Israel Medical Association Journal

Background: Congestive heart failure is extremely common in octogenarians and is associated with severe fatigue, shortness of breath, recurrent hospitalizations, and death. These patients, many of whom are anemic, are often resistant to standard CHF[1] therapy including angiotensin-converting enzyme inhibitors, beta-blockers and diuretics.

Objectives: To examine whether correction of the anemia (hemoglobin <12 g/dl) in CHF patients lowers their resistance to therapy.

Methods: Forty octogenarians with anemia and severe resistant CHF were administered a combination of subcutaneous erythropoietin and intravenous iron sucrose.

Results: This combination therapy led to a marked improvement in cardiac function, shortness of breath and fatigue, a marked reduction in the rate of hospitalization and a stabilizing of renal function.

Conclusion: Anemia appears to be an important but ignored contributor to the progression of CHF, and its correction may improve cardiac and renal status as well as the quality of life in elderly patients.

Background: An important question on the health agenda concerns the most appropriate place to hospitalize stroke patients and its effect on acute stroke care.

Objectives: To examine how the existing hospital system treats these patients, specifically: a) the departments to which stroke patients are admitted; b) differences in the admission, diagnosis and rehabilitative care of stroke patients, by department; c) patient characteristics, by department; and d) mortality rates during hospitalization.

Methods: We surveyed 616 people with acute stroke (ICD-CM9 430-433, 436) admitted consecutively to one of seven large general hospitals in Israel between October 1998 and January 1999. Data were collected from medical records at admission and at discharge.

Results: Forty-two percent of the patients were admitted to an internal medicine department, 56% to a neurology department, and only 2% to a geriatric department. The majority (95%) underwent a computed tomography scan of the brain, but other imaging tests were performed on fewer patients, with significant differences among hospitals and between internal medicine and neurology departments. Patients admitted to neurology departments were younger and had milder stroke symptoms than did patients admitted to internal medicine departments. Fifty-three percent of patients received at least one type of rehabilitative care during their hospital stay – usually physiotherapy, and least often occupational therapy. Seventeen percent of stroke patients died during hospitalization. Mortality was not found to be related to the admitting department.

Conclusions: Uniform realistic policies and work procedures should be formulated for all hospitals in Israel regarding the admitting department and processes as well as the performance of diagnostic imaging. Standards of medical and rehabilitative care and discharge destination should be developed to promote quality of care while containing utilization and costs.
 

Background: Due to multiple chronic illness and disability, the elderly consume a disproportionately large share of medications.

Objectives: To assess the patterns and determinants of drug use among the community dwelling old-old population.

Methods: The study population included 1,369 old-old persons from the baseline data of the Cross-Sectional and Longitudinal Aging Study (CALAS), which is based on a national random stratified sample of the Israeli Jewish population aged 75–94 years.

Results: The mean number of drugs used by the study population was 3.3, and only 12.5% did not consume any drugs. Multivariate linear regression analysis showed that women used significantly more drugs than men, and that those born in Europe took significantly more drugs than those born in Israel and Asia-Africa. The number of medical conditions was the strongest predictor of drug use. Hospitalizations during the last year and frequent visits to family physician were also significant factors related to drug use. All variables combined explained 40% of the variance in drug use by the old-old. The most commonly used therapeutic groups were cardiovascular drugs (53%), psychotropic drugs (31%), analgesics (30%), and gastrointestinal drugs (28%).

Conclusions: Our data indicate that in addition to the association of drug use with health status and healthcare utilization, the number and type of drugs taken vary with gender and place of birth.

Matrix metalloproteinases are a family of enzymes that degrade different components of extracellular matrix. They play an important role in normal physiologic processes of maintaining tissue integrity and remodeling, as in wound healing, processes of development, and regeneration. However, excessive expression of MMP[1] has been observed in many disease states, including rheumatoid arthritis and osteoarthritis, vascular remodeling in atherosclerosis and aortic aneurysm formation, neoplastic processes, macular degeneration and many others.

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Although the free radical theory of aging is widely accepted among scientists, the possibility of using antioxidants to delay the aging processes seems to encounter considerable skeptism among clinicians. This may be, at least in part, due to lack of knowledge about the basic chemistry and biological behavior of oxidative stress, antioxidants, and the complex interactions between them. However, one cannot ignore the explosive growth of information concerning the mechanisms underlying the processes of aging, their consequences, and the use of antioxidants in suppressing such effects. In order to provide patients with the most accurate information regarding the use of antioxidant supplementation in their diet, it is important to obtain basic data regarding oxidative stress and antioxidants. This article explores the role of oxidative stress in the aging phenomena, recent evidence supporting supplementation of antioxidants for aged people,  the ability of antioxidants to prevent or retard cancer and atherosclerosis (the major causes of mortality in the aged population), and the ability of antioxidant supplementation to delay age-dependent deterioration of cognitive function. Based on the data presented, we conclude that current knowledge provides insufficient and inconclusive support for antioxidant supplementation as a means of delaying aging processes, despite the encouraging results obtained in many studies.

