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עמוד בית Fri, 23.08.19

May 2012


Focus
Y. Gofin, A. Afek, E. Derazne, A. Toker and A. Shamiss

Background: The medical workforce shortage worldwide varies for different residencies.

Objectives: To determine future gaps in medical specialties in Israel by means of a model and to identify trends and considerations among medical students when they choose their residencies.

Methods: The gap (Gi) assessment model was based upon current demand (Di) and existing (Ei) status for each residency, using the formula [Gi=(Di-Ei)/Ei]. Ei represented the proportion of specific residencies in 2006–2010 out of all Israeli residency graduates and Di was based upon questionnaires filled out by medical students at Sackler and Hadassah medical schools in Tel Aviv and Jerusalem respectively (N=909).

Results: The largest relative shortages (Gi ranges from -1 to 1) were in Pathology (G=-1), Rehabilitation Medicine (-0.9), Radiology (-0.8), General Practice (-0.8) and Anesthesiology (-0.8). The highest relative demands were in Surgical subspecialties (2.9) and Obstetrics/Gynecology (OB/GYN) (1.6). More females than males chose residencies in OB/GYN (19.5% vs. 7.1%, P < 0.001) and pediatrics (28.1% vs. 15.4%, P < 0.001). Surgery subspecialties (9% vs. 23.7%, P < 0.001) were male-predominant. The workload consideration was rated higher among females, while income was rated higher among males. Among students in clinical years, compared to pre-clinical, there was a decline in the selection of some professions, including Surgical subspecialties (9.7% vs. 19.5%, P < 0.001).

Conclusions: The suggested model, based on a survey of demand and current or projected future needs, can be used to assess gaps and plan early interventions. Programs at the level of medical school may affect residency preferences. The decline in selection of surgical professions and the increasing workload as a consideration for residency choice should be given attention.

 


D. Amital, H. Amital, G. Shohat, Y. Soffer and Y. Bar-Dayan

Background: On 4 February 2008, two terrorists armed with suicide bombs arrived at the open market in the southern Israeli city of Dimona. One detonated his bomb at approximately 10:30 a.m. causing multiple casualties. Short-term emotional effects and acute stress reactions usually appear among survivors after such incidents.

Objectives: To compare the differences in emotions and in disturbances of daily life activities that emerge a couple of days following such an event and to identify patterns of stress development among resilient and low-resilient members of the population in Dimona and in the general population of Israel.

Methods: A telephone survey of two randomly selected representative samples of adults (428 Israeli residents and 250 Dimona residents) was conducted 2 days after the event.

Results: A higher prevalence of stress and fear and a lower prevalence of joy were reported among the population of Dimona compared to the general population in Israel (P < 0.05). Differences were also recorded when the population of Dimona was categorized by their personal degree of resilience (P < 0.05). A higher prevalence of disturbances in daily life activities and changes in leisure activity was found in the low-resilient population in Dimona (P < 0.01).

Conclusions: This study demonstrates that following a public terror event, self-reported low-resilient subjects have a higher prevalence of disturbances in daily life activities, as well as adverse emotional responses. These differences must be addressed by the relevant social service agencies for immediate public intervention

Original Articles
A. Zamora-Ustaran, R.O. Escarcega-Alarcón, M. Garcia-Carrasco, E. Faugier, S. Mendieta-Zeron, C. Mendoza-Pinto, Á. Montiel-Jarquin, M. Muñoz-Guarneros, A. Lopez-Colombo and R. Cervera

Background: Data on pediatric antiphospholipid syndrome (APS) are very sparse.

Objectives: To describe the main clinical characteristics, laboratory data and complications of pediatric APS patients, and to analyze the differences between primary APS and APS associated with systemic lupus erythematosus (SLE).

Methods: We retrospectively reviewed clinical and laboratory data of 32 children at “Federico Gomez,” the children’s hospital of México. Nineteen patients had SLE, 12 (37.5%) had primary APS and 1 (3%) had immune thrombocytopenic purpura. We collected information on sociodemographic variables, vaccinations, age at onset, and family history of rheumatic disease, hematological disorders, skin disorders and non-thrombotic neurological disorders. Immunological features included immunoglobulin (Ig) G and M aCl antibodies, IgG and IgM b2 glycoprotein I, lupus anticoagulant, anti-dsDNA and antinuclear antibodies.

