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We present a patient with amyotrophic lateral sclerosis (ALS), dependent on noninvasive ventilation, whose advance directives precluded life-prolonging measures. The patient was found in cardiac arrest and in accordance with the directives of her surrogate decision maker, underwent intubation and mechanical ventilation. Later, an additional surrogate decision maker disapproved of ventilation and when the ventilator was disconnected for bronchial suctioning, she asked the nurse not to reconnect the patient to the ventilator. We discuss the legal, psychological and ethical aspects of implementation of Israeli law in this complex patient.

We wish to describe the omission of adverse event reporting on finerenone in a recently published trial. We suspect that this case illustrates the tip of an iceberg of underreporting of adverse events in clinical trials. We propose as a requirement in clinical trials, to have routine direct reporting by patients for safety monitoring.

Background Simulation-based training improves residents’ skills for end-of-life (EOL) care. In the field, staff providers play a significant role in handling those situations and in shaping practice by role modeling. We initiated an educational intervention to train healthcare providers for improved communication skills at EOL using simulation of sensitive encounters with patients and families. Methods Hospital physicians and nurses (n = 1324) attended simulation-based workshops (n = 100) in a national project to improve EOL care. We analyzed perceptions emerging from group discussions following simulations, from questionnaires before and after each workshop, and from video-recorded simulations using a validated coding system. We used the simulation setting as a novel tool for action research. We used a participatory inquiry paradigm, with repetitive cycles of exploring barriers and challenges with participants in an iterative pattern of observation, discussion and reflection – including a description of our own responses and evolution of thought as well as system effects. Results The themes transpiring included lack of training, knowledge and time, technology overuse, uncertainty in decision-making, poor skills for communication and teamwork. Specific scenarios demonstrated lack of experience at eliciting preferences for EOL care and at handling conflicts or dilemmas. Content analysis of simulations showed predominance of cognitive utterances - by an order of magnitude more prevalent than emotional expressions. Providers talked more than actors did and episodes of silence were rare. Workshop participants acknowledged needs to improve listening skills, attention to affect and teamwork. They felt that the simulation-based workshop is likely to ameliorate future handling of EOL situations. We observed unanticipated consequences from our project manifested as a field study of preparedness to EOL in nursing homes, followed by a national survey on quality of care, leading to expansion of palliative care services and demand for EOL care education in various frameworks and professional areas. Conclusions Reflective simulation exercises show barriers and paths to improvement among staff providers. When facing EOL situations, physicians and nurses use cognitive language far more often than emotions related expressions, active listening, or presence in silence. Training a critical mass of staff providers may be valuable to induce a cultural shift in EOL care.

Background By 2020, the World Health Organization predicts that two-thirds of all diseases worldwide will be the result of lifestyle choices. Physicians often do not counsel patients about healthy behaviors, and lack of training has been identified as one of the barriers. Between 2010 and 2014, Hebrew University developed and implemented a 58-h Lifestyle Medicine curriculum spanning five of the 6 years of medical school. Content includes nutrition, exercise, smoking cessation, and behavior change, as well as health coaching practice with friends/relatives (preclinical years) and patients (clinical years). This report describes this development and diffusion process, and it also presents findings related to the level of acceptance of this student-initiated Lifestyle Medicine (LM) curriculum. Methods Students completed an online semi-structured questionnaire after the first coaching session (coaching questionnaire) and the last coaching session (follow-up questionnaire). Results Nine hundred and twenty-three students completed the coaching questionnaire (296 practices were with patients, 627 with friends /relatives); and 784 students completed the follow-up questionnaire (208 practices were with patients, 576 with friends /relatives). They reported overall that health coaching domains included smoking cessation (263 students), nutrition (79), and exercise (117); 464 students reported on combined topics. Students consistently described a high acceptance of the curriculum and their active role in coaching. Further, most students reported that they were eager to address their own health behaviors. Conclusions We described the development and acceptance of a student-initiated comprehensive LM curriculum. Students perceived LM as an important component of physicians’ professional role and were ready to explore it both as coaches and in their personal lives. Thus, medical school deans might consider developing similar initiatives in order to position medical schools as key players within a preventive strategy in healthcare policy.

Availability of surgical site infection (SSI) surveillance rates challenges clinicians, healthcare administrators and leaders and the public. The purpose of this report is to demonstrate the consequences patient self-assessment strategies have on SSI reporting rates. We performed SSI surveillance among patients undergoing general surgery procedures, including telephone follow-up 30 days after surgery. Additionally we undertook a separate validation study in which we compared patient self-assessments of SSI with surgeon assessment. Finally, we performed a meta-analysis of similar validation studies of patient self-assessment strategies. There were 22/266 in-hospital SSIs diagnosed (8.3%), and additional 16 cases were detected through the 30-day follow-up. In total, the SSI rate was 16.8% (95% CI 10.1–18.5). In the validation survey, we found patient telephone surveillance to have a sensitivity of 66% (95% CI 40–93%) and a specificity of 90% (95% CI 86–94%). The meta-analysis included five additional studies. The overall sensitivity was 83.3% (95% CI 79–88%), and the overall specificity was 97.4% (95% CI 97–98%). Simulation of the meta-analysis results divulged that when the true infection rate is 1%, reported rates would be 4%; a true rate of 50%, the reported rates would be 43%. Patient self-assessment strategies in order to fulfill 30-day SSI surveillance misestimate SSI rates and lead to an erroneous overall appreciation of inter-institutional variation. Self-assessment strategies overestimate SSIs rate of institutions with high-quality performance and underestimate rates of poor performance. We propose such strategies be abandoned. Alternative strategies of patient follow-up strategies should be evaluated in order to provide valid and reliable information regarding institutional performance in preventing patient harm.

