Israel Medical Association Journal

Background: Vascular insufficiency is considered to play an important role in the pathogenesis of normal-tension glaucoma (NTG). Autoregulation of blood flow in the eye has been shown to be impaired in NTG, resulting in the inability to compensate for changes in intraocular pressure or blood pressure in order to maintain adequate perfusion. Objectives: To evaluate the occurrence of combined bradycardia-hypotension during 24 hour monitoring of blood pressure and heart rate in patients with NTG.

Methods: Eleven NTG patients participated in the study. All had episodic symptoms of dizziness or lightheadedness, but were confirmed as not having a diagnosis of orthostatic hypotension. Twenty-four hour monitoring was performed with systemic blood pressure and heart rate automatically measured every 20 minutes during daytime and every hour during the night. The cardiac diastolic and systolic double products (dDP and sDP) at each reading were calculated by multiplying the heart rate by the respective blood pressure. dDP < 3600 and sDP < 5400 (corresponding to a heart rate of 60 beats/min and a blood pressure of 60 and 90 mmHg, respectively) were considered abnormally low, and dDP < 2500 and sDP < 4000 (corresponding to a heart rate 50 beats/min and a blood pressure of 50 and 80 mmHg, respectively) were considered severely abnormal.

Results: dDP was abnormally low in all 11 NTG patients on at least one occasion, the majority occurring during the night-time hours, while abnormally low sDP was present in 8 of the 11 patients. The mean cumulative duration of low dDP readings was 4.2 ± 3.2 hours. Severely low dDP readings were observed in six patients.

Conclusions: Abnormally low dDP was recorded in all NTG patients, lasting more than an hour in the majority of cases. Abnormally decreased dDP may represent a state of cardiovascular autonomic dysregulation, resulting in low ocular perfusion in certain NTG patients.

Background: Comorbid depression may play an important role in non-compliance with medical treatment among patients with chronic illnesses. Glaucoma is a potentially blinding chronic disease requiring life-long commitment to medical therapy. Patient's failure to adhere to anti-glaucoma treatment may lead to disease progression and visual loss.

Objectives: To assess the prevalence of depressive symptoms in glaucoma patients and the association between these symptoms and non-compliance with anti-glaucoma therapy.

Methods: This was a cross-sectional observational study. Compliance with pharmacotherapy was assessed with the Morisky Medication Adherence questionnaire (eight items). Screening for depression was performed by means of the CES-D scale (Center for Epidemiologic Studies Depression scale). The association between depression and compliance rates was analyzed.

Results: The study group comprised 76 glaucoma patients; 19.7% of the subjects were classified as "non-compliant" (Morisky cutoff < 10) and 21.1% suffered from depression (CES-D cutoff ≥ 16). We found a similar level of non-compliance when comparing depressed with non-depressed glaucoma patients. However, a significant correlation was observed between the level of depression and the level of non-compliance (P = 0.04).

Conclusions: Our study revealed a similar rate of depression in glaucoma patients and the general Israeli population. The presence of depression was not associated with the presence of non-compliance, yet the level of depression was associated with the level of non-compliance.

Background: The compliance of hospital staff with guidelines for the active surveillance of methicillin-resistant Staphylococcus aureus (MRSA) in Israel has not been determined.

Objectives: To evaluate the compliance of hospital staff with guidelines for the active surveillance of MRSA and assess its impact on the incidence of nosocomial MRSA bacteremia.

Methods: We assessed compliance with MRSA surveillance guidelines by assessing adherence to the screening protocol and reviewing medical and nursing charts of patients colonized with MRSA, and observed hand hygiene opportunities among health care workers and colonized patients. Rates of nosocomial MRSA bacteremia and of adherence with hand hygiene among overall hospital staff were obtained from archived data for the period 2001–2010.

Results: Only 32.4% of eligible patients were screened for MRSA carriage on admission, and 69.9% of MRSA carriers did not receive any eradication treatment. The mean rate of adherence to glove use among nurses and doctors was 69% and 31% respectively (P < 0.01) and to hand hygiene 59% and 41% respectively (P < 0.01). The hospital overall rate of adherence to hand hygiene increased from 42.3% in 2005 to 68.1% in 2010. Rates of nosocomial MRSA bacteremia decreased by 79.2%, from 0.48 (in 2001) to 0.1 (in 2010) per 1000 admissions (P < 0.001).

Conclusions: The compliance of medical and nursing staff with guidelines for active MRSA surveillance was poor. The encouraging increase in adherence to hand hygiene and concomitant decrease in nosocomial MRSA bacteremia is gratifying. The deficiencies in compliance with MRSA infection control policy warrant an adjusted strategy based on the hospital resources.

Suicide is universal within the range of human behaviors and is not necessarily related to psychiatric morbidity, though it is considerably more prevalent among psychiatric patients. Considering the limitations of medical knowledge, psychiatrists cope with an unfounded and almost mythical perception of their ability to predict and prevent suicide. We set out to compose a position paper for the Israel Psychiatric Association (IPA) that clarifies expectations from psychiatrists when treating suicidal patients, focusing on risk assessment and boundaries of responsibility, in the era of defensive medicine. The final draft of the position paper was by consensus. The IPA Position Paper established the first standard of care concerning expectations from psychiatrists in Israel with regard to knowledge-based assessment of suicide risk, elucidation of the therapist's responsibility to the suicidal psychotic patient (defined by law) compared to patients with preserved reality testing, capacity for choice, and responsibility for their actions. Therapists will be judged for professional performance rather than outcomes and wisdom of hindsight. This paper may provide support for psychiatrists who, with clinical professionalism rather than extenuating considerations of defensive medicine, strive to save the lives of suicidal patients.
 

Background: Religiosity has been examined as a mechanism of stress management. Since many studies have shown a high rate of psychological morbidity among medical students during different stages of training, it is important to investigate whether religiosity may serve as a protective factor.

Objectives: To assess the association between religiosity and depression or anxiety in a sample of medical students and to compare the results with a matched sample of students from other fields of study.

Methods: This cross-sectional study examined a sample of Tel Aviv University medical students and compared them with students in other faculties at the same university for any association between religiosity and depression or anxiety. The subjects completed the Beck Depression Inventory, the Beck Anxiety Inventory, a modified religiosity inventory, and a demographic and psychosocial variables inventory.

Results: Findings did not show a significant association between religiosity and depression or anxiety in the general sample (n=119). A positive significant correlation between religiosity and anxiety was found among medical students, with 29.4% of them reporting anxiety and 25.2% depression. While high rates of depression and anxiety were reported by students in the first to third years (pre-clinical years), there was a decrease in depression and anxiety in the fourth to sixth years (clinical years). However, higher anxiety and depression scores were noted among controls as compared to medical students.

Conclusions: In contrast to another recent investigation, a negative correlation between religion and depression/anxiety does not necessarily exist. An association between religiosity and mental health could have many theoretical and practical implications and requires further investigation. Similar to previous studies, the rates of depression and anxiety among Israeli medical students were comparable with those of other countries. These rates are considered higher than those in the general population and emphasize the importance of alertness to mental health issues among students, especially during the early study years.