Echinococcal Cyst Rupture in a 3-Year-Old Boy With a Minor Abdominal Trauma Identified by a Point-of-Care Ultrasound E-Fast Examination: A Case Report and Literature Review.

ABSTRACT: Point-of-care ultrasound is now widely used in adult and pediatric emergency departments as part of the rapid evaluation and treatment of patients in urgent care settings. It has been shown to be a powerful tool to aid in decision making in both trauma and acute medical situations. We describe a case of a 3-year-old boy who presented with abdominal pain and fever after a minor abdominal trauma, highlighting the use of point-of-care ultrasound to arrive at the diagnosis of a ruptured echinococcal cyst.

[THE TIME HAS COME! COMPLEMENTARY MEDICINE IN MEDICAL TRAINING IN ISRAEL].

INTRODUCTION: The use of complementary and alternative medicine (CAM) has become increasingly popular in most Western countries. As a result, safety-related issues associated with these practices have become more apparent, including adverse effects and negative interactions with conventional medical therapies. The potential dangers associated with CAM are further exacerbated by the absence of high-quality clinical research on the subject; a lack of a basic understanding of the principles of CAM among physicians; and a reluctance of patients to disclose their use of CAM, including those modalities being used in parallel with conventional medical treatments. The increase in CAM use by their patients and the increased potential for harmful effects and interactions are central to the increasing interest among physicians and other healthcare professionals in learning more about CAM paradigms and practices of care. In light of this increasing interest in CAM, the majority of medical schools in the U.S. and Canada and a large number in Europe are providing their students with compulsory or elective courses on this subject. A similar process is taking place in Israel, with the Faculty of Medicine at the Hebrew University in Jerusalem having completed its first compulsory course in CAM at the Hadassah University Medical Center, Ein Karem. The increased use of CAM presents a number of challenges to the conventional medical profession. Medical schools can and should provide students with the knowledge and skills which will enable them to discuss CAM use with their patients, providing evidence-based guidance on the safe and effective use of these modalities.

Pulmonary Embolism for the Cardiologist: Emphasis on Diagnosis.

PURPOSE OF REVIEW: Pulmonary embolism (PE) is a common condition with high morbidity and mortality particularly if misdiagnosed or untreated. It has non-specific clinical manifestations, often presenting similarly to other cardiovascular conditions. The aim of this review is to summarize the clinical presentation, diagnostic algorithms, and imaging studies utilized to efficiently make or exclude the diagnosis of pulmonary embolism. RECENT FINDINGS: Recent cohort studies have raised questions about the classic presentations of PE (particularly with regard to syncope) or lack thereof. Diagnosis of PE continues to evolve with new diagnostic algorithms, use of age-adjusted D-dimer cutoffs, validation of older algorithms, and emerging data on multimodality ultrasound and ventilation-perfusion (V/Q) single-photon emission computed tomography (SPECT) imaging in the diagnosis of PE. Optimizing clinical outcomes of PE depend on correct diagnosis of the condition. Given significant variability in clinical presentation, use of a diagnostic algorithm is essential. Use of a clinical decision rule and D-dimer testing can risk stratify patients to allow for judicious use of diagnostic imaging. V/Q scan, CT pulmonary angiography, and lower extremity ultrasound remain the diagnostic imaging modalities of choice with other promising imaging modalities requiring further study.

[Promoting research in a medical center--the management narrative].

Promoting research within a medical institute is a delicate balance between the importance of facilitating academia and maximizing resources towards the primary goal of a hospital--healing sick people. Shaare Zedek Medical Center have successfully adopted a "niche" approach to research in which the hospital invests in selected talented clinicians-scientists rather than futile expectation that all clinicians would be engaged in high impact research. Moreover, these research excellence centers are developing into a driving force to also foster research endeavors of other clinicians and residents in the hospital. In this special issue of Harefuah honoring Shaare Zedek investigators, 18 manuscripts included reflect the diversity of research projects performed in the medical center. We believe that this project will assist and encourage clinicians to be engaged in research, at all levels and disciplines.