Background Shared decision-making (SDM) takes place when clinicians help patient identify best course of action in the context of their preferences. Methods The aim of this paper is a narrative review of the literature with special focus on the humanistic dimensions of SDM. Results We show that SDM is largely underused in practice, because of many barriers such as time constraints and poor skills. Conclusions We suggest that listening and empathy are key challenges in communicating uncertainty, which require emotional intelligence and trust building skills. To promote implementation, we propose the development of tools, simulation-based training and the design of improved measures for SDM quality. While essential for patients, we believe that SDM may restore meaning in healthcare.

Objectives To evaluate the quality of end-of-life (EOL) care in nursing homes. Design Survey and semistructured interviews. Setting Jerusalem district nursing homes. Participants Staff members of 28 long-term care and skilled nursing facilities in the Jerusalem area in Israel of various ethnic, religious, and administrative affiliations (N = 207). Measurements Qualitative analysis of semistructured interviews and statistical analysis of questionnaires. Results Most staff members reported that EOL preferences were unknown for more than 90% of residents and that fewer than 10% had a healthcare proxy. Most staff members recalled conducting fewer than five EOL conversations over the past year with residents or family members and could recall fewer than five cases in which a resident was allowed to die in the nursing home. According to staff opinions the prevalence of tube feeding was estimated at greater than 10%, initiated because of aspiration, malnutrition, and understaffing, often against family's preferences. More than 25% of staff members believed that pain management was inadequate. Knowledge about management of chronic pain was poor in half of nurses and nearly one-third of physicians. Most staff would rather not receive the treatments they administered to residents. Conclusion Nursing homes in Jerusalem lack competency for quality EOL care, and there are multiple psychological, training, and policy challenges to improvement.

Objective Distal radius fracture (DRF) in postmenopausal women is often the first clinical sign of osteoporosis (OP). Despite the availability of effective treatments, only a minority of patients who sustain a fragility fracture are tested for OP. The purpose of this study was to examine whether a simple intervention by the hospital staff increases rates of OP workup. Materials and Methods We conducted a prospective randomized clinical trial. Ninety nine patients after DRF were randomized to two groups. Both groups were contacted after their fracture and were asked to answer a questionnaire and were informed about the possible relationship between DRF and OP. In the intervention group, patients were sent an explanatory pamphlet and a letter to their primary care physician. An additional survey was conducted to establish whether the intervention improved the number of patients who undergo OP workup. Results The intervention increased the proportion of patients who turned to their primary care physician from 22.9% to 68.6%, and increased the proportion of patients undergoing OP workup from 14.3% to 40% ( p Conclusion Women with DRF who receive an explanation about possible OP implications and are sent explanatory materials are more likely to undergo OP workup.

Background Among the challenges encountered during the care of patients at the end-of-life (EOL), eliciting preferences of patients with whom there is no ability to communicate is common and stressful for all those concerned and charged with patient care. Legal facilities available include patient delegation of proxy decision-makers (PDM) prior to communication incapacity. We sought to estimate family physician awareness and attitude with regard to these aspects of patient care. Methods A telephone survey of family physicians in the Jerusalem, Israel, district using a standard questionnaire. Results 74 family physicians responded to the survey. The response rate was 42 % and the cooperation rate was 66 %. Most of the respondents, (64 %), reported knowing that the PDM delegation facility exists, though only 24 % claimed to have suggested to their patients that they consider this option. Approximately three-quarters, (78 %), treat patients with whom they discussed other aspects of severe disease, disability or EOL. None of the physicians working predominantly with religiously observant groups reported suggesting PDM delegation. Conclusions There is an apparent gap between family physician knowledge and their performance to empower the persistence of patient autonomy, should communication ability cease. System-wide interventions to increase EOL communication skills, starting at medical school and henceforth, are necessary in order to promote better EOL care and meaningful resource use.

The illusion of accuracy and precision in testing is often associated with overconfident safety checks before catastrophes: National Aeronautics and Space Administration (NASA) “no safety-of-flight issues,” Deepwater Horizon site in Gulf Mexico reported as “industry model for safety” a year before its explosion, and Fukushima nuclear plant safety test found “satisfactory” at seismic magnitude viewed highest possible. In health care, testing overuse and misuse play significant roles in overconfidence and mistakes. Gaps between systems are most susceptible to errors, such as in miscommunications between the laboratory and the clinic. A safety culture is characterized by ability to communicate, anticipation of misunderstanding and resilient learning from failures. The discussion will show how messages from the laboratory may reduce the false sense of certainty from a test result; how results of tests are meaningless without pre-test estimates; how multiplicity of routine tests increases chances of false positivity; and how reporting measurement limitations can educate all users, including laboratory technicians, clinicians and patients, about the importance of quality assurance and about the pervasive nature of uncertainty beyond analytical performance. In conclusion, an illusion of accuracy and precision in testing evokes among clinicians a false sense of certainty leading to overuse and misuse of tests. Messages from the laboratory may reduce overconfidence from test results and lead to safer use of testing.

