BACKGROUND:Tracheostomy is commonly performed in hospitalized patients requiring prolonged mechanical ventilation. Tracheostomy tubes can promote bacterial biofilm formation, potentially leading to local tracheitis or lower respiratory tract infections (RTIs). The distribution of pathogens and their resistance profiles vary by clinical setting, antimicrobial exposure, and patient factors. AIMS:To describe the microbiological findings from sputum cultures in tracheostomy patients, assess the prevalence and risk factors for multidrug-resistant organisms (MDROs), and evaluate empiric antibiotic management of RTI episodes. METHODS:We conducted a retrospective, single-center study of adults who underwent tracheostomy between 2020 and 2024. Data on patient characteristics, sputum cultures, and RTI management were extracted from electronic health records. RESULTS:Among 507 patients, 257 (50.7%) had at least one MDRO-positive sputum culture, while 153 (30.2%) had only susceptible organisms. Higher Charlson Comorbidity Index, longer hospital stays, and prolonged antibiotic exposure prior to tracheostomy were independently associated with MDRO isolation (OR 1.18, 1.01, 1.06, respectively; p<0.05). The most commonly isolated organisms were Enterobacterales, Pseudomonas aeruginosa, Acinetobacter species, Staphylococcus aureus, and Corynebacterium striatum. Among 646 RTI episodes, empiric antibiotics were initiated in 440 (68.1%), with 231 (67.5%) deemed appropriate based on culture results. CONCLUSIONS:Despite prolonged admission, nearly a third of the patients harbored only susceptible organisms in their sputum cultures. Empiric treatment was inappropriate in about one third of the RTI episodes. Implementing local antibiograms, applying MDRO risk stratification, and optimizing sputum culture quality may improve empiric treatment accuracy in this vulnerable population.

BACKGROUND Inflammation of the aorta is a potentially life-threatening condition. Infectious aortitis has been associated with various pathogens, although Escherichia coli has rarely been implicated. CASE REPORT We describe an 82-year-old man with a past medical history of diabetes mellitus type II and ischemic heart disease, who presented with a 2-week history of back and abdominal pain. Imaging revealed aortitis with a periaortic fluid collection, from which E. coli was isolated. The patient underwent urgent endovascular aneurysm repair (EVAR) and was treated with 4 weeks of intravenous cefuroxime followed by prolonged oral antibiotics, with normalization of inflammatory markers. Four months later he was readmitted because of septic shock and a large periaortic abscess was diagnosed. He required open drainage and aortic repair and died of complications. We review the literature of 33 cases involving E. coli aortitis, including the present case, of whom the mean age was 69±11, 26 (79%) were male, 31 (94%) were diagnosed by computed tomography (CT) scan, and 27/31 (87%) received surgical intervention. Further, 25 out of 30 patients (83%) for whom all data regarding interventions and survival were available, survived. CONCLUSIONS Aortitis due to E.coli is a potentially fatal infection. Treatment consists preferably of a combination of prolonged intravenous antibiotics - for at least 6 to 12 weeks - and a surgical intervention. If possible, the patient should undergo EVAR, and if not, open corrective surgery, which is associated with a survival rate of 83%.

Background Hyponatremia and urinary retention are common medical problems. While associations between the two are documented, research has not clearly established the incidence of urinary retention in hyponatremic patients. Objectives To determine the incidence of urinary retention in hyponatremic patients and assess whether urinary catheter insertion affects the sodium correction rate. Methods A prospective, single centre, observational study including patients hospitalized in Internal Medicine and Geriatric wards. A total of 199 older patients (mean age 84.4, 39% men) were investigated: 100 with hyponatremia ≤129 mEq/L (of these, 70 had severe hyponatremia ≤125 mEq/L) and 99 normonatremic controls. The incidence of urinary retention was checked in all groups. Hyponatremic patients underwent complete assessment for the cause of hyponatremia and sodium levels were followed up for 48 hours. Results There was a marked increase in the incidence of urinary retention in older hyponatremic patients compared to those with normal sodium levels (41% vs 21%, p=0.004). The difference was even greater when comparing those with severe hyponatremia to controls (44% vs 21%, p=0.001). Among hyponatremic patients with and without urinary retention, there was no difference in sodium correction rate between the two groups. Patients with polyuria secondary to post-obstructive diuresis had more rapid sodium correction (9.2±6.8 mEq/L vs 5.8±4.8 mEq/L, p=0.05). Conclusions There was a significantly higher incidence of urinary retention in older patients with hyponatremia, which correlates with hyponatremia severity. Post-obstructive diuresis following catheter insertion is associated with more rapid sodium correction. We recommend routine bladder scanning for all patients with hyponatremia.

