Israel Medical Association Journal

It is indisputable that internal medicine is the cornerstone of medical activities, including medical education, in hospital clinical activities, and clinical and basic medical research.

The medical landscape in Israel is exceptionally demanding, far exceeding the norms of the countries that are members of the Organisation for Economic Co-operation and Development (OECD). We have fewer hospital beds per capita, a greater workload for each physician, and in the future, we will face the challenge of teaching more medical students across our current clinical fields.

The Israeli Society of Internal Medicine has made it its mission to advance internal medicine across all dimensions of the healthcare system in Israel. As such, for the third consecutive year, we are honored to present an issue of the Israel Medical Association Journal (IMAJ) dedicated to research in the different fields of internal medicine that are conducted by physicians from various departments across the country.

This year, we emphasize even more strongly that research is an integral part of our clinical practice. At a time when the basic sciences phase of residency is under threat, it is crucial to underscore its importance. In this issue of IMAJ, we have chosen to publish various studies that were conducted during the basic sciences phase of the residency in internal medicine, highlighting how this training period can be optimally utilized to advance research while simultaneously progressing and maturing through clinical training.

Background: Hospital-at-Home (HaH) programs offer medical services in the patient's home as an alternative to hospitalization across various medical fields. Previous studies have demonstrated that HaH provides several benefits for patients and the healthcare system. Rambam Health Care Center was the pioneer hospital in introducing HaH in Israel. Since April 2021, in collaboration with Maccabi Healthcare Services, the center has been providing home hospitalization services for patients with acute internal medicine illnesses based on an innovative model.

Objectives: To describe demographic data, background diseases, indications for HaH admissions, length of stay (LOS), 1-month and 1-week readmission rates, home mortality, and 1-month mortality.

Results: The study included 262 patients (135 men, 127 women), mean age 69.7 years (range 24–98, median 73). Patients had significant co-morbidities, with a Charlson Comorbidity Index score of 6.7. Among the patients, 170 were independent, 61 were incapacitated, and the remainder had various functional limitations. Most admissions were from internal medicine departments, 39 originating from the emergency department and the rest from other acute care wards. The primary indications for HaH admission included pneumonia, urinary tract infections, and cellulitis. The average hospital LOS was 48.9 hours, while the HaH LOS was 3.43 days. Readmission rates for the same initial conditions were 10% within 1 week and 14% within 1 month. Twenty-one patients died within 1 month of discharge from HaH, including one death during the HaH period.

Conclusions: This study highlighted the feasibility of home hospitalization as a viable alternative to traditional inpatient care in internal medicine.

Background: Opioid-base sedation is considered the first line choice in ventilated patients in intensive care units (ICU). Few studies have examined sedation in ventilated patients outside the ICU. A pilot program was initiated in the internal medicine ward A at Meir Hospital in Kfar Saba, Israel. A new sedation protocol was implemented for opioid-based versus benzodiazepine-based sedation in ventilated patients.

Objectives: To compare the rates and intensity of delirium between patients who received opioid-based sedation vs. benzodiazepine-based sedation. To compare parameters related to morbidity and mortality.

Methods: We conducted a retrospective before-after intervention study based on data collection. Patients who were admitted to the internal medicine ward A from January 2020 to January 2021 and required sedation and ventilation were included. Demographic data, medical history data, admission data, Richmond Agitation and Sedation Scale scores, hemodynamic parameters, reports of falls and self-harm, and data regarding unplanned extubation were collected, as well as the need for additional sedative drugs.

Results: Chronic hypertension was more common in the opioid group. Delirium intensity tended to be higher in the benzodiazepine group. The number of ventilation days was significantly higher in the benzodiazepine group, as was the number of times adjuvant sedation was required.

Conclusions: Opioid-based sedation outside the ICU was associated with shorter ventilation days, tendency toward lower intensity of delirium, and reduction in requirement of adjuvant sedative drugs compared to benzodiazepine-based sedation. Further studies are required to confirm the findings.