Objectives: This article reviews adverse influences of for-profit enterprises on health care and public health, and examines significance for public policy. Research Design: Narrative review. Results: For-profit health-care industries may increase costs and reduce quality, leading to market failure and contributing to the USA’s unflattering position in international comparisons of healthcare efficiency. Drug and device corporations use strategies such as making biased inferences, influencing scientists and physicians, marketing rather than informing the public, and lobbying to control their own industry regulations to create market advantage. Successful marketing leads to the increased use of costly profit-making drugs and procedures over cheaper, nonpatented therapies. Because resources are limited, the overuse of costly modalities contributes to expensive health care, which presents a challenge to universal coverage. The free market also fosters the proliferation of industries, such as tobacco, food, and chemicals, which externalize costs to maximize profits, seek to unduly influence research by paying experts and universities, and attempt to control the media and regulatory agencies. Most vulnerable to the cumulative harm of these tactics are children, the poor, the sick, and the least educated. Conclusions: The free market can harm health and health care. The corporate obligation to increase profits and ensure a return to shareholders affects public health. Such excesses of capitalism pose formidable challenges to social justice and public health. The recognition of the health risks entailed by corporation-controlled markets has important implications for public policy. Reforms are required to limit the power of corporations.

The impact of intensive insulin therapy on the clinical outcomes of hospitalized patients is highly controversial. We used a protocol based on dynamic insulin administration targeted to achieve moderately tight glycemic control and tested its impact on clinical outcomes after cardiac surgery.Patients with diabetes mellitus or random blood glucose greater than 150 mg/dL were treated in the intensive care unit with intravenous insulin, followed by a multi-injection protocol consisting of 4 glargine/aspart insulin injections in the ward, with a glycemic target of 110 to 150 mg/dL. The study cohort (n = 410) consisted of consecutive patients undergoing cardiothoracic surgery. Control patients (n = 207) were admitted during the first 8 months and treated according to standard of care. The intervention group of patients (n = 203) were operated on during the following 8 months. The main outcome measures were glycemic control and the rate of postsurgery infections.During the intervention, mean blood glucose ± SD was 151 ± 19 mg/dL and 157 ± 32 mg/dL in the intensive care unit and ward, respectively, versus 166 ± 27 mg/dL and 184 ± 46 mg/dL during the control period (p0.0001). The incidence of hypoglycemia (blood glucose less than 60 mg/dL) was low and similar in the two groups (2.5% control versus 3% intervention). Intensive insulin treatment decreased the risk for infection from 11% to 5% (56% risk reduction, p = 0.018), mainly by reducing the incidence of graft harvest site infection (6.9% versus 2.5%, p = 0.034). The incidence of atrial fibrillation after coronary artery bypass graft surgery decreased from 30% to 18% (39% risk reduction; p = 0.042).Moderate-intensity dynamic blood glucose control after cardiac surgery is effective and safe, and is associated with improved clinical outcomes.

Background: The rising costs of healthcare and the recognition that many chronic diseases are preventable by healthy lifestyles have led to inquiry about economic incentives for modifying behavior. The present work explored people’s attitudes towards a differential health insurance premium based on lifestyle. Methods: A random dial telephone survey of the Israeli population assessed the degree of agreement with a policy of differential taxing on health insurance premium with a discount for individuals maintaining a healthy lifestyle, such as nonsmoking or regular exercise. Results: A majority (66%) of respondents expressed support for a policy of differential taxing. Support was high across all sectors of society, including Arab Israelis (92%), Russians (71%), orthodox religious individuals (78%), persons with low education (72%) or low income (69%), smokers (51%), and sedentary people (65%).

Objective Ample research has examined physicians' evidence-based medicine (EBM) knowledge and skills; however, previous research has not linked EBM knowledge to objective measures of process of care. Design A cross-sectional study of quality of care measures extracted from electronic medical records and EBM knowledge assessed via a validated questionnaire. Setting One region of the largest Health Maintenance Organization in Israel. Participants Seventy-four physicians and their 8334 diabetic patients, 7092 coronary heart disease patients and 17 132 hypertensive patients. Main outcome measures Outcome measures were four diabetes quality of care indicators (LDL tests, microalbumin tests, hemoglobin A1C tests, eye examination referrals), and two drug prescription indicators (statin prescription for coronary heart disease patients, and thiazide prescription for hypertensive patients). Independent variables were total EBM knowledge and its components: critical appraisal and information retrieval. Results Total EBM knowledge was independently and significantly associated with LDL testing (b = 0.13; P = 0.036), microalbumin testing (b = 0.33; P = 0.001), hemoglobin A1C testing (b = 0.17; P = 0.036), eye examination referrals (b = 0.16; P = 0.021) and statin prescriptions (b = 0.18; P = 0.025). Critical appraisal was independently associated with microalbumin tests (b = 0.46; P = 0.002) and eye examination referrals (b = 0.20; P = 0.048). Information retrieval was only independently associated with hemoglobin A1C testing (b = 0.43; P = 0.004). Thiazide prescription was not associated with EBM knowledge scores. Conclusions Physicians' higher total EBM knowledge primarily correlates with better quality of care; however, correlations were modest and explained only a small portion in the variance of clinical performance. Results indicate that there might be a need to focus on teaching all the components of EBM rather than EBM microskills.

STUDY DESIGN A systematic review of randomized controlled trials. OBJECTIVE To determine the effectiveness of shoe insoles in the prevention and treatment of nonspecific back pain compared with placebo, no intervention, or other interventions. SUMMARY OF BACKGROUND DATA There is lack of theoretical and clinical knowledge of the use of insoles for prevention or treatment of back pain. METHODS We searched electronic databases from inception to October 2008. We reviewed reference lists in review articles, guidelines, and in the included trials; conducted citation tracking; and contacted individuals with expertise in this domain. One review author conducted the searches and blinded the retrieved references for authors, institution, and journal. Two review authors independently selected the relevant articles. Two different review authors independently assessed the methodological quality and clinical relevance and extracted the data from each trial using the criteria recommended by the Cochrane Back Review Group. RESULTS Six randomized controlled trials met inclusion criteria: 3 examined prevention of back pain (2061 participants) and 3 examined mixed populations (256 participants) without being clear whether they were aimed at primary or secondary prevention or treatment. No treatment trials were found. There is strong evidence that the use of insoles does not prevent back pain. There is limited evidence that insoles alleviate back pain or adversely shift the pain to the lower extremities. CONCLUSION There is strong evidence that insoles are not effective for the prevention of back pain. The current evidence on insoles as treatment for low back pain does not allow any conclusions.

