S. Linden
Approximately 60% of all worldwide deaths are caused by chronic disease resulting from modifiable health behaviors. In the United States, structured programs tailored to identify and modify health behaviors of patients with chronic illness have grown into a robust industry called disease management. DM[1] is premised upon the basic assumption that health services utilization and morbidity can be reduced for those with chronic illness by augmenting traditional episodic medical care services and support between physician visits. Given that Israel and the U.S. have similar demographics in their chronically ill populations, it would make intuitive sense for Israel to replicate efforts made in the U.S. to incorporate DM strategies. This paper provides a conceptual framework of how DM could be integrated within the current organizational structure of the Israeli healthcare system, which is uniquely conducive to the implementation of DM on a population-wide basis. While ultimately the decision to invest in DM lies with stakeholders at various institutional levels in Israel, this paper is intended to provide direction and support for that decision-making process.
M. Shtalrid, L. Shvidel, E. Vorst, E.E. Weinmann, A. Berrebi and E. Sigler
Background: Post-transfusion purpura is a rare syndrome characterized by severe thrombocytopenia and bleeding caused by alloimunization to human platelet specific antigens following a blood component transfusion. The suggested incidence is 1:50,000–100,000 transfusions, most often occurring in multiparous women. The diagnosis is not easy because these patients, who are often critically ill or post-surgery, have alternative explanations for thrombocytopenia such as infection, drugs, etc.
Objectives: To describe patients with initially misdiagnosed PTP[1] and to emphasize the diagnostic pitfalls of this disorder.
Patients and Results: During a period of 11 years we have diagnosed six patients with PTP, four women and two men. The incidence of PTP was approximately 1:24,000 blood components transfused. We present the detailed clinical course of three of the six patients in whom the diagnosis was particularly challenging. The patients were initially misdiagnosed as having heparin-induced thrombocytopenia, systemic lupus erythematosus complicated by autoimmune thrombocytopenia, and disseminated intravascular coagulation. A history of recent blood transfusion raised the suspicion of PTP and the diagnosis was confirmed by appropriate laboratory workup.
Conclusions: PTP seems to be more frequent than previously described. The diagnosis should be considered in the evaluation of life threatening thrombocytopenia in both men and women with a recent history of blood transfusion.
E. Kaluski, Z. Gabara, N. Uriel, O. Milo, M. Leitman, J. Weisfogel, V. Danicek, Z. Vered and G. Cotter
Background: External counter-pulsation is a safe and effective method of alleviating angina pectoris, but the mechanism of benefit is not understood.
Objectives: To evaluate the safety and efficacy of external counter-pulsation therapy in heart failure patients.
Methods: Fifteen symptomatic heart failure patients (subsequent to optimal medical and device therapy) underwent 35 hourly sessions of ECPT[1] over a 7 week period. Before and after each ECPT session we performed pro-B-type natriuretic peptide and brachial artery function studies, administered a quality of life questionnaire, and assessed exercise tolerance and functional class.
Results: Baseline left ventricular ejection fraction was 28.1 ± 5.8%. ECPT was safe and well tolerated and resulted in a reduction in pro-BNP[2] levels (from 2245 ± 2149 pcg/ml to 1558 ± 1206 pcg/ml, P = 0.022). Exercise duration (Naughton protocol) improved (from 720 ± 389 to 893 ± 436 seconds, P = 0.0001), along with functional class (2.63 ± 0.6 vs. 1.93 ± 0.7, P = 0.023) and quality of life scores (54 ± 22 vs. 67 ± 23, P = 0.001). Nitroglycerine-mediated brachial vasodilatation increased (11.5 ± 7.3% vs. 15.6 ± 5.2%, P =0.049), as did brachial flow-mediated dilation (8.35 ± 6.0% vs. 11.37 ± 4.9%, P = 0.09).
Conclusions: ECPT is safe for symptomatic heart failure patients and is associated with functional and neurohormonal improvement. Larger long-term randomized studies with a control arm are needed to confirm these initial encouraging observations.
M. Klein, N. Weksler, A. Borer, L. Koyfman, J. Kesslin and G.M. Gurman
Background: Transport of hemodynamic unstable septic patients for diagnostic or therapeutic interventions outside the intensive care unit is complex but sometimes contributes to increasing the chance of survival.
Objective: To report our experience with terlipressin treatment for facilitation of transport to distant facilities for diagnostic or therapeutic procedures in septic patients treated with norepinephrine.
Methods: We conducted a retrospective analysis of the records of our ICU[1], identifying the patients with septic shock who required norepinephrine for hemodynamic support.
