The Predictive Value of Thromboelastogram in the Evaluation of Patients with Suspected Acute Venous Thromboembolism.

INTRODUCTION: The objective of this prospective study was to examine whether thromboelastogram (TEG) can predict the presence of venous thromboembolism (VTE) in patients who arrive at the emergency room with signs/symptoms that raise the suspicion of acute VTE. METHODS: Every patient was tested for D-dimer and all TEG parameters, including: reaction time, clot time formation, alpha-angle, maximal amplitude, clot viscoelasticity, coagulation index, and clot lysis at 30 min. For categorical variables, χ2 or the Fisher exact test were used, and for continuous variables the t test or other non-parametric tests were used. RESULTS: During 2016, a total of 109 patients were enrolled with a median age of 55.7 (21-89) years. Eighteen patients were diagnosed with VTE. Analyzing the different TEG parameters, both as continuous and categorical variables, did not reveal a statistically significant difference between VTE-positive and VTE-negative patients. Combining different TEG parameters or dividing the cohort according to gender, clinical suspicion of VTE (Well's criteria), or different levels of D-dimer did not change the results of the analysis. CONCLUSION: The current study could not demonstrate a significant value of any TEG parameter as a predictor of VTE among patients who came to the emergency room with signs/symptoms that raise the suspicion of VTE.

Alcohol Related Harm: Knowledge Assessment of Medical and Nursing Staff in a General Hospital.

BACKGROUND: The prevalence of alcohol related harm (ARH) in Israel has traditionally been low. The lack of familiarity with ARH may derive from the fact that in the past there was limited clinical exposure to these harms. However, ARH is becoming more common in Israel but it is unclear whether the medical and nursing workforce's knowledge is adequate to manage these problems. Our main objective was to assess knowledge regarding ARH among medical and nursing staff (MNS) in an Israeli university affiliated general hospital. We also aimed to compare knowledge of different MNS groups Methods: One hundred and twenty-seven MNS including consultants (senior physicians), residents, interns and nursing staff completed the Knowledge of Psychiatric Aspects of Alcohol Questionnaire (KPAAQ), a validated measure of knowledge concerning ARH comprised of five categories. RESULTS: There was no significant difference between the four MNS groups in overall mean KPAAQ scores that varied from 45% (nurses) to 54% (interns). However, direct comparisons indicate that physicians scored higher than nurses (p=0.02). overall. The mean score for the KPAAQ category "alcohol withdrawal syndrome" was below 40% for all MNS groups. Physicians scored significantly higher than nursing staff (p=0.005). All MNS mean scores were greater than 63% for the category "alcohol in pregnancy." This was the highest category score. CONCLUSIONS: Assessment of knowledge regarding ARH among MNS in a general hospital with a standardized instrument demonstrated no significant difference in knowledge of ARH among nursing staff, interns, residents and consultants apart from knowledge about alcohol withdrawal. However, the overall score of the physicians as a whole was significantly higher than the nursing group. These findings suggest a need to implement educational interventions in MNS to increase knowledge of ARH so as to promote the provision of brief interventions for patients with ARH.

Preliminary results of a controlled educational intervention on alcohol related harm among medical students with a 12-month follow-up.

BACKGROUND: There are no studies that use validated questionnaires on Alcohol Related Harm (ARH) in order to assess retention of educational programs among medical students. Objective of study to assess retention of an educational inter-vention on ARH among medical students. METHOD: Seventeen fifth year medical students were assessed with the Knowledge of Psychiatric Aspects of Alcohol Questionnaire (KPAAQ) 12 months after an educational intervention on ARH and compared with a control group. RESULTS: Significant retention was found in the study group. CONCLUSIONS: This preliminary research is the first controlled study on medical student retention of an ARH educational intervention using a validated questionnaire.

Psychopathology of Israeli Soldiers Presenting to a General Hospital Emergency Department: Lessons for the Attending Physician and Psychiatrist.

