Israel Medical Association Journal

Background: The prevalence of morbid obesity is increasing rapidly. Weight reduction is very difficult using diet restriction and physical activity alone. Sibutramine has been shown to be effective and safe as an adjuvant therapy to diet restrictions.

Objectives: To describe our experience using sibutramine in weight reduction treatment of adolescents suffering from morbid obesity.

Methods: The study group comprised 20 young persons (13 females, mean age 15 years 4 months, range 13–18 years) with morbid obesity (body mass index over the 95th percentile for age and/or ≥ 30 kg/m²) were treated with sibutramine 10 mg once a day for 1 year.

Results: Mean BMI[1] was 40 ± 5.6 kg/m² (range 30.1–49.5 kg/m²) at the beginning of treatment. Most patients showed an early weight reduction to mean BMI 39.3 ± 4.9 and 35.9 ± 5.7 at 3 and 6 months respectively, but stopped losing weight over the next 6 months. During the follow-up period 17 patients discontinued the treatment. The main reason for dropout was the slow rate of weight reduction after 6 months. Patients suffering from concomitant disorders (severe asthma, hypertension, sleep obstructive apnea) showed improvement after weight reduction. Adverse reactions from the treatment were transient, mild and well tolerated.

Conclusions: Sibutramine may help in achieving weight reduction for a short period and in improving concomitant health problems, however its long-term effect is limited.

Epidemiologic data demonstrate a long-linear realationship between low density lipoprotein-cholesterol levels and risk of coronary heart disease.

Objectives: To assess the effect of a vaginal ring delivering estradiol and progesterone in postmenopausal women and to determine whether continuous administration can relieve climacteric symptoms, produce an acceptable pattern of vaginal bleeding and control endometrial proliferation.

Methods: Twenty-nine postmenopausal women with an intact uterus were studied. All had climacteric symptoms. The vaginal rings contained 0.36 g estradiol and either 3.6 g progesterone (high dose progesterone) or 1.8 g (low dose progesterone), and were kept in place for 4–6 months. Serum progesterone, estradiol and estrone were measured and endometrial thickness determined. All women kept a daily diary of bleeding/spotting and completed a questionnaire on climacteric symptoms at monthly intervals. The low dose progesterone group comprised 14 women and the high dose progesterone group 15 women.

Results: A total of 18 patients (9 in each group) completed the study. Mean levels of estradiol, estrone and progesterone were at their peak after 2 to 4 weeks. All rings were effective in alleviating vasomotor symptoms, although there was evidence of the "escape from effect" in month 6. Endometrial thickness increased in 6 of the 29 women but biopsy in each case showed no evidence of hyperplasia. Of the 18 women who completed the study, 5 had amenorrhea throughout, 7 had amenorrhea after 3 months, and the remainder had one or two bleeding episodes after 3 months. Therapy was discontinued in 11 women.

Conclusions: A vaginal ring delivering estradiol and progesterone controlled climacteric symptoms, prevented endometrial proliferation, and provided an acceptable bleeding pattern. It should be viewed as a promising alternative for short-term estrogen-progesterone therapy.

Objective: To investigate hemodynamic variables, including small and large artery compliance, in cirrhotic patients during total paracentesis.

Methods: The study included 15 cirrhotic patients admitted for an episode of tense diuretic-resistant ascites. Hemodynamic variables including vascular compliance were measured using an HDI pulse wave cardiovascular profiling instrument CR-2000. The variables were measured in these patients before, immediately after and 24 hours following large volume (mean 5.6 L) paracentesis.

Results: Cardiac output increased immediately after paracentesis due to increment in stroke volume, with no change in heart rate. However, 24 hours later the cardiac output decreased to below the basal level. The fluctuation was statistically significant (P < 0.05). There was no change in large artery compliance, but small artery compliance increased after paracentesis (P < 0.05) and partially returned to the basal level after 24 hours. Systemic vascular resistance measurement showed the same pattern of change: vasodilatation occurred during paracentesis and was attenuated 24 hours later.

Conclusions: Large volume paracentesis with albumin replacement caused an accentuation of the vasodilatation (small but not large artery) already present in these patients. This may be the first sign of enhanced vasodilatation due to large volume paracentesis before the clinical expression of impaired hemodynamics and deterioration of renal function.

Objectives: To minimize ventilatory limitation during training of patients with severe COPD[1] by applying bi-level positive pressure ventilation during training in order to augment training intensity (and effect).