Background: Completing internal medicine specialty training in Israel involves passing the Israel National Internal Medicine Exam (Shlav Aleph), a challenging multiple-choice test. multiple-choice test. Chat generative pre-trained transformer (ChatGPT) 3.5, a language model, is increasingly used for exam preparation.

Objectives: To assess the ability of ChatGPT 3.5 to pass the Israel National Internal Medicine Exam in Hebrew.

Methods: Using the 2023 Shlav Aleph exam questions, ChatGPT received prompts in Hebrew. Textual questions were analyzed after the appeal, comparing its answers to the official key.

Results: ChatGPT 3.5 correctly answered 36.6% of the 133 analyzed questions, with consistent performance across topics, except for challenges in nephrology and biostatistics.

Conclusions: While ChatGPT 3.5 has excelled in English medical exams, its performance in the Hebrew Shlav Aleph was suboptimal. Factors include limited training data in Hebrew, translation complexities, and unique language structures. Further investigation is essential for its effective adaptation to Hebrew medical exam preparation.

Background: At the beginning of 2020, the coronavirus disease 2019 (COVID-19) pandemic presented a new burden on healthcare systems.

Objectives: To evaluate the impact of the COVID-19 pandemic on the outcome of non-COVID patients in Israel.

Methods: We conducted a retrospective observational cohort study at a tertiary medical center in Israel. From December 2018 until June 2022, 6796 patients were hospitalized in the internal medicine wards. Patients were grouped based on their admission date: admitted during COVID waves (waves group), admitted between waves (interim group), and admitted during the same months in the previous year (former-year group).

Results: Mortality during hospitalization and 30-day mortality were higher in the waves group compared to the interim and former-year groups (41.4% vs. 30.5% and 24%, 19.4% vs. 17.9% and 12.9%, P < 0.001). In addition, 1-year mortality was higher in the interim group than in the waves and former-year group (39.1 % vs. 32.5% and 33.4%, P = 0.002). There were significant differences in the readmissions, both at 1 year and total number. The waves group had higher rates of mechanical ventilation and noradrenaline administration during hospitalization. Moreover, the waves group exhibited higher troponin levels, lower hemoglobin levels, and more abnormalities in liver and kidney function.

Conclusions: Hospitalized non-COVID patients experienced worse outcomes during the peaks of the pandemic compared to the nadirs and the preceding year, perhaps due to the limited availability of resources. These results underscore the importance of preparing for large-scale threats and implementing effective resource allocation policies.

Background: The prognosis of long-term clinical outcomes for each patient is of utmost importance.

Objectives: To evaluate the association between rates of family attendance during rounds and long-term outcomes.

Methods: We conducted a historic cohort study.

Results: We followed 200 consecutive patients for a median of 19 months. Within the group of patients that had family members present in > 75% of rounds, the 30-day re-hospitalization rate was tenfold higher (P = 0.017). The overall prognosis (including median survival length) of patients who had the highest rates of family attendance (> 75%) was significantly worse compared to patients who had lower rates (P = 0.028). High rates of family attendance were found to correlate with other established risk factors for long-term mortality, including advanced age (r = 0.231, P = 0.001) and in-hospital delirium.

Conclusions: High family attendance during physician rounds in an internal medicine department is associated with worse patient prognosis.

Internal medicine is no doubt one of the main pillars of modern medicine. For years it has been considered to be the basis and foundation of medical education and proper clinical service. During the recent coronavirus disease 2019 (COVID-19) pandemic, internal medicine departments were recognized worldwide, and clearly in Israel, to be the true Corona Warriors that provided medical care to patients as well as support and comfort to families. Around the globe, the public applauded and appreciated the bravery of our medical staff, who without hesitation and under direct personal danger provided the best medical care possible despite the hardships of the time. The high personal price and even the heavy cost of staff member lives lost in offering medical care to the pubic did not stop our quest for ongoing medical research.

Background: Most dyspneic patients in internal medicine departments have co-morbidities that interfere with the clinical diagnosis. The role of brain natriuretic peptide (BNP) levels is well-established in the acute setting but not in hospitalized patients.

Objectives: To evaluate the additive value of BNP tests in patients with dyspnea admitted to medical wards who did not respond to initial treatment.