BACKGROUND: There is scant research on the psychopathology of Israeli soldiers who present to a general hospital emergency department (ED). OBJECTIVES: To assess the psychopathology among a cohort of Israeli soldiers who presented to a general hospital ED for mental health assessment. METHODS: The demographic and clinical characteristics of 124 consecutive soldiers who presented to the ED for psychiatric assessment between January 2008 and September 2012 were reviewed. Twenty-seven soldiers from the cohort were contacted for follow-up by telephone on average 52 months later. RESULTS: The reasons for presentation to the ED, usually during the early stages of military service, included self-harming behavior, suicidal ideation, somatoform complaints, and dissatisfaction with their military service. Psychiatric diagnoses included adjustment disorder and personality disorder. Self-harming behavior/suicidal ideation was significantly correlated with unspecified adjustment disorder (P = 0.02) and personality disorder (P = 0.001). At follow-up, there was a lack of substantial psychopathology: none of the subjects engaged in self-harming behavior/suicidal ideation and a consistent trend was observed toward clinical improvement. CONCLUSIONS: Psychiatric intervention of soldiers who present to a general hospital ED because of emotional difficulties may provide the opportunity for crisis intervention and validation of the soldier's distress. To the best of our knowledge this is the first Israeli study of psychopathology among soldiers who presented to an ED.

[SELECTING A SPECIALTY BY INTERNS IN A CHANGING PERIOD: A MULTI-YEAR AND SINGLE-CENTER EXPERIENCE].

AIMS: To collect data on the expectations of interns at the onset of their internship regarding their professional future and the actual realization of these expectations of medical graduates who completed their internship in one medical center during the years 2010-2015. BACKGROUND: The internship year may have great importance in the decision-making process regarding selection of future residency. Previous research conducted 10-20 years ago involved graduates of Israeli medical schools. In the current era up to 50% of interns are foreign medical graduates (FMG), and it is not clear whether all of these professionals find a residency or employment according to their wishes. METHODS: Our hospital's database includes demographic details of all 237 graduates of the aforementioned years, according to gender (64% male); medical school (Israeli 50%); and ethnicity (Jewish, 66%). The aim of the study was to call all graduates according to the telephone numbers in the database and obtain relevant information on the basis of a pre-arranged script and with a standardized questionnaire to achieve uniform collection of data. RESULTS: Of 237 graduates, 151 (64%) responded, of whom 101 (64%) were male, 90 (60%) were Jewish, and 80 (54%) were FMG. Most interns had decided on a future career at the onset of their internship (114, 75%), but at its completion this rate had decreased to 88 (59%). Their preferences included surgical specialties 40 (36%), pediatrics 34 (30%), internal medicine 22 (19%), family practice 9 (8%), and other specialties 8 (7%). At the conclusion of the internship 108 (75%) immediately started a residency program; the remainder started employment in the community not within the context of a residency. A high degree of satisfaction was examined for three factors: personal relations and ethics - 114 (76%), professional learning - 108 (72%) and counseling regarding their professional future - 46 (31%). At the onset of their internship,) 75 77%( of the men and 46 )75%( of the women had decided upon their future career, without major change by the year's end. In reality, 43 (84%) of the women started a residency, but only 63 (65%) of the men (p=0.013). At the start of the year 67 (77%) of the Jewish interns and 46 (75%) of the Arab interns had decided on a future career; at the end of the year, the rate for Jewish interns had increased to 74 (85%) and it had decreased to 31 (67%) for Arab interns (p=0.026). Of the Jewish sector 74 (85%) had actually started a residency, as compared to 33 (54%) of the Arab sector (p<0.001) and 26 (43%) Arab graduates started work in the community not within the context of a residency. The rate of Israeli graduates who at onset of their internship had decided on their future choice was similar to that of FMG, 55 (82%) as compared to, respectively, 58 (73%) (Non significant), but at the end of the year a significant gap had opened up, 47 (86%) vs. 40 (52%), respectively (p=0.04). In addition, and not surprisingly, there were significant differences in the three measures of satisfaction between the Israeli and foreign graduates. CONCLUSIONS: During the internship year significant differences emerge between the interns, according to gender, ethnic background or the country they had studied medicine. Improved counseling could possibly help interns to secure optimal employment, especially for foreign medical graduates.

