Israel Medical Association Journal

Background: The compliance of hospital staff with guidelines for the active surveillance of methicillin-resistant Staphylococcus aureus (MRSA) in Israel has not been determined.

Objectives: To evaluate the compliance of hospital staff with guidelines for the active surveillance of MRSA and assess its impact on the incidence of nosocomial MRSA bacteremia.

Methods: We assessed compliance with MRSA surveillance guidelines by assessing adherence to the screening protocol and reviewing medical and nursing charts of patients colonized with MRSA, and observed hand hygiene opportunities among health care workers and colonized patients. Rates of nosocomial MRSA bacteremia and of adherence with hand hygiene among overall hospital staff were obtained from archived data for the period 2001–2010.

Results: Only 32.4% of eligible patients were screened for MRSA carriage on admission, and 69.9% of MRSA carriers did not receive any eradication treatment. The mean rate of adherence to glove use among nurses and doctors was 69% and 31% respectively (P < 0.01) and to hand hygiene 59% and 41% respectively (P < 0.01). The hospital overall rate of adherence to hand hygiene increased from 42.3% in 2005 to 68.1% in 2010. Rates of nosocomial MRSA bacteremia decreased by 79.2%, from 0.48 (in 2001) to 0.1 (in 2010) per 1000 admissions (P < 0.001).

Conclusions: The compliance of medical and nursing staff with guidelines for active MRSA surveillance was poor. The encouraging increase in adherence to hand hygiene and concomitant decrease in nosocomial MRSA bacteremia is gratifying. The deficiencies in compliance with MRSA infection control policy warrant an adjusted strategy based on the hospital resources.

Background: There is a wide treatment gap between evidence-based guidelines and their implementation in primary care.

Objective: To evaluate the extent to which physicians "literally" follow guidelines for secondary prevention of dyslipidemia and the extent to which they practice "substitute" therapeutic measures.

Methods: We performed a post hoc analysis of data collected in a prospective cluster randomized trial. The participants were 130 primary care physicians treating 7745 patients requiring secondary prevention of dyslipidemia. The outcome measure was physician "literal" adherence or "substitute" adherence. We used logistic regressions to evaluate the effect of various clinical situations on “literal” and “substitute” adherence.

Results: "Literal" adherence was modest for ordering a lipoprotein profile (35.1%) and for pharmacotherapy initiations (26.0%), but rather poor for drug up-titrations (16.1%) and for referrals for specialist consultation (3.8%). In contrast, many physicians opted for "substitute" adherence for up-titrations (75.9%) and referrals for consultation (78.7%). Physicians tended to follow the guidelines “literally” in simple clinical situations (such as the need for lipid screening) but to use "substitute" measures in more complex cases (when dose up-titration or metabolic consultation was required). Most substitute actions were less intense than the actions recommended by the guidelines.

Conclusions: Physicians often do not blindly follow guidelines, but rather evaluate their adequacy for a particular patient and adjust the treatment according to their assessment. We suggest that clinical management be evaluated in a broader sense than strict guideline adherence, which may underestimate physicians' efforts.
 

Pulmonary epithelioid hemangioendothelioma (PEH), previously known as "intravascular bronchoalveolar tumor," is a rare vascular malignancy with an unpredictable prognosis. Treatment can vary from observation in asymptomatic patients to surgery in patients with resectable disease or chemotherapy in patients with disseminated disease. This report describes the clinical, radiological and pathological features of three cases of PEH and a review of the current literature.
 

Background: Staphylococcus aureus infection is a major cause of morbidity and mortality worldwide. Clindamycin is widely used in the treatment of staphylococcal infections; however, it is our impression that in the last few years, inducible clindamycin resistance (ICR) has become more prevalent.

Objective: To assess the prevalence of ICR[1] in methicillin-sensitive Staphylococcus aureus (MSSA) infections among pediatric patients in Israel.

Methods: We reviewed the files of children diagnosed with MSSA[2] infections during the period January 2006 to June 2007 for full antibiogram (including the D-test for ICR), phage typing and randomly amplified polymorphic DNA.

Results: Altogether, 240 MSSA isolates were recovered, mainly from wounds and abscesses. ICR was detected in 62 of 68 erythromycin-resistant/clindamycin-sensitive strains (91%); the ICR rate for the total number of isolates was 26% (62/240). Phage type analysis demonstrated that 38 of 61 ICR isolates

(62%) were sensitive to group 2, compared to 42 of 172 isolates (24%) that did not express ICR (P < 0.01). On randomly amplified polymorphic DNA, phage type 2 isolates expressing ICR belonged to the same clone, which was different from ICR isolates sensitive to other phages and from isolates not expressing ICR.

Conclusions: Inducible clindamycin resistance is common among methicillin-sensitive Staphylococcus aureus in Israeli children. The D-test should be performed routinely in all isolates of MSSA.