In 2001 the number of residents aged 65 and over in Israel was 639,000, or 10% of the population. The rate of increase of the elderly population is twice that of the general population, thus the predicted number of elderly for 2020 is around 1,025,000, representing a 60% increase. While this process is determined by a decline in both fertility and mortality, in Israel, immigration has also been a central factor in the process of aging. Life expectancy stands at 76.7 for men and 80.9 for women; at age 65 it is 16.4 years for men and 18.5 for women. The major factor influencing the increase in life expectancy during the past two decades has been the prevention of death among older people. Population aging, or “the demographic transition,” also represents an "epidemiological transition” – from high rates of infectious and communicable diseases, to high rates of chronic diseases among older people. During the past two decades, the number of disabled elderly has increased more than 2.5 times. In 2001, there were about 97,400 disabled elderly in Israel, constituting about 15% of all elderly. By the year 2010, the number of disabled elderly is expected to reach 120,100. The rate of increase of the disabled elderly population is almost double that of the total elderly population, due to changes in this population’s composition. However, recent research indicates that new cohorts of elderly are healthier than earlier cohorts but experience a decline in health at older ages. While advances in standard of living, medicine, and technology have made this possible, a greater allocation of resources is required to prevent disability and maintain the quality of life.

The Arab population of Israel is relatively young. However, a significant increase is expected in the number of elderly Arabs in the coming years. At the end of 2001 there were 38,500 Arab elderly, but their number is expected to reach 92,100 by 2020. This will represent a nearly 2.5-fold increase in absolute numbers. As the population ages, the number and percentage of people with chronic diseases and related disabilities will rise significantly. While the Arab elderly are much younger than the Jewish elderly, they are more disabled and therefore have greater medical and nursing needs. An extremely important measure of the need for formal services is an elderly person’s functional ability, especially the ability to live independently. The percentage of Arab elderly who are disabled and need help with activities of daily living is two times higher than that of the Jewish elderly population. At present, 30% of the Arab elderly (39% of the women and 20% of the men), compared to 14% of Jewish elderly (17% of the women and 11% of the men), need help in at least one ADL[1] (bathing, dressing, eating, mobility in the home, rising and sitting, getting in and out of bed). Concomitant with demographic changes are forces that affect the ability of informal support systems to provide care. For example, the rising number of Arab women in the labor force together with changes in elderly peoples' living arrangements have increased the need for formal services to share responsibility for the elderly with families. As services are developed, questions arise regarding the extent to which they have been adapted to the culture and norms of Arab society and meet that society’s unique needs. This paper elaborates on some of these issues.

Background: Multifetal pregnancy reduction has been implemented for improving the outcome of multifetal pregnancies. Recent studies reported no difference in pregnancy outcome between reduced twins and non-reduced twins, but the neonatal course and subsequent outcome in reduced twin pregnancies were not well documented.

Objective: To compare the neonatal course and outcome, as well as the gestational and labor characteristics, in twins from reduced multifetal pregnancies and in non-reduced twins.

Methods: This is a retrospective case-control study of the neonatal course of twins from reduced multifetal pregnancies. We found 64 mothers with multifetal pregnancy reduction who delivered twins during 1989–1997; 64 gestational age-matched non-reduced twin pregnancies served as controls. The following neonatal variables were examined: major malformations; small birth weight for gestational age; and neonatal morbidities including respiratory distress syndrome, apnea, pneumothorax, bronchopulmonary dysplasia, hyperbilirubinemia, sepsis, necrotizing enterocolitis, retinopathy of prematurity, seizures, intraventricular hemorrhage, periventricular leukomalacia, ventriculomegaly, and hydrocephalus. In addition, we evaluated several neonatal interventions (surfactant replacement, mechanical ventilation, phototherapy, total parenteral nutrition), and some laboratory abnormalities (thrombocytopenia, leukopenia, anemia, and hypoglycemia), duration of hospitalization, and neonatal mortality.

Results: Gestational and labor variables were not significantly different between multifetal pregnancies reduced to twins and non-reduced twin pregnancies. The neonatal morbidity and mortality were not significantly different between twin neonates from multifetal pregnancy reduction and non-reduced control twins.