Perioperative Cannabis Use in Bariatric Patients: A Review of Outcomes and Proposed Clinical Pathway for Management.

Legalization of marijuana has led to increased prevalence of medical and recreational cannabis use, underscoring the importance for anesthesiologists, surgeons, and perioperative physicians to understand the effects of this drug in patient care. Bariatric surgical patients represent a unique target population to understand peri-operative cannabis use and its effects as these patients undergo an extensive preoperative psychological and nutritional evaluation. Standardized guidelines on cannabis use in bariatric surgery are lacking and many clinicians remain uncertain on how to handle cannabis use in the peri-operative period. Here, we summarize the data on cannabis use in bariatric patients, specifically exploring anesthetic considerations, weight loss, complications, mortality, and psychiatric outcomes. We propose a clinical pathway to assist clinicians with perioperative decision making in bariatric patients who use marijuana.

International medical evacuation in children: a primary care pediatric clinic's 3-year experience.

BACKGROUND: The decision whether to immediately evacuate children who have become ill is a challenge for pediatricians working in countries with limited medical resources. The aim of this study is to describe the injuries and diseases that required evacuation of children from our clinics in Ho Chi Minh City and Hanoi to tertiary critical care hospitals over a 3-yr period. METHODS: A retrospective chart review was performed of all patients aged less than 17 yr who underwent an international medical evacuation between April 1, 2006, and February 28, 2009. Patients were allocated to one of two groups: those requiring immediate aeromedical evacuation by air ambulance and those whose condition allowed nonurgent evacuation by commercial flight. RESULTS: There were 19 international medical evacuations that were executed: 5 immediate aeromedical evacuations with air ambulance and 14 nonurgent evacuations using commercial flights. Immediate evacuations were undertaken to Thailand and Singapore to access pediatric cardiac surgery and intensive care facilities. Some evacuations were performed mainly at parental request. CONCLUSIONS: Aeromedical evacuation requires a multidisciplinary approach and patient age, local resources, availability, location of resources, and parental preference are important factors to be considered. Effective communication is paramount and choice of transportation should be governed by pre-established policies and procedures if possible.

[Complementary and alternative medicine--time for research and regulation].

The usage of complementary and alternative medicine [CAM] is increasing in popularity in the modern world. In this issue of Harefuah, seven articles relate to various aspects of CAM: the use of various modalities of CAM in four community clinics in Northern Israel, an assessment of the needs and expectations of patients on chemotherapy from the integration of CAM in palliative oncological care, a description of a series of quality research studies relating to CAM in hemato-oncological disorders and autoimmune diseases and a discussion of ethical dilemmas and issues relating to Jewish law. Other authors review the history of clinical studies with an emphasis on mind-body connection and the placebo effect. The conclusion that may be derived about CAM from this compilation of articles is that, despite the ltack of scientific evidence to support the paradigm underlying most CAM modalities and the scarcity of evidence to support its efficacy, the increasing popularity of CAM should lead us to expand research into CAM and to teach our medical students about CAM. We should do so for the sake of proper doctor-patient relationships and to prevent improper use of CAM by the general public. The diversity of CAM modalities and the heterogeneity of training patterns among those who practice CAM call for the prompt regulation of training and licensing of all CAM practitioners.

No-shows in ambulatory clinics and non-utilized appointments for elective operations in selected surgical departments at a tertiary hospital in Israel.