Medical tradition considers a physical examination (PE) an essential part of the clinical encounter. In real medical practice, however, a full PE may not be necessary when the diagnosis is clear after anamnesis and general impression. We assessed the value of PEs in 500 diagnoses of upper respiratory infection (URI) and the attitudes of 123 doctors regarding the utility of PEs in virtual cases. Methods Computerized files of consecutive cases with a diagnosis of URI over 8 months in two practices were reviewed and correlation studies between the extent of PE and clinical outcomes were performed. In addition, doctors’ attitudes and declarations about PEs were compared. Results Five hundred paediatric and adult patients were included. Less than one-fifth underwent a full PE. More patients who underwent a full PE returned because they still felt unwell or their parents felt they were unwell. Fewer doctors declared actually having performed PEs than supported giving one in two virtual cases of URI. Specialized doctors were less inclined to perform PEs than doctors without a specialization. Conclusions Our study suggests that in many cases presenting as URI, doctors may conduct limited PEs or even omit them entirely.

Octogenarian Israeli prime-minister Ariel Sharon recently sustained a mild, reversible stroke. A patent foramen ovale (PFO) was detected and anticoagulants were given pending PFO closure. A few days later, he sustained major intracerebral hemorrhage and has since remained in vegetative state. The events triggered serious criticism in the mass media, experts promoting one management option over others. Because knowledge of outcome and hindsight bias evaluation of appropriateness of care, we sought to systematically review the clinical case.We performed a formal decision analysis to identify the preferred management between anticoagulation, antiplatelets, PFO closure, or no treatment. Using the best evidence available, we built a decision tree.recurrent stroke and treatment complications within 1 year.Optimal decision was found to be critically sensitive to assumptions about etiology, efficacy and safety of treatments, recurrence risk, and to small changes in utilities. In multiway sensitivity analysis, when the risk of recurrent stroke was0.12 per year, no treatment was the best management. PFO closure is dominant only when the risk of recurrent stroke is0.12 per year closure effectiveness is assumed to be0.28. When closure effectiveness is0.6, it is inferior to anticoagulation and antiplatelet management.Uncertainties precluded a clear-cut answer and choice was found to be a "toss-up," often associated with much controversy. Use of novel therapies, such as PFO closure, outside clinical trials will not reduce uncertainty about efficacy.

Objective. We conducted a systematic review of studies designed to increase awareness of, knowledge about, and consumption of folic acid before and during pregnancy. Data sources. Studies were identified from Cochrane Library, Medline, and the references of primary studies and reviews. Study inclusion and exclusion criteria. Studies included randomized controlled trials, quasi-experimental interrupted time series studies, follow-up studies, case-control studies, and before-and-after studies, all of which were conducted between 1992 and 2005 on women ages 15 to 49 years and/or health professionals, evaluating awareness and/or knowledge and/or consumption of folic acid both before and after intervention. Studies were excluded if data were not presented both before and after intervention or were other outcomes than those mentioned here. Data extraction. Data were extracted in relation to characteristics of studies, participants, interventions, and outcomes. Data synthesis. Because of heterogeneity, we performed a narrative synthesis describing the direction and the size of effects. Results. On average, women's awareness increased from 60% to 72%, knowledge from 21% to 45%, and consumption from 14% to 23%. Conclusions. Interventions had a positive effect on folic acid intakes before and during pregnancy, although the average usage reached less than 25%. So what? Further research is needed to design more effective interventions to increase periconceptional use of folic acid.

Rationale, aims and objectives To date, primary care doctors’ (PCDs) evidence-based medicine (EBM) skills have rarely been studied. We conducted a cross-sectional study to evaluate PCDs’ practical EBM skills and to determine risk markers associated with these skills. Methods The study sample consisted of 70 PCDs (70.7% response rate) practising in a busy urban setting from a large health maintenance organization. Participants were given a short validated questionnaire gauging attitudes, barriers, online medical resources utilization, as well as demographic and personal characteristics. Additionally, doctors completed an online and written exam evaluating their ability to formulate clinical questions, and retrieve medical information efficiently. Data analysis was performed using both bivariate and multivariate analysis (linear regression). Results PCDs found it difficult to formulate clinical questions both in the written and online exam, mostly neglecting to mention the Patient and Comparison components of PICO (patient, intervention, comparison and outcome). Search strategies primarily dispensed with the use of MeSH terms, ignoring appropriate limits. Doctors final scores were low (score = 41.5/100, SD = 16.2). In bivariate analysis clinical experience was negatively correlated with the final score (r = −0.36, P = 0.01), and specialists’ scores were significantly higher than general practitioners’ scores (46.7/100 and 31.5/100 respectively, P

