Israel Medical Association Journal

Background: Benign prostate hyperplasia (BPH) is a common age-dependent urological condition that can disrupt quality of life if the patient's treatment choice is inappropriate. 

Objectives: To examine whether patients’ demography and personality affect their decision regarding the type of treatment: namely, conservative or surgical. 

Methods: A total of 105 BPH patients treated during the period 2005–2008 were retrospectively categorized into three groups according to treatment received: (i) medication only (n=056), (ii) combined treatment (the initial medication treatment was switched to surgical treatment) (n=32), and (iii) surgery only (n=17). A prerequisite for inclusion in the study was use of BPH medication for at least half a year before the study (groups 1 and 2). These groups completed the International Prostate Symptom Score (IPSS) questionnaire at the start of BPH medical treatment (IPSS 1) and at the start of the trial (IPSS 2), and the staff calculated the difference (IPSS 1-IPSS 2 = Delta IPSS = DIPSS).  All three groups provided demographic data (age, country of origin, education) and completed tri-dimensional personality questionnaires (TPQ) to measure three independent "temperament" personality dimensions to evaluate how different individuals feel or behave: novel seeking (NS), harm avoidance (HA), and reward dependence (RD). Data were analyzed using chi-square, t-test, one-way ANOVA and logistic regression.

Results: Demographic variables and the RD dimension differed according to choice of BPH treatment. 

Conclusions: Our study suggests that symptomatic BPH treatment is influenced less by the patient's personality and more by his life circumstances. Israeli-born patients were more conservative, Russian-born patients were ambivalent, and other foreign-born patients predominantly preferred surgical treatment. We assume that personality has a more decisive effect on patients with malignant disease and they accept the medical advice more easily. 

 

Background: While earlier studies indicated that cholesterol levels decrease significantly after an acute myocardial infarction (MI), a more recent study refuted this observation. 

Objectives: To assess changes in plasma lipid levels after onset of acute MI, and determine important predictors of lipid dynamics.

Methods: We prospectively measured lipid levels of patients who presented with an acute MI. Blood samples were drawn on admission to the hospital (day 1), after fasting at least 12 hours overnight (day 2), and on the 4th day of hospitalization (day 4). 

Results: Of 67 acute MI patients, 30 were admitted for ST elevation MI (STEMI) and 37 for non-STEMI. Both total cholesterol and low density lipoprotein cholesterol (LDL-C) levels decreased significantly (by 9%) in the 24 hours after admission and by 13% and 17% respectively on day 4. High density lipoprotein cholesterol (HDL-C) levels as well as triglycerides did not change significantly. Independent predictors of LDL-C decrease were the presence of diabetes mellitus [odds ratio (OR) 6.73, P = 0.01), and elevated cardiac troponin T (cTnT) levels (OR 1.81, P < 0.04).

Conclusions: LDL-C levels decrease significantly after an acute MI. The reduction is correlated with cTnT levels. Diabetes is a strong independent predictor of LDL-C decrease. In acute MI patients only measurements taken within 24 hours of onset should be used to guide selection of lipid-lowering medication.

 

Fungal diseases affect a large proportion of the population, ranging in severity from mild superficial infections to life-threatening invasive diseases. Estimates of disease burden are needed to inform public health policies. We estimated the incidence of fungal diseases in Israel based on published surveillance data and risk-based calculations using previously established models. Deaths associated with fungal diseases were estimated from local surveillance data (candidemia) and published reports (invasive aspergillosis). Candidemia was estimated in 649 persons/year and invasive aspergillosis in 254 persons/year; the associated mortality was 2.75 and 0.96 per 100,000 population/year, respectively. Recurrent Candida vulvovaginitis occurs in 130,440 women annually. National incidence rates of cryptococcosis, pneumocystis pneumonia and mucormycosis could not be reliably estimated. Single-center data-derived estimates yielded 24, 26 and 20 cases/year, respectively. Allergic bronchopulmonary aspergillosis, asthma with fungal sensitization and allergic fungal sinusitis affect 8297 (range 2323–11,615), 14,372 (14,372–17,965) and 39,922 (15,969–183,643) persons, respectively. In Israel, candidemia and invasive aspergillosis rank high among infection-related causes of mortality. Allergic fungal diseases cause chronic or recurrent symptoms in a large population and may contribute to asthma-related hospitalization and death. These general estimates should serve as a primer for future efforts to study fungal epidemiology. 

 

Background: Discharge summaries after hospitalization provide the most reliable description and implications of the hospitalization. A concise discharge summary is crucial for maintaining continuity of care through the transition from inpatient to ambulatory care. Discharge summaries often lack information and are imprecise. Errors and insufficient recommendations regarding changes in the medical regimen may harm the patient’s health and may result in readmission.

Objectives: To evaluate a quality improvement model and training program for writing postoperative discharge summaries for three surgical procedures.

Methods: Medical records and surgical discharge summaries were reviewed and scored. Essential points for communication between surgeons and family physicians were included in automated forms. Staff was briefed twice regarding required summary contents with an interim evaluation. Changes in quality were evaluated.

