D. Antonelli, S. Atar, N.A. Freedberg and T. Rosenfeld
Background: Torsade de pointes is rarely associated with chronic amiodarone treatment, despite the effect of amiodarone on QT interval prolongation.
Objective: To identify risk factors and associated conditions that may cause TdP[1] in patients on chronic amiodarone treatment.
Methods: We reviewed the data of six consecutive patients on chronic amiodarone treatment who were admitted to the intensive cardiac care unit due to syncope and TdP.
Results: The patients’ median age was 73.5 years, and five were women. Concomitantly, loratadine was given to two patients and trazodone to one patient. Associated and attributing conditions to the development of TdP were hypokalemia in three patients, drug-induced bradycardia in one and reduced left ventricular function in four.
Conclusions: TdP associated with chronic amiodarone treatment may occur when amiodarone is co-administered with drugs that may potentially prolong QT interval. Additional risk factors for amiodarone-associated TdP include female gender, hypokalemia, reduced left ventricular function and bradycardia.
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[1] TdP = torsade de pointes
J. Cohen, D. Starobin, G. Papirov, M. Shapiro, E. Grozovsky, M.R. Kramer and P. Singer
Background: While increasing numbers of patients require prolonged mechanical ventilation, resources for weaning are either limited (ICU beds) or inadequate (general wards).
Objectives: To report on our initial experience over a 7 month period with an eight-bed mechanical ventilation weaning unit.
Methods: Sixty-nine patients requiring MV[1] for >10 days were admitted to the unit (nurse:patient ratio 1:4). Data collected included reason for MV, duration of hospital stay, and MVWU[2] course. Outcome results (successful weaning and mortality) were compared to those in historic controls (patients ventilated in the general wards over a 4 month period prior to the MVWU; n = 100).
Results: The mean age of the patients was 68 ± 16.6 years and hospital stay prior to MVWU admission 28.6 ± 24.2 days (range 10–72). The main reasons for MV included acute exacerbation of chronic obstructive pulmonary disease (31%) and recent pneumonia (28%). Mean MVWU stay was 13.5 ± 15.7 days (range 1–72 days). Thirty-four patients (49%) underwent tracheostomy. Fourteen patients required admission to the ICU[3] due to deterioration in their status. Twenty-nine patients (42%) were successfully weaned and discharged to the wards. A further 20 patients were transferred to the chronic ventilation unit of a regional geriatric rehabilitation hospital, where 5 were subsequently weaned and 15 required prolonged ventilation. Compared to controls (matched for age and reason for mechanical ventilation), more MVWU patients underwent successful weaning (49% vs. 12%, P < 0.001) and their mortality rate (n = 12) was significantly lower (17% vs. 88%, P < 0.001).
Conclusion: The higher level of care possible in a MVWU may result in a significantly improved rate of weaning and lower mortality. The assessment of long-term outcome in patients discharged to pulmonary rehabilitation centers requires further investigation.
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[1] MV = mechanical ventilation
[2] MVWU = mechanical ventilation weaning unit
[3] ICU = intensive care unit
M. Ben-Haim, M. Carmiel, N. Lubezky, R. Keidar, P. Katz, A. Blachar, A. Nomrod, P. Sorkine, R. Oren, J.M. Klausner and R. Nakache
Background: Adult-to-adult living donor liver transplantation is becoming an alternative to cadaveric transplantation in urgent and elective settings. Donor selection crucially affects donor safety and recipient outcome.
Objective: To present our algorithm of urgent and elective donor selection.
Methods: Urgent selection is expeditious and protocol‑based. Elective selection permits a comprehensive process. Both include medical, psychosocial and surgical-anatomic evaluations. Liver volumes and vascular anatomy are evaluated with computerized tomographic angiography. Informed consent is obtained after painstaking explanations. Independent institutional committees review and approve all cases.