Objective. Evaluation and improvement of pain management in our emergency department (ED). Design. This was a ‘before–after’ study. For each subject, the nurse, the physician, and the patient were asked to rate the initial intensity of the pain on a Visual Analogue Score (VAS). The timing and the type of analgesics administered were then recorded and follow-up VAS was performed. Setting. A teaching, community-based, 400-bed hospital. Study participants. 140 patients admitted for acute pain related to orthopedic injuries. Main outcome measures. The gap between the VAS expressed by the patient and estimated by the staff, the proportion of patients receiving analgesics, and the length of time delays between admission and analgesic administration. Intervention. The intervention included education of medical and nursing staffs, insertion of a VAS template in the patient’s chart, initiation of routine VAS assessment and re-assessment, and implementation of a protocol for pain management with standing orders for nurses. Results. The VAS gap between the patient and the nurse decreased significantly from 1.91 2.04 to 1.03 1.97 after the intervention ( P = 0.01). The percentage of patients receiving analgesics rose from 70 to 82% following the intervention. Time from admission to analgesia decreased from 80 ± 68 min (mean ± SD) before the intervention, to 58 ± 37 min after the intervention ( P = 0.05). Conclusion. Inadequate pain management in the ED appears related to poor staff assessment of pain and may be improved by routine VAS recording and by a nurse-based pain protocol.

The constitutive cyclooxygenase (COX)-1 enzyme has been considered the physiologically important isoform for prostaglandin synthesis in the normal kidney. It has, therefore, been suggested that selective inhibitors of the ‘inducible’ isoform (COX-2) may be free from renal adverse effects. We studied the renal effects of the predominantly COX-2 antagonist nabumetone in isolated perfused kidneys. As compared with controls, kidneys removed after in vivo administration of oral nabumetone (15 mg/kg) disclosed altered renal function with reduced glomerular filtration rate, filtration fraction, and urine volume and enhanced hypoxic outer medullary tubular damage. By contrast, renal function and morphology were not affected in vivo by nabumetone or its active metabolite 6-methoxy-2-naphthylacetic acid. The latter agent (10–20 mg/kg i.v.) did not significantly alter renal microcirculation, as opposed to a selective substantial reduction in medullary blood flow noted with the nonselective COX inhibitor indomethacin (5 mg/kg i.v.). In a rat model of acute renal failure, induced by concomitant administration of radiocontrast, nitric oxide synthase, and COX inhibitors, the decline in kidney function and the extent of hypoxic medullary damage with oral nabumetone (80 mg/kg) were comparable to a control group, and significantly less than those induced by indomethacin. In rats subjected to daily oral nabumetone for 3 consecutive weeks, renal function and morphology were preserved as well. Both nabumetone and 6-methoxy-2-naphthylacetic acid reduced renal parenchymal prostaglandin E2 to the same extent as indomethacin. It is concluded that while nabumetone adversely affects renal function and may intensify hypoxic medullary damage ex vivo, rat kidneys are not affected by this agent in vivo, both in acute and chronic studies. COX selectivity may not explain the renal safety of nabumetone.

Compensated heart failure predisposes to outer medullary tubular injury: Studies in rats.BackgroundHeart failure (HF) is considered a putative factor predisposing to acute renal failure (ARF). Since outer medullary hypoxic injury may play an important role in the pathogenesis of acute tubular necrosis, we explored the impact of experimental HF on the propensity to develop ARF with hypoxic medullary injury following the inhibition of prostaglandin and nitric oxide synthesis.MethodsCompensated, high-output HF was induced in Sprague-Dawley rats by aorto-caval fistula. At the eighth to ninth postoperative day, the rats were injected with indomethacin and Nω nitro-L-arginine methyl ester (L-NAME; ARF protocol) and were sacrificed 24 hours later for morphologic evaluation.ResultsKidney function comparably declined in HF-ARF rats and in control sham operated animals (CTR-ARF). Nevertheless, outer medullary hypoxic damage with medullary thick ascending limb (mTAL) necrosis occurred almost exclusively in the HF-ARF group (11 ± 4% vs. 0.2 ± 0.2% of tubules in CTR-ARF, P < 0.03). In a third group of HF animals subjected to vehicles only (HF-Nil), kidney function was preserved and renal morphology remained intact. Papillary-tip necrosis was consistently found in all animals subjected to indomethacin and L-NAME, irrespective of preconditioning. Morphometric evaluation disclosed that HF was not associated with mTAL hypertrophy.ConclusionsIncipient HF predisposes to hypoxic outer medullary injury, probably reflecting the impact of regional vasoconstrictive stimuli rather than tubular hypertrophy when protective local vasodilating mechanisms are hampered. The presence and extent of outer medullary hypoxic damage cannot be predicted from the functional derangement, which in the experimental settings may also represent prerenal azotemia or papillary damage.

Chronic tubulo-interstitial disease, an important cause of end-stage renal disease, often results from the combined effects of a disturbed urinary outflow tract and urinary tract infection. Acute unilateral ureteral obstruction in rats rapidly induces foci of medullary necrosis, confined to the region of the papilla and fornices. This injury may provide a nidus for bacterial invasion and may invoke reactive and regenerative changes, ultimately leading to chronic pyelonephritis and tubulo-interstitial nephropathy. To explore this possibility, adult rats underwent renal morphological evaluation 2-7 days following transient 24-h unilateral ureteral obstruction. In some experiments the bladder was inoculated with bacteria (10(8)-10(9) cfu/ml Escherichia coli in 0.5 ml) after release of ureteral obstruction, with subsequent cultures obtained from the pelvis of both kidneys and from the urinary bladder. Morphologic evaluation of perfusion-fixed kidneys, 2-7 days after the release of 24-h ureteral obstruction disclosed papillary necrosis, urothelial proliferation, marked inner-stripe interstitial expansion, and fibrosis and proximal tubular (S3) dilatation. The lateral (perihilar region) was predominantly affected, with lesions spreading from the fornices. There was some progression of interstitial fibrosis during the postobstructive time course or following more prolonged ureteral obstruction. By contrast, infection hardly contributed to the tubulointerstitial changes. In rats subjected to infection, cultures were positive in all 15 postobstructive kidneys, as opposed to five contralateral kidneys (P0.0001). Viable counts from the postobstructive kidney were also higher than those from the contralateral side (79,000 +/- 12,000 vs 2900 +/- 1600 cfu/ml, mean +/- SEM, P0.0001), and were comparable to those obtained from the bladder (77,000 +/- 13,000 cfu/ml). We conclude that transient ureteral obstruction predisposes to ascending pyelonephritis and to tubulointerstitial disease. This vulnerability may relate to altered urodynamics and medullary tissue destruction.