Results: The patients included 24 females and 8 males. The most common thrombotic events were small vessel thrombosis (44%), venous thrombosis (28%) mainly deep venous thrombosis (DVT) in lower extremities, and arterial thrombosis (25%). The most common clinical non-thrombotic manifestations were hematological (53%) and neurological disorders (22%). There were no significant differences between groups with regard to the site of thrombosis, non-thrombotic clinical manifestations or laboratory features.

Conclusions: There were some important differences between the clinical manifestations of APS in children compared with adults, but we found no significant differences between patients with primary and APS associated with SLE. Larger studies in Latin American APS children are necessary to determine whether there are differences between ethnic groups.

 


D. Antonelli, D. Peres and Y. Turgeman
Background: Alcohol consumption in Israel has increased over the last 20 years. Patients with alcohol use disorder (AUD) who present at a hospital enable early intervention. Objectives: To examine, for the first time, the characteristics of AUD patients in an Israeli general hospital, including whether their alcohol use is documented in their file.

Methods: A group of 178 consecutive patients referred for psychiatric consultation was compared to a second group of 105 hospitalized patients who were not referred. These two groups were studied to compare risk factors for AUD. Patients in both groups were prospectively interviewed using a CAGE questionnaire, demonstrated as an effective screening instrument for AUD. Patients’ files in both groups were examined for documentation of alcohol use.

Results: There was no significant difference between the prevalence of AUD in the two groups. The groups were then merged since no significant difference in the risk factor effects between the two groups was found. The risk factors for AUD in the final statistical analysis were lower educational status, living alone, being born in the Former Soviet Union and weaker religious observance. Post-traumatic stress disorder (PTSD), cigarette smoking and substance use were found to be independent risk factors. Soldier status was associated with significant alcohol misuse and AUD (CAGE1–4). Alcohol consumption was documented in the files of AUD patients in 48% of the first group and 21% of the second.

Conclusions: Physicians often neglect to take a history of alcohol consumption. Routine use of the CAGEquestionnaire is recommended in Israeli general hospitals. Special attention should be given to PTSD patients and to soldiers.
S. Jaworowski, D. Raveh, J.-L. Golmard, C. Gropp and J. Mergui

Background: Alcohol consumption in Israel has increased over the last 20 years. Patients with alcohol use disorder (AUD) who present at a hospital enable early intervention. Objectives: To examine, for the first time, the characteristics of AUD patients in an Israeli general hospital, including whether their alcohol use is documented in their file.

Methods: A group of 178 consecutive patients referred for psychiatric consultation was compared to a second group of 105 hospitalized patients who were not referred. These two groups were studied to compare risk factors for AUD. Patients in both groups were prospectively interviewed using a CAGE questionnaire, demonstrated as an effective screening instrument for AUD. Patients' files in both groups were examined for documentation of alcohol use.

Results: There was no significant difference between the prevalence of AUD in the two groups. The groups were then merged since no significant difference in the risk factor effects between the two groups was found. The risk factors for AUD in the final statistical analysis were lower educational status, living alone, being born in the Former Soviet Union and weaker religious observance. Post-traumatic stress disorder (PTSD), cigarette smoking and substance use were found to be independent risk factors. Soldier status was associated with significant alcohol misuse and AUD (CAGE1–4). Alcohol consumption was documented in the files of AUD patients in 48% of the first group and 21% of the second.

Conclusions: Physicians often neglect to take a history of alcohol consumption. Routine use of the CAGEquestionnaire is recommended in Israeli general hospitals. Special attention should be given to PTSD patients and to soldiers.
 

L. Barski, R. Nevzorov, E. Rabaev, A.B. Jotkowitz, I. Harman-Boehm, M. Zektser, L. Zeller, E. Shleyfer and Y. Almog

Background: Diabetic ketoacidosis (DKA) is a common and serious complication of diabetes mellitus (DM).

Objectives: To evaluate the clinical characteristics, hospital management and outcomes of patients with DKA.

Methods: We performed a retrospective cohort study of patients hospitalized with DKA during the period 1 January 2003 to 1 January 2010. Three groups were compared: patients with mild DKA, with moderate DKA, and with severe DKA. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30 days all-cause mortality, length of hospital stay, and complication rate.