Bone loss and hematological malignancies in adults: a pilot study.

PURPOSE: Bone loss-osteopenia and osteoporosis-is a recognized consequence of solid tumors in adults, of pediatric hematological malignancies, and of the treatment for these diseases, but little research has been published on the adverse effects of hematological malignancies on the bone in adults. The aim of this study is to identify hematological diseases that are associated with the highest prevalence and severity of osteoporosis. METHODS: We evaluated DXA (dual-energy X-ray absorptiometry) in a cross-section of 181 adult patients with hematological neoplasms, excluding multiple myeloma. All patients were over 18 years of age, signed a local institutional review board (IRB)-approved consent form, and had completed a questionnaire regarding predisposing factors to osteoporosis. This data was supplemented by hospital charts. RESULTS: Bone loss as measured by DXA T scores was found in 65% of patients, of whom 38% had osteopenia and 27% osteoporosis. DXA Z scores under - 2.0 were found in 11.4% of patients, compared to the expected 2.5% of the normal population. The DXA Z scores varied by diagnosis, showing bone loss in 49% of chronic lymphocytic leukemia/small lymphocytic lymphoma, compared to 67% of non-Hodgkin lymphoma and 88% of Hodgkin disease; the scores were not affected by the duration of time from diagnosis to DXA (3.6, 2.0, and 1.6 years, respectively). CONCLUSION: Adult patients with hematological malignancies have significant bone loss compared to a normal age-matched population. The type of diagnosis is more important than the time from diagnosis in predicting risk for bone loss. Recognition of bone loss in these patients may warrant prophylactic measures and lifestyle changes before, during, and after therapy.

Spondylodiskitis and endocarditis due to Streptococcus gordonii.

BACKGROUND: Streptococcus gordonii is an infrequent cause of infective endocarditis (IE); associated spondylodiskitis has not yet been described in the literature. PURPOSE: We describe 2 patients who presented with new-onset, severe back pain; blood cultures revealed S. gordonii bacteremia, which led to the diagnosis of spondylodiskitis and IE. We review our 2-decade experience with S. gordonii bacteremia to describe the clinical and epidemiological characteristics of these patients. RESULTS: In our hospital over the last 20 years (1998-2017), a total of 15 patients with S. gordonii bacteremia were diagnosed, including 11 men and 4 women, and the mean age was 65 ± 22 (range 23-95). The most common diagnosis was IE (9 patients), spondylodiskitis (the presented 2 patients, who in addition were diagnosed with endocarditis), necrotizing fasciitis (1), sternitis (1), septic arthritis (1) and pneumonia (1). The 11 patients with IE were treated with penicillin ± gentamicin, or ceftriaxone for 6 weeks, 5 required valve surgery and 10/11 (91%) attained complete cure. The 2 patients with diskitis required 2-3 months of intravenous antibiotics to achieve complete cure. CONCLUSION: Spondylodiskitis was the presenting symptom of 2/11 (18%) patients with S. gordonii endocarditis. Spondylodiskitis should probably be looked for in patients diagnosed with S. gordonii endocarditis and back pain as duration of antibiotic treatment to achieve complete cure may be considerably longer.

[MONITORING UNITS IN DEPARTMENTS OF INTERNAL MEDICINE: FREQUENCY, IMPACT AND SATISFACTION].

