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BACKGROUND: Mortality rates used to evaluate and improve the quality of hospital care are adjusted for comorbidity and disease severity. Comorbidity, measured by International Classification of Diseases codes, do not reflect the severity of the medical condition, that requires clinical assessments not available in electronic databases, and/or laboratory data with clinically relevant ranges to permit extrapolation from one setting to the next. AIM: To propose a simple index predicting mortality in acutely hospitalized patients. DESIGN: Retrospective cohort study with internal and external validation. METHODS: The study populations were all acutely admitted patients in 2015-16, and in January 2019-November 2019 to internal medicine, cardiology and intensive care departments at the Laniado Hospital in Israel, and in 2002-19, at St. James Hospital, Ireland. Predictor variables were age and admission laboratory tests. The outcome variable was in-hospital mortality. Using logistic regression of the data in the 2015-16 Israeli cohort, we derived an index that included age groups and significant laboratory data. RESULTS: In the Israeli 2015-16 cohort, the index predicted mortality rates from 0.2% to 32.0% with a c-statistic (area under the receiver operator characteristic curve) of 0.86. In the Israeli 2019 validation cohort, the index predicted mortality rates from 0.3% to 38.9% with a c-statistic of 0.87. An abbreviated index performed similarly in the Irish 2002-19 cohort. CONCLUSIONS: Hospital mortality can be predicted by age and selected admission laboratory data without acquiring information from the patient's medical records. This permits an inexpensive comparison of performance of hospital departments.

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BACKGROUND: In developing countries, it may be easier to use the reasons why patients come to the emergency room (ER) instead of sentinel practices to identify influenza epidemics. METHODS: We studied the reasons why adult patients present to the ER in order to attempt to predict increased hospital activity as a result of influenza. The daily frequency of presenting symptoms during the 30 days of maximal influenza activity was compared to the other days of the study period (335 days). RESULTS: During the influenza period, more patients presented with fever, syncope or near syncope, cough, asthma attack, and paralysis than on the days outside of this period. On 50% of the days, eight or more patients presented with fever, an 8.36 (95% CI=4.6-15.19) higher frequency than during the rest of the year. During the subsequent year, days with excess presentations by patients with a principal complaint of fever predicted increased hospital activity due to influenza with no false-positive periods. CONCLUSIONS: We conclude that an increase in the number of patients presenting to the ER complaining of fever can identify increased hospital influenza activity.

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OBJECTIVE: Pseudomembranous colitis (PMC) is well recognized as an important cause of diarrhoea in patients receiving antibiotics, with significant consequences of morbidity and mortality. Mortality among elderly patients is high, and even with successful treatment, a significant number of patients relapse. To evaluate the outcome of elderly patients with PMC, and to try to identify risk factors that might influence mortality or relapse. METHOD: We studied 72 consecutive hospitalized patients with endoscopically proven PMC. The medical records of all patients with their clinical history and laboratory data were reviewed in detail. These data included: pre-hospitalization residence and physical status, background medical history, presenting symptoms, antibiotic history, haematological and biochemical parameters, treatment, duration of hospitalization, complications, mortality within 30 days of hospitalization and relapse. RESULTS: Of the 72 patients (M/F=34/38, mean age=77 years), 47% were nursing home residents. Prior to hospitalization, 91.6% of patients had received antibiotic treatment (cephalosporins - 64%, penicillins - 42% and quinolones - 28%), 26% of patients received antacid therapy and 36% had been fed with a nasogastric tube (NGT). Thirty-seven (51%) patients recovered without complications, 21 (29%) patients died within 30 days of hospitalization and 14 (19%) patients were re-hospitalized because of relapse of PMC. Multivariate analysis revealed that white blood cell count above 20 x 10(3)/mm3 (P=0.009), serum albumin level of less than 2.5 g/dl (P=0.02), and pre-hospitalization NGT feeding (P=0.01) were associated with high mortality. Treatment with acid-reducing drugs (P=0.01) and living at a nursing home (P=0.06) were associated with high relapse rates. CONCLUSION: Pseudomembranous colitis is an important complication of antibiotic therapy and is associated with high mortality and recurrence rate, especially in old and debilitated persons. Pre-admission NGT feeding, severe leucocytosis and hypoalbuminaemia on admission are associated with increased mortality. Pre-hospitalization acid reducing treatment and nursing home residency are associated with increased risk of recurrence.

