Israel Medical Association Journal

Objectives: To assess the prevalence of metabolic syndrome and different glucose intolerance states in healthy, overweight Arab individuals attending a primary healthcare clinic in Israel.

Methods: We randomly recruited 95 subjects attending a primary healthcare clinic who were healthy, overweight (body mass index >27) and above the age of 40. Medical and family history was obtained and anthropometric parameters measured. Blood chemistry and oral glucose tolerance test were performed after overnight fasting.

Results: Twenty-seven percent of the subjects tested had undiagnosed type 2 diabetes according to WHO criteria, 42% had impaired fasting glucose and/or impaired glucose tolerance and only 31% had a normal OGTT[1]. Metabolic syndrome was found in 48% according to criteria of the U.S. National Cholesterol Education Program, with direct correlation of this condition with BMI[2] and insulin resistance calculated by homeostasis model assessment. Subjects with metabolic syndrome had a higher risk for abnormality in glucose metabolism, and the more metabolic syndrome components the subject had the higher was the risk for abnormal glucose metabolism. Metabolic syndrome predicted the result of OGTT with 0.67 sensitivity and 0.78 specificity. When combined with IFG[3], sensitivity was 0.83 and specificity 0.86 for predicting the OGTT result.

Conclusions: According to our initial evaluation approximately 70% of the overweight Arab population in Israel has either metabolic syndrome or abnormal glucose metabolism, indicating that they are at high risk to develop type 2 diabetes and cardiovascular morbidity and mortality. This population is likely to benefit from an intervention program.

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[1] OGTT = oral glucose tolerance test

[2] BMI = body mass index

[3] IFG = impaired fasting glucose
 

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
 

Objectives: To determine to what extent the current Centers for Disease Control guidelines are practiced in Israel, the reasons for their adoption or rejection, and the need for local official guidelines.

Methods: A telephone questionnaire was conducted of all 27 delivery units in Israel. Answers were obtained from 26, either from the clinical director or the senior obstetrician in charge at the time of the interview.

Results: Only in 2 of the 26 delivery units (8%) are the CDC[1] guidelines adhered to exactly; in 6 units they are deliberately rejected, and in 8 units they are not practiced, although they are allegedly implemented. Thus, the CDC guidelines are not practiced in 14 delivery units (54%). Medico-legal consideration is the sole or major reason for adopting these guidelines in 80% (16/20) of the delivery units where they are seemingly implemented. In the majority of these units (18/20) there is readiness to abandon current practice, should local guidelines differ from those of the CDC, provided that local guidelines are issued by an authoritative source.

Conclusion: CDC guidelines are either deliberately rejected or incorrectly practiced in most Israeli delivery units. The medico-legal argument is one of the main reasons for practicing these guidelines. Since the CDC guidelines probably do not apply in Israel, official local guidelines are urgently needed.

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[1] CDC = Centers for  Disease Control

Objective: To identify risk factors and associated conditions that may cause TdP[1] in patients on chronic amiodarone treatment.

Methods: We reviewed the data of six consecutive patients on chronic amiodarone treatment who were admitted to the intensive cardiac care unit due to syncope and TdP.

Results: The patients’ median age was 73.5 years, and five were women. Concomitantly, loratadine was given to two patients and trazodone to one patient. Associated and attributing conditions to the development of TdP were hypokalemia in three patients, drug-induced bradycardia in one and reduced left ventricular function in four.

Conclusions: TdP associated with chronic amiodarone treatment may occur when amiodarone is co-administered with drugs that may potentially prolong QT interval. Additional risk factors for amiodarone-associated TdP include female gender, hypokalemia, reduced left ventricular function and bradycardia.

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[1] TdP = torsade de pointes

Objectives: To report on our initial experience over a 7 month period with an eight-bed mechanical ventilation weaning unit.

Methods: Sixty-nine patients requiring MV[1] for >10 days were admitted to the unit (nurse:patient ratio 1:4). Data collected included reason for MV, duration of hospital stay, and MVWU[2] course. Outcome results (successful weaning and mortality) were compared to those in historic controls (patients ventilated in the general wards over a 4 month period prior to the MVWU; n = 100).

