Israel Medical Association Journal

Background: At the start of the Bone and Joint Decade 2000-2010, a paleopathologic study of the physically disabled may yield information and insight on the prevalence of crippling disorders and attitudes towards the afflicted in the past compared to today.

Objective: To analyze “The procession of the Cripples,” a representative drawing of 31 disabled individuals by Hieronymus Bosch in 1500.

Method: Three specialists - a rhumatologist, an orthopedic surgeon and neurologist - analyzed each case by problem-solving means and clinical reasoning in order to formulate a consensus on the most likely diagnosis.

Result: This iconographic study of cripples in the sixteenth century reveals that the most common crippling disorder was not a neural form of leprosy, but rather that other disorders were also prevalent, such as congenital malformation, dry gangrene due to ergotism, post-traumatic amputations, infectious diseases (Pott’s, syphilis), and even simulators. The drawings show characteristic coping patterns and different kinds of crutches and aids.

Conclusion: A correct clinical diagnosis can be reached through the collaboration of a rheumatologist, an orthopedist and neurologist. The Bone and Joint Decade Project, calling for attention and education with respect to musculoskeletal disorders, should reduce the impact and burden of crippling disease worldwide through early clinical diagnosis and appropriate treatment.
 

Background: Urinary incontinence in older women is common. Its characteristics and impact on quality of life is not well established since these women are usually reluctant to tell their healthcare providers about the problem.

Objective: To determine the characteristics of urinary incontinence in women and the manner in which it affects patients quality of life.

Methods: Twenty family physicians were requested to distribute a questionnaire to the first 25 consecutive women aged 30 to 75 years who visited their clinic for any reason. The questionnaire covered general health issues, symptoms of urinary incontinence, and quality of life.

Results: A total of 418 women, mean age 50.0 ± 11.8 years, completed the questionnaire (84% response rate). Of these, 148 (36%) reported having episodes of urinary incontinence. Urinary incontinence was found to be associated with older age, menopause, obesity and coexisting chronic disorders. Sixty percent of the women with urinary incon­tinence found it to be a disturbing symptom, and 44% reported that it had a detrimental effect on their quality of life. Only 32% of the affected women had sought medical advice, half of them from their family physician. Treatment was recommended to 66% of those who sought help, and in about two-thirds of these it brought some measure of relief.

Conclusions: Urinary incontinence is a common com­plaint among women attending primary care clinics, but it does not receive appropriate attention, Though it often adversely affects quality of life, only a small proportion of women seek medical advice. Family physicians should raise the issue as a part of the routine general health check-up.
 

Background: Cryosurgery is a minimally invasive treat­ment option for prostate cancer.

Objectives: To report on the first series of cryosurgical ablation for prostate cancer performed in Israel.

Methods: Cryosurgical ablation of the prostate was undertaken in 2 patients aged 53-72 diagnosed with adenocarcinoma of the prostate. The procedures were performed percutaneously and were monitored by real-time trans-rectal ultrasound. The CRYOHIT machine applying Argon gas was used with standard or ultra-thin cryoprobes. The average follow-up was 12.8 months postsurgery (range 1- 24 months).

Results: No rectal or urethral injuries occurred and all patients were discharged from hospital within 24-48 hours. The duration of suprapubic drainage was 14 days in 10 patients and prolonged in 2. Early complications included penoscrotal edema in four patients, perineal hematoma in three, hemorrhoids in two and epidydimitis in one. Long-term complications included extensive prostatic sloughing in one patient and a perineal fistula in another, both of whom required prolonged suprapubic drainage. Minimal stress incontinence was noted in two patients for the first 8 weeks after surgery. None of the patients has yet regained spontaneous potency. A prostate-specific antigen nadir of less than 0.5 ng/ml was achieved in eight patients and an undetectable PSA level below 0.1 ng/ml in five patients.

Conclusion: Cryoablation for prostate cancer is safe and feasible, and the preliminary results are encouraging. Further study is needed to elucidate the efficacy of the procedure.

Objective: To explore the putative effect of cardiac rehabilitation programs on the health-related quality of life’ and ‘return to work’ in pre-retirement patients one year after coronary artery bypass grafting.

