Since the beginning of medical history, ethics has interested medical practitioners. The subject has become particularly important in recent years due to the huge advancements in medicine and medical technology and has elicited much public interest. While international ethical principles and guidelines have been established, classical Jewish tradition has always placed great emphasis on bioethics. Prof. Avraham Steinberg’s monumental Encyclopedia of Jewish Medical Ethics presents the subject comprehensively and in depth. We propose a bioethics syllabus, to be integrated into the medical curriculum in three stages: i) preclinical – covering basic ethical concepts and principles, relevant history, and ethical codes; ii) clinical  – covering bioethical topics relating to the human life cycle; iii) prior to students' final examinations and further specialization – covering bioethical topics relating to their personal interests. Steinberg’s Encyclopedia is an ideal basis for the development of a professional course, including Jewish traditional aspects. Such a course would provide future physicians with a varied cultural and intercultural background, help shape their image, and improve the quality of medical care.

It is common knowledge that in addition to the slaughter of millions of innocent civilians, Nazism caused direct damage to patient care by euthanasia of the handicapped, gruesome human experimentation, and ethnic cleansing of German medical schools. In gastroenterology, 53 prominent academicians living in Nazi-occupied Europe were persecuted by the Nazis. Prior studies analyzed this persecution as it related to gastroenterologists rather than to patient care. What is not known, however, is that Nazi persecution led to a delay of more than one generation in the clinical application of major inventions by these gastroenterologists. These included flexible fiberoptic endoscopy, which was delayed from 1930 to 1957. Fiberoptic transmission was invented by Heinrich Lamm in 1930. Lamm was exiled from Nazi Germany in 1936, and this technique was clinically applied to endoscopy by Hirschowitz only in 1957. Another innovation was fecal occult blood testing for early colon cancer detection, which was devised by Ismar Boas before 1938. Boas committed suicide under Nazi oppression in 1938 and this modality was clinically applied by Greegor only in 1967. The acceptance of refugees from Nazi Germany or Austria into America or into the future State of Israel helped mitigate some of this damage. For example, eight eminent academic gastroenterologists who fled Nazi-occupied countries to then mandatory Palestine made major contributions to the development of academic gastroenterology in the soon-to-be established State of Israel.

Background: Reports of burn injuries in children are usually made by highly specialized burn units. Our facility admits children with burns < 20% total body surface area, while those with major burns are transferred to burn units at tertiary care facilities.

Objectives: To review our experience with thermal burns.

Methods: We conducted a retrospective review of all thermal burns admitted to our hospital during a 5 year period.

Results: Among 266 patients (69.2% boys) aged 3.5 ± 3.6 years, children < 3 years old were the most frequently injured (64.7%). Scalds (71.4%) were the most common type of burn. Partial thickness burns were sustained by 96.6% of children and TBSA[1] burned was 4.2 ± 3.6%. The mean hospital stay was 3.8 ± 4.5 days, and was significantly prolonged in girls (4.6 ± 4.8 vs. 3.5 ± 4.3 days, P = 0.01). Percent TBSA burned was correlated with patient age (r = 0.12, P = 0.04) and length of hospital stay (r = 0.6, P < 0.0001). Six patients (2.3%) (mean age 3.4 ± 2.3 years) were hospitalized in the Pediatric Intensive Care Unit due to toxin-mediated illness.

Conclusions: Children under the age of 3 years are at increased risk for burn injury, but older children sustain more extensive injuries. Prevention and awareness are needed for child safety.

There has been a paradigm shift in the treatment of rheumatoid arthritis in recent years. Early and aggressive treatment with good control of disease activity has improved the prognosis of the disease, however, there is significant variability in the response of patients to different therapeutic agents. Hence it is essential to find the predictors of response to a drug at baseline so that we can avoid the delay in achieving remission and improve the outcome. Here we review the literature on available predictors for treatment response in general and specifically for methotrexate and biological agents. We also look at specific scores or indices that can help predict the response in individual patients.

Chronic fatigue syndrome is a heterogeneous disorder with unknown pathogenesis and etiology, characterized by disabling fatigue, difficulty in concentration and memory, and concomitant skeletal and muscular pain. Several mechanisms have been suggested to play a role in CFS[1], such as excessive oxidative stress following exertion, immune imbalance characterized by decreased natural killer cell and macrophage activity, immunoglobulin G subclass deficiencies (IgG-1[2], IgG-3) and decreased serum concentrations of complement component. Autoantibodies were also suggested as a possible factor in the pathogenesis of CFS. Recent studies indicate that anti-serotonin, anti-microtubule-associated protein 2 and anti-muscarinic cholinergic receptor 1 may play a role in the pathogenesis of CFS. It has been demonstrated that impairment in vasoactive neuropeptide metabolism may explain the CFS symptoms

Background: In the western world, trauma is the leading cause of disability and mortality in the 1–39 years age group. Road accidents constitute the most frequent cause of mortality among children older than 1 year and falls from a height are the most frequent cause of injuries requiring hospitalization.

Objectives: To analyze the epidemiology and characteristics of severe pediatric trauma due to falls from a height in northern Israel. This analysis should aid in planning an effective intervention plan.

Methods: This observational study included all patients aged 0–14 who died or were admitted to an intensive care unit in northern Israel following a steep fall. Demographic and clinical data were collected retrospectively for 3 years and prospectively for 1 year.

