Israel Medical Association Journal

Background: Health care workers bear the risk of both contracting influenza from patients and transmitting it to them. Although influenza vaccine is the most effective and safest public health measure against influenza and its complications, and despite recommendations that HCWs[1] should be vaccinated, influenza vaccination coverage among them remains low.

Objectives: To characterize influenza vaccination coverage and its determinants among employees in an Arab hospital in Israel.

Methods: An anonymous, self-administered questionnaire was distributed among employees involved in patient care in the winter of 2004–2005 at Nazareth Hospital in Israel. The questionnaire included items related to health demographic characteristics, health behaviors and attitudes, knowledge and attitude concerning influenza vaccination, and whether the respondent had received the influenza vaccine during the previous winter or any other winter.

Results: The overall rate of questionnaire return was 66%; 256 employees participated in the study. The immunization coverage rate was 16.4%, similar to that reported for other hospitals in Israel. Logistic regression analysis demonstrated a significant association only between influenza vaccination coverage and the presence of chronic illness and influenza vaccination in the past.

Conclusions: Influenza vaccination coverage among Nazareth Hospital health care workers was low. They did not view themselves as different to the general population with regard to vaccination. An intervention program was launched after the study period, aimed at increasing the knowledge on the efficacy and safety of the vaccine, stressing the importance of vaccinating HCWs, and administering the vaccine at the workplace. The program raised the vaccination coverage to 50%.

[1] MHC = mother and child health

Background: Peritonitis is a major complication of chronic peritoneal dialysis therapy. It is recommended that each center monitor infection rates in order to define the local microbiological profile and implement an appropriate empiric antibiotic regimen.

Objectives: To analyze the microbiological profile of peritonitis in our pediatric dialysis unit and identify local predisposing factors.

Methods: In this retrospective study we reviewed the files of children treated with chronic PD[1] during the 10 year period 1997–2007.

Results: Eighty peritonitis episodes were recorded in 29 children (20 male, 9 female) aged 0.1–18.5 years (median 11.75) treated with peritoneal dialysis for 6–69 months (median 19) for a total of 578 patient-months. The annual peritonitis rate was 1.66/patient. The main pathogens were coagulase-negative Staphyloccocus (32.5%) and Pseudomonas spp. (16%), which were also cultured in most cases (64–69%) from the exit site during the 3 months preceding peritonitis. No peritonitis occurred in 31% of the patients (median age 12.5 years). All patients less than 5 years old had at least one peritonitis episode. Contaminating conditions (gastrostomy, enuresis, diaper use), found in 44% of the study group, and first infection within 6 months from starting PD were significantly associated with an increased peritonitis rate (P = 0.01, P = 0.009, respectively). Recurrent peritonitis led to a switch to hemodialysis in 18% of patients. There were no deaths.

Conclusions: The risk factors for peritonitis in our study were: first infection within less than 6 months from starting treatment, Pseudomonas exit-site colonization, and contaminating conditions (gastrostomies, diaper use, enuresis). These susceptible subgroups as well as very young age (< 5 years) at starting PD should be especially targeted during training of caregivers and follow-up to prevent later complications.  

[1] PD = peritoneal dialysis

Background: HER2 is an important prognostic and predictive marker in invasive breast cancer. It is currently assessed by immunohistochemistry for protein over-expression and by fluorescence in situ hybridization for gene amplification. The immunohistochemistry-equivocal cases (2+) are currently retested by FISH[1] to determine eligibility for trastuzumab treatment. Retesting by FISH significantly raises the cost of patient management and sometimes delays treatment. The 4B5 is a new, FDA-approved, rabbit monoclonal antibody for HER2 testing.

Objectives: To examine the reliability of 4B5 IHC[2] HER2 testing in cases found to be HER2 status equivocal by CB11 IHC.

Methods: Twenty-eight invasive breast cancer cases, with an equivocal HER2 status by CB11 IHC, were retested by the 4B5 antibody as well as by FISH analysis. The scoring was performed using the same guidelines as HercepTest and was correlated with the FISH ratio. Results: Of the original 28 CB11 clone designated equivocal cases, 14 (50%) showed negative HER2 staining using the 4B5 clone (HercepTest score 0 and 1+). Five cases (18%) proved to be positive (HercepTest score 3+) and 9 cases (32%) remained equivocal (HercepTest score 2+). The corresponding FISH ratio results showed that all 4B5 negative cases were negative by FISH testing, with a negative predictive value of 100% 4 of 5 of the 4B5-positive cases were positive by FISH testing, with a positive predictive value of 80%. One 4B5-positive case was borderline-high (2.2 ratio) by FISH. The correlation between 4B5 IHC and FISH was statistically significant (P = 0.0013) by chi-square test.

Conclusions: Sequential testing by 4B5 IHC could greatly reduce the need for FISH testing in cases considered HER2 equivocal by CB11 IHC.
 

 
[1] FISH = fluorescence in situ hybridization

[2] IHC = immunohistochemistry

Background: In many hospitals a chest X-ray is performed routinely at each patient’s admission. There are scant data regarding its usefulness in contemporary patient populations, which are characterized by patients’ increasing age, severity of illness, and different comorbidities.

Methods: We studied consecutive patients admitted during a 2 month period to a single department of medicine, where hospital policy mandates performing a CXR[1] on admission or soon after. Two senior clinicians who were not involved in the care of these patients assessed the discharge summaries for a clinical indication to perform CXR on admission, as well as its contribution to patient management (major positive, major negative, minor positive, or no contribution). Logistic regression analysis was performed with the SPSS 12 software program.