Results: Terlipressin was given to 30 septic shock patients (15 females and 15 males) who were on high dose norepinephrine (10 μg/min or more) in order to facilitate their transport outside the ICU. The dose of terlipressin ranged from 1 to 4 mg, with a mean of 2.13 ± 0.68 mg. The dose of norepinephrine needed to maintain systolic blood pressure above 100 mmHg decreased following terlipressin administration, from 21.9 ± 10.4 μg/min (range 5–52 μg/min) to 1.0 ± 1.95 (range 0–10) (P < 0.001). No patients required norepinephrine dose adjustment during transport. No serious complications or overshoot in blood pressure values were observed following terlipressin administration. Acrocyanosis occurred only in eight patients receiving more than 1 mg of the drug. The overall mortality rate was 50%.
Conclusions: Our data suggest that terlipressin is effective in septic shock. Because it is long-acting and necessitates less titration it might be indicated for patient transportation.
N. Hazanov, M. Attali, M. Somin, N. Beilinson, S. Goland, M. Katz and S.D.H. Malnick
Background: Despite the spleen having a very rich blood supply, there is a paucity of reports of splenic emboli.
Objectives: To investigate the incidence of splenic emboli treated in a single general internal medicine department over the last 3 years.
Methods: We examined the records of a 35 bed internal medicine department in a hospital in the center of Israel.
Results: Over a period of 3 years 13 patients admitted to one internal medicine department developed acute abdominal pain and areas of hypoperfusion in the spleen on contrast computed tomography imaging. The patients were treated with anticoagulants, their course was benign and there were no long-term sequelae.
Conclusions: Embolus to the spleen is not rare in an internal medicine department. Diagnosis can be easily made by contrast CT scanning and treatment with anticoagulants results in a good prognosis.
V.H. Eisenberg, D. Raveh, Y. Meislish, B. Rudensky, Y. Ezra, A. Samueloff, A.I. Eidelman and M.S. Schimmel
Background: Previous assessments of maternal group B Streptococcus carrier rates in women delivering at Shaare Zedek Medical Center ranged between 3.5 and 11% with neonatal sepsis rates of 0.2–0.9/1000 live births. Because of low colonization and disease rates, routine prenatal cultures of GBS[1] were not recommended, and intrapartum prophylaxis was mainly based on maternal risk factors.
Objectives: To determine whether this policy is still applicable.
Methods: We performed prospective sampling and follow-up of women admitted for labor and delivery between February 2002 and July 2002. Vaginal and rectal cultures were obtained before the first pelvic examination. GBS isolation was performed using selective broth medium, and identified by latex agglutination and serotyping. Demographic data were collected by means of a standardized questionnaire. Data on the newborns were collected throughout 2002.
Results: Of the 629 sampled women, 86 had a positive culture and a carrier rate of 13.7%. A borderline significantly higher carriage rate was observed among mothers of North American origin (21% vs. 13.1%, P = 0.048), and a higher attack rate in their infants (3.8/1000 compared with 0.5/1000 live births in our general maternal population, P = 0.002). Eight newborns had early-onset neonatal GBS sepsis (a rate of 0.8/1000 live births), but none of them benefited from intrapartum antibiotic prophylaxis.
Conclusions: An increased neonatal disease rate was observed in a population with a higher colonization rate than previously seen. In lieu of the higher carrier rates, we now recommend routine prenatal screening for GBS in our perinatal population.
H.S. Oster, M. Hoffman, S. Prutchi-Sagiv, O. Katz, D. Neumann and M. Mittelman
Recombinant human erythropoietin has become an essential part of the management of anemic patients with end-stage renal disease. It is also used to treat the anemia associated with cancer and other diseases, and it improves quality of life. In recent years, studies in animals and humans have focused on the use of rHuEPO[1] for other indications. It has been found to play a role in both cardioprotection and neuroprotection. It has effects on the immune system, and can cause regression in hematologic diseases such as multiple myeloma. It may also improve the response of solid tumors to chemotherapy and radiation therapy. On the other hand, concerns have been raised following two studies of patients with solid tumors in whom those treated with rHuEPO had diminished survival. Criticism of the design of these studies makes it clear that large, well-designed, randomized trials must be performed to determine the role of rHuEPO in the treatment of cancer, and more generally to clarify the full clinical benefits of the drug, while minimizing the harm.
N. Rosenberg and R. Dardik
O. Kostiuk, I. Levi, M. Krieger, Y. Assouline-Dayan and I. Barshack
L. Michael, T. Arazi-Kleinman, A. Yosephovich and S. Bar-Meir
R. Shihada, A. Brodsky and M. Luntz