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We hypothesize that the frequency of reasons patients present to the emergency department will change during epidemics and might be a valuable component of a disease surveillance system. We found support for this hypothesis over a two-year period with high frequency days of fever clustering during two periods of increased hospital influenza activity, but not during any other period during the two-years. This methodology appears to be superior to the previous use of triage nurses defining patients with symptom complexes. Such a system could result in online monitoring, be independent of the medical personnel (use of admission secretary), and might be able to identify various epidemics including increased hospital disease activity due to bio-terror attacks, influenza, and food poisoning. This would have important implications for limiting the spread of disease and for the acute planning of distribution of medical resources. Studies are warranted in various settings to determine whether or not changes in the daily frequencies of reasons patients present to the ED will allow identification of epidemics.

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Four patients with no known predisposing conditions developed tricuspid valve endocarditis. All patients had community-acquired infection with a rapidly progressive course that was complicated by right heart failure and respiratory insufficiency. Pulmonary involvement was prominent in all cases. The infectious process was due to Staphylococcus aureus in three patients and to Streptococcus intermedius in one patient. Three patients underwent early surgical intervention; the outcome was favourable in all cases. It is clear that tricuspid valve endocarditis can occur in the absence of known predisposing factors, and when Staphylococcus aureus is involved, the course of the disease may be acute and rapidly progressive.

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In a retrospective study, 80 episodes of nontyphoid salmonella (NTS) bacteremia in children were compared with 55 episodes in adults over a 10-year period. The study disclosed major differences in the predisposition, clinical presentation, and outcome as well as the microbiology of NTS bacteremia in relation to age. Adults were more likely than children to have predisposing diseases (95% vs. 15%, respectively; P < .0001) and to receive prior medications (95% vs. 23%, respectively; P < .0001), particularly immunosuppressive agents (58% vs. 5%, respectively; P < .0001). In most adults (67%), NTS infection presented as a primary bacteremia and was associated with a high incidence of extraintestinal organ involvement (34%) and a high mortality rate (33%). In children, NTS bacteremia was usually secondary to gastroenteritis (75%) and caused no fatalities. Although group D Salmonella (78%) and the serovar Salmonella enteritidis were the predominant isolates from adults, the emergence of infections due to group C Salmonella (46%) and the serovar Salmonella virchow in children was noted.

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We present 2 cases in which the transfusion of small volumes of packed RBC was sufficient to precipitate symptomatic hypocalcemia. Subsequent inquiry revealed that both of the patients had preexisting, untreated, and asymptomatic hypocalcemia, 1 following partial thyroidectomy many years earlier and the other with documented hypocalcemia but without a definitive diagnosis.

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This study evaluated and compared the usage and costs of antibiotics in seven hospitals in the North of Israel and was the first of its kind. We also attempted to determine whether the presence of an Infectious Diseases Unit or Consultant affects antibiotic usage and costs.

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In April 1993 a national survey of pneumococcal bacteremia in hospitalized Israeli adults was started, and this survey covered 23 of the 24 Israeli medical centers. During the first 2 years, 603 episodes of pneumococcal bacteremia were recorded. The overall annual incidence of pneumococcal bacteremia in Israeli adults was 14.5 episodes per 100,000 inhabitants, and the overall mortality rate was 27.8%. Pneumonia was the source of bacteremia in 70.8% of cases, primary bacteremia was the source in 17.5%, meningitis was the source in 7.5%, and otitis media/sinusitis was the source in 4.2%. Of the 258 pneumococcal isolates for which an MIC was determined, 88.8% were susceptible to penicillin, 9.3% were partially resistant, and only 1.9% were highly resistant. Twenty-four serogroups were identified from 398 strains tested. The highest percentage of penicillin-resistant strains belonged to serogroups 23, 19, 9, 4, and 6. Although only 13 of these 24 serogroups correspond to the serotypes included in the 23-valent pneumococcal vaccine, they accounted for 94% of all isolates.