Results: The study population comprised 675 patients whose mean age was 64.5 ± 17.2 years. Their presenting complaints included chest pain (18%), dyspnea (12%), weakness (10.5%), fever (9%), abdominal pain (8%) and neurologic complaints (7.5%). Physical examination of the chest was normal in 585 (87%) of the cases and abnormal in 87 (13%). Examination of the heart was normal in 518 (77%) and abnormal in 129 (19%). In 19.6% (130 cases) CXR was not performed. Of the 545 CXRs done, 260 (48%) were normal. In only 128 (23.5%) did the admission CXR make a major positive contribution to diagnosis or treatment. In 61 (11.2%) it provided a minor positive contribution and in 153 (28.1%) a major negative contribution. In 184 patients (33.8%) the CXR did not affect either diagnosis or management. It made a major positive contribution to management in patients for whom there was an indication for performing the X-ray (odds ratio 10.3, P < 0.0005) and in those with a relevant finding on physical examination (OR[2] 1.63, P = 0.110). For a major negative contribution of the CXR to management (i.e., ruling out clinically important possibilities), the clinical indication was also very important (OR 72.9, P < 0.005). When patients with either a clinical indication for performing a CXR or an abnormal chest examination were excluded, 329 patients remained (60% of the 545 who had a CXR) in only 12 of them (3.6%) did the routine admission CXR contribute to patient management.

Conclusions: A routine admission CXR has a significant impact on patient management only in those patients in whom there are relevant findings on physical examination or a clear clinical indication for performing the test. There is no need to routinely order CXR on admission to hospital.

[1] CXR = chest X-ray

[2] OR = odds ratio

Background: Osler taught that splenic infarction presents with left upper abdominal quadrant pain, tenderness and swelling accompanied by a peritoneal friction rub. Splenic infarction is classically associated with bacterial endocarditis and sickle cell disease.

Objectives: To describe the contemporary experience of splenic infarction.

Methods: We conducted a chart review of inpatients diagnosed with splenic infarction in a Jerusalem hospital between 1990 and 2003.

Results: We identified 26 cases with a mean age of 52 years. Common causes were hematologic malignancy (six cases) and intracardiac thrombus (five cases). Only three cases were associated with bacterial endocarditis. In 21 cases the splenic infarction brought a previously undiagnosed underlying disease to attention. Only half the subjects complained of localized left-sided abdominal pain, 36% had left-sided abdominal tenderness 31% had no signs or symptoms localized to the splenic area, 36% had fever, 56% had leukocytosis and 71% had elevated lactate dehydrogenase levels. One splenectomy was performed and all patients survived to discharge. A post hoc analysis demonstrated that single infarcts were more likely to be associated with fever (20% vs. 63%, p < 0.05) and leukocytosis (75% vs. 33%, p = 0.06)

Conclusions: The clinical presentation of splenic infarction in the modern era differs greatly from the classical teaching, regarding etiology, signs and symptoms. In patients with unexplained splenic infarction, investigation frequently uncovers a new underlying diagnosis. 

Background: While family presence during resuscination has been researched extensively in the international and especially American medical literature, in Israel this subject has rarely been researched. Because such policies have become common practice in many countries, it is important to investigate the attitudes of health care staff in Israeli emergency departments to better understand the potential implication of adopting such policies.

Objectives: To examine the attitudes of the physicians and nurses in the ED of Soroka Medical Center to FPDR[1]. 

Methods: The methods we used were both qualitative (partly structured open interviews of 10 ED staff members from various medical professions) and quantitative (an anonymous questionnaire that collected sociodemographic, professional, and attitude data).

Results: The qualitative and quantitative results showed that most staff members opposed FPDR. The main reasons for objecting to FPDR were concern about family criticism, the added pressure that would be put on the staff members, fear of lawsuits, fear of hurting the feelings of the families, and the danger of losing one’s objectivity while treating patients. Physicians objected more strongly to FPDR than did nurses.  

Conclusions: More research is needed on FPDR in Israel, including an examination of its medical, ethical, legal and logistic aspects. In addition to the views of the medical staff, the attitudes of patients and their families should also be examined.

[1] FPDR = family presence during resuscitation

 

Background: Due to increasing antimicrobial resistance there has been renewed interest in old drugs that have fallen into disuse because of toxic side effects.

Objectives: To evaluate the susceptibility profile, in our hospital, of Enterobacteriaceae and Streptococcus pneumoniae isolates to chloramphenicol and to compare them with the susceptibility to amoxicillin-clavulanate.

Methods: All isolates of Enterobacteriaceae and S. pneumoniae recovered in our lab during a one year period were tested for susceptibility to chloramphenicol and amoxicillin-clavulanate or penicillin, respectively.

Results: Of 413 Enterobacteriaceae isolates, 182 (44.1%) were resistant to amoxicillin-clavulanate, but only 76 (18.4%) were resistant to chloramphenicol. Of 189 isolates of S. pneumoniae, 4 (2.1%) were highly resistant to penicillin and 73 (38.8%) were partially resistant, while only 2 (1.1%) were resistant to chloramphenicol. None of the 24 S. pneumoniae isolates causing invasive diseases exhibited resistance to chloramphenicol.

Conclusions: In an era of increasing resistance to many antibiotic preparations, chloramphenicol might have a role in the treatment of intraabdominal and respiratory tract infections.