Israel Medical Association Journal

Background: Control of diabetes is challenging, and frequent treatment changes are needed. 

Objective: To study the effect of the recommendation to start insulin glargine or insulin determir (long-acting insulin treatment, LAI) at discharge from hospital, on glucose control in the community setting.

Methods: Included were type II diabetes patients who were referred to and received a consultation from the hospital diabetes clinic during their hosptialization, as part of a routine consultation for diabetes management. During the visit, all patients were recommended long-acting insulin-based treatment, as inpatient treatment and at discharge. Follow-up was done by the primary physician in the community or by a community-based diabetes clinic. Glycosylated hemoglobin, glucose levels and other laboratory tests were obtained from the community health records before hospitalization and 6–12 months later. Medical treatment was ascertained by reviewing the actual usage of prescriptions.

Results: Eighty patients (58% males, mean age 64.1 ± 12.7 years) were included in the analysis. HbA1c levels were 10.1 ± 2.4% before admission, but improved significantly at follow-up (8.6 ± 2.2%, P < 0.001). Seventy-one percent of the patients were taking the LAI treatment and the rest were using non-LAI medications. Changes in diabetes control were similar between the LAI and non-LAI groups (HbA1c was reduced by 1.5 ± 3.2% and 1.9 ± 3.1% respectively). The rate of repeated admissions was also similar, averaging at 1.3 admissions for both groups, the minority of which were related to glucose control.

Conclusions: Insulin glargine or determir-based treatment does not show any superiority over other anti-diabetes treatment. It is our opinion that this treatment should be used as tailored therapy and should not be recommended routinely to all patients.
 

Background: Primary liver masses in children may require intervention because of symptoms or concern about malignant transformation.

Objectives: To review the management and outcomes of benign liver masses in children. Methods: We conducted a retrospective chart review of children with liver masses referred to our institution during the period 1997–2009.

Results: Benign liver masses were identified in 53 children. Sixteen of these children (30%) had hemangioma/infantile hepatic hemangioendothelioma (IHH) and 15 (28%) had focal nodular hyperplasia. The remainder had 6 cysts, 4 hamartomas, 3 nodular regenerative hyperplasia, 2 adenomas, 2 vascular malformations, and one each of polyarteritis nodosa, granuloma, hepatic hematoma, lymphangioma, and infarction. Median age at presentation was 6 years, and 30 (57%) were female. Masses were initially noticed on imaging studies performed for unrelated symptoms in 33 children (62%), laboratory abnormalities consistent with liver disease in 11 (21%), and palpable abdominal masses in 9 (17%). Diagnosis was made based on characteristic radiographic findings in 31 (58%), but histopathological examination was required for the remaining 22 (42%). Of the 53 children, 27 (51%) were under observation while 17 (32%) had masses resected. Medications targeting masses were used in 9 (17%) and liver transplantation was performed in 4 (8%). The only death (2%) occurred in a child with multifocal IHH unresponsive to medical management and prior to liver transplant availability.

Conclusions: IHH and focal nodular hyperplasia were the most common lesions. The majority of benign lesions were found incidentally and diagnosed radiologically. Expectant management was sufficient in most children after diagnosis, although surgical intervention including liver transplant was occasionally necessary.
 

Background: Whereas procoagulation abnormalities in acute stress are well established, little is known about the mechanism of hypercoagulation in chronic stress, such as post-traumatic stress disorder (PTSD). This is crucial, given the fact that chronic coagulation disturbances have been associated with increased morbidity and premature mortality due to thromboembolism and cardiovascular disorders, complications recently described in PTSD patients.

Objectives: To explore the mechanisms of hypercoagulation in chronic PTSD.

Methods: Thirty patients diagnosed with chronic PTSD were enrolled and compared with a control group matched for age, gender and ethnicity. Hypercoagulation state was evaluated by levels of fibrinogen, D-dimer, prothrombin fragment F 1+2, von Willebrand factor (vWF) antigen, factor VIII activity, activated protein C resistance, ProC Global assay, and tissue factor antigen. Psychiatric evaluation was performed using the Mini-International Neuropsychiatric Interview and Clinician Administered PTSD Scale (CAPS).

Results: vWF antigen levels were significantly higher in patients with chronic PTSD compared with the controls (121.3 ± 42 vs. 99.7 ± 23, respectively, P = 0.034). Higher levels of vWF antigen and factor VIII activity were found in patients with severe chronic PTSD (CAPS > 80), compared to controls and patients with chronic PTSD and less severe symptoms (CAPS ≤ 80). However, no differences were observed in any other studied coagulation parameters between patients and controls.

Conclusions: Increased levels of vWF antigen and factor VIII activity were documented in severe chronic PTSD. These findings suggest that the higher risk of arterial and venous thromboembolic events in PTSD patients could be related to endothelial damage or endothelial activation.
 

Background: A crucial part of controlling blood pressure is non-pharmaceutical treatment. However, only a few studies specifically address the question of hypertensive patients’ compliance with physicians’ recommendations for a healthy lifestyle.

Objectives: To explore factors associated with hypertensive patients’ compliance with lifestyle recommendations regarding physical activity, smoking cessation and proper diet.