Methods: We searched the records of patients who were hospitalized in the department of internal medicine D at Sheba Medical Center during 2012 and were tested for BNP in the ward. Data collected included co-morbidity, medical treatments, diagnosis at presentation and discharge, lab results including BNP, re-hospitalization, and mortality at one year following hospitalization.

Results: BNP results were found for 169 patients. BNP was taken 1.7 ± 2.7 days after hospitalization. According to BNP levels, dividing the patients into tertiles revealed three equally distributed groups with a distinctive character. The higher tertile was associated with higher rates of cardiac co-morbidities, including heart failure, but not chronic obstructive pulmonary disease. Higher BNP levels were related to one-year re-hospitalization and mortality. In addition, higher BNP levels were associated with higher rates of in-admission diagnosis change.

Conclusions: BNP levels during hospitalization in internal medicine wards are significantly related to cardiac illness, the existence of heart failure, and patient prognosis. Thus, BNP can be a useful tool in managing dyspneic patients in this setting.

Background: Screening for asymptomatic urinary retention (AUR) in older adult men at hospital admission to the internal medicine department has never been studied.

Objectives: To assess the incidence of AUR in older adult men at hospital admission, its risk factors, and its outcome.

Methods: The study comprised 111 older adult men aged ≥ 75 years who were admitted to three internal medicine departments. All men underwent post-void residual (PVR) urine volume measurement on the morning following admission by using a portable ultrasound bladder scan. AUR was defined as a PVR urine volume of ≥ 200 ml without symptoms. Men with AUR had a follow-up phone call concerning symptoms and urinary catheter status30 days following hospitalization.

Results: Seven (6.3%) men had AUR. Relative to the 104 men without AUR, they had significantly higher prevalence of severe dependency (6/7 vs. 33/104, 85.7% vs. 31.7%, (P = 0.007), cognitive impairment (5/7 vs. 19/104, 71.4% vs. 18.3%, P = 0.005), and use of anticholinergic agents (4/7 vs. 19/104, 57.1% vs. 18.3%, P = 0.033). A urinary catheter was inserted in one man (14.3%), but it was removed later during hospitalization. No symptoms were reported and no urinary catheter was inserted following hospitalization in men with AUR.

Conclusions: AUR in older adult men at hospital admission is uncommon and has a favorable outcome. Hence, screening for AUR in all older adult men at admission is not recommended, but it may be considered in severely dependent older adult men with cognitive impairment who use anticholinergic agents

Background: In February 2020, the World Health Organisation designated the name COVID-19 for a clinical condition caused by a virus identified as a cause for a cluster of pneumonia cases in Wuhan, China. The virus subsequently spread worldwide, causing havoc to medical systems and paralyzing global economies. The first COVID-19 patient in Israel was diagnosed on 27 February 2020.

Objectives: To present our findings and experiences as the first and largest center for COVID-19 patients in Israel.

Methods: The current analysis included all COVID-19 patients treated in Sheba Medical Center from February 2020 to April 2020. Clinical, laboratory, and epidemiological data gathered during their hospitalization are presented.

Results: Our 162 patient cohort included mostly adult (mean age of 52 ± 20 years) males (65%). Patients classified as severe COVID-19 were significantly older and had higher prevalence of arterial hypertension and diabetes. They also had significantly higher white blood cell counts, absolute neutrophil counts, and lactate dehydrogenase. Low folic acid blood levels were more common amongst severe patients (18.2 vs. 12.9 vs. 9.8, P = 0.014). The rate of immune compromised patients (12%) in our cohort was also higher than in the general population. The rate of deterioration from moderate to severe disease was high: 9% necessitated non-invasive oxygenation and 15% were intubated and mechanically ventilated. The mortality rate was 3.1%.

Conclusions: COVID-19 patients present a challenge for healthcare professionals and the whole medical system. We hope our findings will assist other providers and institutions in their care for these patients.

Background: C-reactive protein (CRP) blood level is associated with clinical outcomes of several diseases. However, the independent predictive role of CRP in the heterogeneous population of patients admitted to internal medicine wards is not known. 

