Israel Medical Association Journal

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.

Background: The 20%–60% rate of acute anterior myocardial infarction (AAMI) patients with concomitant left ventricular thrombus (LVT) formation dropped to 10–20% when thrombolysis and primary percutaneous coronary intervention (PPCI) were introduced.

Objective: To test our hypothesis that prolonged anticoagulation post-PPCI will lower the LVT incidence even further.

Methods: Included in this study were all 296 inpatients with ST elevation AAMI who were treated with PPCI (from January 2006 to December 2009). Treatment included heparin anticoagulation (48 hours) followed by adjusted doses of low molecular weight heparin (3 more days). All patients underwent cardiac echocardiography on admission and at discharge. LVT and bleeding complications were reviewed and compared.

Results: LVT formation was present on the first echocardiogram in 6/296 patients. Another 8/289 patients displayed LVT only on their second echocardiogram (4.7%, 14/296). LVT patients had significantly lower LV ejection fractions than non-LVT patients at admission (P < 0.003) and at discharge (P < 0.001), and longer time to reperfusion (P = 0.168). All patients were epidemiologically and clinically similar. There were 6 bleeding episodes that required blood transfusion and 11 episodes of minor bleeding.

Conclusions: Five days of continuous anticoagulation therapy post-PPCI in inpatients with AAMI is associated with low LVT occurrence without remarkably increasing bleeding events.
 

Background: Carbon dioxide is the most widely used gas to establish pneumoperitoneum during laparoscopic surgery. Gastrointestinal trauma may occur during the peritoneal insufflation or during the operative phase itself. Early diagnosis of these injuries is critical.

Objectives: To assess changes in end-tidal carbon dioxide (E_TCO₂) following gastric perforation during pneumoperitoneum in the rat.

Methods: Wistar rats were anesthetized, tracheotomized and mechanically ventilated with fixed minute volume. Each animal underwent a 1 cm abdominal longitudinal incision. A 0.3 x 0.3 cm cross-incision of the stomach was performed in the perforation group but not in the controls (n=10/group), and the abdomen was closed in both groups. After stabilization, CO₂-induced pneumoperitoneum was established at 0, 5, 8 and 12 mmHg for 20 min periods consecutively, each followed by complete pressure relief for 5 minutes.

Results: Ventilatory pressure increased in both groups when pneumoperitoneal pressure ≥ 5 mmHg was applied, but more so in the perforated stomach group (P = 0.003). E_TCO₂ increased in both groups during the experiment, but less so in the perforated group (P = 0.04). It then returned to near baseline values during pressure annulation in all perforated animals but only in the 0 and 5 mmHg periods in the controls.

Conclusions: When subjected to pneumoperitoneum, E_TCO₂ was lower in rats with a perforated stomach than in those with an intact stomach. An abrupt decrease in E_TCO₂ during laparoscopy may signal gastric perforation.
 

Background: Frequent readmissions significantly contribute to health care costs as well as work load in internal medicine wards.

Objective: To develop a simple scoring method that includes basic demographic and medical characteristics of  elderly patients in internal medicine wards, which would allow prediction of readmission within 3 months of discharge.

Methods: We conducted a retrospective observational study of 496 hospitalized patients using data collected from discharge letters in the computerized archives. Univariate and multivariate logistic regression analyses were performed and factors that were significantly associated with readmission were selected to construct a scoring tool. Validity was assessed in a cohort of 200 patients.

Results: During a 2 year follow-up 292 patients were readmitted at least once within 3 months of discharge. Age 80 or older, any degree of impaired cognition, nursing home residence, congestive heart failure, and creatinine level > 1.5 mg/dl were found to be strong predictors of readmission. The presence of each variable was scored as 1. A score of 3 or higher in the derivation and validation cohorts corresponded with a positive predictive value of 80% and 67%, respectively, when evaluating the risk of rehospitalization.

Conclusions: We propose a practical, readily available five-item scoring tool that allows prediction of most unplanned readmissions within 3 months. The strength of this scoring tool, as compared with previously published scores, is its simplicity and straightforwardness.
 

The Dutch painter Rembrandt van Rijn (1606–1669) left behind the largest collection of self-portraits in the history of art. Although about 40 of his oil paintings could be considered “self-portraits,” controversy still exists regarding 14 of them. We undertook to determine the identity of the painter or the subject. Our work was based on the generally accepted premise that these portraits represent a “realistic” rendering of the subject. Self-portraits on which there is consensus regarding the authenticity were chosen as the basis for our measurements. Using a computerized technique we measured the brow ptosis. We also subjectively analyzed Rembrandt's facial aging and the unique asymmetrical elements in his face. We could not add any useful information on 6 of the 14 portraits and suggest that 8 should be considered authentic. Facial aging analysis and the unique surface anatomy allowed us to confirm Rembrandt as the painter in four of six self-portraits. We confirmed Rembrandt as the subject and painter in three more paintings. Of the two paintings in which the subject’s identity was controversial, we determined Rembrandt as the subject in one. We were able to date Rembrandt’s age in two other works and considered another portrait to be a copy. Our methodology may serve as an additional tool for the authentication of self-portraits.
 

Background: Patient protection requires the provision of informed consent for participation in medical research. The MacArthur Competence Assessment Tool for Clinical Research (MacCAT-CR) is frequently used for screening the capacity of research subjects to consent to participate in research.

Objectives: To evaluate the utility of the Hebrew translation of the MacCAT-CR for the assessment of capacity of patients with chronic schizophrenia to provide informed consent to participate in clinical trials.

Methods: We evaluated the translated MacCAT-CR by comparing the capacity of patients with chronic schizophrenia to provide informed consent to participate in clinical trials. The following standardized neurocognitive assessment tools were used: Addenbrooke’s Cognitive Examination (ACE) and Frontal Assessment Battery (FAB), as well as the attending doctor’s assessment.

Results: Twenty-one patients participated. Mean MacCAT-CR score was12 ¡À 10.57 (range 0¨C32), mean FAB score was 9.9 ¡À 4.77 (range 1¨C18), mean ACE was 59.14 ¡À 16.6 (range 27¨C86) and mean doctor’s assessment was 5.24 ¡À 1.18 (range 3¨C7).

Conclusions: The Hebrew-version of the MacCAT-CR helped identify patients with the capacity to provide informed consent for participation in research. Patients with FAB scores ¡Ý 12 tended to score higher on the Hebrew-version of the MacCAT-CR, thus confirming the utility of the Hebrew version of the MacCAT-CR. During the screening process for clinical trials it may be practical to administer the concise FAB questionnaire, and then administer the MacCAT-CR only to those who scored ¡Ý 12 on the FAB.