Clinical impact of the accelerate PhenoTest® BC system on patients with gram-negative bacteremia and high risk of antimicrobial resistance: a prospective before-after implementation study.

BACKGROUND: The Accelerate PhenoTest® BC system (AXDX) is a novel assay for rapid bacterial identification and antimicrobial susceptibility (AST). We report an evaluation of its impact on treatment of patients with Gram-negative bacteremia (GNB) with a high risk of antimicrobial resistance (AMR). METHODS: A prospective single-center evaluation before and after implementation of AXDX in addition to standard-of-care (SOC) microbiology and antimicrobial stewardship program (ASP). Patients with GNB reported during laboratory working hours and prespecified risk factors for AMR were included. The primary outcome was an ASP-oriented beneficial antimicrobial change, defined as either an escalation of an inappropriate empiric treatment or de-escalation of a broad-spectrum treatment of a susceptible organism. Main secondary outcomes were time to an appropriate treatment, antimicrobial treatment duration, length of stay (LOS) and mortality. RESULTS: Included were 46 and 57 patients in the pre- and post-intervention periods, respectively. The median time to an AST-oriented beneficial change was 29.2 h vs. 49.6 h, respectively (p < 0.0001). There were no significant differences in the time to appropriate treatment, LOS or mortality. Antimicrobial treatment duration was longer during the intervention period (10 vs. 8 days, p = 0.007). AXDX failed to correctly identify pathogens in all 6 cases of polymicrobial bacteremia. In two cases patient care was potentially compromised due to inappropriate de-escalation. CONCLUSIONS: AXDX implementation resulted in a 20.4-hour shorter time to an ASP-oriented beneficial antimicrobial change. This should be weighed against the higher costs, the lack of other proven clinical benefits and the potential harm from mis-identification of polymicrobial bacteremias.

Resilience, sense of danger, and reporting in wartime: a cross-sectional study of healthcare personnel in a general hospital.

BACKGROUND AND AIMS: Maintaining healthcare services and ensuring the presence of healthcare personnel (HCP) during periods of conflict and high-intensity warfare in Israel including the significant security event that occurred on May 2021, pose significant challenges for hospitals in the range of missile attacks. The May 2021 event, marked by intense hostilities and military actions, brought about heightened security escalations and increased risks in the region. Despite the prevailing threat of missile attacks and ongoing security concerns, hospitals in the affected areas were required to sustain their services and uphold care standards. In light of these circumstances, this study aims to identify the factors that influence the percentage of HCP reporting for work during these intense periods of security escalations and wartime in Israel. Specifically, it explores the relationships between resilience, sense of danger, and HCP absenteeism in the context of the ongoing conflict. The findings of this study can provide valuable insights for designing interventions aimed at decreasing HCP absenteeism during security escalations, wartime, and emergency situations, ultimately contributing to the resilience and effectiveness of healthcare delivery in this challenging environment. METHODS: During a relative calm period from December 2021 to January 2022, a cross-sectional study was conducted at a southern Israeli general hospital, situated within the range of missile attacks in the midst of a longstanding conflict. The study focused on HCP who were employed before May 21, which marked the end of the last war state at that time. The questionnaire, consisting of measures for resilience using the Conor-Davidson scale (CD-RISC 10) and the sense of danger assessed with the Solomon & Prager inventory, was administered online to all hospital employees at Assuta Ashdod Hospital, located in the southern city of Ashdod, Israel. This approach was chosen due to the challenging nature of conducting a study during an existing war, making it impractical to carry out the research during such periods of active war. RESULTS: In total, 390 employees completed the survey (response rate of 24%). Of this sample, 77.4% reported fully to work during the last security escalations in May 2021. Most of the sample (84.1%) felt insecure on the way to work. The HCP who reported fully to work had a higher level of resilience than employees who reported partially or did not come to work at all (p = .03). A higher sense of danger in the workplace correlated with a 73% increase in absenteeism (p < .01). Absenteeism (partial or full) was higher among HCP with children who require supervision (p < .01). Hospital preparedness for emergencies as perceived by the employees increased HCP attendance at work (p = .03). CONCLUSIONS: Hospital management should consider designing programs aimed at potentially strengthening the level of resilience and fostering a greater sense of security among hospital personnel, which might encourage greater attendance at work during wartime, crises, or emergencies.

