Despite the wide endorsement of shared decision making (SDM), its integration into clinical practice has been slow. In this paper, we suggest that this integration may be promoted by teaching SDM not only to residents and practicing physicians, but also to undergraduate medical students. The proposed teaching approach assumes that SDM requires effective doctor–patient communication; that such communication requires empathy; and that the doctor’s empathy requires an ability to identify the patient’s concerns. Therefore, we suggest shifting the focus of teaching SDM from how to convey health-related information to patients, to how to gain an insight into their concerns. In addition, we suggest subdividing SDM training into smaller, sequentially taught units, in order to help learners to elucidate the patient’s preferred role in decisions about her/his care, match the patient’s preferred involvement in these decisions, present choices, discuss uncertainty, and encourage patients to obtain a second opinion.
Effective chest compressions have been proven to be a key element in a successful cardiopulmonary resuscitation (CPR). However, unintended injuries have been described in the medical literature for decades, including major intrathoracic injuries. We present a case of an 80-year-old man after a successful CPR who was later diagnosed with deep epicardial laceration as a result of effective chest compressions.
Introduction: Microvasculopathy is characterized by progressive structural and functional damage to the microvessels and plays a key role in the pathogenesis of various connective tissue diseases (CTD). Nailfold videocapillaroscopy is an optimal and validated method for analysis of microvascular abnormalities and is able to differentiate secondary Raynaud’s phenomenon (RP) of CTD from primary RP and healthy subjects.
Aim: To assess and analyze nailfold capillaroscopic findings in Indian subjects with secondary Raynaud and to compare with findings in healthy subjects.
Methods: A total of 62 study participants including cases and controls underwent nailfold videocapil-laroscopy. Capillary loop length, capillary width, capillary density, presence/absence of tortuosity, giant loops, neoangiogenesis, microhemorrhages, and avascular areas were the parameters studied.
Results: All the quantitative and qualitative parameters studied were significantly associated with second¬ary RP. Mean loop length in cases of connective tissue diseases was significantly less than in the controls (225.74 µm versus 282.97 µm) (P=0.002). Capillary density was also reduced significantly in the cases as compared to the controls (4.6 versus 7.39/mm) (P<0.01), whereas it was markedly decreased in systemic sclerosis (SSc) and mixed connective tissue diseases (MCTD), and near normal in systemic lupus erythematosus (SLE). Tortuosity was the most frequent (77.4%) qualitative parameter. Scleroderma pattern was found in 62.5% of patients with SSc and in 60% with MCTD. Non-specific pattern was found in 80% of SLE cases and 50% of dermatomyositis cases.
Conclusion: Both quantitative and qualitative capillaroscopic changes are significantly associated with secondary RP. Scleroderma pattern was predominant in SSc and MCTD, whereas non-specific pattern was predominantly found in SLE and dermatomyositis.
Objective: Israeli hospitals were confronted with a major national outbreak of carbapenemase-producing Enterobacterales (CPE) starting in 2006, caused predominantly by monoclonal Klebsiella pneumoniae carbapenemase (KPC)-producing Klebsiella pneumoniae. Our hospital, Rambam Health Care Campus (RHCC), was one of the medical centers affected by this outbreak. We aimed to investigate the changing epidemiology of CPE at RHCC since 2006.
Methods: This was a retrospective observational cohort study performed in Northern Israel (Haifa) at RHCC, which is a primary tertiary acute care academic hospital. The study included all patients who had acquired CPE at RHCC between January 2005 and December 2020.
Results: The proportion of patients infected with K. pneumoniae dropped from 100% of all CPE in the first years to 28% (37/134) in 2020. In 2014, the carbapenemase in 94% of all CPE patients (89/95) was KPC. This decreased to 56% in 2020, while New Delhi metallo-β-lactamase (NDM) and OXA-48 carbapenemases increased from 4% and 2% to 29% (39/134) and 12.7% (17/134) of CPE, respectively.
Conclusions: The CPE epidemic evolved from KPC-producing K. pneumoniae to involve different Enterobacterales and carbapenemases. Our results are a microcosm of the current global epidemiology attesting to globalization in bacteriology. The results have implications for infection control and antibiotic treatment of CPE infections.
