Community clinic and emergency department physicians' adherence to acute pharyngitis antibiotic treatment guidelines.

BACKGROUND: Antibiotic treatment guidelines for common infectious diseases enable proper diagnosis and treatment and avoid unnecessary antibiotic treatment, preventing both financial expenditure and antimicrobial resistance to antibiotics. METHODS: The aim of our study was to investigate whether community physicians referring patients to the medical centre and whether emergency department (ED) physicians diagnose and treat acute pharyngitis according to these guidelines. We conducted a retrospective study. Data were collected on 99 patients admitted with the diagnosis of acute pharyngitis. The patients were admitted to the medical centre between 2015 and 2014. The physicians' adherence to antibiotic guidelines for indication, type and duration of treatment for acute pharyngitis was examined. RESULTS: The adherence of community physicians regarding the indication for antibiotic treatment was low (16%). The adherence of community and ED physicians regarding the type of treatment was high (96% and 99%, respectively). The adherence of ED physicians regarding the duration of treatment was higher than the adherence among community physicians (58% and 13.3%, respectively, Wilcoxon signed-rank test, P < .001). Interns tended to adhere to the guidelines more than seniors (36.4% versus 12.0%, respectively, Fisher's exact test, P = .07). CONCLUSIONS: There is a lack of compliance with the guidelines among community physicians regarding the diagnosis and antibiotic treatment of acute pharyngitis, which is characterized by excessive antibiotic treatment. Therefore, ways to increase awareness and adherence to clinical guidelines, and to allow the conditions in the clinics to fulfil the guidelines should be investigated.

[WHY ARE SOME OF THE HOSPITALIZATIONS LENGTHS IN ISRAEL SO LONG?]

INTRODUCTION: Prolonged hospitalizations are a major challenge for any society and to the Israeli health system in particular. Identifications of predictors underlines the areas that require comprehensive interventions to prevent long hospital stays. Analysis of the literature points out that discharges from internal medicine wards should be preplanned and coordinated. It is obvious that the care of those with special needs such as the elderly, dependent, lonely, disabled and patients with comorbidities mandates the development of proper community-based care that will be a continuation of in-hospital therapy. It seems inevitable that this urgent need will require a medical professional whose main task will be coordination of care in and out of the hospital.

Giant cell arteritis (GCA) as a risk factor for seizures: a cohort study.

OBJECTIVES: The objective of this study was to assess the risk of seizures in Giant Cell Arteritis (GCA) patients in a large cohort of Israeli subjects, in comparison to matched controls. METHODS: Patients diagnosed with GCA between 2002 and 2017 were included. Controls were matched based on sex, age, socioeconomic status, country of birth, diabetes mellitus, and hypertension in a 4:1 ratio. Patients with seizure records prior to the study period were excluded. Hazard ratios for seizures was obtained by cox regression models. RESULTS: The study cohort was composed by 8,103 GCA patients and 32,412 matched controls. The GCA group included 5,535 women (68%), 2,644 patients born in Israel (33%), and 2,888 patients with low socioeconomic status (36%). The median age of this group was 71. During the followed cumulative person-years of 54,641 and 222,537 in the GCA and control group, respectively, 15.92 cases per 10,000 person-years was found in the GCA group, compared to 9.62 per 10,000 person-years in the controls. GCA was associated with seizures in the unadjusted (HR = 1.66, 95% CI [1.29 to 2.13]) and adjusted (HR = 1.67, 95% CI [1.3 to 2.14]) models. GCA was also associated with seizures after controlling for strokes (HR = 1.55, 95% CI [1.16 to 2.07]). CONCLUSION: According to this study, individuals with GCA are at a higher risk of developing seizures when compared to the general population. This increased risk is independent of their predisposition for stroke. One proposed mechanism is that the GCA pro-inflammatory state may decrease the neuronal threshold for depolarization.

Two cases of dermatomyositis associated with neuroendocrine tumors.