[IMPLEMENTATION OF AN INNOVATIVE PROGRAM - PROFESSIONAL NURSING COMPETENCE ADAPTED TO CLINICAL NEEDS TO IMPROVE THE PROFESSIONAL QUALITY AND QUALITY OF CARE AT ASSUTA ASHDOD PUBLIC HOSPITAL].

INTRODUCTION: Health systems in Israel and around the world are facing an increase in life expectancy and chronic diseases, along with technological developments, healthcare transparency, and increased customer (patients') requirements. Medical teams must provide high professional responses to these challenges. Nurse training in Israel occurs on both academic and professional levels. The last decade has shown an academic trend in the nursing profession, where most training options integrate a bachelor's degree and a registered nurse certificate. At the professional level, academic nurses can expand their professional competence through advanced clinical training, and a nurse practitioner program. There is a growing trend among policy makers for placing nurses with such recognized training in various key positions such as head nurse, and shift managers in specific wards and units.

[FIVE YEARS HAVE PASSED SINCE SAMSON ASSUTA ASHDOD UNIVERSITY HOSPITAL WAS OPENED].

INTRODUCTION: Five years have passed since the Samson Assuta Ashdod Hospital was opened for the public, the first hospital founded in Israel after decades. The count started as the doors of the emergency medicine ward opened to the public, thus expressing the point in time when, for the first time, the hospital staff could manage a patient from the time of his entrance to the hospital till the completion of definite care (such as surgery, cardiac catheterization and more). This was in comparison to treatment of only selected (ambulatory and elective) patients in the new hospital during the initial running period that lasted for half a year. Five years after opening the hospital, the medical skills and the services have developed, and the hospital continues to grow. Parallel to the expansion of medical activity, the academic activity and research have bloomed as expected in a hospital affiliated to the University of Ben Gurion. In this issue of the journal we provide a glimpse into this field in the hospital.

Challenges of a regional trauma center in treating combat and civilian casualties. The experience of Assuta Ashdod Hospital in the Iron Swords War.

INTRODUCTION: Assuta Ashdod Hospital is a regional trauma center. The hospital received casualties on the first day of the civilian massacre of October 7th and thereafter. The Assuta Ashdod Hospital was designated as an emergency landing site only for unstable or deteriorating patients who would not survive longer flights to a central trauma center. The aim of this study is to share our experience and challenges as a new regional trauma center in a war zone. METHODS: A descriptive cohort study consisting of all trauma patients admitted in the Emergency Department, between October 7, 2023, and December of the same year. The data is part of the Israel National Trauma Registry. RESULTS: A total of 397 heavily wounded patients were admitted, of which 3 were declared dead on arrival, 95 were hospitalized and 299 were discharged from the emergency department after initial care. Of the 95 wounded patients hospitalized, 60 (63.1 %) had a single mechanism of injury, of which, 35.7 % were penetrating injuries. The most frequent injury was to the extremities (60 %) followed by chest and abdomen, 35.7 % and 14.7 % respectively. Multi-trauma injuries were present in 40 % of the wounded patients. The average ISS was 15 (median=9). Of all patients, 10.5 % of patients were considered to have severe and 23.1 % to have profound (very-severe) injuries by the ISS classification. Twelve patients received whole blood transfusions, fourteen received the Massive Transfusion Protocol. Sixty-one of the 95 (64 %) patients underwent surgery, with a total of 137 surgeries performed. Sixty-seven percent of surgical procedures were orthopedic and 16.7 % were of general surgery. The average length of stay was 6.5 days (median=6). We transferred 14 patients to central trauma centers, 3 of which did not survive. CONCLUSION: The outcomes of patients admitted to the Assuta Ashdod Hospital were good in treating major trauma patients in a mass casualty event, reaffirming its capabilities as an excellent regional trauma center. Therefore, we suggest that the guidelines for evacuation of battle or major casualty events victims only to central trauma centers unless patients are unstable should be reconsidered, and regional trauma centers could effectively share the burden of the treatment of those patients.

Combination treatment of persistent COVID-19 in immunocompromised patients with remdesivir, nirmaltrevir/ritonavir and tixegavimab/cilgavimab.

