Israel Medical Association Journal

Objectives: To assess the academic and psychological effects of political conflict on students.

Methods: We asked all students to fill out an anonymous Google electronic survey describing their experience during the war and evaluating the debriefing. A team of students and administrators reviewed the responses.

Results: Sixty-six students (40% of the school) responded (first year 26%, second year 39%, third year 24%, fourth year 8%, taking time off 3%, age 23–40 years old). Eighty-three percent were in Israel for some portion of the war and 34% attended the debriefing. Factors that influenced individuals’ decision to return/stay in the war zone were primarily of an academic and financial nature. Other factors included family pressure, information from peers and information from the administration. Many reported psychological difficulties during the war rather than physical danger, describing it as “draining” and that it was difficult to concentrate while studying. As foreigners, many felt their role was undefined. Although there is wide variation in the war’s effect on daily activities and emotional well-being during that time, the majority (73%) reported minimal residual effects.

Conclusions: This study lends insight to the way students cope during conflict and highlights academic issues during a war. Open and frequent communication and emphasis on the school as a community were most important to students.

Objectives: To describe and identify clinical characteristics, prognostic factors and visual outcome in a group of patients with OGI in southern Israel.

Methods: We conducted a retrospective review of all cases of OGI examined in the ophthalmology department at Soroka University Medical Center, Beer Sheva, Israel, from 1996 to 2005. A total of 118 eyes with OGI were detected and analyzed statistically. We recorded demographic data, cause of injury, initial visual acuity (VA), associated globe morbidity and injuries, Ocular Trauma Score (OTS), surgical procedures, postoperative complications, and final VA.

Results: The mean age of the study group was 36.1 years and included 84% males. The median follow-up was 13.3 months (range 6–66 months). The annual incidence of open globe injuries was 3.1 cases/100,000. In 84 cases (71%) the mechanism of open eye injury was laceration. Most of the injuries were work related (45%). Bilateral injury was observed in two patients. An intraocular foreign body was observed in 45 eyes (38%). Primary surgical repair was performed in 114 eyes. Six patients (5.1%) had complications with post-traumatic endophthalmitis and 12 patients (10.1%) underwent evisceration or enucleation. Clinical signs associated with poor visual outcomes included reduced initial VA, eyelid injury, and retinal detachment at presentation.

Conclusions: In our study population the most important prognostic factors in open globe injury were initial VA, eyelid injury and retinal detachment.

Objectives: To report our first year experience with a CPU located in an internal medicine department as compared to the year before establishment of the CPU.

Methods: We retrospectively evaluated the medical records of consecutive patients who were admitted to our internal medicine department for the investigation of chest pain for 2 different years: a year before and a year after the establishment of the CPU in the department. We focused on the patients' characteristics and the impact of the CPU regarding the investigational modalities used and the length of in-hospital stay.

Results: In the year before establishment of the CPU, 258 patients were admitted to our department with chest pain, compared to 417 patients admitted to the CPU in the first year of its operation. All patients were followed for serial electrocardiographic and cardiac enzyme testing. All CPU patients (100%) underwent investigation compared to only 171 patients (66%) in the pre-CPU year. During the year pre-CPU, 164 non-invasive tests were performed (0.64 tests per patient) compared to 506 tests (1.2 tests/patient) in the CPU population. Coronary arteriography was performed in 35 patients (14%) during the pre-CPU year, mostly as the first test performed, compared to 61 patients (15%) during the CPU year, mostly as a second test, with only 5 procedures (1.1%) being the first test performed. The length of hospitalization was significantly shorter during the CPU year, 37.8 ± 29.4 hours compared to 66.8 ± 46 hours in the pre-CPU year.

Conclusions: Establishment of a CPU in an internal medicine department significantly decreased the need for invasive coronary arteriography as the first modality for investigating patients admitted with chest pain, significantly decreased the need for invasive procedures (especially where no intervention was performed), and significantly shortened the hospitalization period. CPU is an effective facility for rapid and effective investigation of patients admitted with chest pain. 

Objectives: To assess opioid use during a 6 year period (2001–2006) among cancer patients served by Clalit Health Services, the largest health management organization in Israel.

Methods: Purchasing data of opioids authorized for use in Israel were obtained from the computerized databases of Clalit for the period 2001–2006. Patients' demographic and cancer morbidity data were extracted. The data were analyzed by translating the purchased opioids (fentanyl patch, oxycodone, buprenorphine, methadone, hydromorphone) to oral morphine equivalents (OME).

Results: During the study period 182,066 Clalit members were diagnosed with cancer; 58,443 (32.1%) of them died and 31,628 (17.3%) purchased opioids at least once. In 2001, 7.5% of Clalit cancer patients purchased opioids at least once within 5 years of the initial diagnosis. Between 2002 and 2006 this percentage increased consistently, reaching 9.9% in 2006. The average daily dose of opioids increased from 104.1 mg OME in the year 2001 to 115.2 mg OME in 2006 (11% increase). The average duration of opioid purchasing was 5.0 ± 8.3 months (range 1–84 months, median 2). During the study period 19,426 cancer patients who purchased opioids at least once died; only 14.3% (3274) were still alive 2 years after their first opioid prescription.