Dermatomyositis is an idiopathic inflammatory myopathy with cutaneous manifestations, which is associated with several types of malignancies, yet it has been rarely linked to neuroendocrine tumors (NETs). Here we report two cases of dermatomyositis associated with NETs of differing primary sites. Case 1: A 46-year-old female presented with a facial rash and proximal muscle weakness of both extremities. Investigations revealed elevated creatine kinase (CK) and positive anti-transcriptional intermediary factor 1-γ antibody (TIF1γ). The patient had been diagnosed with dermatomyositis and underwent a total body CT scan, which revealed prominent mediastinal lymphadenopathy, which a subsequent biopsy determined to be neuroendocrine carcinoma of small cell type. Treatment with high-dose corticosteroids was initiated, in addition to chemotherapy-based oncological management. Case 2: A 54-year-old female presented with a facial rash, progressive dyspnea, and general malaise. Laboratory investigations revealed positive anti-melanoma differentiation-associated gene-5 (MDA5) and positive anti-Ro antibody, with a normal level of creatine kinase (CK). A chest CT scan revealed multiple ground-glass opacities. Despite treatment with high-dose intravenous methylprednisolone, IVIG and an infusion of the anti-IL-6 sarilumab [Kevzara], the patient rapidly deteriorated and was intubated. Within days, the patient developed bowel ischemia and underwent a laparotomy which was then complicated by an invasive infection. This resulted in patient's death. Pathology results from colonic tissue demonstrated an appendiceal neuroendocrine tumor. These cases demonstrate the heterogeneity and complexity of dermatomyositis in association with neuroendocrine tumors.

Physician adherence to acute rhinosinusitis antibiotic treatment guidelines.

Antibiotic treatment guidelines promote proper diagnosis and treatment and optimize antibiotic treatment, minimizing both antimicrobial resistance to antibiotics and financial expenditure. This study aimed to investigate whether community physicians and emergency department (ED) physicians diagnose and treat acute rhinosinusitis according to accepted guidelines. This was a retrospective study of medical records and referrer letters of patients admitted to the medical center between 2014 and 2015. Physician adherence to antibiotic guidelines regarding indication, type and duration of treatment was assessed. Overall, the study included 84 patients diagnosed with acute rhinosinusitis and admitted to the ED. Fewer than 20% of doctors treating patients with rhinosinusitis at our institution followed the current recommended guidelines. In most cases, the type of treatment administered by ED physicians and by community physicians complied with the guidelines (90% and 96%, respectively, p=0.564). The duration of treatment prescribed by the ED physicians aligned with the guidelines in 37.7% of the cases. There was insufficient compliance with acute rhinosinusitis treatment guidelines among all treating physicians in this study, which was characterized by excessive antibiotic treatment. Therefore, ways to increase understanding and adherence to clinical guidelines, and to provide optimal settings in the clinics to carry out the guidelines should be investigated.

C-KIT Expression in Orbital Cavernous Venous Hemangiomas.

Orbital (slow flow) cavernous venous hemangiomas (OCVH) are the most common benign orbital tumors in adults. The c-KIT is a tyrosine kinase receptor, which is expressed on several types of cells, is thought to play a key role in tumor pathogenesis. The purpose of this study was to evaluate the presence of the receptor c-KIT in OCVH. Our retrospective study examined 16 orbital cavernous venous hemangiomas from 16 cases operated on between 2006-2016 at Emek Medical Center. The mean tumor size was 18.4 mm. Symptoms appeared between 6 months and 22 years before operation. All specimens were analyzed for the c-KIT receptor through immunohistochemistry. The c-KIT was expressed by the endothelium in all 16 preparates. Staining was strong in two cases, moderate in six, and weak in eight cases, with no statistically significant correlation between staining and tumor size (p = 0.69) or the symptom duration (p = 0.15). We conclude that c-KIT may play an important role in the pathogenesis of OCVH. This pilot study is significant in that tumor-targeted therapy such as Imatinib Mesylate and Sunitinib may have a role in treating surgically complicated cases located in the orbital apex. A large multicenter collaborative study is necessary to examine the role of c-KIT in OCVH.

Diagnostic and Prognostic Value of Chest Radiographs for COVID-19 at Presentation.