Methods: The study group comprised 19 patients (18 males, 1 female) with a mean age of 64 ± 9 years. Mean forced expiratory volume in 1 second was 32 ± 4% of predicted, and all were ventilatory-limited (exercise breathing reserve 3 ± 9 L/min, normal >15 L/min). The patients were randomized: 9 were assigned to training with BiPAP[2] and 10 to standard training. All were trained on a treadmill for 2 months, twice a week, 45 minutes each time, at maximal tolerated load. Incremental maximal unsupported exercise test was performed before and at the end of the training period.

Results: BiPAP resulted in an increment of 94 ± 53% in training speed during these 2 months, as compared to 41 ± 19% increment in the control group (P < 0.005). Training with BiPAP yielded an average increase in maximal oxygen uptake of 23 ± 16% (P < 0.005), anaerobic threshold of 11 ± 12% (P < 0.05) and peak O₂ pulse of 20 ± 19% (P < 0.05), while peak exercise lactate concentration was not higher after training. Interestingly, in the BiPAP group, peak exercise ventilation was also 17 ± 20% higher after training (P < 0.05). Furthermore, contrary to our expectation, at any given work rate, ventilation (and tidal volume) in the BiPAP group was higher in the post-training test as compared to the pre-training test, and the end tidal partial pressure of CO₂ at 55 watts was lower, 40 ± 4 and 38 ± 4 mmHg respectively (P < 0.05). No improvement in exercise capacity was observed after this short training period in the control group.

Conclusion: Pressure-supported ventilation during training is feasible in patients with severe COPD and it augments the training effect. The improved exercise tolerance was associated with higher ventilatory response and therefore lower P_ETCO₂[3] at equal work rates after training.

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[1] COPD = chronic obstructive pulmonary disease

[2] BiPAP = bi-level positive pressure ventilation

[3] P_ETCO₂ = end tidal partial pressure of CO₂
 

Background: Many medical school curricula include training for ethical considerations, legal comprehension, implementation of patients' rights, awareness of cultural differences and communication skills (ELCE).

Objectives: To explore medical students' perceptions of their ELCE training during the clinical phase as well as the relationship between humanistic practice skills' experiences and the quality of clinical training.

Methods: A cross-sectional survey was carried out in two cohorts during their clinical year period at Tel Aviv University's Sackler Faculty of Medicine at the end of their internal medicine and surgery clerkships in the 2002 academic year. The research tool was an 18 item Likert-type questionnaire (ELCEQ), based on the literature of biomedical ethics, legal aspects and behavior of practice skills. The content validation of the questionnaire was established by consulting experts among the school's faculty. It was circulated among the students by representatives of the Unit of Medical Education.

Results: The response rate was 88%. Students reported only a few opportunities for gaining experience in humanistic practice skills. A weak correlation was found between students' assessment of the quality of clinical training and their experiences in humanistic practice skills.

Conclusions: A wider and more relevant range of active experiences in humanistic practice skills should be available to students during the clerkships. Correspondingly, there is a need for the clinical faculty to find innovative ways to internalize their task as role models and ensure that students acquire and are able to practice those skills.
 

Background: The relationship between the amount of rehabilitation therapy and functional outcome in stroke patients has not been established.

Objectives: To evaluate the effectiveness of inpatient rehabilitation for post-acute stroke, and examine the relationship between intensity of therapies and functional status at discharge.

Methods: We evaluated 50 first-stroke patients, average age 63 years, in a prospective, descriptive study. The impairment and Functional Independence Measurement were assessed both at admission to rehabilitation and at discharge. Patients were monitored weekly during their stay by means of discipline-specific measures of activity level. Predictor variables included intensity of physical, occupational and speech therapies; demographic characteristics; length of stay; and time since the stroke.

Results: A significant reduction in impairment was observed at discharge. The predictors of gains and activity level at discharge as well as motor vs. cognitive components of the FIM[1] were neither consistent nor did they occur in the same trend of functional improvement. Greater FIM motor level at discharge was associated with younger age, higher admission motor and cognitive level, and receipt of any speech therapy, while greater FIM cognitive level was associated with higher cognitive level at admission, shorter interval from onset to admission, and more intense occupational therapy. More intense OT[2] was associated with greater and more cognitive improvement during the hospitalization.   

Conclusion: Since the sample was relatively small and heterogeneous in terms of the patients’ functional abilities, the findings cannot be generalized to the whole population of stroke patients. Further efforts to identify the best timing, modalities, intensity and frequency of the various treatments are needed to improve the cost-benefit equation of rehabilitation in stroke patients.

While some claim that germ-line engineering is a definite possibility, the law in Israel and in most countries states that it should be avoided. This paper suggests that using GLE[1] in order to ‘self-evolve’ (when it becomes safe) is not only inevitable but also morally justified. This paper argues that,  

• The great achievements of healthcare during the last century, enabling longer life, have made almost everyone prey to late-onset diseases.