We present a retrospective study on the treatment outcomes of severely immunocompromised patients with persistent COVID-19. The study analyzed data from 14 patients who received a combination of tixegavimab/cilgavimab and antiviral medications. Response was evaluated based on symptom improvement, PCR cycle-threshold values, and C-reactive protein levels. Eleven patients achieved complete clinical and virological resolution, while three showed partial responses. The study suggests a potential association between non-response and tixegavimab/cilgavimab neutralization. The findings underscore the need for tailored treatment approaches and further research on optimal strategies for managing persistent COVID-19, as well as the development of antivirals and variant-specific monoclonal antibodies.

Return to flight with multiple sclerosis: aeromedical considerations.

Multiple sclerosis (MS) is the most frequent demyelinating disease of the central nervous system, with versatile manifestations--relapsing-remitting or progressive--and an unpredictable course, with prognoses ranging from minimal neurological impairment to severely disabled. Disease modifying agents can minimize relapse rate and slow disease progression. Yet most patients suffer relapses and progression despite use of these agents. Several of the manifestations of MS may cause overall decrease in the performance of the aviator. These include cognitive impairment, fatigue, and depression. Episodes of spasms, dysarthria, ataxia, parasthesias, diplopia, and hemiplegia, as well as drug side effects may also affect flight. Seizures and episodes of vertigo may occur suddenly and result in in-flight incapacitation. We present our experience with two aviators with definite MS and a navigator with probable MS. The various manifestations of MS are specifically addressed with an emphasis on the aeromedical implications.

Inflammatory bowel disease in military aviators: 14 cases with return to flying duty.

Inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, is not a rare entity among military aviators. This relapsing inflammatory condition which may also affect extra intestinal organs can cause recurrent symptoms with considerable morbidity. The unpredictable nature of the disease, side effects of medications, and potential surgical procedures are obvious aeromedical concerns let alone the disease's extra-intestinal manifestations, some of which may result in sudden incapacitation. We present 14 military aviators who were diagnosed with inflammatory bowel disease and returned to flight duty after stabilization of symptoms. Mean follow-up period was 102 months (total of 1,429 months) without any adverse effects on flight safety. Only 4 aviators were grounded for a cumulative duration of 35 months during that period. We believe that because adequate disease control is readily feasible in most cases, safe return to flight duty within a short period is reasonable in uncomplicated cases.

Screening echocardiography of military aircrew candidates: aeromedical implications.

OBJECTIVES: Cardiovascular evaluation has a significant aspect in the medical screening process of aircrew candidates. Echocardiography may identify asymptomatic cardiac abnormalities which can jeopardize the aviator and flight safety, as well as conditions which may progress and disqualify a trained aviator. We assessed the value of adding routine echocardiography to the aeromedical screening process. METHODS: The study population consisted of 17- to 21-year-old healthy aircrew candidates. We retrospectively reviewed all routine echocardiographic studies performed during 1997-2008 at our clinic. Studies performed for a clinical indication were excluded. RESULTS: A total of 2,657 echocardiographic studies were analyzed. 2,506 were considered 'normal' (94.3%). 151 studies (5.7%) demonstrated findings which required further consideration and were considered 'abnormal'. Additional consideration included limitation to low-performance aircrafts (n = 22, 14.7%), prompt disqualification (n = 23, 15.3%), or further cardiovascular assessment (n = 106, 70% of 'abnormal' studies), which resulted in disqualification of 2 more candidates. Echocardiography resulted in disqualification of 0.94% of candidates, limitation to low-performance aircrafts in 0.83%, and need for follow-up in additional 1.54%. CONCLUSIONS: Echocardiographic screening affected aeromedical designation and follow-up decisions in 3.31% of candidates. Contribution of routine echocardiography is dependent on aeromedical policies. The Israeli Air Force policies regarding common findings are presented.

Myasthenia gravis and return to flying status.