Conclusions: Multifetal pregnancy reduction to twins appears to bear no adverse effect on the intrauterine course of the remaining fetuses or their neonatal course and outcome when born after 28 weeks of gestation.
 

Background: Little information is available on the clinical practice and implementation of guidelines in treating acute myocardial infarction patients in Israel.

Objective: To assess patient characteristics, hospital course, management, and 30 day clinical outcome of all AMI[1] patients hospitalized in Israel during a 2 month period in 2000.

Method: We conducted a prospective 2 month survey of consecutive AMI patients admitted to 82 of 96 internal medicine departments and all 26 cardiac departments operating in Israel in 2000. Data were collected uniformly by means of a hospital and 30 day follow-up form.

Results: During the survey 1,683 consecutive patients with a discharge diagnosis of AMI were included. Their mean age was 66 years; 73% were male. The electrocardiographic pattern on admission revealed ST elevation, non-ST elevation and an undetermined ECG[2] in 63%, 34% and 4% of patients respectively. Aspirin and heparin were given to 95% of patients. Beta-blockers and angiotensin-converting enzyme inhibitors were given to 76% and 65% of patients respectively. Among hospital survivors, 45% received lipid-lowering drugs. Thrombolytic therapy was administered in 28% of patients, coronary angiography was used in 45%, and 7% of patients underwent primary percutaneous coronary intervention. The 7 and 30 day mortality rates were 7% and 11% respectively.

Conclusions: This nationwide survey shows that one-third of the AMI patients in Israel are elderly (≥ 75 years). The survey suggests that clinical guidelines for the management of patients with AMI are partially implemented in the community. Data from large surveys representing the "real world" practice are of utmost importance for the evaluation of clinical guidelines, research and educational purposes.

Background: Although the preferred management of a patient presenting with an acute myocardial infarction is in a coronary care unit, data based on discharge diagnoses in Israel indicate that many of these patients are treated outside such units.

Objectives: To compare the demographic and clinical characteristics, treatment and mortality of AMI[1] patients treated inside and outside a CCU[2].

Methods: We compiled a registry of all patients admitted to three general hospitals in Haifa, Israel during January, March, May, July, September and November 1996.

Results: The non-CCU admission rate was 22%. CCU patients were younger (61.6 vs. 65.5 years), less likely to report a past AMI (18% vs. 34%), and arrived earlier at the emergency room. Non-CCU patients were more likely to present with severe heart failure (30 vs. 11%). Non-CCU patients received less aspirin (81 vs. 95%) and beta-blockers (62 vs. 80%). Upon discharge, these patients were less frequently prescribed beta-blockers and cardiac rehabilitation programs. CCU-treated patients had lower unadjusted mortality rates at both 30 days (odds ratio=0.35) and in the long term (hazards ratio=0.57). These ratios were attenuated after controlling for gender, age, type of AMI, and degree of heart failure (OR[3]=0.91 and HR[4]=0.78, respectively).

Conclusions: A relatively high proportion of AMI patients were treated outside a CCU, with older and sicker patients being denied admission to a CCU. The process of evidence-based care by cardiologists was preferable to that of internists both during the hospital stay and at discharge. In Israel a significant proportion of all AMI admissions are initially treated outside a CCU. Emphasis on increasing awareness in internal medicine departments to evidence-based care of AMI is indicated.

Background: The frequent systemic side effects associated with the use of systemic carbonic anhydrase inhibitors have adversely affected the compliance to treatment in glaucoma patients, obviating their long-term use. The introduction of the topical CAI[1], dorzolamide, has further reduced their use. However, the tolerability of dorzolamide in patients who have been intolerant to systemic CAIs has not been evaluated prospectively.

Objectives: To study the tolerability and efficacy of dorzolamide (a topical CAI) in a selected group of glaucoma and ocular hypertensive patients who have been intolerant to systemic CAI.

Methods: A 3 month prospective study was conducted in 39 patients. Following recruitment, patients were evaluated on the day of switching from systemic CAI to dorzolamide and for five more visits. The SF-36 health assessment questionnaire was used to evaluate changes in well-being and quality of life, and the intraocular pressure was measured periodically.

Results: Within 4 weeks of switching from systemic CAI to dorzolamide, the mean health assessment scores improved significantly in seven of the eight categories of the SF-36, and remained generally unchanged for the rest of the study. No significant differences were noted between the mean IOP[2] on day 0 and the following measurements throughout the 84 days of dorzolamide therapy.

Conclusion: In glaucoma patients who were intolerant to systemic CAI, topical CAI dorzolamide offers a similar efficacy and better tolerability.