Results: Summaries from 61 cholecystectomies, 42 hernioplasties and 45 colectomies were reviewed. The average quality score of all discharge summaries increased from 72.1 to 78.3 after the first intervention (P < 0.0005) to 81.0 following the second intervention. As the discharge summary’s quality improved, its length decreased significantly.

Conclusions: Discharge summaries lack important information and are too long. Developing a model for discharge summaries and instructing surgical staff regarding their contents resulted in measurable improvement. Frequent interventions and supervision are needed to maintain the quality of the surgical discharge summary.  

Background: Previous studies led to the recommendation to schedule planned elective cesarean deliveries at or after 39 weeks of gestation, and not before 38 weeks. The question is whether this practice is appropriate in face of possible risks to the newborn should the pregnancy have to be ended by cesarean section before the scheduled date.

Objectives: To compare the outcomes of newborn infants who were delivered on their scheduled day by elective cesarean section versus those who required delivery earlier.

Methods: This single-center retrospective study was based on medical records covering a period of 18 months. We compared the neonatal outcomes of 272 infants delivered by elective cesarean section as scheduled (at 38.8 ± 0.8 weeks gestation) and 44 infants who had to be delivered earlier than planned (at 37.9 ± 1.1 weeks). 

Results: We found no morbidity directly related to delivery by cesarean section before the scheduled date. There were no significant differences in the need for resuscitation after delivery. Although more of the infants who were delivered early were admitted to intensive care and overall stayed longer in the hospital (5.8 ± 7.3 vs. 3.9 ± 0.8 days, P < 0.02), their more severe respiratory illness and subsequent longer hospitalization was the result of their younger gestational age. Transient tachypnea of the newborn was associated with younger gestational age at delivery in both groups.

Conclusions: We suggest continuing with the current recommendation to postpone elective cesarean singleton deliveries beyond 38–39 weeks of gestation whenever possible.

Background: Late nephrology referral, before initiation of dialysis treatment, is associated with adverse outcome.

Objectives: To investigate the implications of late nephrology referral on mortality among dialysis patients in Israel.

Methods: We retrospectively analyzed 200 incident dialysis patients. Patients were defined as late referrals if they started dialysis less than 3 months after their first nephrology consultation. Survival rates and risk factors for mortality were analyzed

Results: The early referral (ER) group comprised 118 patients (59%) and the late referral (LR) group 82 patients (41%). The mortality rate was 44.5% (53 patients) in the ER and 68% (n=56) in the LR group. The 4 year survival rate was 41.1% in the ER and 18.7% in the LR group (P < 0.0001). The mortality rate increased with late nephrology referral (HR 1.873, 95%CI 1.133–3.094), with age (HR 1.043 for each year, 95%CI 1.018–1.068), with diabetes (HR 2.399, CI 1.369-4.202), and with serum albumin level (HR 0.359 for an increase of each 1 g/dl, 95%CI 0.242–0.533). The median survival time was higher for the ER group in women, in patients younger than 70, and in diabetic patients. A trend for longer survival time was found in non-diabetic patients. Survival time was not increased in early referred patients older than 70 and in male patients.

Conclusions: Late nephrology referral is associated with an overall higher mortality rate in dialysis patients. The survival advantage of early referral may have a different significance in specific subgroups. The timing of nephrology referral should be considered as a modifiable risk factor for mortality in patients with end-stage renal disease. 

Background: Tinea pedis is a common chronic skin disease; the role of contaminated clothes as a possible source of infection or re-infection has not been fully understood. The ability of ultraviolet light to inactivate microorganisms has long been known and UV is used in many applications.

Objectives: To evaluate the effectivity of sun exposure in reducing fungal contamination in used clothes.

Methods: Fifty-two contaminated socks proven by fungal culture from patients with tinea pedis were studied. The samples were divided into two groups: group A underwent sun exposure for 3 consecutive days, while group B remained indoors. At the end of each day fungal cultures of the samples were performed.

Results: Overall, there was an increase in the percentage of negative cultures with time. The change was significantly higher in socks that were left in the sun (chi-square for linear trend = 37.449, P < 0.0001).

* Louis Brandeis, Associate Justice of the U.S. Supreme Court, 1913

Conclusions: Sun exposure of contaminated clothes was effective in lowering the contamination rate. This finding enhances the current trends of energy saving and environmental protection, which recommend low temperature laundry.

Objectives: To describe a novel, hybrid technique combining SILS and conventional laparoscopy using minimal abdominal wall incisions.

Methods: Fifty patients diagnosed with symptomatic cholelithiasis were operated using two reusable 5 mm trocars inserted through a single 15 mm umbilical incision and a single 2–3 mm epigastric port. This technique was dubbed “minimal incision laparoscopic cholecystectomy” (MILC).

Results: MILC was completed in 49 patients (98%). In five patients an additional 3 mm trocar was used and in 2 patients the epigastric trocar was switched to a 5 mm trocar. The procedure was converted to CLC in one patient. Mean operative time was 29 minutes (range 18–60) and the average postoperative hospital stay was 22 hours (range 6–50). There were no postoperative complications and the cosmetic results were rated excellent by the patients.

Conclusions: MILC is an intuitive, easy-to-learn and reproducible technique and requires small changes from CLC. As such, MILC may be an attractive alternative, avoiding the cost and complexity drawbacks associated with SILS.