Results: The study population comprised 220 patients with DKA. In the mild (78 patients) and moderate (116 patients) groups there was a higher proportion of patients with type 1 DM (75.6%, 79.3%) compared with 57.7% in the severe group (26 patients, P = 0.08). HbA1C levels prior to admission were high in all three groups, without significant difference (10.9 ± 2.2, 10.7 ± 1.9, and 10.6 ± 2.4 respectively, P = 0.9). In all groups the most frequent precipitating factors were related to insulin therapy and infections. The patients with severe DKA had more electrolyte abnormalities (hypokalemia, hypomagnesemia, hypophosphatemia) compared with the mild and moderate forms of the disease. While 72.7% of the entire cohort was hospitalized in the general medical ward, 80.8% of those with severe DKA were admitted to the intensive care unit. The in-hospital mortality rate for the entire cohort was 4.1%, comparable with previous data from experienced centers. Advanced age, mechanical ventilation and bedridden state were independent predictors associated with 30 day mortality: hazard ratio (HR) 1.1, 95% confidence interval (CI) 1.02–1.11; HR 6.8, 95% CI 2.03–23.1; and HR 3.8, 95% CI 1.13–12.7, respectively.

Conclusions: Patients with DKA in our study were generally poorly controlled prior to their admission, as reflected by high HbA1c levels. Type 2 DM is frequently associated with DKA including the severe form of the disease. The most common precipitating factors for the development of DKA were related to insulin therapy and infections. Advanced age, mechanical ventilation and bedridden state were independent predictors of 30 day mortality.
 

O. Wolf, M. Westreich and A. Shalom

Background: There are two main approaches to breast reduction surgery today: the traditional long scar ("Wise-pattern") technique and the more recent short ("vertical") scar technique, which is becoming more popular. During the last two decades there has been a gradual shift between the two techniques, including in our institute.

Objectives: To evaluate the evidence behind this obvious trend.

Methods: We retrospectively collected data from archived hospital charts of all patients who underwent breast reduction surgery during the period 1995–2007. Epidemiological, clinical and postoperative data were analyzed and compared between patients who were operated on by means of the short scar vs. the long scar techniques.

Results: During the study period 91 patients underwent breast reduction surgery in our department: 34 with the Wise-pattern breast reduction technique and 57 with the short-scar procedure. There was no significant difference in operative and postoperative data, including length of hospital stay. In some of the categories there was even a slight advantage (but not statistically significant) to the former. The only significant difference was the size of reduction, with a tendency to prefer the long scar technique for larger reductions; however, with gained experience the limit for short scar reductions was gradually extended to a maximum of 1470 g.

Conclusions: We noticed a sharp increase in the safe and uneventful practice of the short scar technique in breast reduction in our institute for removing ≤ 1400 g – especially in young women without extreme ptosis. This observation, together with other advantages, namely, reduced scar length, prolonged shape preservation and better breast projection, support use of this technique.
 

Reviews
J. Mejia-Gomez, T. Feigenber, S. Arbel-Alon, L. Kogan and A. Benshushan

For the past 15 years gynecological oncologists have been seeking ways to preserve woman’s fertility when treating invasive cervical cancer. For some women with small localized invasive cervical cancers, there is now hope for pregnancy after treatment. Many cases of cervical cancer are diagnosed in young woman who wish to preserve their fertility. As more women are delaying childbearing, fertility preservation has become an important consideration. The standard surgical treatment for stage IA2-IB1 cervical cancer is a radical hysterectomy and bilateral pelvic lymphadenectomy. This surgery includes removal of the uterus and cervix, radical resection of the parametrial tissue and upper vagina, and complete pelvic lymphadenectomy. Obviously the standard treatment does not allow women future childbearing. Radical trachelectomy is a fertility-sparing surgical approach developed in France in 1994 by Dr. Daniel Dargent for the treatment of early invasive cervical cancer. Young women wishing to bear children in the future may be candidates for fertility-preservation options. The radical trachelectomy operation has been described and performed abdominally, assisted vaginally by laparoscopy and robotically. In this review we discuss the selection criteria for radical trachelectomy, the various possible techniques for the operation, the oncological and obstetric outcomes, and common complications.

 


Case Communications
הבהרה משפטית: כל נושא המופיע באתר זה נועד להשכלה בלבד ואין לראות בו ייעוץ רפואי או משפטי. אין הר"י אחראית לתוכן המתפרסם באתר זה ולכל נזק שעלול להיגרם. כל הזכויות על המידע באתר שייכות להסתדרות הרפואית בישראל. מדיניות פרטיות
ז'בוטינסקי 35 רמת גן, בניין התאומים 2 קומות 10-11, ת.ד. 3566, מיקוד 5213604. טלפון: 03-6100444, פקס: 03-5753303