• The conundrum of healthcare allocation is worsening, partly due to late-onset dysfunctional genes that have escaped the barriers of natural selection.


• Trying to free future generations from late-onset diseases (such as Alzheimer’s for instance) may be considered as ‘eugenics’ but, if pursued freely and justly, is a noble goal.


• We will be affecting future generations whether or not we use GLE.


• By definition, GLE might be reversible; it follows therefore that GLE may not necessarily represent the dramatic change inserted in the germ line forever – as is usually suggested.


• Reproductive freedom and justice are paramount in this scenario. These values are not necessarily incompatible if the right policies are in place.

Background: Various medical centers in Israel have recently incorporated electronic medical record systems. Knowing the EMR[1] systems’ features and pattern of use is an essential step for developing locally and nationally integrated systems.

Objectives: To evaluate the status of EMR systems in all major general hospitals in Israel in terms of the applications used and the patterns of use.

Methods: Structured questionnaires were sent to hospital directors and directors of medical informatics units of 26 general and pediatric hospitals serving the vast majority of the population in Israel. The qheuestionnaire included questions pertaining to the EMR systems, their usage and the attitude of the participants to data security issues.

Results: Of the 26 general hospitals 23 (88.4%) returned the questionnaires. Of these, 21 (91.3%) use EMR systems. Twenty-seven different types of systems are in use in Israeli hospitals, and generally more than one type is used in a hospital. [YD1] Physicians work with EMR systems in over 98% of the departments. Also, the EMR systems are used for clinical admission and discharge in over 90% of the departments and for medical daily follow-up in about 45%.

Conclusions: Most of the hospitals in Israel use EMR systems but there is no standard data model. Physicians are the main users but the amount of data entered is still limited. Adoption of standards is essential for integration of electronic patient records across Israeli healthcare organizations.

Background: Follow-up examinations in a rehabilitation center clinic after stroke are essential for coordinating post-acute services and monitoring patient progress. Of first-stroke patients discharged from our rehabilitation ward to the community 92% are invited for ambulatory check-up once every 6 months.

Objectives: To review patient complaints at follow-up and the recommendations issued by the attending physical medicine and rehabilitation specialist at the outpatient clinic.

Methods: We extracted relevant data from the records, and assessed the relationship between functional status on admission and discharge (measured by FIM[1]), length of stay, and number of complaints. Patients were divided according to the side of neurologic damage, etiology, whether the stroke was a first or recurrent event, and main clinical syndrome (neglect or aphasia).

Results: Patients' complaints included: decreased hand function (40%), general functional deterioration (20%), difficulty walking (11%), speech dysfunction (10%), various pains (especially in plegic shoulder) (8%), urine control (2%), sexual dysfunction (3%), swallowing difficulties (2%), and cognitive disturbances (2%). Patients received the following recommendations: physiotherapy (52.5%), occupational therapy (37.5%), speech therapy (12.5%), different bracing techniques (22.5%), pain clinic treatment (12.5%), changing medication prescriptions (7.5%), psychological treatment (10%), sexual rehabilitation (5%), vocational counseling (2.5%), counseling by social workers (2.5%), and recurrent neuropsychological diagnosis (2.5%). A reverse correlation was found between the number of complaints and FIM at admission (P = 0.0001) and discharge (P = 0.0003), and between LOS[2] and FIM at admission (P = 0.0001) and discharge (P = 0.004). A direct correlation was found between the number of complaints and LOS (P = 0.029). No relation was found between age, type of stroke, first and recurrent event, and clinical syndromes and patient complaints in the outpatient rehabilitation. Community rehabilitation services met 58% of all recommendations in 62% of patients, mainly physiotherapy and occupational therapy, with 34% of patients waiting for implementation of the recommendations and 4% not available for follow-up.

Conclusions: Follow-up examinations should be an integral part of post-stroke rehabilitation. Rehabilitation treatment in the community must be strengthened.

The management of uncontrolled bleeding in trauma patients is difficult in the prehospital setting, especially when transfer time to a care facility is prolonged. The goal of treatment is to stabilize the patient until surgery can be performed. In modern practice, the major aspects of optimal patient stabilization are the timing and volume of resuscitation and the use of blood products. The main problems are the logistics of handling the blood products as well as achieving the appropriate endpoint or resuscitation, while balancing the need to maintain blood pressure with the need to avoid deleterious coagulopathy. This work reviews current therapeutic modalities for prehospital management of uncontrolled bleeding trauma patients, namely low volume resuscitation, packed red blood cells, hemoglobin solutions, perfluorocarbons, hypertonic saline solutions, and recombinant activated factor VII.