INTRODUCTION: Myasthenia gravis (MG) is a common primary disorder of neuromuscular transmission. Although MG was once a fatal disease, today treatment with immunomodulating agents and cholinomimetic medications with good supportive care have improved the prognosis and the ability of patients to adapt to their workplaces, including the flight environment. CASES: The diagnosis of MG in two aircrew members illustrates the range of severity for MG from isolated ocular symptoms to relentlessly progressive generalized disease, as well as the unpredictability of the disease and difficulty in treatment. Nevertheless, both patients were returned to limited flying status. DISCUSSION: MG presents the potential for subtle progression with resulting effects on flight performance. In addition to the disease itself, flight surgeons must also consider problems related to treatment and its side effects. Progression and exacerbations of MG can develop during the course of the disease, requiring careful adjustments to treatment regimens. Taking all these factors into consideration, including the unpredictability of this disease, pilots with apparently stabilized MG should nevertheless be assigned only to duties during which the patient would be able to maintain and use his flying capabilities without risking the mission, himself, and other crewmembers.

Large-scale air-medical transport from a peripheral hospital to level-1 trauma centers after remote mass-casualty incidents in Israel.

INTRODUCTION: Mass-casualty incidents (MCIs) result in the evacuation of many patients to the nearest medical facility. However, an overwhelming number of patients and the type and severity of injuries may demand rapid, mass airmedical transport to more advanced medical centers. This task may be challenging, particularly after a MCI in a neighboring country. The Israeli Air Force Rescue and Airmedical Evacuation Unit (RAEU) is the main executor of airmedical transport in Israel, including MCIs. PROBLEM: The available data on airmedical transport from remote MCIs are limited.The objective of this study was to evaluate the airmedical transport from a rural hospital after two remote MCIs. METHODS: The study was retrospective and reviewed descriptive records of airmedical transports. RESULTS: The RAEU was involved in airmedical transports from a peripheral hospital shortly after two remote MCIs that occurred in the Sinai desert near the Egyptian-Israeli border. Nineteen (22.4%) and 25 (100%) of the treated trauma patients from each event were airmedically transported to Level-1 Trauma Centers in Israel within hours of the dispatch.The rapid dispatch and accumulation of medical personnel and equipment was remarkable. The airmedical surge capacity was broad and sufficient. Cooperation with local authorities and a tailored boarding procedure facilitated a quality outcome. CONCLUSIONS: The incorporation of a large-scale airmedical transport program with designated multidisciplinary protocols is an essential component to a remote disaster preparedness plan.

Role of air-medical evacuation in mass-casualty incidents--a train collision experience.

BACKGROUND: On 21 June 2005, a passenger train collided with a truck near Revadim, Israel. The collision resulted in a multiple-scene mass-casualty incident in an area characterized by difficult access and a relatively long distance from trauma centers. A major disaster response was initiated by civilian and military medical forces including the Israeli Air Force (IAF) Search and Rescue teams. The air-medical evacuation from the accident site to the trauma centers, the activities of the airborne medical teams, and the lessons learned from this event are described in this report. METHODS: A retrospective analysis of data gathered from relevant elements that participated in management, treatment, and evacuation from the accident site was conducted. RESULTS: The accident resulted in 289 injured passengers and seven of the injured were killed. Six helicopters (performing nine sorties) participated. Helicopters evacuated trauma victims and aided in transporting air-medical teams to the site of the collision. Overall, 35 trauma victims (10 urgent) were evacuated by air to trauma centers. The length of time between the first helicopter landing and completion of the air evacuation was 83 minutes. The air-medical evacuation operation was controlled by the commander of the IAF Search and Rescue. Different crew compositions were set in real time. CONCLUSIONS: Air-medical evacuation during this unique event enabled prompt transportation of casualties from the scene to trauma centers and provided reasonable distribution of patients between various centers in the region. This operation highlighted the necessity for flexibility in medical decision-making and the need for nonconventional solutions regarding crew compositions during management of an airborne evacuation in similar settings. Air-medical evacuation should be considered as a part of responses to mass-casualty incidents, especially when the site is remote or characterized by accessibility difficulties.

Unilateral optic disc swelling in a fighter pilot.