Background Thyroid dysfunction (TD) is associated with increased cardiovascular morbidity and mortality. Early detection may influence the clinical management. Objective To determine the prevalence, predictors, and prognostic value of TD among hospitalized cardiac patients. Methods A retrospective analysis of a 12-year database consisting of nonselectively adult patients admitted to a Cardiology Department and who were all screened for serum thyroid-stimulation-hormone (TSH) levels . Statistical analysis of demographic and clinical characteristics, mortality and length of hospital stay (LOS) was performed. Results A total of 14369 patients were included in the study; mean age was 67 years, 38.3% females. 1465 patients (10.2%) had TD. The most frequent type of TD was mildly elevated TSH (5.4%) followed by mildly reduced TSH (2.1%), markedly elevated TSH (1.5%), and markedly reduced TSH (1.2%). Female gender, history of hypothyroidism, heart failure, atrial fibrillation, renal failure and amiodarone use were significantly associated with TD. During follow-up 2975 (20.7%) patients died. There was increased mortality in the mildly reduced TSH subgroup (hazard ratio [HR] =1.44), markedly elevated TSH subgroup (HR=1.40) and mildly elevated TSH subgroup (HR=1.27). LOS was longer for patients with TD; the longest stay was observed in the markedly elevated TSH subgroup (odds ratio=1.69). Conclusion The prevalence of TD in hospitalized cardiac patients is 10.2%. TD is associated with an increased mortality rate and LOS. Consequently, routine screening for thyroid function in this population is advisable, particularly for selected high-risk subgroups. Future studies are needed to determine whether optimizing thyroid function can improve survival in these patients.

Context:Various genes have been associated with familial and sporadic primary hyperparathyroidism (PHPT), including activating mutations of the glial cells missing transcription factor 2 (GCM2) gene.Objective:The aim of this study was to assess the prevalence of the GCM2 p.Tyr394Ser variant in the Jerusalem Ashkenazi Jewish (AJ) population with PHPT, and to conclude whether routine genetic testing is justified.Methods:The blood of 40 self-reported AJ patients with PHPT and 200 AJ controls was tested for the GCM2 p.Tyr394Ser variant. Demographic and medical information was extracted from the patients' charts and evaluated accordingly.Results:Two (5%) PHPT patients and 3 (1.5%) controls were heterozygotes for the tested variant. Our patients were mostly (87.5%) sporadic cases. One of the heterozygote patients had familial PHPT; the other had 2 parathyroid adenomas, and the levels of his blood and urinary calcium were extremely high.Conclusion:Our results suggest that in AJ patients with sporadic, single-gland PHPT, the likelihood of the tested variant is low and genetic testing should be limited to those with familial PHPT or multiglandular disease.

INTRODUCTION:acute urinary tract obstruction (aUTO) is a common finding in older hospitalised patients. Anecdotal reports described hyponatraemia in patients with aUTO, which subsides rapidly with relief of the obstruction.The aim of this study was to determine the incidence, severity and subsequent correction of hyponatraemia in patients with aUTO.METHODS:this is a prospective, single-centre, observational study including inpatients in the internal medicine and geriatric wards. A total of 204 patients were investigated, 104 with aUTO and 100 controls. The prevalence, severity and associations of hyponatraemia between aUTO and control patients were compared.RESULTS:the incidence of hyponatraemia was similar in aUTO and control groups 28% versus 22%, respectively (P = 0.42). However, the incidence of severe hyponatraemia was significantly higher in the study group 7% versus 1% (P = 0.04). Mean sodium level was lower in hyponatremic patients with aUTO 127.7 ± 5.9 mEq/l versus 130.8 ± 3 mEq/l (P = 0.013). Serum sodium remained largely unchanged in the control group (∆Na 1.5 ± 2.3 mEq/l) but increased significantly within 48 hours following catheter insertion in patients with urinary retention (∆Na 5.3 ± 4.2 mEq/l overall in the aUTO group and 9.6 ± 3 mEq/l in those with urinary retention and severe hyponatraemia (P = 0.002)).

