Aliza Noy, MD, Ruth Orni-Wasserlauf, MD, Patrick Sorkine, MD and Yardena Siegman-Igra, MD, MPH.
Background: An increase in multiple drug-resistant Klebsiella pneumoniae due to extended spectrum -lactamase production has recently been reported from many centers around the world. There is no information in the literature regarding this problem in Israel. A high prevalence of ceftazidime-resistant K. pneumoniae was noted in our Intensive Care Unit in the first few months of 1995.
Objective: To describe the epidemiology of ceftazidime-resistant K. pneumoniae in our medical center, as representing the situation in tertiary care hospitals in Israel.
Methods: We vigorously restricted the use of ceftazidime in the ICU and enforced barrier precautions. The susceptibility rate of K. pneumoniae was surveyed in the ICU and throughout the hospital before and after the intervention in the ICU.
Results: Following the intervention, the susceptibility rate of K. pneumoniae increased from 11% (3/28) to 47% (14/30) (P0.01) among ICU isolates, from 55% (154/280) to 62% (175/281) (P=0.08) among total hospital isolates, and from 61% (50/82) to 74% (84/113) (P0.05) among total hospital blood isolates, although no additional control measures were employed outside the ICU.
Conclusions: The epidemiology of ceftazidime-resistant K. pneumoniae in our medical center is similar to that reported from other centers around the world. Early awareness to the emergence of this resistance, identification of the source of the epidemic, and prompt action at the putative source site may reduce the rate of acquisition and spread of such resistance inside and outside of the source unit.
Donald S. Berns, PhD and Bracha Rager, PhD
As the twenty-first century begins it becomes increasingly apparent that the twentieth century, which opened with the promise of the eradication of most infectious diseases, closed with the specter of the reemergence of many deadly infectious diseases that have a rapidly increasing incidence and geographic range. Equally if not more alarming is the appearance of new infectious diseases that have become major sources of morbidity and mortality. Among recent examples are HIV/AIDS, hantavirus pulmonary syndrome, Lyme disease, hemolytic uremic syndrome (caused by a strain of Escherichia coli), Rift Valley fever, Dengue hemorrhagic fever, malaria, cryptosporidiosis, and schistosomiasis. The reasons for this situation are easily identified in some cases as associated with treatment modalities (permissive use of antibiotics), the industrial use of antibiotics, demographic changes, societal behavior patterns, changes in ecology, global warming, the inability to deliver minimal health care and the neglect of well-established public health priorities. In addition is the emergence of diseases of another type. We have begun to characterize the potential microbial etiology of what has historically been referred to as chronic diseases.
Maya Koren Michowitz, MD, Yoav Michowitz, MD, Ronit Zaidenstien, MD and Ahuva Golik, MD
Eli Magen, MD and Reuven J. Viskoper, MD
Renin-angiotensin-aldosterone systems play a critical role in the development and progression of cardiovascular diseases, and inhibitors of angiotensin-converting enzyme have proven effective for the treatment of these diseases. Since angiotensin II receptor antagonists can inhibit the effects of angiotensin II via ACE-independent pathways, e.g., chymase, they were considered to be more effective than ACEIs. On the other hand, ACE inhibitors can increase bradykinin, and thus, nitric oxide, which may cause potent cardioprotection, inhibition of smooth muscle proliferation and attenuation of inflammation mechanisms. It appears that angiotensin II receptor antagonists and ACEIs may mediate cardioprotection in different ways. This is the rationale to explore the possibility of a combined administration of both drugs for the treatment of chronic heart failure and other cardiovascular pathology. In this review we try to analyze the role of ACE, kinins and chymase inhibition in the pathophysiology and treatment of cardiovascular diseases.
Daniel E. Furst, MD and Alan Tyndall, MD
Rita Rachmani, MD, Zohar Levi, MD, Rika Zissin, MD, Merav Lidar, MD and Mordechai Ravid, MD, FACP
Jayson Rapoport, MB, BS, MRCP
Atzmon Tsur, MD and Gershon Volpin, MD
Howard A. Schwid, MD
Anesthesia simulators are rapidly becoming more prevalent worldwide. Several types of anesthesia simulators utilizing a variety of technologies are available. High fidelity mannequin-based simulators, low fidelity screen-based simulators, and relatively inexpensive intermediate fidelity simulators have found applications in training, assessment of clinical competence, and research. A number of recent studies support the use of anesthesia simulators and may lead to widespread adoption of simulation in other fields of medicine.
Rosalie Ber, MD, DSc, Gershon B. Grunfeld, PhD and Gideon Alroy, MD
The Rappaport Faculty of Medicine of the Technion established an Ethics in Medicine Forum in March 1993. The main objective of the forum was to increase awareness of the philosophical principles of ethics in medicine, as defined and developed in the western world during the last three decades. The multidisciplinary forum meets once a month during the academic year. Our 7 years experience is documented. Of the 45 meetings, 30 were clinically “oriented and of these more than half were based on cases. Only 15 meetings were purely theoretical. Our principal a assumption was that any and every topic could be discussed, including those covered by the law We explored a how well western philosophical principles and rules fit the Israeli picture. Many of the forum discussions related to 0 the draft of the Patient’s Bill of Rights which came into effect on 12 May 1996. The role of the ‘legal’ hospital ethics committees was compared to that of the “advisory” ethics committees whose members constituted a large share of our forum. The multicultural Israeli population and the practice of medicine therein raised many lively discussions. The principle of autonomy in the ultra-orthodox and in the family setting was a highly controversial issue. The forum served as a workshop for examining traditional medical ethical principles, which we strongly feel needs to he amended in light of the 1996 Patient’s Bill of Rights. From our 7 years experience with an Ethics in Medicine Forum we recommend that medical ethical deliberations focus on genuine medical cases.