Results: Between July 2003 and June 2004 we evaluated 43 potential live donors for 12 potential recipients (fulminant hepatic failure, n=5; chronic end-stage liver disease, n=6); primary graft non-function, n=1). Thirty-three candidates (76%) were excluded due to blood type incompatibility (n=14, 42%), incompatible anatomy (n=8, 24%) – including problematic volume distribution (n=2) or vascular anatomy (n=6) – psychosocial issues (n=4, 12%), or medical co-morbidity (n=7, 22%). Five recipients (FHF[1], n=4; chronic ESLD[2], n=1) were successfully transplanted from living donors. In the acute setting, two patients (FHF, PGNF[3]) died in the absence of an appropriate donor (cadaveric or living donor). In the elective group, one patient died of unexpected variceal bleeding and one received a cadaveric graft just before the planned living donor transplantation was performed. One candidate was transplanted overseas and two cases are scheduled. The ratio of compatibility for donation was 34% (10/29) for blood type-compatible candidates.
Conclusions: Donor selection for living donor liver transplantation is a complex, labor-intensive multidisciplinary process. Most exclusions are due to blood type incompatibility or anatomic details. Psychosocial aspects of these donations warrant special attention.
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[1] FHF = fulminant hepatic failure
[2] ESLD = chronic end-stage liver disease
[3] PGNF = primary graft non-function
E. Zimlichman, D. Mandel, F.B. Mimouni, S. Vinker, I. Kochba, Y. Kreiss and A. Lahad
Background: The health system of the medical corps of the Israel Defense Force is based primarily upon primary healthcare. In recent years, health management organizations have considered the primary care physician responsible for assessing the overall health needs of the patient and, accordingly, introduced the term “gatekeeper.”
Objectives: To describe and analyze how PCPs[1] in the IDF[2] view their roles as primary care providers and to characterize how they perceive the quality of the medical care that they provide.
Methods: We conducted a survey using a questionnaire that was mailed or faxed to a representative sample of PCPs. The questionnaire included demographic background, professional background, statements on self-perception issues, and ranking of roles as a PCP in the IDF.
Results: Statements concerning commitment to the patient were ranked higher than statements concerning commitment to the military organization. Most physicians perceive the quality of the medical care service that they provide as high; they also stated that they do not receive adequate continuous medical education.
Conclusions: Our survey shows that PCPs in the IDF, like civilian family physicians, perceive their primary obligation as serving the needs of their patients but are yet to take on the full role of “gatekeepers” in the IDF’s healthcare system. We conclude that the Medical Corps should implement appropriate steps to ensure that PCPs are prepared to take on a more prominent role as “gatekeepers” and providers of high quality primary medical care.
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[1] PCP = primary care physician
[2] IDF = Israel Defense Force
I. Layish, A. Krivoy, E. Rotman, A. Finkelstein, Z. Tashma and Y. Yehezkelli
Nerve agent poisoning is characterized by the rapid progression of toxic signs, including hypersecretions, tremor, convulsions and profound brain damage. In the political arena of today's world, the threat of nerve agent use against military troops has prompted armies to search for prophylactic protection. The two main strategies for prophylaxis include biological scavengers that can bind or cleave nerve agents before they react with AChE, and antidotes as prophylactic treatment. Pyridostigmine is the current pretreatment for nerve agent poisoning and is in use by most of the armed forces in Western countries. However, since pyridostigmine barely crosses the blood-brain barrier it provides no protection against nerve agent-induced central injury. Pyridostigmine is ineffective when administered without post-exposure treatment adjuncts. Therefore, other directions for prophylactic treatment should be explored. These include combinations of carbamates (reversible acetylcholinesterase inhibitors) and central anticholinergics or NMDA receptor antagonists, benzodiazepines or partial agonists for benzodiazepine receptor, and other central AChE[1] inhibitors approved for Alzheimer's disease. The transdermal route is an alternative way for delivering the prophylactic agent. Administration of prophylaxis can be extended also for civilian use during wartime.
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[1] AChE = acetylcholinesterase
A.L. Alkalay, H.B. Sarnat, L. Flores-Sarnat and C.F. Simmons
Profound neonatal hypoglycemia is one of the leading causes of brain injury. Hypoglycemic encephalopathy is caused by lack of glucose availability to brain cells. Although sharing a similar pathogenesis with hypoxic-ischemic encephalopathy, hypoglycemic brain insult has distinctive metabolic, brain imaging, electroencephalographic, and histopathologic findings.
M. Leitman, E. Peleg, R. Krakover, E. Sucher, S. Rosenblath, R. Zaidentstein and Z. Vered
S. Eylon, R. Wishnitzer and M. Liebergall