תוצאת חיפוש

Incidence, Antimicrobial Resistance and Mortality in Bloodstream Infections in the Critically Ill

Lavi Oud, Shelly Krimerman, Isaac Srugo

General Intensive Care Unit and Clinical Microbiology Dept., Bnai-Zion Medical Center, Haifa

Bloodstream infections (BSI) are 7-fold more common in patients admitted to the intensive care unit (ICU) rather than to other hospital wards. The epidemiology of BSI in critically ill patients in Israel has not been systematically addressed. We examined the annual trends in BSI in patients in a general ICU of evolving patterns of antimicrobial resistance and associated mortality rates for the years 1994-1996. The presence of the systemic inflammatory response syndrome (SIRS) when the first positive blood cultures are taken was a prerequisite for its definition as clinically significant. The unit site, staff, practice guidelines, and type of patient were unchanged during the study period. Blood cultures were positive in 220.7-332.0 patients per 1000 ICU admissions, 18-22-fold more common than in regular ward patients. SIRS was a universal finding in these ICU patients. There was multi-drug resistance for the majority of species cultured, reaching 100% in some cases. Crude hospital mortality of ICU patients, with and without positive blood cultures, was 31-54% and 5-14%, respectively. The introduction of a new blood culture system (Bactec 9240) in 1996 was associated with a 61% increase in the rate of patients with positive blood cultures, accounted for mostly by increased isolation of coagulase-negative staphylococci. However the mortality rate for the latter decreased by 59%, suggesting the possibility of a selective increase in detection of contaminated cultures. Although highly prevalent in the study population and generally defining a patient group with high mortality risk, the specificity of SIRS-associated positive blood cultures may be species and culture-system dependent. These findings re-emphasize the need for both improved control measures for the epidemic proportions of BSI and multi-drug antimicresistance, as well as more specific indicators of the clinicaof positive blood cultures in critically ill patients.

Stromal Uterine Sarcoma arising from Intestinal Endometriosis after Abdominal Hysterectomy and Salpingoophorectomy

Munir Bishara, Eitan Scapa

Institute of Gastroenterology, Hepatology and Nutrition, Assaf Harofeh Medical Center, Zerifin (Affiliated with the Sackler Faculty of Medicine, Tel Aviv University)

The incidence of ectopic endometriosis is 4% to 18%. The intestinal type is quite common with the rectosigmoid the most likely part of the bowel to be involved due to its pelvic location. A 43-year-old woman, whose symptoms, X-ray and endoscopic findings suggested malignancy of the rectosigmoid, is presented. Primary malignancy of the bowel was excluded by endoscopic biopsies. Histological examination at operation showed stromal sarcoma of the uterus with foci of endometriosis. There is no report in the English literature of transformation of intestinal endometriosis into malignancy, such as stromal sarcoma of the uterus, which imitates a primary malignancy with obstruction of the rectosigmoid.

Angina Pectoris and the Severity of Coronary Artery Stenosis

Reuben Ilia, Sara Carmel, Carlos Cafri, Moshe Gueron

Dept. of Cardiology, Soroka Medical Center, and Dept. of the Sociology of Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheba

The relationship between angina pectoris and the severity of coronary artery disease was evaluated in 146 patients with normal segmental and global, left ventricular, systolic performance. None had unstable angina or a previous myocardial infarction. A strong relationship was found between angina and the severity of coronary artery disease (p<0.005). Significant, stable, angina pectoris as a clinical symptom indicated advanced coronary artery disease in this selected group of patients.

Recurrent Chronic Multifocal Bone Infection

Mordechai Kligman, Benny Bernfeld, Moshe Roffman

Dept. of Orthopedic Surgery, Carmel Medical Center, Haifa

We present a 9-year-old girl who had chronic recurrent multifocal osteomyelitis. The bones involved were: right clavicle, distal fibula (bilateral), left sacroiliac and right wrist. After 10 years of follow-up, she is asymptomatic but presents radiological evidence of lesions in the right clavicle and left sacroiliac joint. The diagnosis was made by exclusion criteria. The biopsy and results of cultures from various bones were negative 4 times. Although chronic recurrent multifocal osteomyelitis is rare, it should be considered in the differential diagnosis of acute or chronic osteomyelitis and neoplasms. Its recognition avoids unnecessary laboratory tests and antibiotic therapy.