Background: Wounds of the lower extremities are a significant problem, being severe and costly to treat. Adjunctive treatment with hyperbaric oxygenation (HBOT) has proven to be a useful and cost-effective means of treating ischemic wounds, mainly in diabetic patients.

Objectives: To describe patients with ischemic wounds treated at the Rambam and Elisha Hyperbaric Medical Center and their wound improvement following HBOT.

Methods: We conducted a retrospective cohort study of all patients (N=385) treated in the center during 1998–2007 for ischemic non-healing wounds in the lower extremities.

Results: The mean age of the patients was 61.9 years (SD 13.97). Most of them were diabetic (69.6%) and male (68.8%). Half of the subjects had a wound for more than 3 months prior to undergoing pre-HBOT transcutaneous oximetry (TcPO₂) testing. Most of the wounds were classified as Wagner degree 1 or 2 (39.1% and 46.2% respectively). The median number of treatments per patient was 29. Only 63.1% of patients had continuous treatments. Approximately 20% of patients experienced mild side effects. An improvement occurred in 282 patients (77.7%) following HBOT: 15.2% fully recovered, 42.7% showed a significant improvement (and were expected to heal spontaneously), and 19.8% a slight improvement.

Conclusions: HBOT can benefit the treatment of non-healing ischemic wounds (especially when aided by pretreatment TcPO₂ evaluation; data not shown). Our experience shows that this procedure is safe and contributes to wound healing.

Attention deficit hyperactivity disorder (ADHD) is among the most prevalent chronic health disorders affecting school-age children. The disorder is the subject of much debate for several reasons, the major one being the diagnostic process, which in some aspects is unstructured and can be relatively easily biased. The impact of undiagnosed or misdiagnosed ADHD on the lives of many children can be severe. Therefore, it is important to understand the complexities of the diagnostic procedure in ADHD, including the cultural bias effect, the limitations of the DSM-IV-TR definitions, the effect of comorbid conditions on the diagnostic process, the gene-environment interactions, and the need to compose an objective, more accurate, and generally accepted diagnostic battery of tests. This review addresses the diagnostic difficulties of ADHD and considers some steps that would make ADHD a more easily identifiable disorder.
 

Background: A new approach for assessing non-cognitive attributes in medical school candidates was developed and implemented at the Hebrew University Medical School. The non-cognitive tests included a biographical questionnaire, a questionnaire raising theoretical dilemmas and multiple mini-interviews.

Objectives: To evaluate the effects of the change in the admission process on students' demographics and future career choices.

Methods: A questionnaire including questions on students’ background and future residency preferences was administered to first-year students accepted to medical school by the new admission system. Results were compared with previous information collected from students admitted through the old admission process.

Results: Students accepted by the new process were significantly older (22.49 vs. 21.54, P < 0.001), and more had attended other academic studies before medical school, considered other professions besides medicine, and majored in humanities combined with sciences in high school. Significantly more students from small communities were admitted by the new system.  Differences were found in preferences for future residencies; compared with the old admission process (N=41), students admitted by the new system (N=85) had a more positive attitude towards a career in obstetrics/gynecology (41% vs. 22%, P < 0.001) and hematology/oncology (11.7% vs. 4.8%, P < 0.001), while the popularity of surgery and pediatrics had decreased (34.5% vs. 61%, P < 0.001 and 68.7% vs. 82.5%, P < 0.001 respectively).

Conclusions: Assessment of non-cognitive parameters as part of the admission criteria to medical school was associated with an older and more heterogenic group of students and different preferences for future residency. Whether these preferences in first-year students persist through medical school is a question for further research.
 

Background: Esophageal perforations and postoperative esophageal leaks are associated with substantial morbidity and mortality and pose a difficult therapeutic challenge. 

Objectives: To evaluate the outcome of removable self-expanding metallic stents (SEMS) as a treatment for postoperative leaks and perforations of the esophagus and stomach.

Methods: We conducted a retrospective study of all patients in one medical center who underwent temporary insertion of a covered plastic stent for postoperative leaks and perforations of the esophagus and stomach from June 2009 to February 2010. Data were retrieved from hospital and outpatient clinical data charts. Data included indication for insertion, post-insertion outcome including stent complications, and follow-up after stent removal.

Results: The indications for stent insertion were postoperative leak in four patients and postoperative esophagopleural fistula in one patient. Three of the patients had a leak at the gastro-esophageal junction following laparoscopic sleeve gastrectomy. In all cases the stent insertion was completed successfully. In three patients the stent migrated distally. In two of these three it was repositioned or replaced endoscopically, and in the third it was excreted in the feces. Stents were removed electively after 6 to 7 weeks. All patients recovered fully and were discharged from the hospital.

Conclusions: SEMS insertion may have an important role in the management of postoperative leaks and perforations of the esophagus and stomach and should be considered in such cases.