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Henig O.,Lady Davis Carmel Medical Center | Yahav D.,Rabin Medical Center | Yahav D.,Tel Aviv University | Leibovici L.,Rabin Medical Center | And 3 more authors.
Clinical Microbiology and Infection | Year: 2013

Reliance on evidence-based medicine requires high methodological standards from guideline developers. We sought to determine the methodological quality of guidelines on pneumonia and urinary tract infections (UTIs). We included guidelines published by national or international committees in the last 10 years providing recommendations for antibiotic type or duration. We applied the Appraisal of Guidelines for Research and Evaluation II checklist, adding under each item the specific focus relevant to bacterial infections, addressing antibiotic resistance and local epidemiology. Three assessors scored each guideline independently. Mean aggregated scores, converted to percentage per domain, are presented. We included 13 guidelines on the treatment of pneumonia and seven guidelines for the treatment of UTI. 'Scope and purpose' scored 69.4% for pneumonia and 71.4% for UTI. Guidelines were downgraded for lack of an epidemiological overview relevant to intended users. 'Stakeholder involvement' scored 39.5% for pneumonia and 44.5% UTI, with the major fault being lack of patient consultation. 'Rigour of development' scored 42.8% for pneumonia and 56.9% for UTI. Commonly, the search process lacked precision, no risk of bias assessment was performed, outcomes in primary studies were not critically assessed or used to direct recommendations, and there was no formal methodology for formulating recommendations. 'Clarity of presentation' scored highest: 67.7% for pneumonia and 68.5% for UTI. 'Applicability' of the guidelines in antibiotic stewardship programmes was usually not addressed: 16.9% and 25.4%, respectively. 'Editorial independence' scored 30.6% for pneumonia and 55.6% for UTI. Formal examination of guidelines in infectious diseases showed worrying findings related to core methodology and potential bias caused by competing interests. © 2013 European Society of Clinical Microbiology and Infectious Diseases.


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.


Zadik Y.,Hebrew University of Jerusalem | Jeffet U.,Israel Defense Forces | Jeffet U.,Rambam Health Care Center | Levin L.,Rambam Health Care Center
Military Medicine | Year: 2010

Military fighters are at high risk for oral/tooth injuries. Our aim was to evaluate the knowledge and willingness to use preventive measures among this population to reduce oral trauma. A total of 336 fighters were randomly assigned to two groups. The control group answered a structured questionnaire, which included questions regarding: knowledge of the benefits of mouthguard use, past/current use, and willingness to use a mouthguard. The intervention group received a 60-minute dental trauma lecture, and responded to the same questionnaire. Significantly more subjects in the intervention group were familiar with the benefits of mouthguards compared to the control group, but there was no difference between the groups in their willingness to use mouthguards routinely. Discomfort and potential interference to sport performance were the most common reasons for rejection. It seems that a structured lecture is not sufficient for ensuring usage of mouthguards in a military population. Emphasis on motivation or mandating use may be required. Copyright © Association of Military Surgeons of the US. All rights reserved.


Kluger Y.,Rambam Health Care Center | Ben-Ishay O.,Rambam Health Care Center
Case Reports in Oncology | Year: 2015

High mesenteric root sarcomas are difficult to manage due to their proximity to the superior mesenteric vessels. Resection of these tumors along with the blood vessels may lead to a complicated and protracted convalescence for the patient. Resection remains the main treatment modality for these tumors. During operation on high mesenteric root sarcomas, sound clinical judgment is needed for the decision not to sacrifice vital blood vessels. © 2015 The Author(s). Published by S. Karger AG, Basel.


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.,Beilinson Hospital | Yahav D.,Beilinson Hospital | Yahav D.,Tel Aviv University | Avni T.,Beilinson Hospital | 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.


Hardak E.,Rambam Health Care Center | Yigla M.,Rambam Health Care Center | Yigla M.,Technion - Israel Institute of Technology | Berger G.,Rambam Health Care Center | And 3 more authors.
American Journal of the Medical Sciences | Year: 2012

INTRODUCTION: Nocardiosis, although very rare, is considered as an important opportunistic infection; however, recent literature is limited. This study describes all cases of nocardial infection treated in the authors' hospital to provide more information about clinical manifestations, species isolated, treatment and outcome of patients with nocardiosis. METHODS: A retrospective review of the clinical features and outcome of nocardial infections was conducted during a 15-year period (1996-2010) at Rambam Health Care Campus. RESULTS: The study included 53 patients with nocardial infection, 43 of them had underlying immunodeficiency. The most common clinical form was pulmonary nocardiosis with and without dissemination (60%), followed by skin and soft tissue infection (21%), bacteremia (11%) and pertonitis (5%). Resistance to trimethoprim/sulfamethoxazile was detected in 15% of isolates; to imipenem in 5% and to ciprofloxacin in 65%. Overall mortality was 25% (13/53), mainly observed in patients with pulmonary involvement (37.5%). CONCLUSIONS: Nocardiosis is a rare infection and mainly affects immunocompromised patients. Higher index of suspicion is needed for earlier diagnosis and treatment to improve prognosis. © Copyright 2012 Southern Society for Clinical Investigation.


