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Leibovici L.,Tel Aviv University | Paul M.,Rambam Health Care Center
Clinical Microbiology and Infection | Year: 2015

Maximal antibiotic treatment for all patients suspected of harbouring a bacterial infection is non-viable, because it will rapidly induce resistance and exhaust this finite resource. This raises two ethical dilemmas: the question of whether we are justified in increasing the danger to a present, named, patient so as to benefit future, unknown, patients; and whether we are allowed to do so without asking the present patient for consent. Although the considerations for healthy elderly patients are similar to younger adults, the answers are complex when addressing patients with dementia, severely reduced quality of life and at end of life. We argue that a public debate on the balance between benefit to a present patient versus harm to future patients should be conducted. Such a debate should include examinations of scenarios in which antibiotic treatment does not gain any benefit in a patient with infection: at the end of life; in situations in which resistance is such that empirical antibiotic treatment seldom matches the susceptibilities of the pathogen; and in patients with no quality of life. An explicit cost-benefit model, incorporating quality of life and risk of resistance, in computerized decision support might obviate a clinician's need to deal with these difficult issues at bedside. © 2014 European Society of Clinical Microbiology and Infectious Diseases.

Gordin A.,University of Toronto | Gordin A.,Rambam Health Care Center | Chadha N.K.,University of Toronto | Campisi P.,University of Toronto | And 3 more authors.
Archives of Otolaryngology - Head and Neck Surgery | Year: 2010

Objectives: To develop an anatomically shaped endotracheal tube (ETT) and to compare the degree of induced laryngeal injury of this ETT with that of a standard ETT using an animal model. Design: Randomized controlled animal study. Subjects: Eight Sus scrofa piglets (15-20 kg) randomly intubated with either a standard or a modified uncuffed ETT. Interventions: The modified ETT was handcrafted by gluing and then trimming dry polyvinyl acetate foam circumferentially to the distal end of a standard uncuffed ETT. After intubation, the foam quickly self-expanded as it absorbed the secretions of the laryngopharynx and adopted the shape of the intraluminal airway. This conforming shape also sealed the larynx to allow for positive pressure ventilation. Both groups were intubated for 4 hours under constant hypoxic conditions (mean oxygen saturation <70%) to enhance and accelerate intubation damage. They were then humanely killed, and the larynx and trachea were harvested for histologic examination. Main Outcome Measures: The severity of laryngeal injury graded on a scale from 0 to 4 (0 indicates normal; 1, epithelial compression; 2, epithelial loss; 3, subepithelial and glandular necrosis; and 4, perichondrium involvement). Results: All of the specimens histologically demonstrated areas of inflammation and epithelial loss. The standard ETT caused substantial deep damage, with a mean (SD) severity score of 2.79 (0.74). The modified ETT caused mainly superficial damage, with a mean (SD) severity score of 1.65 (0.56) (P<.001). Conclusion: The modified ETT objectively caused less laryngotracheal damage compared with the standard ETT and may be of potential clinical benefit. ©2010 American Medical Association. All rights reserved.

Levin L.,Rambam Health Care Center
Refuat ha-peh eha-shinayim (1993) | Year: 2010

An implant-supported restoration offers a predictable treatment for tooth replacement. Reported success rates for dental implants are high. Nevertheless, failures that mandate immediate implant removal do occur. The consequences of implant removal jeopardize the clinician's efforts to accomplish satisfactory function and esthetics. For the patient, this usually involves further cost and additional procedures. The aim of this paper is to describe different methods and treatment modalities to deal with dental implant failure. The main topics for discussion include identifying the failing implant, implants replacing failed implants at the exact site, and the use of other restorative options. When an implant fails, a tailor made treatment plan should be provided to each patient according to all relevant variables. Patients should be informed regarding all possible treatment modalities following implant failure and give their consent to the most appropriate treatment option for them.

Shiber S.,Rabin Medical Center | Yahav D.,Rabin Medical Center | Yahav D.,Tel Aviv University | Avni T.,Rabin Medical Center | And 4 more authors.
Journal of Antimicrobial Chemotherapy | Year: 2015

Background: Data on the relative efficacy of β-lactam/β-lactamase inhibitors (BL/BLIs) versus carbapenems are scant. Methods: This is a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing any BL/BLI versus any carbapenem for the treatment of sepsis. The primary outcome was all-cause mortality. A broad search was conducted with no restrictions on language, publication status or date. Two reviewers independently applied the inclusion criteria and extracted the data. Assessment of risk of bias was performed using the domain-based approach. Subgroup analyses were used to investigate heterogeneity and focus on patient groups more likely to harbour ESBL-positive bacteria. Risk ratios (RRs) with 95% CIs were calculated and pooled. Results: Thirty-one RCTs were included. There was no difference between BL/BLIs and carbapenems in terms of mortality (RR 0.98, 95% CI 0.79-1.20), without heterogeneity. No differences were observed with regard to clinical or microbiological failure and bacterial superinfections. The results were not affected by risk of bias. No differences were detected in the subgroups of patients with nosocomial infections, Gram-negative infections and neutropenic fever. Adverse events requiring discontinuation were more common with BL/BLIs, on account of an increased incidence of diarrhoea. However, Clostridium difficile-associated diarrhoea (RR 0.29, 95% CI 0.10-0.87) was more frequent with carbapenems and seizures were more frequent with imipenem (RR 0.21, 95% CI 0.05-0.93). Conclusions: No differences in efficacy between BL/BLIs and carbapenems exist in RCTs including patient populations with a certain, albeit unknown, rate of ESBL-positive bacteria causing infections. © The Author 2014. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.

Wigler R.,Rambam Health Care Center
Refu'at ha-peh veha-shinayim (1993) | Year: 2012

Recently a number of published articles concerning a new treatment method in traumatized young permanent teeth with a wide open apex that have lost vitality, with or without periapical lesions have shown success. This new treatment is entitled "Revascularization" and its aim is to promote root maturation in infected immature teeth with open apices. This procedure stimulates the formation of hard tissue as well as elongation and thickening of the dentinal walls and closure of the root apex. Sometimes the vitality of the teeth is regained. The aim of the present publication is to describe the revascularization technique and to clarify the indications of its use.

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