Israel Medical Association Journal

Background: Some specialists and policy makers advocate progression of the mental health reform in Israel by transferring beds from psychiatric to general hospitals.

Objectives: To compare the demographic, diagnostic and psychopathological profiles of psychiatric inpatients hospitalized in psychiatric and general hospitals, as well as their patterns of drug abuse and to estimate the preparedness of general hospitals for the possible expansion of their psychiatric services.

Methods: Between 2002 and 2006 a total of 250 patients were consecutively admitted to the Jerusalem Mental Health Center-Kfar Shaul Hospital and 220 to the psychiatric department of Sheba Medical Center, a general hospital in central Israel; the patients’ ages ranged from 18 to 65. The two groups were compared for demographic features, psychiatric diagnoses and severity of psychopathology (utilizing PANSS, HAD-21, YMRS rating scales). Drug abuse was diagnosed by urine analyses and self-report.

Results: The patients in the psychiatric hospital were significantly younger, predominantly male, and more dependent on social security payments. In the general hospital, diagnoses of affective and anxiety disorders prevailed, while in the psychiatric hospital schizophrenic and other psychotic patients constituted the majority. The patients in the general hospital were decidedly more depressed; in the psychiatric hospital, notably higher rates of manic symptoms as well as positive, negative and general schizophrenic symptoms were reported. For the most abused substances (opiates, cannabis and methamphetamines) the rates in the psychiatric hospital were significantly higher.

Conclusions: The differences between the two groups of inpatients were very pronounced, and therefore, the transferring of psychiatric beds to general hospitals could not be done without serious and profound organizational, educational and financial changes in the psychiatric services of general hospitals. Since each of the two inpatient systems has particular specializations and experience with the different subgroups of patients, they could coexist for a long time.
 

Background: Diarrhea is a leading cause of child mortality worldwide. Rotavirus is one of the most common causes of severe diarrhea and dehydration in children.

Objectives: To compare the demographic, clinical and laboratory characteristics of patients with rotavirus gastroenteritis to those with other causes of gastroenteritis.

Methods: The medical records of children aged 0–18 years hospitalized with acute gastroenteritis in our facility between 1 January 2004 and 31 March 2006 were retrieved. Patients with rotavirus gastroenteritis were compared with patients who were rotavirus negative.

Results: The study group comprised 533 patients; 202 tested positive for rotavirus and 331 tested negative. Compared to patients with rotavirus-negative gastroenteritis, patients with rotavirus-positive gastroenteritis had a higher incidence of vomiting (185/202 vs. 212/331, 92% vs.  64%, P < 0.001), lethargy (67 vs. 51, 33% vs. 15%, P < 0.001), and dehydration (81 vs. 78 vs. 40% vs. 24%, P < 0.001). The need for intravenous rehydration therapy and the duration of hospitalization were higher in patients with rotavirus gastroenteritis.

Conclusions: Vomiting and dehydration are more common in hospitalized children with rotavirus gastroenteritis than in children with gastroenteritis due to other causes.
 

Background: During military escalations emergency departments provide treatment both to victims of conflict-related injuries and to routine admissions. This requires special deployment by the hospitals to optimize utilization of resources.

Objectives: To evaluate “routine” visits to the ED[1] during Operation Cast Lead in Israel in 2008–2009.

Methods: We obtained data regarding routine visits to the ED at Soroka University Medical Center throughout OCL[2]. The visits one month before and after OCL and the corresponding periods one year previous served as controls.

Results: The mean number of daily visits throughout the study period (126 days) was 506 ± 80.9, which was significantly lower during OCL (443.5 ± 82) compared with the reference periods (P < 0.001). Compared to the reference periods, during OCL the relative rates were higher among Bedouins, visitors from the region closest to the Gaza Strip (< 30 km), patients transported to the ED by ambulance and patients of employment age; the rates were lower among children. No difference in the different periods was found in the rate of women patients, distance of residence from Beer Sheva, rate of patients referred to the ED by a community physician, and hour of arrival. The overall in-hospital admission rate increased during OCL, mainly in the internal medicine and the obstetric departments. There was no change in the number of in-hospital births during OCL; however, the rate of preterm labors (32–36 weeks) decreased by 41% (P = 0.013).

Conclusions: Throughout OCL the number of routine ED visits decreased significantly compared to the control periods. This finding could help to optimize the utilization of hospital resources during similar periods.

Background: Many patients in the internal medicine ward have anemia. The etiology for the anemia may be multifactorial and, in the setting of inflammatory process when the ferritin is increased, it is difficult to diagnose iron deficiency anemia. Soluble transferrin receptor (sTfR) had been suggested as an indicator for iron deficiency. No study has investigated the meaning of high sTfR as the only positive marker of iron deficiency anemia (IDA) caused by gastrointestinal tract (GIT) bleeding in hospitalized patients.