INTRODUCTION: Pulmonary opacities in COVID-19 increase throughout the illness and peak after ten days. The radiological literature mainly focuses on CT findings. The purpose of this study was to assess the diagnostic and prognostic value of chest radiographs (CXR) for coronavirus disease 2019 (COVID-19) at presentation. METHODS: We retrospectively identified consecutive reverse transcription polymerase reaction-confirmed COVID-19 patients (n = 104, 75% men) and patients (n = 75, 51% men) with repeated negative severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) tests. Two radiologists blindly and independently reviewed the CXRs, documented findings, assigned radiographic assessment of lung edema (RALE) scores, and predicted the patients' COVID-19 status. We calculated interobserver reliability. The score use for diagnosis and prognosis of COVID-19 was evaluated with the area under the receiver operating characteristic curve. RESULTS: The overall RALE score failed to identify COVID-19 patients at presentation. However, the score was inversely correlated with a COVID-19 diagnosis within ≤2 days, and a positive correlation was found six days after symptom onset.Interobserver agreement with regard to separating normal from abnormal CXRs was moderate (k = 0.408) with low specificity (25% and 27%). Definite pleural effusion had almost perfect agreement (k = 0.833) and substantially reduced the odds of a COVID-19 diagnosis. Disease distribution and experts' opinion on COVID-19 status had only fair interobserver agreement. The RALE score interobserver reliability was moderate to good (intraclass correlation coefficient = 0.745). A high RALE score predicted a poor outcome (intensive care unit hospitalization, intubation, or death) in COVID-19 patients; a score of ≥5 substantially increased the odds of having a poor outcome. CONCLUSION: Chest radiography was found not to be a valid diagnostic tool for COVID-19, as normal or near-normal CXRs are more likely early in the disease course. Pleural effusions at presentation suggest a diagnosis other than COVID-19. More extensive lung opacities at presentation are associated with poor outcome in COVID-19 patients. Thus, patients with more than minimal opacities should be monitored closely for clinical deterioration. This clinical application of CXR is its greatest strength in COVID-19 as it impacts patient care.

Anticitrullinated Protein Antibodies Induce Inflammatory Gene Expression Profile in Peripheral Blood Cells from CCP-positive Patients with RA.

OBJECTIVE: Anticitrullinated protein antibodies (ACPA) have major diagnostic significance in rheumatoid arthritis (RA). ACPA are directed against different citrullinated antigens, including filaggrin, fibrinogen, vimentin, and collagen. The presence of ACPA is associated with joint damage and extraarticular manifestations, suggesting that ACPA may have a significant role in the pathogenesis of RA. METHODS: To verify the effect of ACPA on RA-immune cells, peripheral blood mononuclear cells (PBMC) from cyclic citrullinated peptide (CCP)-positive patients with RA and healthy controls were cocultured in vitro with ACPA. ACPA-positive stained cells were analyzed by flow cytometry and the effect of ACPA on mRNA expression levels was evaluated by real-time PCR. We tested whether the stimulatory effects induced by ACPA could be inhibited by the addition of a new multiepitope citrullinated peptide (Cit-ME). RESULTS: We found that ACPA bind specifically to PBMC from CCP-positive patients with RA through the Fab portion. ACPA induce upregulation of pathogenic cytokine expression (4- to 13-fold increase) in PBMC derived from CCP-positive patients with RA. Moreover, ACPA upregulated IL-1ß and IL-6 mRNA expression levels by 10- and 6-fold, respectively, compared to control IgG. Cit-ME, a genuine ligand of ACPA, inhibited the ACPA-induced upregulation of IL-1ß and IL-6 by 30%. CONCLUSION: ACPA bind to a limited percentage of PBMC and upregulate inflammatory cytokine expression, suggesting that ACPA is involved in RA pathogenesis. Targeting ACPA to decrease their pathogenic effects might provide a novel direction in developing therapeutic strategies for RA.

Coexistence of ischemic heart disease and rheumatoid arthritis patients-A case control study.

BACKGROUND: Over the last few decades, several studies have demonstrated the connection between Rheumatoid Arthritis (RA) and Ischemic Heart Disease (IHD). The additional risk for RA patients to also suffer from IHD varies based on the definition of the diseases in question, the populations evaluated, and the variables included in the studies. OBJECTIVES: To quantify the association between RA and IHD according to certain demographics as well as traditional cardiovascular risk factors in order to determine their roles in the development of coronary artery disease among patients with RA. METHODS: Using data from the largest HMO in Israel, the Clalit Health Services, we selected for patients with RA. These patients were compared with age and sex matched controls with regards to the prevalence of IHD in a case-control study. Chi-square and t-tests were used for univariate analysis and a logistic regression model was used for multivariate analysis. RESULTS: The study included 11,782 patients with RA and 57,973 age and sex matched controls. The prevalence of IHD in patients with RA was increased compared with the prevalence in controls (16.6% and 12.8% respectively, P<0.001). In a multivariate analysis, RA was associated with higher proportions of IHD (OR 1.346, 95% confidence interval 1.255-1.431).