E. Soudry, C.L. Sprung, P.D. Levin, G.B. Grunfeld and S. Einav
Background: Physicians’ decisions regarding provision of life-sustaining treatment may be influenced considerably by non-medical variables.
Objectives: To examine physicians’ attitudes towards end-of-life decisions in Israel, comparing them to those found in the United States.
Methods: A survey was conducted among members of the Israel Society of Critical Care Medicine using a questionnaire analogous to that used in a similar study in the USA.
Results: Forty-three physicians (45%) responded, the majority of whom hold responsibility for withholding or withdrawing life-sustaining treatments. Preservation of life was considered the most important factor by 31 respondents (72%). The quality of life as viewed by the patient was generally considered less important than the quality of life as viewed by the physician. Twenty-one respondents (49%) considered withholding treatment more acceptable than withdrawing it. The main factors for decisions to withhold or withdraw therapy were a very low probability of survival of hospitalization, an irreversible acute disorder, and prior existence of chronic disorders. An almost similar percent of physicians (93% for Israel and 94% for the U.S.) apply Do Not Resuscitate orders in their intensive care units, but much less (28% vs. 95%) actually discuss these orders with the families of their patients.
Conclusions: Critical care physicians in Israel place similar emphasis on the value of life as do their U.S. counterparts and assign DNR orders with an incidence equaling that of the U.S. They differ from their U.S. counterparts in that they confer less significance to the will of the patient, and do not consult as much with families of patients regarding DNR orders.
A. Halevy, A. Stepanasky, Z. Halpern, I. Wasserman, Z. Chen-Levy, S. Pytlovich, O. Marcus, A. Mor, P. Hagag, T. Horne, S. Polypodi and J. Sandbank
Background: Among the various new technologies in the field of parathyroid surgery are intraoperative quick parathormone measurements.
Objectives: To evaluate the contribution of QPTH measurements during parathyroidectomy to the achievement of higher success rates.
Methods: QPTH assay using Immulite Turbo Intact PTH was measured in 32 patients undergoing parathyroidectomy: 30 for primary and 2 for secondary hyperparathyroidism. QPTH levels were measured at time 0 minutes (before incision) and at 10, 20, and 30 minutes after excision of the hyperfunctioning gland. Only a drop of 60% or more from the 0’ level was considered to be a positive result.
Results: The mean QPTH level at time 0’ for PHPT patients was 38.12 ± 25.15 pmol/L (range 9.1–118 pmol/L). At 10 minutes post-excision of the hyperfunctioning gland (or glands), QPTH dropped by a mean of 73.80% to 9.89 ± 18.78 pmol/L.
Conclusions: Intraoperative QPTH level measurement is helpful in parathyroid surgery. A drop of 60% or more from 0’ level indicates a successful procedure, and further exploration should be avoided.
N. Berkman, A. Avital, E. Bardach, C. Springer, R. Breuer and S. Godfrey
Background: Leukotriene antagonist therapy in asthmatic patients alleviates symptoms and improves exercise tolerance, however the effect of these drugs on bronchial provocation tests and exhaled nitric oxide levels are less clearly established.
Objective: To determine the effect of montelukast treatment on airway hyperresponsiveness to exercise, methacholine and adenosine-5’-monophosphate and on exhaled nitric oxide levels in steroid-naive asthmatics.
Methods: Following a 2 week run-in period, 20 mild to moderate asthmatics were enrolled in an open label 6 week trial of oral montelukast-sodium therapy. Bronchial hyperreactivity (exercise, methacholine and adenosine-5’-monophosphate challenges) and exhaled nitric oxide levels were measured before and after the 6 week period.
Results: Montelukast treatment resulted in a significant improvement in exercise tolerance: median DFEV1 20.0% (range 0–50) prior to treatment vs. 15.0% (range 0–50) post-treatment (P = 0.029). A significant difference was also observed for exhaled NO following therapy: median NO 16.0 ppb (range 7–41) vs. 13.0 (range 4.8–26) (P = 0.016). No change was seen in baseline lung function tests (FEV1, MEF50) or in the bronchial responsiveness (PC20) for methacholine and adenosine-5’-monophosphate.
Conclusions: This study demonstrates that the leukotriene antagonist, montelukast-sodium, reduces bronchial hyperreactivity in response to exercise and reduces exhaled nitric oxide levels but has little effect on bronchial responsiveness to methacholine and adenosine challenges.