BACKGROUND: The phenomenon of a patient missing a medical appointment without notification is called a "no-show". In contrast, "non-utilized appointments" are a broader phenomenon including all appointments that didn't occur as registered - whether due to actions taken by providers or patients. Both no-shows and non-utilized appointments can lead to reduced quality of care, loss in productivity, financial losses and impaired patient outcomes. METHODS: The study was carried out between August 2016 and January 2017 in the ENT, Orthopedics and General Surgery Departments of the Jerusalem-based Shaare Zedek Medical Center. The study team sought to examine the reasons for non-utilized appointments in elective operations. The study team also interviewed no-show ambulatory care patients regarding the causes of the no-show and reviewed medical records of no-show patients to determine the nature of the missed appointments. RESULTS: The rate of non-utilization of appointments for elective operations was 6%. The leading reasons for non-utilization of these appointments were: patient health issues, patient surgery postponement and surgery schedule overload (together accounting for 52% of cases and 72% of known reasons). The no-show rate for ambulatory clinic appointments was approximately 15%. The leading reasons for ambulatory clinic no-shows were: administrative issues, illness and forgetfulness (together accounting for 58% of all reasons). The leading types of appointments missed were:post-operation follow-ups and chronic illness follow-up (together accounting for 46% of cases and 63% of known reasons). CONCLUSIONS: In this study, the non-utilized appointment rate for elective operations was found to be lower than those noted in the medical literature, while the no-show rate for ambulatory visits was found to be similar to that found in the literature. There is room to question the necessity of certain types of postoperative follow-up appointments since they are at "high risk" for no-show. One promising way to reduce the no-show rate would involve improving the hospital's information and computing systems in order to identify patients who are susceptible to a no-show incident.

Ethnic-based separation in maternity Departments in Israel - a balanced practical view.

Ethnic-based separation in public hospitals in Israel is a sensitive issue that was recently brought forward by the media and was recently discussed in the Israel Journal of Health Policy Research.The above paper maintains that ethnic separation in inpatient rooms does take place some of the time and this runs contrary to the ethos of neutrality in medicine. The authors recommend implementing a national policy that prohibits ethnic-based separation in hospital inpatient rooms.In this commentary I point to the fact that the authors' research indicates that often times ethnic separation is not based on racism, and while the call for unequivocal prohibition of discriminatory ethnic-based separation is of course morally justified, such an across-the-board prohibition is actually an imposition of mixed rooms under all circumstances.I recommend a more balanced and still ethically acceptable approach: any request by patients for a separate room that is overtly based on ethnic discrimination should be immediately rejected and that hospital directors should be called upon by the Ministry of Health not to take a back seat on this issue, to be proactive in explaining to the staff the importance of absolute avoidance of any discriminatory considerations in the placement of patients, and to monitor the extent of ethnic separation expecting to see in every department ethnically mixed rooms.

Emergency with Resiliency Equals Efficiency - Challenges of an EMT-3 in Nepal.

The 7.8 MW (moment magnitude scale) earthquake that hit Nepal on April 25, 2015 caused significant casualties and serious damage to infrastructure.The Israeli Emergency Medical Team (IEMT; later verified as EMT-3) was deployed 80 hours after the earthquake. A Forward Disaster Scout Team (FDST) that was dispatched to the disaster area a few hours after the disaster relayed pre-deployment information.The EMT staff was comprised of 42 physicians. A total of 1,668 patients were treated. The number of non-trauma cases increased as the days went by. The hospitalization rate was 31%. Wound debridement procedures were the most common operations performed. YitzhakA, MerinO, HalevyJ, TarifB. Emergency with resiliency equals efficiency- challenges of an EMT-3 in Nepal. Prehosp Disaster Med. 2018;33(6):673-677.

Public and private patients in Jerusalem hospitals: who operates on whom?