Angioedema Caused by Splenectomy with Malignant Lymphoma Foll-Owed by Multiple Myeloma 7 Years Later

A. Shahar, R. Sharon, M. Lorber, S. Pollack

Institute of Allergy, Clinical Immunology and AIDS and Institute of Hematology, Rambam Medical Center and B. Rappaport Technion- Faculty of Medicine, Haifa

Acquired C1-inhibitor (C1-INH) deficiency has been reported in patients with immunoglobulin abnormalities and lymphoproliferative disorders, and angioedema has appeared simultaneously with the lymphoproliferative disease. We present a 50-year-old woman with acquired C1-INH deficiency and angioedema which preceded by 7 years the diagnosis of malignant mantle cell lymphoma. During the interval she was treated with Danazole and there were no attacks of angioedema. When routine follow-up bone marrow aspiration revealed infiltration of nonspecified lymphoma cells, exploratory laparotomy and splenectomy were performed. A month later Danazol was stopped, C1-INH levels returned to normal and there were no attacks of angioedema. Mantle cell lymphoma consisting of lymphocytes with cytoplasmic IgM-lambda was diagnosed in the excised spleen but chemotherapy was not initiated. 6 months later, a second lymphoproliferative disorder, multiple myeloma IgA kappa, was diagnosed.

Use of Student Feedback by Pre-Clinical and Clinical Course Directors

Ruth Abramowitz, Netta Notzer

Medical Education Unit, Sackler Faculty of Medicine, Tel Aviv University

We examined the conceptual and instrumental uses of student feedback on teaching by 2 preclinical and clinical course directors with authority to change structure and content of the courses, assess suitability of instructors and to change methods of student feedback questionnaires have been collected systematically for over 2 decades. A report based on this feedback is sent to course directors, the dean, his assistants and the head of the curriculum committee. Course directors from both groups made broad use of the feedback but made greater use of the report than preclinical course directors. Students had greater regard for individual teaching by clinical course directors than by preclinical course coordinators. No relationship was found between the degree of use of feedback by members of either group and their level of teaching. We conclude that senior faculty use student feedback in their decisions regarding the structure and teaching methods of their courses and are not influenced by individual assessments, positive or negative, by their students.

Gonadotropin-Releasing Hormone (GNRH) in Selecting Patients for Varicocelectomy

Ephraim Segenreich, Solomon Israilov, Joseph Shmueli, Eva Niv, Ciro Servadio

Andrology Unit, Institute of Urology, Rabin Medical Center, Beilinson Campus, Petah Tikva; and Sackler School of Medicine, Tel Aviv University

The gonadotropin-releasing hormone (GnRH) test was performed on 182 patients with various degrees of varicocele before and after low, inguinal, spermatic vein ligation, and on 18 controls. The levels of follicle-stimulating hormone (FSH) and luteinizing hormone, a synthetic GnRH (LH), were evaluated before and 45 minutes after intravenous injection of 100 mcg relisorm L. FSH levels increased more than 2-fold in 118 patients [64.8%] and LH levels increased more than 5-fold in 135 patients [74.1%]). In the control group the increase was less in all cases. Therefor, whenever FSH increased more than 2-fold and LH more than 5-fold, we considered the test positive (pathologic); On this basis the GnRH test was positive in 126 (69.2%) and negative (normal) in 56 (30.7%). Of the 126 with positive tests, only 32 (27.3%) still had a positive result 5-6 months after operation. There was correlation between a positive GnRH test and significant improvement in sperm parameters after varicocelectomy: of the 126 with positive tests before operation, sperm parameters improved in 87 patients (69%), while in the 56 patients with negative tests before operation, in only 7 (12.5%) was there improvement after correction. We conclude that a positive GnRH test indicates impairment of the hypothalamic-pituitary-gonadal axis caused by varicocele and could serve as a marker for surgical intervention with good prediction of outcome.