BACKGROUND:The short Synacthen test (SST) is widely used to assess the hypothalamus-pituitary-adrenal axis in the outpatient setting. However, in the inpatient setting, technical difficulties to adhere to the protocol may pose a challenge for using this test.AIMS:To find the most suitable basal serum cortisol (BSC) cut-off for predicting an adequate response to the SST in non-critically inpatients without conducting the actual test.METHODS:Information was retrieved retrospectively from medical files of 197 patients who had had a 250 μg SST between the years 2000 and 2016 at the Shaare Zedek Medical Center. BSC, electrolytes, creatinine, thyroid-stimulating hormone, blood counts and blood pressure values were evaluated for a correlation with the results of the SST.RESULTS:A BSC cut-off of 280 nmol/L provides a negative predictive value of 94% for adrenal insufficiency (AI). Using a cut-off of 380 nmol/L increases the sensitivity to 96% and yields a negative predictive value of 95.8%.CONCLUSIONS:In this study, we found two suitable BSC cut-offs for predicting an adequate response to the SST in hospitalised patients. We suggest using the lower cut-off (280 nmol/L) for patients with a low level of suspicion for AI and using the higher cut-off (380 nmol/L) for patients with a higher level of suspicion. A BSC above this cut-off makes the diagnosis of AI very unlikely and precludes the need for a Synacthen test.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Background Many in-patients require care from practitioners in various disciplines. Consultations most probably have significant implications for hospitalization outcomes. Purpose To determine key aspects of consultations provided by various departments to formulate an optimal policy. Methods This study comprised two methods: first, a questionnaire was completed in 2019 by 127 physicians interns, residents and senior doctors) from the medical and surgical departments (64 from the surgical wards, 43 from the medical wards and 22 from the emergency room and General ICU) regarding the availability, timeliness and documentation rate of the consultations they received from different disciplines. The investigators rounded through the various departments that were included in the study and they accosted a sample of interns, residents and attending physicians, who were then asked to fill the questionnaire. Overall compliance of filling the questionnaire was 95%. Residents accounted for 72% of the filled questionnaires, seniors and interns accounted for 15 and 13% respectively. Second, a convenience sample of 300 electronic records of hospitalized patients (135 from the surgical wards, 129 from the Medical wards and 36 from the emergency room and General ICU) of actually carried out consultations was reviewed for validated indicators of quality for both the consultation request and response. We used a 5-point Likert scale, ranging from poor (1) to superb (5), to grade the measured parameters. Results The availability, timeliness and documentation rate for medical consultations were 4 ± 0.9, 4.1 ± 0.9 and 4.3 ± 0.9 respectively, as compared with surgical consultations 3.2 ± 1.1, 3.4 ± 1.2 and 3.6 ± 1.2 respectively ( P < 0.001). The mean time (in hours) from the consultation request till documentation (of the requested consultation) by consultants in the medical and surgical departments was 3.9 ± 5.9 and 10.0 ± 15.6, respectively ( P < 0.001). The quality of requests of consultations from the medical and surgical departments was 3.4 ± 1.1 and 2.8 ± 1.2, respectively (P < 0.001). Two different models of consultations are employed: while each medical department adopts several departments for medical consultations, each day’s on-call surgeon provides all the hospital’s surgical consultations. Conclusion We detected significant differences in key aspects of consultations provided by the departments. The medical model of consultations, in which each medical department adopts several other wards to which it provides consulting services upon request, should probably be adopted as a major policy decision by hospitals directors to enhance inter-departmental consultations.