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Most patients with chronic idiopathic thrombocytopenic purpura (TTP) show a good initial response to treatment with corticosteroids. However the disease relapses in more than 90% when steroid dosage is reduced. Recently 100% success was reported for a new therapeutic protocol in 12 patients (ranging in age from 13-60, half of them women) with chronic ITP refractory to corticosteroids or to splenectomy. They were given pulsed therapy with oral dexamethasone, 40 mg/day on 4 consecutive days each month, for 6 months. This treatment protocol was used in an attempt to avoid splenectomy. 5 patients (42%) had a complete response but 7 did not. The median follow-up in those who responded was 7 months (range 6-8). Of the 7 who did not respond, 5 had not completed treatment: 3 because of urgent splenectomy and 2 because of lack of response after 3 courses of therapy accompanied by side-effects. Most patients suffered typical corticosteroid side-effects, principally restlessness, insomnia, and withdrawal effects. These were milder and better tolerated in those treated with Dexacort solution (20 mg ampules) rather than dexamethasone tablets. Despite complete response in only 5 of the 12 patients (42%), we feel that pulsed high-dose dexamethasone is effective and should be tried in TTP refractory to conventional corticosteroid therapy, before resorting to splenectomy.

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In the past 3 years 71 procedures for insertion of a percutaneous gastrostomy for enteral feeding were performed under X-ray control. The indication for gastrostomy was inability or refusal of the patient to swallow food, in the absence of mechanical obstruction of the gastrointestinal tract. The age range was 66-93 years (mean 82). Most patients had suffered strokes and some had dementia or Parkinson's disease. The procedure was successful in 69/71 patients (97%). 9 (12.6%) died within 30 days of causes related to their underlying condition, rather than to the procedure; 1 developed peritonitis and 6 (8.4%) developed minor infections at the site of entry of the gastrostomy tube. This is the first account of this technique to appear in the Hebrew medical literature. In our opinion the technique should be adopted as the preferred method for forming a gastrostomy, as it is quicker, safer and cheaper than the operative method, and even easier to perform than endoscopic percutaneous gastrostomy.

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Two patients with acute tricuspid bacterial endocarditis in which a normal right ventricular Doppler filling pattern was demonstrated early following valvectomy are reported. After surgery, on pulsed Doppler examination, the sample volume positioned at the right atrioventricular level revealed a normal M-shaped filling pattern. A pathologic monophasic pattern was documented a few months later. Our findings suggest that early after surgery the preserved gradient throughout ventricular diastole leads to a passive and active filling similar to normal. Only at a later stage is the grossly dilated right atrium unable to maintain active filling, and the 'A' wave disappears despite the fact that sinus rhythm is maintained. Tricuspid valve diastolic motion represents a product of the several factors that determine atrioventricular gradient, but the valve itself appears not to be involved in the generation of a normal filling pattern.

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Sera from 183 healthy, elderly subjects and 92 young, control subjects were tested by the Elisa method for antibodies against double-stranded (ds) and single-stranded (ss) DNA, and sera from the elderly were tested for antinuclear antibodies as well. Significantly higher levels of anti-ss-DNA were found in the elderly, but levels of anti-ds-DNA did not differ significantly; no sera positive for anti-ds-DNA were found. levels of antibodies to DNA were similar in men and women. In those 85 and over, mean levels of anti-ds-DNA were lower than in those 65-84 (63 vs. 44, p less than 0.05). 13 of those over 65 (7.1%) tested positive for antinuclear factor, 2 of whom had positive titers of anti-ss-DNA. The results of this study support the hypothesis that elevated levels of anti-ss-DNA are age-related and not disease-related.

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Neuroleptic malignant syndrome (NMS) is an uncommon, life-threatening complication of treatment with neuroleptic drugs. Its main features are hyperthermia, extrapyramidal signs, and autonomic instability with fluctuating consciousness. It is believed that NMS is related to dopamine receptor blockade in the brain. We describe a case in a 52-year-old diabetic woman who developed NMS after taking Torecan (thiethylperazine), a phenothiazine drug, for 3 months to relieve dizziness. It is important to recognize this syndrome early and to treat immediately.

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Positive titers of antibodies against double-stranded (ds) and single-stranded (ss) DNA were found in the sera of 4 and 6 patients, respectively, of 18 who had familial Mediterranean fever (FMF). While anti-dsDNA antibodies were found only in patients with active disease, there was no correlation between the presence of anti-ssDNA antibodies and disease activity. The antibody titers were lower than those found in patients with active systemic lupus erythematosus. This may be due in part to the fact that all the FMF patients were treated with colchicine.

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