BACKGROUND: Due to increasing numbers of elderly, seriously ill patients and shortage of ICU beds, many hospitals have established monitoring units (MU) in their medical departments. OBJECTIVES: (1) To assess the national prevalence of MUs in medical departments; (2) to determine the outcome of consecutively admitted MU patients; (3) to evaluate patient/ family satisfaction with care. METHODS: The case control study included all 123 patients hospitalized in the MU during a 5-month period, compared with two control groups: (1) 123 patients admitted to medical departments, matched at a ratio of 1:1 by gender, age±10 years and mechanical ventilation; (2) all 52 medical patients treated in the ICU. The main endpoint was 28-day survival. RESULTS: A total of 76/99 (77%) directors of medical departments in Israel responded: 70 (92%) reported the presence of a MU, 64 (92%) have 5-7 beds and 47 (67%) have one nurse per shift. Baseline characteristics of enrolled MU and medical department patients were similar, although 52 medical ICU patients were younger (56±21 vs. 73±14, p<0.001) and had a lower incidence of kidney failure (11.5% vs. 41.5%, p<0.001). The predicted mortality rates were higher for MU patients compared to medical department patients, but 28-day survival rates were similar (64-70%, NS). The questionnaire showed high rates of satisfaction (from 0=low to 5=high): highest with MU care: (4.79±0.48), followed by ICU (4.41±1.06) and lowest for medical department nursing care (4.27±0.84)(p=0.017). CONCLUSIONS: Monitoring units are ubiquitous in Israeli hospitals and contribute to survival and satisfaction with care.

Operating a Monitoring Unit in the Geriatric Department: Effects on Outcomes.

OBJECTIVES: To compare the effect of a five-bed geriatric monitoring unit (MU) on in-hospital mortality and length of stay with the effect of usual care in a geriatric hospital department and a medical MU. DESIGN: Prospective, case-control, noninterventional study. PARTICIPANTS: All individuals hospitalized for 24 hours or longer in the geriatric MU (n = 89, aged 53-101, mean age 82.2 ± 9.6) over a period of 5 months (January-May 2015); individuals admitted to the geriatric department (n = 178, aged 55-100, mean age 83.2 ± 9.8), matched at a ratio of 1:2 according to sex, age ±5 years, and need for mechanical ventilation; and individuals admitted to a similar five-bed medical MU (n = 95, aged 35-90, mean age 68.2 ± 14.4) during the same period. MEASUREMENTS: Primary outcome was in-hospital mortality. RESULTS: The predicted death rate was 49 ± 26 for participants in the geriatric MU, 39.6 ± 27 for those in the medical MU (P = .02), and 36.7 ± 27 for those in the geriatric department (P < .001). Observed in-hospital mortality was higher for geriatric MU participants (n = 40, 44.9%) than for the department control group (n = 48, 27%) (P = .002), although the mortality ratios (actual divided by predicted death rates) of these two groups were similar, indicating that the more severely ill participants in the geriatric MU did better than control participants in the departments, in particular those requiring hemodynamic pressure support and those with acute renal failure. CONCLUSION: For elderly, severely ill adults, care in a geriatric MU was associated with lower in-hospital mortality than care in the hospital geriatric ward and a longer stay and may be an alternative to medical MU admission.

Anti-Factor Xa Activity of Prophylactic Enoxaparin Regimens in Critically Ill Patients.

BACKGROUND: Enoxaparin is frequently used as prophylaxis for deep venous thrombosis in critically ill patients. OBJECTIVES: To evaluate three enoxaparin prophylactic regimens in critical care patients with and without administration of a vasopressor. METHODS: Patients admitted to intensive care units (general and post-cardiothoracic surgery) without renal failure received, once daily, a subcutaneous fixed dose of 40 mg enoxaparin, a subcutaneous dose of 0.5 mg/kg enoxaparin, or an intravenous dose of 0.5 mg/kg enoxaparin. Over 5 days anti-activated factor X levels were collected before the daily administration and 4 hours after the injection. RESULTS: Overall, 16 patients received the subcutaneous fixed dose, 15 received the subcutaneous weight-based dosage, and 8 received the dose intravenously. Around two-fifths (38%) of the patients received vasopressors. There was no difference between anti-activated factor X levels regarding vasopressor administration. However, in all three groups the levels were outside the recommended range of 0.1 IU/ml and 0.3 IU/ml. CONCLUSIONS: Although not influenced by vasopressor administration, the enoxaparin regimens resulted in blood activity levels outside the recommended range.