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.


PubMed | Rambam Health Care Center and Technion - Israel Institute of Technology
Type: Journal Article | Journal: Journal of clinical ultrasound : JCU | Year: 2016

To evaluate compliance with a management strategy for use in emergency department (ED) patients with suspected deep vein thrombosis (DVT) based on Wells score (WS), D-dimer concentrations, and sonographic (US) examinations.Retrospective and prospective data on risk factors, physical examination findings, D-dimer concentrations, and US results were collected and reviewed. The prevalence of DVT for each WS category and D-dimer level was calculated.In the retrospective part of the study, 475 consecutive patients were included. Patients risk for DVT was scored as high (n = 129 [27.2%]), moderate (n = 95 [20%]), or low (n = 251 [52.8%]). D-Dimer test results were available for 34 (7.2%) of the patients. DVT was diagnosed in 105 (22.1%) patients: 99 (76.7%) at high, 4 (4.2%) at moderate, and 2 (0.8%) at low risk. The mean D-dimer concentration was 3,071.7 ng/ml in patients with DVT. In the prospective part of the study, 50 patients were enrolled. Their risk levels for DVT were scored as high (n = 23 [46%]), moderate (n = 7 [14%]), and low (n = 20 [40%]). D-Dimer testing was performed in all patients. The mean D-dimer concentration was 2,966.9 ng/ml in patients with DVT. DVT was diagnosed in 13 (26%) of these 50 patients: 12 (52.2%) at high and 1 (14.3%) at moderate risk for DVT. No patients in the low-risk group and with normal D-dimer concentrations had DVT.We identified significant correlation between WS, D-dimer concentration, and diagnosis of DVT on US examination. DVT can be excluded with certainty in patients admitted to the ED with a low-risk score for DVT and a negative D-dimer concentration, thus avoiding the need for performing US examinations. A low level of compliance with this management strategy was found in our ED.


PubMed | Pelvipharm, Rambam Health Care Center, Metabrain Research and University of Versailles
Type: Journal Article | Journal: The Journal of urology | Year: 2016

Erectile dysfunction is highly prevalent in type II diabetes mellitus. Low intensity extracorporeal shock wave therapy improves erectile function in patients with erectile dysfunction of vasculogenic origin, including diabetes. However, its mode of action remains unknown. We investigated the effects of low intensity extracorporeal shock wave therapy compared to or combined with sildenafil on erectile dysfunction in a type II diabetes mellitus model. Our purpose was to test our hypothesis of a mode of action targeting the cavernous nitric oxide/cyclic guanosine monophosphate pathway.GK rats, a validated model of type II diabetes mellitus, and age matched Wistar rats were treated with low intensity extracorporeal shock wave therapy twice weekly for 3 weeks. Treatment was repeated after a 3-week no-treatment interval. The penis was stretched and dipped in a specifically designed water-filled cage. Shock waves were delivered by a calibrated probe yielding a controlled energy flux density (0.09 mJ/mm(2)). The probe was attached to an electrohydraulic unit with a focused shock wave source, allowing for accurate extrapolation to humans. Following a 4-week washout period erectile function was assessed as well as endothelium dependent and independent, and nitrergic relaxations of the corpus cavernosum of GK rats.Low intensity extracorporeal shock wave therapy significantly improved erectile function in GK rats to the same extent as sildenafil. Treatment effects were potentiated when combined with sildenafil. Shock wave effects were not associated with improved cavernous endothelium dependent or independent, or nitrergic reactivity.Low intensity extracorporeal shock wave therapy improved erectile function in GK rats. Unexpectedly, this was not mediated by a nitric oxide/cyclic guanosine monophosphate dependent mechanism. Sildenafil increased shock wave efficacy. This preclinical paradigm to deliver low intensity extracorporeal shock wave therapy to the rat penis should help further exploration of the mode of action of this therapy on erectile tissue.

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