Conclusions: Opioid purchasing increased during the study period, especially during the final months of life. Children (0–18 years old) and elderly male patients (≥ 65 years) began opioid treatment later compared to other age groups. Only a few patients had an opioid early enough to relieve their pain. 

Objective: To determine whether there are such ethnic differences and what, if anything, is their clinical relevance.

Methods: Of the 3663 enrolled infants born at the Hillel Yaffe Medical Center during the 12 month study period, 55 were of Ethiopian origin and their medical records were retrospectively surveyed. The retrieved data were compared with those of 167 randomly selected non-Ethiopian newborns (controls). Exclusion criteria were preterm delivery, admission to the neonatal intensive care unit, and congenital birth defects.

Results: Newborn infants of Ethiopian origin spit up 57% more than control infants. The difference in the number of spit ups was more obvious when only the infants who spit up were compared (2.3 ± 1.7 Ethiopian newborns vs. 1.5 ± 0.9 controls, P = 0.002), although the percentage of infants who spit up was the same in the two groups. There was no difference in weight gain, days of hospitalization, bilirubin levels or nutrition type between the groups.

Conclusions: Infants of Ethiopian origin spit up more than the control newborn infants of non-Ethiopian origin, while other clinical parameters were similar. In the absence of other pathological signs, spitting up is a non-relevant clinical condition.

Objectives: To review our use of ECMO over a 10 year period.

Methods: All children supported with ECMO from 2000 to 2010 were reviewed. Most of these children suffered from cardiac anomalies. The patients were analyzed by age, weight, procedure, RACHS-1 when appropriate, length of support, and outcome.

Results: Sixty-two children were supported with ECMO; their median age was 3 months (range 0–216 months) and median weight 4.3 kg (range 1.9–51 kg). Thirty-four patients (52.3%) needed additional hemofiltration or dialysis due to renal failure. The children requiring ECMO support represented a wide spectrum of cardiac lesions; the most common procedure was arterial switch operation 27.4% (n=17). ECMO was required mainly for failure to separate from the heart-lung machine (n=55). The median duration of ECMO support was 4 days (range 1–14 days); 29 (46.7%) patients were weaned successfully from ECMO during this time period, and 5 of them died during hospitalization, yielding an overall hospital survival rate of 38.7%.

Conclusions: ECMO support has significant survival benefit for patients with post-cardiotomy heart failure. Its early deployment should be considered in cardiopulmonary resuscitation.

Objectives: To investigate the reasons for non-adherence associated with cardiovascular risk factors among Bedouins.

Methods: We identified Bedouin patients with HTN, DM or LMD from medical records and randomly selected 443 high adherent and 403 low adherent patients. Using trained interviewers we conducted in-depth structured interviews regarding knowledge and attitudes to chronic illness and its treatment, health services evaluation, and socio-demographic factors.

Results: The study population included 99 high and 101 low adherent patients. More low adherent patients agreed that traditional therapy can replace prescribed medications for DM, HTN or LMD (47% vs. 26%, P < 0.01), and 10% used only traditional medications. Also, more low adherent patients believed that the side effects of prescribed drugs are actually worse than the disease itself (65% vs. 47%, P < 0.05), and 47% cited this as a reason for discontinuing drug treatment (47% vs. 31%, P < 0.05).

Conclusions: Our findings suggest that in this minority population the basis for non-adherence derives directly from patients' perceptions of chronic disease and drug treatment. A focused intervention should emphasize the importance of early evidence-based drug therapy with open patient-physician dialogue on the meaning of chronic disease and the side effects of prescribed drugs.

Objectives: To retrospectively determine the clinical response to ¹³¹I-MIBG therapy at low doses in patients with refractory neuroblastoma.

Methods: We performed a retrospective chart review of 10 patients with neuroblastoma treated with ¹³¹I-MIBG at Rambam Health Care Campus from 1994 to 2012. Clinical data, number of ¹³¹I-MIBG courses delivered, toxicities, and clinical responses were reviewed. MIBG scan was performed after each course.

Results: Twenty-one courses of ¹³¹I-MIBG were delivered to 10 patients (3 girls, 7 boys). Their mean age was 3.8 years (range 1.5–6 years). All patients received several protocols of chemotherapy including the high dose form. Three patients received three courses of ¹³¹I-MIBG with a minimum of 6 weeks between each course, five patients received two courses, and two patients received only one course. An objective response to the first course was obtained in nine patients and to the second course in six of eight, and in three children who underwent the third course the pain decreased. One patient has no evidence of disease, four are alive with disease, and five died of the disease. No unanticipated toxicities were observed.

Conclusions: Low dose ¹³¹I-MIBG is an effective and relatively non-toxic treatment in neuroblastoma disease palliation. Rapid and reproducible pain relief with ¹³¹I-MIBG was obtained in most of the children. Treatment with systemic radiotherapy in the form of low dose ¹³¹I-MIBG was easy to perform and effective in cases of disseminated neuroblastoma, demonstrating that this primary therapy can be used for palliative purposes.