Mortality due to blaKPC Klebsiella pneumoniae bacteraemia.

OBJECTIVES: To determine the mortality rate secondary to blaKPC Klebsiella pneumoniae (KPC/Kp) bacteraemia, compared with that from ESBL-producing K. pneumoniae (ESBL/Kp) bacteraemia, and to determine associated risk factors. METHODS: This was a retrospective case-control study of all 68 KPC/Kp bacteraemia patients diagnosed since 2006, matched by year of isolation, gender and age, at a ratio of 1:2, to 136 ESBL/Kp bacteraemia patients. RESULTS: There were no demographic differences between the two groups, but there were minor clinical differences. Fewer KPC/Kp study patients than ESBL/Kp control patients had a systolic blood pressure <90 mmHg (32/68, 47% versus 86/136, 63%, respectively, P = 0.02) or urinary catheterization (32/68, 47% versus 90/136, 66%, respectively, P = 0.005), while the KPC/Kp bacteraemia group had a greater incidence of acute renal failure (45/68, 66% versus 67/136, 49%, respectively, P = 0.02). There was no difference between the two groups in duration of hospitalization. The mortality rate of the KPC/Kp bacteraemia group was 44/68 (65%) compared with 54/136 (40%) in the ESBL/Kp bacteraemia control group (P = 0.008), which in the multivariate analysis remained highly significant (P < 0.001). Only 11/68 (16%) of KPC/Kp patients were functionally independent at discharge compared with 43/136 (32%) ESBL/Kp patients (P = 0.012). CONCLUSIONS: The selection of an ESBL/Kp control cohort with a ratio of 1:2 (study versus control group) helped resolve an as yet insufficiently settled question: bacteraemia with KPC/Kp is an independent risk factor for death, justifying the strict adherence to cohorting and isolation procedures.

[Effect of a computer application on appropriate use and control of broad spectrum antibiotics].

BACKGROUND: Antibiotics are among the greatest contributions of modern medicine. However, since the onset of the antibiotic age, resistance has emerged, threatening the future usability of these drugs. The complexity of antibiotic prescribing and associated expense has led to the development of infectious disease (ID) expert stewardship programs. PURPOSE: To describe an in-house created computer application, in use since 2005 with which all restricted antimicrobials are ordered and approved by ID physicians before being supplied by the pharmacy. RESULTS: In the nine years since the application was adopted by the entire hospital, 173,436 prescriptions for restricted antibiotics have been ordered through the application, of which 52% were for male patients, 8% for children ≤ 20 years, 31% for adults 21-70 years old and 61% for patients > 70. All prescriptions were reviewed by ID physicians; their response included approval (mean 87%, range 82-92%), rejection (7%, 3-12%), or change (6%, 4-18%). The latter two decisions always involved written and/or oral interaction with the prescribing physicians. The result analysis showed that: by clinical diagnoses, the approval rate ranged from 82% (for central line associated infection) to 94% (for tuberculosis); by class of antimicrobial, the approval rate ranged from 71% (IV ciprofloxacin) to 95% (IV amoxicillin-calvulanate). Overall hospital expenditure on antimicrobials, corrected by 100 admissions and 100 admission days, did not change significantly. CONCLUSIONS: During the nine years of its use, the described computer program has significantly contributed to physician awareness of appropriate antibiotic use, provided tools to assist physicians in their choice of antimicrobial treatment, allowed ID supervision with unprecedented scope and depth and has significantly contributed to cost control.