Background: With the availability of coronavirus disease 2019 (COVID-19) vaccine, concerns have been raised regarding pre-vaccination seroprevalence in healthcare workers (HCW). This study examines the seroprevalence of HCW at an Israeli tertiary medical center before first BNT162b2 vaccination.
Methods: This was a retrospective observational study. Before vaccination, HCW at our center were offered serological testing. Data on their epidemiological, workplace, and quarantine history were collect¬ed. The SARS-CoV-2 IgG assay was performed pre-vaccination.
Results: A total of 4,519 (82.5%) of the HCW were tested. Of these, 210 were seropositive; 101 had no known history of COVID-19. Of the 101 asymptomatic HCW, only 3 (3%) had worked at COVID-19 depart¬ments, and 70 (69.3%) had not been previously quarantined. Positive serology was similarly distributed across age groups, and about 40% had no children. Nearly half of the HCW tested were administrative and service staff. Overall, seropositive tests were associated with having no children (OR 1.42, 95% CI 1.06–1.89; P=0.0218), history of having been quarantined without proof of disease (OR 6.04, 95% CI 4.55–8.01; P<0.001), and Arab ethnicity (OR 3.36, 95% CI 2.54–4.43; P<0.001). Seropositivity was also more prevalent in members of the administration compared to other sectors, medical and paramedical, who are exposed to patients in their daily work (OR 1.365, 95% CI 1.02–1.82; P=0.04).
Conclusions: The low percentage of asymptomatic COVID-19 among our HCW may reflect the high compliance to personal protective equipment use despite treating hundreds of COVID-19 patients. The relatively high number of childless seropositive HCW could reflect misconceptions regarding children as a main source of infection, leading to carelessness regarding the need for appropriate out-of-hospital protection.
Objectives: Anti-osteoporotic drugs (AOD) are essential for secondary prevention of osteoporotic fracture (OF) in patients with established osteoporosis. However, data about AOD utilization rates are scarce among patients with OF. This study was therefore aimed at determining the AOD utilization rates among those particularly vulnerable patients.
Materials and Methods: This cross-sectional study followed the medical records of patients with OF starting from their first OF diagnosis date. Each patient’s preventive osteoporosis treatments (vitamin D, calcium+vitamin D) and AOD utilization rate were recorded for a 12-month period following OF diagnosis.
Results: A total of 210 patients (168 females, mean age: 67.8±11.9 years; 42 males, mean age 62.4±16.1 years) were enrolled in the study. Of these, 65.7% (n=138) did not use any medication for primary protection against osteoporosis before OF diagnosis. The ratio of patients not using any type of medication for secondary prevention after OF increased from 26.5% to 51% during a 12-month period. In addition, by one year following diagnosis, AOD usage rate had decreased from 62.3% to 41.3%.
Conclusion: The AOD usage rates for secondary prevention of OF were insufficient, and cessation rates were high. Identification of factors associated with decreased AOD utility rates will provide important information for guiding patient follow-up in order to reduce the occurrence of OF.
Food security and nutrition were major drivers of cultural evolution by enabling sociotypic development and communal living after the Neolithic agricultural revolution some 12,000 years ago. The sociotype unites concepts from the sciences and the humanities; in concert with the genotype it determines an individual’s phenotype (observable traits and behavior), and together they advance societal culture. As such, the sociotype relates to an individual’s dynamic interactions with the surrounding social environment through¬out life and comprises three domains: the Individual, Relationships, and Context. Nutrition affects each domain, respectively, by ensuring the following dimensions of food security: utilization (metabolic fuel and health); accessibility (physical and economic); and availability (the right to nutritious food for all citi¬zens). The sociotype is influenced by multiple factors, including diet–gene interactions, allostasis, micro¬biota, oxytocin, and culturally through mate selection, family bonds, social communication, political ideol¬ogies, and values. Food security, sociotypes, and culture form a complex adaptive system to enable coping with the circumstances of life in health and disease, to achieve sustainable development, and to eradicate hunger. The current geopolitical unrest highlights the absolutely critical role of this system for global security, yet many challenges remain in implementing this paradigm for society. Therefore, sustainable food security must be considered a fundamental human right and responsibility for safeguarding the survival and progress of the sociotypes of humankind (Homo cultures) worldwide.