Background Elderly patients admitted because of acute cholecystitis are usually not operated during their initial admission and receive conservative treatment. To help formulate a new admission policy regarding elderly patients with acute cholecystitis we compared the demographic and clinical characteristics and outcome of patients > 65 with acute cholecystitis admitted to medical or surgical wards. Methods This retrospective study included all patients > 65 years admitted for acute cholecystitis between January, 2009 and September, 2016. Data were retrieved from the electronic health records. Results A total of 187 patients were detected, 54 (29%) in medical departments and 133 (71%) in surgical wards. The mean age (±SD) was 80 ± 7.5 and was higher among those in medical than surgical wards (84 ± 7 versus 79 ± 7, p < 0.05). Patients hospitalized in medical departments had more comorbidity, disability and mental impairment. However, there was no difference in mortality between the two groups, 1 (2%) and 6 (4%) respectively. Independent predictors for hospitalization in medical departments were chronic obstructive pulmonary disease (OR = 9.8, 95% C. I 1.6–59) and the Norton Scale score (NSS)(OR = 0.7, 95% C. I 0.7–0.8). Impaired mental condition was the only predictor for hospitalization > 1 week. The strongest predictor for having cholecystostomy was admission to the surgical department (OR = 14.7, 95% C. I 3.9–56.7). Linear regression showed a negative correlation between NSS and length of hospitalization (LOH; Beta = − 0.5). Conclusion Elderly patients with acute cholecystitis who require conservative management, especially those with severe functional and mental impairment can be safely hospitalized in medical departments. Outcome was not inferior in terms of mortality and LOH. These results have practical policy implications for the placement of elderly patients with acute cholecystitis in medical rather than surgical departments.

CONTEXT:Bilateral adrenal hemorrhage is a rare condition with potentially life-threatening consequences such as acute adrenal insufficiency. Early adrenal axis testing, as well as directed imaging, is crucial for immediate diagnosis and treatment. Coronavirus disease 2019 (COVID-19) has been associated with coagulopathy and thromboembolic events.CASE DESCRIPTION:A 66-year-old woman presented with acute COVID-19 infection and primary adrenal insufficiency due to bilateral adrenal hemorrhage (BAH). She also had a renal vein thrombosis. Her past medical history revealed primary antiphospholipid syndrome (APLS). Four weeks after discharge she had no signs of COVID-19 infection and her polymerase chain reaction test for COVID-19 was negative, but she still needed glucocorticoid and mineralocorticoid replacement therapy. The combination of APLS and COVID-19 was probably responsible of the adrenal event as a "two-hit" mechanism.CONCLUSIONS:COVID-19 infection is associated with coagulopathy and thromboembolic events, including BAH. Adrenal insufficiency is life threatening; therefore, we suggest that early adrenal axis testing for COVID-19 patients with clinical suspicion of adrenal insufficiency should be carried out.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)

Background: Antibiotic stewardship programs are necessary to test the appropriateness of local guidelines for empirical antibiotic treatment by audits. Objectives: To assess whether compliance to local guidelines achieved a higher rate of appropriate antibiotic treatment and reduced morbidity and mortality, and whether infectious disease counseling improved the rate of appropriate treatment. Methods: Our cohort comprised 294 patients with proven bacteremia. Data were retrieved from medical records including diagnosis, empiric antibiotic treatment, and outcomes. Results: The empirical treatment was consistent with bacterial susceptibility in 227 patients (77%), and matched in 64% of the time to the first line, and another 24% to the second line of institutional guidelines. A strong correlation was found between appropriate empiric treatment according to bacterial susceptibility and reduced mortality (odds ratio [OR] 0.403, P = 0.007). A similar correlation was found with the choice of appropriate antibiotics according to local guidelines (OR 0.392, P = 0.005). Infectious disease consultation was related to an increase in the rate of appropriateness of treatment according to guidelines (85% vs.76%, P = 0.005). A tendency to increased appropriateness was related to microbial susceptibility (87% vs. 74%, P = 0.07). Conclusions: In this study, initiation of appropria to empiric antibiotic therapy, according to the hospital's guidelines, was found associated with reduced mortality in patients with bacteremia.