BACKGROUND: Debate continues in Israel as to whether to allow patients in public hospitals to choose their physician in return for an additional, out-of-pocket payment. One argument against this arrangement is that the most senior physicians will devote most of their time to private patients and not be sufficiently available to public patients with complex cases. OBJECTIVES: To analyze the patterns of surgical seniority in Jerusalem hospitals from a number of perspectives, including the extent to which: a) opting for private care increases the likelihood of being treated by a very senior surgeon; b) public patients undergoing complex operations are being treated by very senior surgeons, c) the most senior surgeons allocate a significant portion of their time to private patients. METHODS: Demographic and clinical data were retrieved from the operating room records of three of the public hospitals in Jerusalem for all 38,840 operations performed in 2001. Of them, roughly 6000 (16%) were performed privately. Operations were classified as "most complex," "moderately complex" and "least complex" by averaging the independent ratings of eight medical and surgical experts. The surgeon's seniority was graded as "tenured" (tenured board-certified specialists, including department heads), "senior" (non-tenured board-certified specialists), and "residents." For each operation, we considered the seniority of the lead surgeon and of the most senior surgeon on the surgical team. RESULTS: The lead surgeon was of tenured rank in 99% of the most complex private cases and 74% of the most complex public cases, in 93% of the moderately complex private and 35% of the moderately complex public cases, and in 92% of the least complex private and 32% of the least complex public cases. The surgical team included a tenured physician in 97%, 66%, and 53% of the most complex, moderately complex, and least complex public operations, respectively. In both private and public cases, a board-certified (tenured or senior) specialist was a member of the surgical team for almost all of the most complex and moderately complex operations. On average, over half of the operations in which the lead surgeon was a department head were performed on public patients. Among tenured surgeons, those who spent more hours than their colleagues leading private operations also tended, on average, to spend more hours leading public operations. CONCLUSIONS: Private patients have an advantage over public patients in terms of the seniority of the lead surgeon. However, there is also substantial involvement of very senior surgeons in the treatment of public patients, particularly in those cases that are most complex.

The use of adenosine in the treatment of a high-flow vein of Galen malformation in an adult.

The treatment of high-flow vein of Galen aneurysmal malformations (VGAM) remains a therapeutic challenge for the neurosurgeon and the neurointerventionalist, as it is associated with high morbidity and mortality rates despite recent advances in open cranial surgery and interventional neuroradiology. A 37-year-old patient presented with a history of non-specific headaches. He had a history of heart failure since birth that was caused by an untreated VGAM. Intravenous boluses of adenosine were injected as an attempt to slow down the arteriovenous shunting of a VGAM prior to endovascular treatment. Adenosine can be a very useful adjunct in patients with extremely high arteriovenous shunting. n-butyl cyanoacrylate (n-BCA) should be the embolic material of choice due to its quick polymerization and adhesive properties.

Defensive medicine in Israel - a nationwide survey.

BACKGROUND: Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily as a safeguard against possible malpractice liability. We studied the extent, reasons, and characteristics of defensive medicine in the Israeli health care system. METHODS AND FINDINGS: Cross-sectional study performed in the Israeli health care system between April and July 2008 in a sample (7%) of board certified physicians from eight medical disciplines (internal medicine, pediatrics, general surgery, family medicine, obstetrics and gynecology, orthopedic surgery, cardiology, and neurosurgery). A total of 889 physicians (7% of all Israeli board certified specialists) completed the survey. The majority [60%, (95%CI 0.57-0.63)] reported practicing defensive medicine; 40% (95%CI 0.37-0.43) consider every patient as a potential threat for a medical lawsuit; 25% (95%CI 0.22-0.28) have previously been sued at least once during their career. Independent predictors for practicing defensive medicine were surgical specialty [OR=1.6 (95%CI 1.2-2.2), p=0.0004], not performing a fellowship abroad [OR=1.5 (95%CI 1.1-2), p=0.027], and previous exposure to lawsuits [OR=2.4 (95%CI 1.7-3.4), p<0.0001]. Independent predictors for the risk of being sued during a physician's career were male gender [OR=1.6 (95%CI 1.1-2.2), p=0.012] and surgery specialty [OR=3.2 (95%CI 2.4-4.3), p<0.0001] (general surgery, obstetrics and gynecology, orthopedic surgery, and neurosurgery). CONCLUSIONS: Defensive medicine is very prevalent in daily physician practice in all medical disciplines. It exposes patients to complications due to unnecessary tests and procedures, affects quality of care and costs, and undermines doctor-patient relationships. Further studies are needed to understand how to minimize defensive medicine resulting from an increased malpractice liability market.