Rationale, aims and objectives Despite advances in our understanding of cognitive biases in clinical practice, little is known about correction or prevention of diagnostic errors. The presence of a single misleading detail may lead clinicians down a cognitive and actual path toward an incorrect diagnosis. Methods In a large teaching hospital, we surveyed 51 attending doctors in internal medicine, presenting each with 10 clinical vignettes and soliciting their diagnosis of the condition leading to the presentation. Each of the 10 clinical cases included a single misleading detail. Results This survey elicited a wrong diagnosis in 90% of cases, which was reduced to 30% when omitting the misleading detail from the vignette. Diagnostic accuracy did not improve by warning doctors about potentially misleading information. Asking doctors to identify a leading diagnostic detail and then to formulate an alternative diagnosis after omission of the detail, significantly reduced diagnostic error rate by nearly 50%. Conclusion Systematic re-examination of leading diagnostic clues may help to reduce errors in diagnosis.

Background Mass media are a leading source of health information for general public. We wished to examine the relationship between the intensity of media coverage for selected health topics and their actual risk to public health. Methods Mass media reports in the United States on emerging and chronic health hazards (severe acute respiratory syndrome (SARS), bioterrorism, West Nile Fever, AIDS, smoking and physical inactivity) were counted for the year 2003, using LexisNexis database. The number of media reports for each health risk was correlated with the corresponding death rate as reported by the Centers for Disease Control and Prevention. Results The number of media reports inversely correlated with the actual number of deaths for the health risks evaluated. SARS and bioterrorism killed less than a dozen people in 2003, but together generated over 100 000 media reports, far more than those covering smoking and physical inactivity, which killed nearly a million Americans. Conclusions Emerging health hazards are over-reported in mass media by comparison to common threats to public health. Since premature mortality in industrialized societies is most often due to well-known risks such as smoking and physical inactivity, their under-representation on public agendas may cause suboptimal prioritization of public health resources.

Background/Aims: Contrast media (CM) induce a biphasic renal hemodynamic response, with late prominent cortical vasoconstriction and marked outer medullary vasodilation. The objective of the study was to explore a possible role for altered nitric oxide (NO) production or bioavailability in these hemodynamic responses. Methods: We explored the impact of CM (sodium iothalamate) upon rat renal NO synthase (NOS) activity (citrulline recovery) and NO (using a NO electrode). Results: The cortical NOS activity following CM was 11.5 ± 1.0 versus 13.8 ± 1.1 nmol/gww/min (gww = gram wet weight) in controls (p = 0.16, NS). In rats pretreated with the nonselective endothelin antagonist bosentan, CM reduced the cortical NOS activity to 8.5 ± 1.2 nmol/gww/min (p < 0.005 vs. controls). Cortial NO readings declined over 30 min following CM by 13 ± 8% (p < 0.05, Anova), in parallel with the decline in cortical blood flow. The outer medullary NOS activity was not affected by CM (5.2 ± 1.5 vs. 5.5 ± 1.3) nmol/gww/min in controls) or bosentan. Nevertheless, the outer medullary NO reading increased by 36 ± 23% (p < 0.05), with a concomitant increase in regional blood flow. Conclusion: In the cortex, CM might reduce the NOS activity (an effect blunted by endothelin release). This may potentiate the effect of endothelin to induce regional vasoconstriction. In the outer medulla, the vasodilatory response to CM does not seem to be mediated by enhanced NOS activity and might reflect increased local NO bioavailability as the result of regional hypoxia.

The response of insulin-like growth factor (IGF) I in acute renal failure was evaluated in a model of radiocontrast nephropathy associated with selective necrosis of medullary thick ascending limbs. In brief, rats were administered radiocontrast medium or vehicle injections for controls after combined inhibition of prostanoids and nitric oxide. Twenty-four hours after the insult, tissue mRNAs for IGF-I, the IGF-I receptor, and IGF-binding proteins (IGFBP) 1 and 3 were assayed in cortex, medulla, and liver by solution hybridization-RNase protection assay, and IGFBPs were measured in serum and tissue by Western ligand blotting. Cortical IGF-I increased, whereas medullary IGF-I mRNA decreased. Renal IGFBPs decreased, whereas IGFBP-1 mRNA increased. The IGF system in the liver was unchanged. We conclude that general changes in renal IGFBPs in this experimental model of acute renal failure might increase the level of cortical IGF-I in a way that could modulate medullary recovery.