Results: The mean age of the patients was 68 ± 16.6 years and hospital stay prior to MVWU admission 28.6 ± 24.2 days (range 10–72). The main reasons for MV included acute exacerbation of chronic obstructive pulmonary disease (31%) and recent pneumonia (28%). Mean MVWU stay was 13.5 ± 15.7 days (range 1–72 days). Thirty-four patients (49%) underwent tracheostomy. Fourteen patients required admission to the ICU[3] due to deterioration in their status. Twenty-nine patients (42%) were successfully weaned and discharged to the wards. A further 20 patients were transferred to the chronic ventilation unit of a regional geriatric rehabilitation hospital, where 5 were subsequently weaned and 15 required prolonged ventilation. Compared to controls (matched for age and reason for mechanical ventilation), more MVWU patients underwent successful weaning (49% vs. 12%, P < 0.001) and their mortality rate (n = 12) was significantly lower (17% vs. 88%, P < 0.001).

Conclusion: The higher level of care possible in a MVWU may result in a significantly improved rate of weaning and lower mortality. The assessment of long-term outcome in patients discharged to pulmonary rehabilitation centers requires further investigation.

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[1] MV = mechanical ventilation

[2] MVWU = mechanical ventilation weaning unit

[3] ICU = intensive care unit

Objective: To present our algorithm of urgent and elective donor selection.

Methods: Urgent selection is expeditious and protocol‑based. Elective selection permits a comprehensive process. Both include medical, psychosocial and surgical-anatomic evaluations. Liver volumes and vascular anatomy are evaluated with computerized tomographic angiography. Informed consent is obtained after painstaking explanations. Independent institutional committees review and approve all cases.

Results: Between July 2003 and June 2004 we evaluated 43 potential live donors for 12 potential recipients (fulminant hepatic failure, n=5; chronic end-stage liver disease, n=6); primary graft non-function, n=1). Thirty-three candidates (76%) were excluded due to blood type incompatibility (n=14, 42%), incompatible anatomy (n=8, 24%) – including problematic volume distribution (n=2) or vascular anatomy (n=6) – psychosocial issues (n=4, 12%), or medical co-morbidity (n=7, 22%). Five recipients (FHF[1], n=4; chronic ESLD[2], n=1) were successfully transplanted from living donors. In the acute setting, two patients (FHF, PGNF[3]) died in the absence of an appropriate donor (cadaveric or living donor). In the elective group, one patient died of unexpected variceal bleeding and one received a cadaveric graft just before the planned living donor transplantation was performed. One candidate was transplanted overseas and two cases are scheduled. The ratio of compatibility for donation was 34% (10/29) for blood type-compatible candidates.

Conclusions: Donor selection for living donor liver transplantation is a complex, labor-intensive multidisciplinary process. Most exclusions are due to blood type incompatibility or anatomic details. Psychosocial aspects of these donations warrant special attention.

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[1] FHF = fulminant hepatic failure

[2] ESLD = chronic end-stage liver disease

[3] PGNF = primary graft non-function

Objectives: To describe and analyze how PCPs[1] in the IDF[2] view their roles as primary care providers and to characterize how they perceive the quality of the medical care that they provide.

Methods: We conducted a survey using a questionnaire that was mailed or faxed to a representative sample of PCPs. The questionnaire included demographic background, professional background, statements on self-perception issues, and ranking of roles as a PCP in the IDF.

Results: Statements concerning commitment to the patient were ranked higher than statements concerning commitment to the military organization. Most physicians perceive the quality of the medical care service that they provide as high; they also stated that they do not receive adequate continuous medical education.

Conclusions: Our survey shows that PCPs in the IDF, like civilian family physicians, perceive their primary obligation as serving the needs of their patients but are yet to take on the full role of “gatekeepers” in the IDF’s healthcare system. We conclude that the Medical Corps should implement appropriate steps to ensure that PCPs are prepared to take on a more prominent role as “gatekeepers” and providers of high quality primary medical care.