Results: A total of 188 children were severely injured or died following such a fall, with an annual rate of 11.4 per 100,000 children. Over 85% of severe injuries due to falls occurred among non-Jewish children, with an incidence rate 6.36 times higher than among Jewish children (20.17 and 3.17 per 100,000 children, respectively). In the non-Jewish sector 93.7% of the falls occurred at or around the child’s home, mainly from staircases, balconies and roofs.

Conclusions: A very high incidence of severe trauma due to domestic falls from a height was found among non-Jewish children in northern Israel. Domestic falls represent an important epidemiological problem in the non-Jewish pediatric sector, and an effective prevention plan should include measures to modify parents’ attitudes towards safety issues and the creation of a safe domestic environment.
 

Background: Asthma control and treatment compliance are widely investigated issues around the world. Studies have demonstrated relatively low asthma compliance and control in 40–90% of asthma patients in different countries. There are no available data on the Israeli adult asthmatic population

Objectives: To investigate the level of asthma control and compliance in adult asthmatic patients.

Methods: This cross-sectional study of consecutive adult asthmatic patients visiting the pulmonary clinic used a combined questionnaire that included demographics, data on asthma severity and management, and asthma control and compliance scores. Each patient was interviewed and questionnaires were filled out during a routine visit.

Results: The study group comprised 142 males (35.4%) and 259 females (64.6%). Compliance was found optimal in 8 patients (2%), fair in 146 (36%), partial in 156 (39%) and poor in 92 (23%) of the participating asthmatic patients. Asthma control was found optimal in 26 (7%), fair in 124 (31%), partial in 122 (30%) and poor in 129 (32%) patients. Sephardic and Ashkenazi Jewish origin, higher level of education, and treatment protocol including either single fixed-dose inhalers or short-acting beta-agonist bronchodilators significantly improved compliance in our cohort. Socioeconomic status and compliance were found to positively affect asthma control, whereas active smoking negatively affected asthma control in the study patients.

Conclusions: The figures of optimal asthma control and compliance to treatment in Israeli adult asthmatics are low and worse than reported in other studies abroad.
 

Background: Left ventricular outflow gradient is associated with increased morbidity and mortality in hypertrophic cardiomyopathy. Alcohol septal ablation is the alternative to surgery in cases refractory to drug therapy. The implication of LVOG[1] measured 1 week post-ASA[2] for prediction of outcome is unknown.

Objective: To observe the pattern of LVOG course and prediction of long-term clinical and hemodynamic outcome of ASA.

Methods: Baseline clinical and echocardiographic parameters were prospectively recorded in 14 consecutive patients with a first ASA, at the time of ASA, 3 and 7 days after ASA (in-hospital) and 3 and ≥ 12 months after ASA (last follow-up).

Results: There was improvement in NYHA class, exercise parameters and LVOG in 11 of 14 patients (P < 0.005 in all). Maximal creatine kinase level was lower than 500 U/L in those without such improvement and 850 U/L or higher in successful cases. LVOG dropped from 79 ± 30 to 19 ± 6 mmHg after the ASA. LVOG was 50 ± 21 mmHg on day 3, 39 ± 26 on day 7, 32 ± 26 at 3 months and 24 ± 20 mmHg at last follow-up. LVOG identified 27% sustained procedural successes on day 3 and 73% on day 7. The overall predictive accuracy of the test for sustained success and failure was 36% on day 3 and 71% on day 7. Combination of maximal CK[3] and LVOG on day 7 showed four distinct outcome patterns: "early success" with low LVOG and high CK (73% of successful cases), "late success" with high LVOG and high CK, and "early failure" and "late failure" with both low CK and high or low LVOG, respectively
Conclusion: LVOG measurement 7 days post-ASA combined with maximal CK levels predicts late procedural outcome in the majority of patients

Background: Spontaneous coronary reperfusion occurs in 7–27% of patients with ST elevation myocardial infarction, and is an independent predictor of myocardial salvage, percutaneous coronary intervention success, and improved outcome.

Objectives: To determine the optimal PCI[1] time for patients admitted to the hospital due to STEMI[2] with SCR[3].

Methods: We performed a retrospective analysis of all patients admitted to the coronary care unit between July 2002 and November 2004 with a diagnosis of STEMI with SCR.

Results: The study group comprised 86 patients. There was not a single reinfarction episode during an observation period of 6579 patient hours. Cardiac catheterization was executed early (< 24 hours from pain onset) in 26 patients and late (> 24 hours) in 55. Pre-PCI angiographic TIMI flow 2–3 was seen in > 95% in both groups. PCI was performed more frequently in the “early” group (P = 0.024), while multi-vessel coronary artery disease (P = 0.094) requiring coronary bypass surgery (P = 0.056) was observed more frequently in the “late catheterization” group. Myocardial infarction and angina pectoris at 30 days occurred more frequently in the early catheterization group (P = 0.039), however no difference in any major adverse cardiac events was detected during long-term follow-up (491 ± 245 days).

Conclusions: Reinfarction after STEMI with SCR is a rare event. Early PCI in patients with STEMI and SCR, even when executed with aggressive anti-platelet therapy, seems to result in an excess of early MACE, without any long-term advantage. Prospective randomized trials should determine the optimal PCI timing for these patients.