Nitric oxide (NO) exerts profound effects on renal physiology [1—41. Renal NO generation occurs in endothelial cells by the constitutive isoform of nitric oxide synthase (cNOS) and in macrophages, smooth muscle and mesangial cells by the inducible isoform (iNOS). The former system plays an important role in basal renal vascular tone and hemodynamic regulation, in mesangial contraction, renin release and tubuloglomerular feedback. The inducible NOS, widely distributed in the rat kidney, predominantly in the outer medulla and in cortical glomeruli [5], counterbalances vasoconstrictive, thrombogenic and proliferative stimuli associated with cytokine stimulation and inflammatory responses [6]. Intact nitrovasodilation is particularly important at the outer medulla, where tissue oxygen tension as low as 30 mm Hg normally exists [7]. Inhibition of NOS results in profound renal hypoperfusion, both at the cortex and outer medulla [8, 9], associated with substantial aggravation of medullary hypoxia [10]. Blockade of NO synthesis potentiates medullary hypoxic injury from radiocontrast and non-steroidal anti-inflammatory agents [9—111 and augments medullary hypoperfusion and damage during acute ureteral obstruction [121. Recently developed Clark-type selective NO microelectrodes enable real-time monitoring of NO concentrations in vitro in cell lines and incubated tissues [13—17], in organs maintained ex vivo [18] or in the living organism [19, 20]. With concomitant determination of intrarenal blood flow it could be a potent experimental tool for the evaluation of the role of NO in renal hemodynamics. In preliminary studies with the NO electrode, a paradoxical increase in medullary NO reading was noted following NOS inhibition. This led us to evaluate potential artifacts of NO monitoring, such as fluctuations in tissue oxygenation (since oxygen and reactive oxygen species scavenges NO with the production of NO2/NO3 , not sensed by the electrode) and temperature (which markedly affect the electrode current) [21]. Methods

We studied the effect of ketotifen, a second generation H1-receptor antagonist on nitric oxide synthase (NOS) activity in colonic mucosa and in renal tissues, and on rat renal haemodynamics in vivo. Ketotifen (100 μg ml−1) increased human colonic NOS activity from 3.7±0.6 to 14.5±1.3 nmol g−1 min−1 (P

Primary care physicians sometimes encounter patients with clinical complaints that do not fit into a recognized diagnostic pattern. This study was undertaken to assess the way physicians respond to patients whose symptoms are unusual or unexplained that is, what approach they take in the absence of a working hypothesis.We surveyed 130 primary care physicians affiliated with 3 academic centers in Israel, presenting 5 clinical vignettes describing patients who had unusual complaints, no clear diagnosis, and no apparent need for urgent care. We asked physicians to provide the most likely diagnosis for each case and to rate their level of confidence in that diagnosis;respondents were also asked to provide a management strategy for each case and their level of confidence in the chosen approach. Finally, we asked the physicians to estimate how many of their own patients have presentations similar to the individuals in the clinical vignettes.Physicians proposed, on average, 22 diagnoses for each case. Most indicated that they would choose action (testing, consulting, sending the patient to the emergency department, or prescribing) rather than follow-up only (87% vs 13%; P.01). Respondents' confidence in the management approach they had chosen for all the cases was higher than their confidence in the diagnoses (5.6 vs 4.3, respectively, on a scale of1-10; P.001). Physicians estimated that 10% to 20% of the patients they see in their practice have unusual or unexplained symptoms that are difficult to diagnose.Uncertain diagnosis is a regular challenge for primary care physicians. In such cases, we found that physicians prefer a workup to follow-up, an inclination consistent with“action bias.”

Catheter-related bloodstream infection (CR-BSI) is a significant source for morbidity and mortality in addition to increased hospital costs. Patients in intensive care units (ICUs) have a greater risk for CR-BSI. Continuous monitoring and control of intravascular central catheters insertion (CCI) by using checklists have a key role in reducing the rate of infections and improving patient health care quality and safety.To determine the rate of CR-BSI, and to evaluate the adherence of ICU teams to infection control guidelines during CCI prior to and following an intervention program in ICU patients.The present study was conducted in six ICUs at the Hadassah Medical Center, during a period of 15 months. The rate of CR-BSI was determined in 320 patients with central catheters during the first period of the study. Assessment of adherence to infection control guidelines during CCI was carried out by observations. Educational intervention consisted of the introduction of physician guidelines for CCI, implementing a checklist to ensure adherence to the guidelines and lectures for the teams, beginning in the second period of the study. During the third period of the study, the rate of CR-BSI was determined in 336 patients with central catheters in the same ICUs, by the same research methods.Following the intervention, a significant reduction in the rate of CR-BSI was observed in the study population from 9.66 to 3.63 infections per 1000 catheter days, with 62.4% risk reduction for CR-BSI, (P0.001). Improvements were also recorded in the CCI process and the rate of compliance of the ICUs team with infection control guidelines.The implementation of a simple and inexpensive intervention reduced the rate of CR-BSI, leading to improved process of insertion of these catheters.The continuous monitoring of the rate of CR-BSI and using checklists in every CCI process may reduce the morbidity, mortality, hospital stay, and lower hospital costs associated with centrally placed vascular catheters.

Medication administration is one of the most potentially dangerous tasks in hospitals. In recent years, the medical establishment has gained insight into the importance of environmental and ergonomic factors on patient safety. Limited data are available on how a standard designed medication room (MR) supports safety medication administration.Proactive observations were conducted at a tertiary care facility, the Hadassah University Medical Center, Jerusalem, Israel, to determine if safety principles were being implemented in the medication preparation and storage environment. These observations revealed that no designated MRs existed in the hospitals wards and safety systemic weaknesses in medication preparation.Guidelines for planning and designing MRs, based on safety and human engineering principles, were established to promote safer medication administration in hospital wards.The purpose of the survey was to compare the implementation of safety principles among hospital wards before and after MR renovation and among hospital wards with and without a MR. Structured observations in medication preparation areas and storage were designed. Selected safety indicators were measured (e.g. ordering and labeling; storage of intravenous infusions). Each category was subdivided into indicators that were design dependent only (DD), design and behavior dependent (DBD) and behavior dependent only (BD).Indicators that were both DD and DBD showed significant improvement before and after renovation of MRs. Most of the results were not significant for BD indicators. A similar trend was observed in departments with and without a MR. A trend of improvement could be seen in BD-positive indicators, regardless of the presence or absence of a dedicated MR.A standard design MR can improve environmental aspects of safety medication administration.