Optic disc swelling occurs when there is an obstruction to axonal transport at the level of the lamina cribrosa. This may result from compression, ischemia, inflammation, or metabolic and toxic etiologies. Some of these etiologies may be life threatening and others may be self-limited. Thus, differentiating the different etiologies is important, albeit often difficult. We present a case of a 25-yr-old high-performance fighter aviator who presented with unilateral optic disc swelling 2 d after an F-16 flight, in which decompression was suspected. Visual acuity of the affected eye was decreased to 20/25, with enlarged blind spot and shallow arcuate scotomata on visual field testing. Pupil function, brightness intensity, and color vision were normal. Marked swelling of the entire optic disc, retinal flame-shaped hemorrhages, and engorgement of the retinal veins were seen. Since decompression sickness with nitrogen bubbles obstructing the optic nerve head vasculature was suspected, he was treated with hyperbaric oxygen. He rapidly improved, recovering full vision function within 6 d. No concurrent disease was found on extensive investigation. He returned to high-performance aviation 3 mo after onset of symptoms. No recurrence was seen during 3 yr of follow-up.

Tuberous sclerosis in a military pilot.

Tuberous sclerosis (TS) is a multisystem disorder characterized by hamartomas in various organs. It usually manifests itself during infancy or childhood with neurological features, including mental retardation and seizures. We present the case of a military pilot who was diagnosed with TS at 22 yr. of age after he had completed flight training. Suspicion of TS arose from evaluation of a chronic rash around the pilot's nose, and diagnosis was confirmed based on the presence of multiple calcified nodules on CT imaging of the brain. No neurological abnormalities were found. The primary aeromedical concerns were the risk of seizures or development of tumors at sites that might lead to sudden incapacitation. Hamartomas can be reliably detected at an early stage by means of annual history, physical examination, and imaging of tumor-prone organs. After review of the literature and consultation with medical specialists, we assessed the risk of adult-onset seizures in a TS patient without preexisting neurological findings as scarce. The pilot was therefore granted a waiver limited to flying a two-pilot helicopter with a program of tight medical follow-up.

Physical examination and ECG screening in relation to echocardiography findings in young healthy adults.

BACKGROUND AND AIMS: Cardiovascular screening in young adults is an important tool in many occupational settings. Our aim was to test whether screening physical examination and ECG influence the rate of abnormal echocardiogarphic findings in young healthy subjects. METHODS: Consecutive echocardiography results of 18- to 20-year-old flight candidates were analyzed retrospectively. Echocardiographies were performed as part of a screening protocol, which includes ECG, physical examination and referral for echocardiography for any positive finding. A second stage includes universal echocardiography for all candidates. RESULTS: 1,066 subjects were evaluated; 489 subjects underwent echocardiography following referral because of abnormal auscultatory or ECG findings. Findings (mostly mild valvular insufficiencies) were demonstrated in 12.7%, with only 0.6% of subjects disqualified. In subjects who underwent universal echocardiography (n = 577), findings (mostly mild valvular insufficiencies) were detected in 18%, with only 0.5% of subjects disqualified. CONCLUSIONS: The rate of significant echocardiography findings is extremely low in this young and healthy population. The presence of abnormal findings on either physical examination or ECG screening was not demonstrated to alter the rate of abnormal echocardiographic findings. We suggest that the low yield of screening should be weighed against the cost of an unidentified congenital cardiac lesion in the specific setting.

Detection of occult lung impairment in welders by induced sputum particles and breath oxidation.

BACKGROUND: We evaluated particulate matter in combined induced sputum (IS) and oxidation in exhaled breath condensate (EBC) to test whether underlying inflammatory changes are present in asymptomatic welders. METHODS: Thirty welders from the Israel Defense Forces exposed to aluminum/iron (Group 1) or to cadmium/chromium/iron/lead/nickel (Group 2, N = 16) and 27 non-exposed administrators were studied. IS was recovered, particle size distribution, hydrogen peroxide and pH were measured, and exhaled breath condensate was collected. RESULTS: Group 2 had a higher % neutrophils than all other participants (P = 0.0001) and a higher % particles >2 microm in diameter (P = 0.0017). Percent particles and years of exposure highly correlated (P = 0.051). All welders EBC samples had higher concentrations of hydrogen peroxide than controls (P = 0.0001). pH was lower only for Group 2 (P = 0.0001). CONCLUSIONS: Combined IS and EBC measurements detect underlying inflammation in airways of asymptomatic welders. It emerged that airway inflammation is present in asymptomatic welders, and that the particle burden, inflammatory cells, and level of oxidative stress are a function of the type and the duration of welding. Am. J. Ind. Med. 51:503-511, 2008.

Pitfalls in aeromedical and ground crew engagement: lessons learned.