Methods: We performed a secondary data analysis of a representative sample of 1125 hypertensive patients in Israel's two largest health funds. Data were collected in 2002–2003 by telephone interviews using structured questionnaires. The response rate was 77%. Bivariate and multivariate analysis was conducted.

Results: About half of the hypertensive patients reported doing regular exercise and adhering to a special diet; 13% were smokers. About half reported receiving counseling on smoking cessation and diet and a third on physical exercise. A quarter reported receiving explanations regarding self-measurement of blood pressure and signs of deterioration. Multivariate analysis revealed that patients’ beliefs about hypertension management, their knowledge on hypertension and its management, and physician counseling on a healthy lifestyle and self-care, have an independent effect on compliance with recommended lifestyle behaviors.

Conclusions: The low counseling rates suggest that there may be a need to improve physicians’ counseling skills so that they will be more confident and effective in delivering this service to their patients. A model based on educating both physicians and patients may contribute to improving the care of hypertensive patients.
 

Ultrasonography in the intensive care unit (ICU) has become a valuable tool for expeditiously, safely and effectively diagnosing and treating a myriad of conditions commonly encountered in this setting. Most surgeons are familiar with FAST (focused assessment with sonography in trauma) and can readily grasp the fundamentals of a limited or directed ultrasonographic exam. Thus, with appropriate training and practice, surgeons can utilize this tool in visualizing, characterizing and treating life-threatening conditions in their role as intensivists in the surgical ICU (SICU). In this review we will discuss the role of ultrasonography in evaluating the acute cardiac status of a patient in the SICU as well as its use in general critical care for assessing the thoracic, abdominal and vascular systems.
 

Attention deficit hyperactivity disorder (ADHD) is among the most prevalent chronic health disorders affecting school-age children. The disorder is the subject of much debate for several reasons, the major one being the diagnostic process, which in some aspects is unstructured and can be relatively easily biased. The impact of undiagnosed or misdiagnosed ADHD on the lives of many children can be severe. Therefore, it is important to understand the complexities of the diagnostic procedure in ADHD, including the cultural bias effect, the limitations of the DSM-IV-TR definitions, the effect of comorbid conditions on the diagnostic process, the gene-environment interactions, and the need to compose an objective, more accurate, and generally accepted diagnostic battery of tests. This review addresses the diagnostic difficulties of ADHD and considers some steps that would make ADHD a more easily identifiable disorder.
 

Background: The marijuana plant cannabis is known to have therapeutic effects, including improvement of inflammatory processes. However, no report of patients using cannabis for Crohn’s disease (CD) was ever published.

Objectives: To describe the effects of cannabis use in patients suffering from CD.

Methods: In this retrospective observational study we examined disease activity, use of medication, need for surgery, and hospitalization before and after cannabis use in 30 patients (26 males) with CD. Disease activity was assessed by the Harvey Bradshaw index for Crohn’s disease.

Results: Of the 30 patients 21 improved significantly after treatment with cannabis. The average Harvey Bradshaw index improved from 14 ± 6.7 to 7 ± 4.7 (P < 0.001). The need for other medication was significantly reduced. Fifteen of the patients had 19 surgeries during an average period of 9 years before cannabis use, but only 2 required surgery during an average period of 3 years of cannabis use.

Conclusions: This is the first report of cannabis use in Crohn’s disease in humans. The results indicate that cannabis may have a positive effect on disease activity, as reflected by reduction in disease activity index, and in the need for other drugs and surgery. Prospective placebo-controlled studies are warranted to fully evaluate the efficacy and side effects of cannabis in CD.
 

Background: The treatment of rectal cancer has changed significantly over the last few decades. Advanced surgical techniques have led to an increase in the rate of sphincter-preserving operations, even for low rectal tumors. This was facilitated by preoperative oncologic treatment and the use of chemoradiation to downstage the tumor before resection. The introduction of total mesorectal excision further improved the oncologic outcome and became the standard of care. The use of laparoscopy for rectal resection is the most recent addition to this series of improvements, but in contrast to the use of laparoscopy in colon cancer its role is not yet well defined.

Objectives: To present our experience with laparoscopic surgery for upper and lower rectal tumors.

Methods: A database was used to prospectively collect all data on laparoscopic rectal surgery in our department since we started performing these procedures in 1997. Follow-up data were collected from outpatient clinic visits, oncology files and telephone interviews. Updated survival data were retrieved from the national census.

Results: Of 750 laparoscopic colorectal procedures performed over a 13 year period, 67 were for rectal cancer. Of these, 29 were resections for tumors in the upper rectum (11–15 cm from the anal verge) and 38 for tumors at 10 cm or below. Surgery was performed in 24 patients after neoadjuvant chemoradiation. There were 54 sphincter-preserving operations and 13 abdominoperineal resections. The mean operative time was 283 minutes. Conversion to an open procedure was required in 22% of the cases. Anastomotic leaks occurred in 17% of cases. Postoperative mortality was 4.5%. Long-term follow-up was available for 77% of the group, for a mean period of 42 months. Local recurrence was diagnosed in 4.5% of the patients and overall 5 year survival was 68%.

Conclusions: Laparoscopic rectal resection is a demanding procedure. However, laparoscopy may become the preferred approach since it is a minimally invasive procedure and has an acceptable oncologic outcome that is comparable to the open approach. This conclusion, however, needs further validation.