Healthcare facing end-of-life (EOL) raises challenges of overuse of invasive technology, underuse of palliation, suffering of patients and families, serious dilemmas, conflicts and heavy costs. Studies show the feasibility of training residents to handle these challenges with improved communication skills. An intervention was designed to promote quality of EOL care in a large healthcare organization, by training physicians and nurses to improved knowledge and communication skills. An ongoing program was initiated in June 2012 in the 10 hospitals of …

Objective Osteoporosis is often under-treated, and hip fracture is frequently its first manifestation. Hospitalization for a hip fracture is an opportunity to initiate osteoporosis treatment. The aim of this study was to investigate whether a simple intervention improves the implementation rate of a recommended osteoporosis treatment. Methods One hundred elderly patients admitted with low-impact hip fracture were given a 10 minute explanation about osteoporosis and its treatment during their postoperative hospital stay. In addition, the patients received an explanatory brochure and a letter to their primary care physician that included an article on fracture rate reduction with osteoporosis treatment. Implementation of therapy was assessed by a telephone survey 3 and 6 months postoperatively. The patients who had not received treatment at 3 months were given a repeated explanation. The historical control group was comprised of 100 hip fracture patients with similar demographic characteristics, who were operated on and discharged with the standard care recommendations for osteoporosis prevention. Results At the 3 month follow-up, the therapy rate in both groups was similar (19%). Fifty-eight percent of the patients in the study group had no recollection of the intervention. However, after a repeated explanation, at the 6 month follow-up, 39% of the intervention group had received drug therapy for fracture prevention (P Conclusion A simple intervention enlisting the patients' help to involve their primary care physician can increase treatment rates for osteoporosis following a hip fracture. During the immediate postoperative period, the patients and their families have difficulty implementing the recommendations. Therefore, repeated communications are recommended. (Endocr Pract. 2013;19:46-50)

The promotion of quality and safety in health care faces many challenges and barriers including lack of cooperation by physicians. Complexity and uncertainty in measuring quality raise methodological difficulties. Lack of sufficient awareness about these limitations, also among those who measure quality, contributes to physicians lack of interest, suspicion and mistrust. Strategic issues associated with quality assessment in the Israeli health care system derive from lack of regulation and evasiveness about the accountability of executives and governing bodies regarding the quality of the services provided to patients in hospitals and clinics. Some of these challenges relate to the intrusion of market forces into the world of medicine without needed adaptations, so that reimbursement is often conveniently linked to the quantity of services and not to their quality. Efficiency, which characterizes competitive markets, is not easily translated in the clinical world where empathy, listening skills, and capability of explaining are critical physician attributes. This clinical world values giving beyond monetary compensation, and cooperation between institutions--rather than competition--all crucial for the continuity of patient's care. The interface between economics and health care calls for creative thinking, with a novel definition for the social value of medical and nursing care according to their quality and not their quantity.

Shared decision making (SDM) - involving patients in decisions relevant to their health - has been increasingly influential in medical thought and practice around the world. This paper reviews the current status of SDM in Israel, including efforts to promote SDM in the legislation and healthcare system, its influence in medical training and the national health plans, and funding for SDM-related research. Published studies of SDM in Israel are also reviewed. Although informed consent and patients' right to information are regulated by Israeli law, little provision is made for SDM. Further, there are few organized programs to promote SDM among medical professionals or the public, and governmental support of SDM-related research is minimal. Nonetheless, patients have begun to influence litigation in both formal and informal capacities, medical schools have begun to incorporate courses for improving physician-patient communication into their curricula, and the largest national health plan has initiated a plan to increase public awareness. A review of the limited research literature suggests that although patients and physicians express a desire for greater patient involvement, they often have reservations about its implementation. Research also suggests that despite the positive effects of SDM, such an approach may only infrequently be applied in actual clinical practice. In conclusion, though not actively promoting SDM at present, Israel's universal coverage and small number of health plans make rapid, widespread advances in SDM feasible. Israeli policymakers should thus be encouraged to nurture burgeoning initiatives and set plausible milestones. Comparing the status of SDM in Israel with that in other countries may stimulate further advancement.

To study renal cortical and medullary oxygen tensions, we used sensitive Clark-type O2 microelectrodes, inserted by micromanipulators into the cortex and medulla of kidneys of anesthetized rats. As previously reported, under basal conditions, medullary PO2 was significantly lower than cortical PO2. Furosemide, which inhibits reabsorptive transport in the medullary thick ascending limb, increased medullary PO2 from 16 +/- 4 to 35 +/- 4 mmHg (P < 0.0005) without altering cortical PO2. This effect, reproduced by ethacrynic acid and bumetanide, was selective for loop diuretics and was directly due to decreased tubular O2 consumption, since medullary blood flow was remarkably reduced by furosemide (-28 +/- 6% from baseline, P < 0.0001, as measured by a laser-Doppler probe). By contrast, acetazolamide, which decreases proximal tubule metabolism, selectively increased cortical PO2. These data are, in general, consistent with tubular metabolism as a major determinant of intrarenal oxygenation and suggest, in particular, that medullary reabsorptive work is at least in part responsible for renal medullary hypoxia.