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[1] PCP = primary care physician

[2] IDF = Israel Defense Force

Background: Repaglinide, a new insulin secretagogue, is purported to be as effective as sulphonylurea but is less hypoglycemic-prone.

Objectives: To assess the efficacy of repaglinide and its proclivity for hypoglycemia in a post-marketing study.

Methods: The study group comprised 688 patients, aged 26–95 years, clinically diagnosed with non-insulin-dependent type 2 diabetes. The patients were divided into three groups based on previous therapy: a) sulphonylurea-treated (group 1, n=132); b) metformin with or without sulphonylurea where sulphonylurea was replaced with repaglinide. (group 2, n=302); and c) lifestyle modification alone (drug-naïve) (group 3, n=254). At initiation of the study, all patients were transferred from their current treatment to repaglinide. Only patients in group 2, with combined sulphonylurea plus metformin, continued with metformin plus repaglinide. Fasting blood sugar, hemoglobin A1c and weight were measured at study entry and 4–8 weeks following repaglinide therapy. A questionnaire documented the number of meals daily and the presence of eating from fear of hypoglycemia.

Results: The fasting blood sugar level of the entire cohort dropped from 191 ± 2.4 to 155 ± 2.0 mg/dl (P < 0.0001); HbA1c from 8.8 ± 0.1 to 7.7 ± 0.1% (P < 0.0001). The drop of HbA1c in groups 1, 2 and 3 respectively were: 1.04 ± 0.22% (P < 0.0001), 1.14 ± 0.24% (P < 0.0001), and 1.51 ± 0.31% (P = 0.0137). Weight dropped from 81 ± 0.7 to 80.2 ± 0.7 kg (P < 0.0001), and eating from fear of hypoglycemia from 157 to 97 (P < 0.001). The daily number of meals decreased from 2.9 ± 0.4 to 2.4 ± 0.4 (P < 0.001). No serious adverse reactions occurred during the study.

Conclusions: Repaglinide is an effective oral hypoglycemic agent taken either as monotherapy or combination therapy. There is less eating to avoid hypoglycemia, fewer meals consumed, and weight loss.

Background: Alteration of innate and acquired immunity can play a role in the mechanism involved in the development of dementia. Epidemiologic studies indicate that the use of non-steroidal anti-inflammatory drugs can delay the onset or slow progression of Alzheimer disease.

Objectives: To determine whether the use of NSAIDs[1] is associated with natural killer activity alteration in AD[2] and multi-infarct vascular dementia patients, as compared with non-demented elderly and healthy young people.

Methods: In this prospective open study four groups of subjects (AD, VD[3], non-demented elderly, and healthy young people) were treated with an NSAID drug (rofecoxib 12.5 mg/day or ibuprofen 400 mg twice daily) for 7 days. Natural killer cell cytotoxicity was measured after flow cytometry analysis before and after treatment.

Results: Of the 49 subjects studied, 15 had a diagnosis of AD (3 men, 12 women; mean age 83.5 ± 8.1 years), 15 had a diagnosis of multi-infarct VD (7 men, 8 women; mean age 75.5 ± 8.4), 13 were non-demented elderly (1 man, 12 women; mean age 80.2 ± 7.2), and 6 were healthy young volunteers (3 men, 3 women; mean age 36.8 ± 4.4). While all examined subjects showed decreased NK[4] cell cytotoxicity after treatment, this decrease was most prominent and statistically significant in elderly patients suffering from vascular dementia –  from an average of 30.5 ± 11.8% before treatment to 22.5 ± 16% after treatment (P = 0.04). The decrease in NK cell cytotoxicity was only moderate and not statistically significant in all other elderly and young subjects. Young healthy volunteers exhibited a significantly higher total NK cytotoxicity before and after treatment compared to all age groups (P < 0.001).

Conclusion: These findings suggest that NSAIDs decrease NK activity in vascular dementia patients. Our findings also suggest that natural killer activity alteration cannot explain the ability of anti-inflammatory drugs to delay the onset or slow the progression of AD.