Objectives: To determine whether single CRP levels at admission independently predicts clinical outcome and flow of patients in general medicine wards.

Methods: This study comprised 275 patients (50.5% female) with a mean age of 68.25 ± 17.0 years, hospitalized with acute disease in a general internal medicine ward. The association between admission CRP levels and clinical outcomes including mortality, the need for mechanical ventilation, duration of hospitalization, and re-admission within 6 months was determined.

Results: A significant association was found between CRP increments of 80 mg/L and risk for the major clinical outcomes measured. The mortality odds ratio (OR) was 1.89 (95% confidence interval (95%CI, 1.37–2.61, P < 0.001), mechanical ventilation OR 1.67 (95%CI, 1.10–2.34, P = 0.006), re-admission within 6 months OR 2.29 (95%CI, 1.66–3.15 P < 0.001), and prolonged hospitalization >7 days OR 2.09 (95%CI, 1.59–2.74, P < 0.001). Lower increments of10 mg/L in CRP levels were associated with these outcomes although with lower ORs. Using a stepwise regression model for admission CRP levels resulted in area under the receiver operating characteristics curves between 0.70 and 0.76 for these outcomes.

Conclusions: A single admission CRP blood level is independently associated with major parameters of clinical outcomes in acute care patients hospitalized in internal medicine wards.

Background: Basal-bolus (BB) insulin treatment is increasingly used in poorly controlled diabetes patients during hospitalization and is commonly recommended at discharge; however, the extent of adherence with this recommendation is unknown.

Objectives: To determine short-term adherence of type 2 diabetes mellitus (T2DM) patients discharged from internal medicine wards with recommendation for BB insulin treatment.

Methods: Prescription (primary physician adherence) and purchase (patient adherence) of long-acting and short-acting insulins during the first month following discharge from internal medicine wards was determined in 153 T2DM patients. Adherence was defined as full if prescription/purchase of both basal (long-acting) and bolus (short-acting) insulin was completed, and as partial if only one kind of insulin (basal or bolus) was prescribed/purchased. Association between demographic and clinical parameters and adherence was determined.

Results: Full adherence with discharge instructions was higher for primary physicians than for patients )79.1% vs. 69.3%, respectively, P = 0.0182). Pre-hospitalization hemoglobin A1C was significantly associated with adherence by both patients and primary physicians (full-adherence group 9.04% ± 2.04%; no-adherence group 7.51% ± 1.35%, P = 0.002). Age was negatively associated with adherence of both primary physicians and patients; however, this association did not reach statistical significance. Patients with certain background diseases such as atrial fibrillation, coronary heart disease, and chronic heart failure had significantly worse adherence (P < 0.05). When the sole cause of admission was diabetes, full adherence (100%) of both primary physicians and patients was found.

Conclusions: Short-term adherence with discharge recommendation for BB insulin treatment is associated with pre-hospitalization patient characteristics.

Background: Concerns about metformin-associated lactic acidosis (MALA) prohibit the use of metformin in a large subset of diabetic patients, mostly in patients with chronic kidney disease. Increasing evidence suggests that the current safety regulations may be overly restrictive.

Objectives: To examine the association between chronic metformin treatment and lactate level in acute illness on the first day of admission to an internal medicine ward.

Methods: We compared diabetic and non-diabetic hospitalized patients treated or not treated with metformin in different sets of kidney function.

Results: A total of 140 patients participated in the study, 54 diabetic patients on chronic metformin treatment, 33 diabetic patients without metformin and 53 patients with no diabetes. Most participants were admitted for conditions that prohibit metformin use, such as heart failure, hypoxia and sepsis. Average lactate level was significantly higher in the diabetes + metformin group compared to the diabetes non-metformin group. Metformin treatment was not associated with higher than normal lactate level (hyperlactatemia) or low pH. No patient was hospitalized for lactic acidosis as the main diagnosis.

Conclusions: Chronic metformin treatment mildly increases lactate level, but does not induce hyperlactatemia or lactic acidosis in acute illness on the first day of admission to an internal medicine ward. These data support the expansion of metformin use.