.

BACKGROUND: Patients with inflammatory bowel disease might be at increased risk of invasive bacterial infections. OBJECTIVES: The objective of this study was to identify the rate of bacteremia in hospitalised patients with inflammatory bowel disease and risk factors. METHODS: An observational cohort of hospitalised patients with inflammatory bowel disease, aged 16-80 years, from 2008 to 2017 in a large tertiary hospital. Patients with Charlson comorbidity index of 2 or greater were excluded. Patients with one or more positive blood culture were reviewed. Logistic regression was used to evaluate risk factors for bacteremia. RESULTS: Of 5522 admitted patients, only 1.3% had bacteremia (73/5522) (39, Crohn's disease; 25, ulcerative colitis; nine, unclassified inflammatory bowel disease). The most common pathogen was Escherichia coli (19/73 patients). The mortality rate at 30 days of patients with bacteremia was 13.7% (10/73). Longer hospitalisations (mean length of stay (21.6 ± 31.0 vs. 6.4 ± 16.0 days; P < 0.0001) and older age (mean age 47.5 ± 18.0 vs. 40.2 ± 15.4 years, P < 0.0001)) were associated with an increased risk of bacteremia. In multivariate analysis, treatment with either anti-tumour necrosis factor α, purine analogues, steroids or amino salicylates was not associated with an increased risk of bacteremia. Risk was greatest among patients aged 65 years or older (relative risk 2.84, 95% confidence interval 1.6-4.8; P = 0.0001) relative to those under 65 years. CONCLUSION: Age over 65 years, but not inflammatory bowel disease-related medications, is associated with an increased risk of bacteremia in hospitalised patients with inflammatory bowel disease.