Objectives: To demonstrate the importance of high levels of sTfR as a marker for further GIT investigation in cases of anemia where the level of ferritin was normal or increased

Methods: We retrospectively assessed all patients in an internal medicine ward in our facility with anemia, high sTfR[1] levels (> 5.0 mg/L) and normal or high ferritin levels who underwent esophagogastroduodenoscopy and colonoscopy.

Results: Of 32 patients with anemia and normal or high ferritin levels and high sTfR, 22 patients (68%) had findings that explained IDA[2] (in some patients more than one finding). Those findings were colonic polyps (n=9), carcinoma of colon (n=4), duodenal ulcer (n=4), carcinoma of stomach (n=3), colitis (n=3), atrophic gastritis (n=1), erosive gastritis (n=1) and angiodysplasia (n=1).

Conclusions: High sTfR may be a good indicator of IDA caused by GIT[3] bleeding when the ferritin level is normal or high. GIT investigation is warranted in such cases.

Background: A pandemic (H1N1) influenza A virus was identified in 2009.

Objectives: To investigate predictors for pandemic (H1N1) 2009 virus infection among hospitalized patients with a flu-like illness and to identify parameters suggesting a severe clinical course.

Methods: We analyzed a cohort of all patients hospitalized during a 2 month period with a flu-like syndrome who were tested for pandemic (H1N1) 2009 infection. Demographic, clinical and laboratory, along with outcome parameters, were recorded and compared between pandemic (H1N1) 2009 virus-positive and negative hospitalized patients.

Results: Of the 179 examined hospitalized patients suspected of having pandemic (H1N1) 2009 infection 65 (36%) were found positive. These patients tended to be younger and had significantly fewer comorbidities. In addition, they had a significantly higher frequency of fever (94%), cough (86%) and myalgia (29%). Furthermore, age < 65 years and cough were independent predictors for pandemic (H1N1) 2009 virus positivity in a multivariate regression analysis. Notably, 14 of the 65 positive patients (21.5%) had acute respiratory insufficiency requiring treatment in the intensive care unit. These patients were neither older nor previously sicker than patients with non-severe disease, but were distinguished by augmented inflammatory markers, significant lymphopenia associated with disease severity, and overall mortality of 21.4%.

Conclusions: Pandemic (H1N1) 2009 virus-positive hospitalized patients tend to be younger and have fewer comorbidities as compared to compatible negative patients. A significant number of relatively young and previously healthy positive patients might develop severe disease associated with a robust inflammatory reaction and significant lymphopenia.

Background: Community-acquired pneumonia is a common infection and is associated with high rates of morbidity and mortality. Most patients with CAP[1] are treated empirically.

Objectives: To identify common pathogens causing CAP in hospitalized patients in northern Israel and to evaluate the correlation between etiology and disease severity.

Methods: We conducted a prospective study of patients with CAP hospitalized at HaEmek Medical Center, Afula. We collected demographic, clinical and laboratory data (blood and sputum cultures, serology, pneumococcal urinary antigen test, and respiratory multiplex-polymerase chain reaction from nasopharyngeal swab), and radiologic evaluation was performed.

Results: A total of 126 patients and 24 controls were enrolled. At least one pathogen was identified in 84 cases (66.7%), more than one in 43 patients (34.1%), and no pathogens in 42 (33.3%). Typical bacteria were found in 23 (18.3%), atypical bacteria in 66 (52.4%), and viruses in 42 (33.3%). The number (%) of patients with pathogens isolated was: Chlamydophila pneumoniae 26 (20.6%), Streptococcus pneumoniae 23 (18.3%), Mycoplasma pneumoniae 23 (18.3%), influenza virus A-B 20 (15.9%), Coxiella burnetti 8 (6.3%), and parainfluenza and adenovirus 13 (10.3%) each. A correlation was found only between a high PORT score on admission and S. pneumoniae, although atypical pathogens did not show class predominance.

Conclusions: S. pneumoniae, M. pneumoniae and C. pneumoniae were the most common pathogens isolated, while co-infection was very frequent. PORT score did not predict any of the pathogens involved. The choice of empiric antimicrobial treatment for CAP should be made according to local epidemiologic data.

Background: Guidelines are frequently under-implemented in older patients with heart failure. Octogenerians are often excluded from clinical trials.

Objectives: To characterize the clinical profile of the oldest-old (age ≥ 80 years) heart failure patients hospitalized in a subacute geriatric hospital and to evaluate their management and 1 year outcome.

Methods: Patient characteristics and in-hospital course were retrospectively collected. Diagnosis of heart failure was based mainly on clinical evaluation in addition to chest X-ray results and echocardiographic findings when available.