Rational: Phosphaturic mesenchymal tumors (PMTs) are rare tumors often causing tumor-induced osteomalacia (TIO), with surgical resection being the first line in the treatment of TIO. There are very few reports of PMTs located in the brain. The authors present one such case, it's management and outcome as well as a review of the literature. Patient concerns: The authors report of a 58 year old male with a background of osteoporosis, bone pain, muscle weakness and gait disturbances for the past several years. He presented to our institution with newly developed absence spells. He underwent imaging which revealed a brain tumor. Interventions: The patient underwent surgery for what was suspected as a meningioma. A gross total resection was done. The pathological diagnosis was that of phosphaturic mesenchymal tumor. Outcomes: Removal of the tumor helped in alleviating the patient's back symptoms immediately after surgery. The patient was discharged home and was followed up by an endocrinologist, with improvement of his bone pain, his muscle weakness and his gait disturbances. Lessons: PMT with involvement of the brain can be treated surgically. Removal of the tumor will alleviate symptoms in patients harboring this rare brain tumor.

AIMS:To describe three interventions that have improved the quality of the internship.BACKGROUND:All medical school graduates are required to take a one year internship, rotating through various hospital departments. By various objective and subjective measures, the quality, benefit and efficacy of the internship varies significantly between departments and hospitals and also depends on where the interns studied.METHODS:The interventions were: First, all graduates of foreign medical schools (FMG) were required to interview and present a patient, demonstrating practical knowledge of spoken and written Hebrew and basic medical terminology prior to the start of the internship. Second, on the first day of their internship in internal medicine the new interns participate in an orientation day, addressing multiple clinical, administrative and other components. Third, upon the completion of their rotation in internal medicine, the interns participate in an interactive session to help them prepare for their future career.RESULTS:First, during the first 3 years after introducing the Hebrew test, 101 FMGs took the test, 89 (88%) passed the first time, the remainder passed the 2nd or 3rd test after another 1-3 months of studying Hebrew. Of 31 women, 30 (97%) passed the first time, compared to 59/70 (84%) of the men (p=0.065); 27/28 (96%) of Jewish interns passed the first time compared to 62/73 (85%) non-Jewish interns (p=0.99). Physicians report on the significantly increased ability of FMGs to participate in all activities from the onset of their internship. Second, upon completion of the orientation, 137 interns provided feedback of its 12 components; satisfaction was marked on a Likert scale (ranging from 1 [low] to 5 [high]) and ranged from 4.2±0.1 to 4.7±0.6; high/very high satisfaction with the various components ranged from 79% to 96%. Third, feedback was provided by 96 interns after participating in the interactive session helping to prepare for the future; satisfaction with the 5 components of the session ranged from 3.8±0.8 (on the acquired insight into the possibilities, scope and limitations regarding their future career) to 4.5±0.7 (regarding the relevance of such sessions). Sub-analysis revealed several statistically significant differences between male and female interns (male interns indicated these sessions to be more important to them than females, p<0.01), and FMG (as compared to graduates from Israeli medical schools) indicated that they had acquired relevant information more often (p<0.001).CONCLUSIONS:Various interventions positively impact the quality, benefit and efficacy of the internship as observed by physicians working with the residents, as well as perceived by the interns themselves.

A 40-year old man with a history of bipolar disorder and obsessive-compulsive disorder came to the Emergency Department because of general weakness, edema, and purpura on his lower extremities. His past medical history was unremarkable: he did not take any medication, did not suffer from allergies, and, besides his psychiatric background, he mentioned only an episode of self-limited diarrhea 2 years earlier, without pathological findings on colonoscopy. At that time he decided to live on a diet of oats, canned tuna, and eggs, because he believed he was allergic to fructose.

Searchable abstracts of presentations at key conferences in endocrinology ISSN 1470-3947 (print) | ISSN 1479-6848 (online)