Methods: Of the 2085 patients aged 45-4 who survived one year after CABG and were Israeli residents, 145 (6.9%) had participated in rehabilitation programs. Of these, 124 (83%) who answered QOL questionnaires were individually matched with 248 controls by gender, age within 5 years. and the time the questionnaire was answered. All patients had full clinical follow-up including a pre-operative interview. The Short Form-36 QOL questionnaire as well  as a specific questionnaire were mailed to surviving patients one year after surgery. Study outcomes included the scores on eight scales and two summary components of the SF-36, as well as return to work’ and ‘satisfaction with medical services’ from the specific questionnaire. Analysis was done for matched samples.

Results: Cardiac rehabilitation participants had signifi­cantly higher SF-36 scores in general health, physical functioning, and social functioning. They had borderline significant higher scores in the physical summary component of the SF-36. The specific questionnaire revealed significantly better overall functioning, higher satisfaction with medical care. and higher rate of return to work. While participants in cardiac rehabilitation and their controls were similar in their socio­-demographic and clinical profiles, participating patients tended to be more physically active and more fully employed than their controls.

Conclusions: Rehabilitation participants had a self-per­ception of better HRQOL, most significantly in social function­ing. Our findings of more frequent return to work and higher satisfaction with medical care should induce a policy to encourage participation in cardiac rehabilitation programs after CABG.
 

Between the 1960s and 1980s, the main focus of biological research was nucleic acids and the translation of the coded information into proteins. Protein degradation was a neglected area and regarded by many as a scavenger, non-specific and end process. While it was known that proteins are turning over, the large extent and high specificity of the process - where distinct proteins have half-lives that range from a few minutes to several days - have not been appreciated. The discovery of the lysosome by Dr. Christian de Duve did not change this view significantly, as this organelle is involved mostly in the degradation of extra- and not intracellular proteins, and it was clear that lysosomal proteases, similar to those of the gastrointestinal tract, cannot be substrate specific. The discovery of the complex cascade of the ubiquitin pathway has changed this view dramatically. It is now clear that degradation of cellular proteins is a highly complex, temporally controlled, and tightly regulated process that plays major roles in a broad array of basic pathways during cell life and death. With the multitude of substrates targeted and processes involved, it is not surprising that aberrations in the pathway have been recently implicated in the pathogenesis of many diseases, certain malignancies and neurodegeneration among them. Degradation of a protein via the ubiquitin pathway involves two successive steps: a) conjugation of multiple ubiquitin moieties to the substrate, and b) degradation of the tagged protein by the downstream 263 proteasome complex with release of free and re-utilizable ubiquitin. Despite intensive research, the unknown still exceeds what we currently know on intracellular protein degradation and major key problems remain unsolved. Among these are the modes of specific and timed recognition of the myriad substrates of the system and the nature of the mechanisms that underlie aberrations in the system and pathogenesis of diseases.

Trophic factors such as nerve and fibroblast growth factors are important modulators of 13 cell physiology. These two factors induce the extension of neurite-Iike processes in primary cultures of adult rat 13 cells. Moreover, both NGF and FGF enhance glucose-induced insulin secretion. Since â cells synthesize NGF and pancreatic islet cells produce FGFs, it is possible that autocrine/paracrine interactions may be major regulators of insulin secretion, and impairment of these interactions could lead to pathological states such as diabetes mellitus.

Background: Inflammatory mediators, including cytokines and reactive oxygen species. are associated with the pathology of chronic liver disease. Hepatocytes are generally considered as targets but not producers of these important mediators.

Objectives: To investigate whether cells of hepatocellular lineage are a potential source of various cytokines we estimated the expression and secretion of tumor necrosis factor alpha, transforming growth factor beta 1 and interleukins I beta, 6 and 8 in the culture of well-differentiated human HepG2 cells treated for 24 hours with ethanol, acetaldehyde and lipopolysaccharide. Lipid peroxidation damage, glutathione content and glutathione perox­idase, catalase and superoxide dismutase activity were also determined.

Methods: HepG2 cells were treated for 24 hours with ethanol (50 mM), acetaldehyde (175 ìM) and LPS (1 ìg/ml). TNF-á, TGF­-â, L-1â, IL-6 and IL-8 mRNA were determined by reverse transcriptase polymerase chain reaction and secretion by en­zyme-linked immunoassay. Lipid peroxidation damage, glutathione content and antioxidant enzyme activities were determined spectrophotometrically.