Background and Objective: Postoperative (post-op) pain control has an important impact on post-op rehabilitation. The logistics of its maintenance challenge the effect of peripheral nerve block on post-op pain control, with the risk for post-op complications. We hypothesized that perioperative use of local infiltration analgesia (LIA) is comparable to post-op pain control by peripheral nerve block.
Materials and Methods: We evaluated three groups of patients treated with primary total knee arthroplasty (TKA) due to symptomatic end-stage osteoarthritis with post-op pain control by LIA (LIA group, n=52), femoral plus sciatic nerve block (FSNB) (FSNB group, n=54), and without local or regional analgesia as controls (Control group, n=53). The primary outcome variable was the post-op pain level intensity as measured by the visual analog scale (VAS). Secondary outcome variables were knee function measured by the Knee Society Score (KSS) and the quadriceps muscle strength recovery profile.
Results: Up to 4 hours post-op, pain intensity was significantly lower in FSNB patients (P<0.05). This effect of the peripheral nerve block on the pain level disappeared 6 hours post-op. The LIA and FSNB patients showed a significant decrease in pain intensity on days 2 and 3 post-op (P<0.05) with no mutual differences (P>0.05). This effect disappeared on day 4 post-op (P>0.05). The KSS score showed similar significant improvement of functional abilities (P<0.001) in all three groups. There was no difference in KSS scores among the groups 6 months after surgery (P>0.05). Quadriceps muscle recovery profile was similar in the LIA and Control groups, but significantly poorer in the FSNB group (P<0.001).
Conclusion: The value of very short-term and improved pain relief of post-op FSNB over LIA of the surgical wound should be carefully weighed against its cost, logistics, and potential complication threat.
Objective: Cirrhotic cardiomyopathy (CCM) is associated with increased morbidity and mortality in patients with liver cirrhosis. Yet, it remains an under-diagnosed entity. Further, its relation to the severity of cirrhosis is contradictory. We conducted this study on an Indian population to determine the cardiac dysfunctions in cirrhosis of the liver and correlations with etiologies and cirrhosis severity.
Methods: This study enrolled patients with diagnosed liver cirrhosis without any cardiac disease or conditions affecting cardiac function. All participants were evaluated clinically, electrocardiographically, and echocardiographically. Cirrhosis severity was assessed by scores from the Model for End-stage Liver Disease (MELD) and Child–Turcotte–Pugh (CTP) tests. Cirrhotic cardiomyopathy was defined as diastolic dysfunction and/or systolic dysfunction with QT prolongation.
Results: Ninety-six patients were evaluated, and CTP-A stage of cirrhosis was found in 23 (24%), CTP-B in 42 (43.8%), and CTP-C in 31 (32.3%) cases. Systolic dysfunction was most frequent (P=0.014), and left ventricular ejection fraction was significantly reduced (P=0.001) in CTP-C stage of cirrhosis. Cirrhotic cardiomyopathy was found in 39.6% (n=38) of patients; CCM patients had significantly higher CTP scores (9.6±2.6 versus 8.3±2.3, P=0.012) as well as MELD scores (19.72±4.9 versus 17.41±4.1, P=0.015) in comparison to patients without CCM.
Conclusion: Cirrhotic cardiomyopathy has a positive relationship with the severity of cirrhosis. Systolic function declines with the severity of cirrhosis, and overt systolic dysfunction can be present, particularly in the advanced stage of cirrhosis of the liver.
The Joles Jewish Hospital in Haarlem (a small city in the Netherlands) was established in 1930 to provide a Jewish milieu for local patients. Mozes Joles, a wealthy Jewish businessman, bequeathed his fortune to the Haarlem Jewish community to accomplish this objective, and its spiritual leader, Rabbi Simon Philip de Vries, was the driving force in successfully achieving this goal. The Joles Hospital was forcibly closed by the Nazis in 1943, and the postwar leadership of the Haarlem Jewish community decided not to reopen it. Instead, they used the Joles inheritance to build old age homes in both Haifa, Israel, and Haarlem, thus ensuring a Jewish environment for elderly care in both locales. The realization of one man’s charitable act bettered the lives of both ill and elderly individuals.