Results: The study population comprised 96 consecutive unselected heart failure patients hospitalized from January to June 2003. The patients were predominantly women (67%), aged 85 ± 5 years, fully dependent or frail with a high rate of comorbidities. Adherence to guidelines and recommended heart failure medications was poor. Their 1 year mortality was 57%. According to logistic regression analysis, predictors of 1 year mortality were lower body mass index (odds ratio 0.86, 95% confidence interval 0.78–0.96) and high urea levels (OR[1] 1.04, 95% CI[2] 1.02–1.06).

Conclusions: Our study confirms that the management of oldest-old heart failure patients hospitalized in a subacute geriatric hospital was suboptimal and their mortality was exceptionally high.

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%.

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: Streptococcus pneumoniae is now the predominant pathogen causing meningitis. The resistance of S. pneumoniae to penicillin and third-generation cephalosporins has grown steadily.

Objectives: To assess the antibiotic susceptibility of S. pneumoniae isolated from the cerebrospinal fluid of children with meningitis, and determine the antibiotic regimen appropriate for suspected bacterial meningitis in Israel.

Methods:  The study group included 31 children with 35 episodes of meningitis hospitalized from 1998 to 2006. S. pneumoniae isolates from the cerebrospinal fluid were tested for susceptibility to penicillin and ceftriaxone.

Results: Of the 35 isolates, 17 (48.6%) showed resistance to penicillin (minimum inhibitory concentration ≥ 0.12 µg/ml). Only 3 isolates (8.6%) showed intermediate resistance to ceftriaxone (≥ 0.5 and < 2 μg/ml), and none showed complete resistance (MIC[1] ≥ 2 μg/ml). The rates of antibiotic resistance were higher in children who were treated with antibiotics prior to admission (penicillin 88.9% vs. 34.6%, P = 0.007; ceftriaxone 22.2% vs. 3.8%, P = 0.156).

Conclusions:  The rate of penicillin resistance is high in children with S. pneumoniae meningitis in Israel, especially in those treated with oral antibiotics prior to admission. Resistance to ceftriaxone is infrequent though not negligible. On the basis of these findings, current recommendations to empirically treat all children with suspected bacterial meningitis with ceftriaxone in addition to vancomycin until the bacterial susceptibility results become available are justified also in Israel.

Background: Parallel to increased life expectancy, the number of very elderly patients hospitalized in internal medicine departments is growing rapidly, although clinical data on hospital care are lacking.

Objectives: To investigate the sociodemographic data, hospitalization characteristics and outcomes of nonagenarian patients, as these measures are necessary for evaluating prognostic information and predictors of mortality.

Methods: We reviewed the medical records of all patients aged ≥ 90 hospitalized in our institute's Department of Internal Medicine. The data comprised 482 admissions of 333 patients hospitalized over a one year period.

Results: Half of the study patients were residents of nursing institutions. A high rate of atrial fibrillation was documented (106 patients, 32%). Acute infectious diseases constituted the leading diagnosis (276/482 admissions, 57%), followed by acute coronary syndrome (17% of admissions). In-hospital mortality occurred in 74 patients (22%). Chronic therapy with statins or acetylsalicylic acid was inversely related to mortality (P < 0.05). The main predictors for in-hospital death of nonagenarians were pressure sores, older age, atrial fibrillation, malignant disease, and admission due to an acute infection, especially Clostridium difficile-associated diseases. In addition, mental decline, permanent urinary catheter, leukocytosis, renal failure and hypoalbuminemia predicted post-discharge mortality. Admission due to an infectious disease but not acute coronary syndrome was significantly correlated to in-hospital and post-discharge mortality (P < 0.001).

Conclusions: Hospitalized nonagenarians comprise a growing group with distinct characteristics and increasing significance in the daily practice of internal medicine departments. Comprehensive assessment of the elderly at admission together with identification of the above clinical and laboratory risk factors for mortality will help determine in-hospital management, discharge planning and rehabilitation programs.

Background: Secondary thrombocytosis is associated with a variety of clinical conditions, one of which is lower respiratory tract infection. However, reports on thrombocytosis induced by viral infections are scarce.

Objectives: To assess the rate of thrombocytosis (platelet count > 500 x 10⁹/L) in hospitalized infants with bronchiolitis and to investigate its potential role as an early marker of respiratory syncytial virus infection.

Methods: Clinical data on 469 infants aged ≤ 4 months who were hospitalized for bronchiolitis were collected prospectively and compared between RSV[1]-positive and RSV-negative infants.

Results: The rate of thrombocytosis was significantly higher in RSV-positive than RSV-negative infants (41.3% vs. 29.2%, P = 0.031). The odds ratio of an infant with bronchiolitis and thrombocytosis to have a positive RSV infection compared to an infant with bronchiolitis and a normal platelet count was 1.7 (P = 0.023, 95% confidence interval 1.07–2.72). There was no significant difference in mean platelet count between the two groups.

Conclusions: RSV-positive bronchiolitis in hospitalized young infants is associated with thrombocytosis.