Results: Exposure to ethanol for 24 hours induced the expression of TNF-á and TGF- â1. secretion of IL-1â and TGF-â₁ and decreased catalase activity. Acetaldehyde markedly increased TNF-á and IL-8 expression, stimulated IL-1â and IL-8 secretion, increased lipid peroxidation damage and decreased catalase activity, while LPS exposure induced the expression of TNF-á. TGF- â₁, IL-6 and IL-8, the secretion of TGF-â₁, IL-1â, IL-6 and IL-8, and a decrease in catalase activity. No change in GSH, GSHPx or SOD was found in any experimental condition.

Conclusions: The present studies confirm and extend the notion that hepatocytes respond to ethanol, acetaldehyde and LPS-producing cytokines. Oxidative stress produced by the toxic injury plays an important role in this response through up­regulation of inflammatory cytokines.

Background: Information is lacking on the effects of hormone replacement therapy in women with diabetes, especially during moderate chronic hyperglycemia.

Objectives: To study the effects of HRT on the lipid profile and the low density lipoprotein subclass distribution in women with type 2 diabetes under satisfactory and non-satisfactory glycemic control.

Methods: Fifty-four postmenopausal women after a 6 week run-in diet were randomized to receive either placebo(HbAlc <8%, n=13 HbAlc >8%, n=17) or HRT (HbAlc<8%, n=11 HbAlc >8%, n=13) for 12 weeks. HRT consisted of cyclical conjugated estrogens 0.625 mg/day plus medrogestone 5 mg/day. At the beginning and at the end of each treatment period the LDL subclass distribution was estimated by density gradient ultracentrifugation.

Results: At the baseline and during the study, the HbAlc level was significantly higher in hyperglycemic patients than in the near-normoglycemic controls (baseline 10.2±2.9 vs. 6.5±0.7%, P<0.01). They showed a trend for higher total and LDL cholesterol, triglycerides and lower high density lipoprotein-cholesterol compared to near-normoglycemic con­trols, as well as significantly higher triglyceride concentrations in very low density lipoprotein, intermediate density lipoprotein and LDL-1 particles and cholesterol content in LDL-1 and -2 particles. HRT decreased LDL-cholesterol in both groups. In the normoglycemic patients a small increase in HbAlc was observed (6.5±0.7 vs. 7.4+1%, P=004). In all cases, HRT did not modify the proportion of LDL represented by denser LDLs.

Conclusions: HRT did not modify the LDL subclass distribution, even in the presence of moderate chronic hyperglycemia in women with type 2 diabetes.

The Management of a 750-bed tertiary care university hospital that serves the Jerusalem area and nationwide referrals initiated a total overhaul of all its supporting systems. This program, with parallel contingency plans, ensured a smooth transition of all computer-depended and othe services into the year 2000. Because this extraordinary project proved successful, its outcomes are noe being utilized as a unique impetus for implementation of hospital-wide continuous quality improvement programs. This paper reports how the established QI procedures, which were introduced also during the campaign, are now being activated from the baseline of those outcomes that have provided absolute efficacy in all hospital activities. The success of the campaign was achieved through the total involvement of all staff. This involvement was enhanced by the popular appeal of the dramatic deadline of the date 2000, as well as by focusing attention on personnel dynamics. Strategies for sustaining the momentum must be considered.

Background: With market failures characterizing the health care sector, societies are continuously searching for ways to achieve an efficient and fair allocation of resources. A natural source of opinion on the desired allocation of health resources is the public. In fact, several governments have recently involved the general public in decisions about resource allocation in their health systems.

Objectives: To investigate the views of the Israeli Jewish public aged 45-75 on horizontal equity in medical care; specifically, the characteristics (including a lottery) for determining which of two individuals with similar medical need should be treated first, against a background of limited resources.

Methods: A sample of 2,030 individuals was chosen to represent a population of about 800,000 urban Jewish Israelis aged 45–75. Data were collected in face-to-face full sit-down interviews by trained interviewers between October 1993 and February 1994.

Results: The three most preferred prioritizers were chances of recovery, number of dependants, and young age. Random prioritization was preferred by only 8% of the population. Age, level of education and religiosity were the main characteristics associated with the choice.

Conclusions: The Israeli adult public does not favor strict horizontal equity in health care. As in other social programs, “equals” were defined in a multi-criteria manner, based on both medical need and other personal characteristics. The preferred prioritizers seem to reflect universal tastes and cast doubt on the traditional distinction between efficiency and equity and between horizontal and vertical equity when applied to health care.