Aeromedical (AM) evacuation of trauma victims from action is an integral part of trauma care. The Israeli Air Force Rescue and Evacuation Unit is responsible for nearly all AM evacuations in Israel. We present three recent cases, within 1 year of operation, of engagement process failure during evacuations performed by the Rescue and Evacuation Unit. We then discuss possible pitfalls and lessons learned. In sum, we reveal that successful AM and ground crew engagement can save lives, as long as the engagement process is as short and efficient as possible.

Dietary intake of pilots in the Israeli Air Force.

The purpose of this study was to evaluate the dietary intake of pilots in the Israeli Air Force and to determine whether reported consumption met the Military Dietary Reference Intakes. Thirty-one pilots completed a 24-hour dietary recall and physical activity questionnaire. Blood parameter values were collected from medical records. Results showed that energy-adjusted sample mean intakes of nutrients met the military recommendations with the exceptions of dietary fiber (53% of the recommended level) and calcium (84% of the recommended level). Macronutrient distribution of energy was 17% from protein, 47% from carbohydrate, and 36% from fat. Although saturated fat consumption was not more than 10% of energy, cholesterol consumption was well above the 300 mg/d presently recommended. For all pilots, blood parameter values were in the normal range. Overall, the diet of Israeli pilots was found to be well balanced, but negative dietary patterns (i.e., high cholesterol intake and low fiber intake) characteristic of the general population were observed in this group.

Effect of G-force on bicuspid aortic valve in aviators.

BACKGROUND AND AIMS: Bicuspid aortic valve (BAV) is a common congenital cardiac malformation. The major complications are aortic stenosis (AS), aortic regurgitation (AR), infectious endocarditis and aortic dissection. This paper aims to assess the hemodynamic importance of incidentally-found BAV in military aviators and evaluate the effect of high G-force on disease progression. METHODS: Aviators with BAV were detected by reviewing all cardiac assessment records between 1987 and 2005. All aviators underwent annual flight surgeon examination. Echocardiography was performed as recommended by our cardiologists and flight surgeons. RESULTS: Eight newly diagnosed cases of BAV were found. All of the aviators continued active aviation throughout the study period. Repeat echocardiography demonstrated progressive widening of the aortic diameter in five of the eight aviators. No worsening of valve dysfunction was seen in those with mild aortic regurgitation at diagnosis. Left ventricular dimensions and function did not deteriorate. No new valve complications, including infectious endocarditis, were seen. The age at diagnosis strongly correlated with the root diameter change; both total (r = 0.74, p = 0.02) and annualized (r = 0.78, p = 0.02) change. Over a mean follow-up period of 12.1 years, no difference was seen in the progression of BAV in high-performance as compared to low-performance aviators. CONCLUSIONS: Exposure to G-force and anti-G maneuvers does not appear to worsen cardiac and valve function in aviators with BAV.

Postmortem computed tomography in victims of military air mishaps: radiological-pathological correlation of CT findings.

A thorough medical inquiry is included in every aviation mishap investigation. While the gold standard of this investigation is a forensic pathology examination, numerous reports stress the important role of computed tomography in the postmortem evaluation of trauma victims. To characterize the findings identified by postmortem CT and compare its performance to conventional autopsy in victims of military aviation mishaps, we analyzed seven postmortem CT examinations. Musculoskeletal injuries accounted for 57.8% of the traumatic findings identified by postmortem CT. The most frequent findings were fractures of the rib (47%), skull (9.6%) and facial bones (8.6%). Abnormally located air accounted for 24% of findings, for which CT was superior (3.5% detected by autopsy, 100% by postmortem CT, P < 0.001). The performance of autopsy in detecting injuries was superior (autopsy detected 85.8% of all injuries, postmortem CT detected 53.9%, P < 0.001), especially in the detection of superficial lesions (100% detected by autopsy, 10.5% by postmortem CT, P < 0.001) and solid organ injuries (100% by autopsy, 18.5% by postmortem CT, P < 0.001). Performance in the detection of musculoskeletal injuries was similar (91.3% for autopsy, 90.3% for postmortem CT, P = not significant). Postmortem CT and autopsy have distinct performance profiles, and although the first cannot replace the latter it is a useful complementary examination.