Israel Medical Association Journal

Since the Surviving Sepsis Campaign Guideline (SSG) was published in 2004, critical care physicians can readily access the evidence and current recommendations regarding management of patients with severe sepsis and septic shock. However, several issues including a potential conflict of interest in developing the guidelines were disclosed. There have also been dramatic changes in the management of sepsis, supported by high levels of evidence. SSG[1] 2008 was developed to update the evidence using a new grading system. We reviewed select topics, routinely addressed by intensivists in the surgical intensive care unit, that have changed between SSG 2004 and SSG 2008: namely, glucose control, and administration of steroids, recombinant human activated protein C (rhAPC) and total parenteral nutrition.

Background: Percutaneous angioplasty (PTA) and stenting is an established procedure for the treatment of hypertension caused by atherosclerotic renal artery stenosis. However recently, the decision whether or not to perform this procedure has raised considerable debate.

Objectives: To examine the association between the basic clinical and radiological characteristics of candidates for renal artery PTA and the clinical outcome of the procedure in terms of improvement of blood pressure control and renal function.

Methods: We conducted a retrospective cohort study of all patients who underwent percutaneous transluminal renal artery angioplasty (PTRA) and stent implantation in a tertiary medical center during the period 2000–2007. The clinical and radiological data were extracted from the medical file of each patient. Blood pressure measurements and creatinine level were recorded before the procedure and 1 month, 6 months, 12 months and 18 months after PTRA.

Results: Thirty-two patients were included in the final statistical analysis. The mean age of the study population was 66.6 ± 8.8 years old and 75% were men. There was a significant reduction in both systolic and diastolic blood pressure 1 month after the procedure: 160.5 ± 24.7 vs. 141.8 ± 23.6 mmHg and 83.8 ± 12.9 vs. 68.8 ± 11.8 mmHg respectively (P < 0.001). The reduction in blood pressure was constant throughout the follow-up period and was evident 18 months after the procedure: 160.5 ± 24.7 vs. 135.0 ± 35.1 mmHg and 83.8 ± 12.9 vs. 71.3 ± 16.5 mmHg respectively (P < 0.001). However, no improvement in renal function was observed at any time during the follow-up period. We could not demonstrate an association between clinical or radiological features and the clinical outcome after PTRA.

Conclusions: Our findings show that PTRA[1] can be considered an effective procedure for improving blood pressure control in patients with atherosclerotic renal artery stenosis (ARAS) and resistant hypertension. This research, together with previous studies, strengthens the knowledge that the decline in glomerular filtration rate seen in many patients with ARAS is non-reversible and is not improved by PTRA.

Background: Control of diabetes is challenging, and frequent treatment changes are needed. 

Objective: To study the effect of the recommendation to start insulin glargine or insulin determir (long-acting insulin treatment, LAI) at discharge from hospital, on glucose control in the community setting.

Methods: Included were type II diabetes patients who were referred to and received a consultation from the hospital diabetes clinic during their hosptialization, as part of a routine consultation for diabetes management. During the visit, all patients were recommended long-acting insulin-based treatment, as inpatient treatment and at discharge. Follow-up was done by the primary physician in the community or by a community-based diabetes clinic. Glycosylated hemoglobin, glucose levels and other laboratory tests were obtained from the community health records before hospitalization and 6–12 months later. Medical treatment was ascertained by reviewing the actual usage of prescriptions.

Results: Eighty patients (58% males, mean age 64.1 ± 12.7 years) were included in the analysis. HbA1c levels were 10.1 ± 2.4% before admission, but improved significantly at follow-up (8.6 ± 2.2%, P < 0.001). Seventy-one percent of the patients were taking the LAI treatment and the rest were using non-LAI medications. Changes in diabetes control were similar between the LAI and non-LAI groups (HbA1c was reduced by 1.5 ± 3.2% and 1.9 ± 3.1% respectively). The rate of repeated admissions was also similar, averaging at 1.3 admissions for both groups, the minority of which were related to glucose control.

Conclusions: Insulin glargine or determir-based treatment does not show any superiority over other anti-diabetes treatment. It is our opinion that this treatment should be used as tailored therapy and should not be recommended routinely to all patients.
 

Background: The majority of human brucellosis cases in Israel are caused by the ingestion of unpasteurized dairy foods produced from unlicensed family-owned flocks whose products are sold door-to-door at low prices. Exposure to infected farm animals is another major cause of infection.

Objectives: To determine, by examining recent incidence data and brucellosis control programs, whether a reduction in the incidence of human brucellosis in Israel can be sustained.

Methods: Case information is reported to the Health Ministry and national data are compiled and analyzed by the Division of Epidemiology. The current study focuses on data from 1998 through 2009 and discusses several of the major prevention and health education programs that have been implemented.

Results: An incidence decline of almost 70% during the period 1998–2002 was followed by a return to previously existing levels, although the incidence has remained consistently lower than in past decades. The disease is mostly limited to certain sectors of the rural Arab population. In 2009 the incidence rate per 100,000 population was 7.0 among Arabs compared with 0.2 among Jews. Between 1998 and 2009, 63% of cases were from the Beer Sheva and Acre health districts, which together comprise 15.5% of the Israeli population. Control programs - including efforts to combat brucellosis in animals and to discourage the sale of unpasteurized homemade dairy products - have met with partial success.

Conclusions: Without routine vaccination of all family-owned flocks, more effective restraints on the market for unpasteurized dairy foods and improved regional cooperation, human brucellosis will continue to be a contained, but persistent, health problem in Israel due to cultural behavior, socioeconomic factors, and the regional political environment.
 

Background: It is currently recommended that capillary glucose levels of non-critically ill hospitalized diabetic patients be maintained at between 140 and 180 mg/dl. Implementation of these recommendations and evaluation of their effectiveness require that data regarding the glucose control of these hospitalized patients be accessible.

Objective: To analyze glucose control and monitoring of all the diabetic patients hospitalized in the general medicine wards of our medical center.

Methods: Capillary glucose measurements of all diabetic patients hospitalized in our departments of medicine between June and December 2008 were recorded by a central computerized institutional glucometer. Median glucose values and frequency of daily glucose checks per patient were analyzed in the internal medicine wards.

Results: We evaluated 14,366 capillary measurements from 2475 patients; 43% were taken before breakfast and 25% before dinner. A median of one daily determination per patient was obtained. This number increased 1.4-fold in patients with hyperglycemia > 200 mg/dl and 2.5-fold in patients with hypoglycemia. Seventy-five percent of the recorded glucose values were within the recommended target range, with a median daily level of 161 mg/dl and median fasting glucose of 142 mg/dl. A significant variance was found between wards.

Conclusions: The frequency of capillary glucose measurements in diabetic patients hospitalized in general medicine wards was low; most capillary glucose values, however, were within the recommended target range. The optimal monitoring of glucose in these patients remains to be determined.

Pathological gambling is classified in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders) and in the ICD-10 (International Classification of Disease) as an impulse control disorder. The association between impulsivity and pathological gambling remains a matter of debate: some researchers find high levels of impulsivity within pathological gamblers, others report no difference compared to controls, and yet others even suggest that it is lower. In this review we examine the relationship between pathological gambling and impulsivity assessed by various neurocognitive tests. These tests – the Stroop task, the Stop Signal Task, the Matching Familiar Figures Task, the Iowa Gambling Task, the Wisconsin Card Sorting Test, the Tower of London test, and the Continuous Performance Test – demonstrated less impulsivity in gambling behavior. The differences in performance between pathological gamblers and healthy controls on the neurocognitive tasks could be due to addictive behavior features rather than impulsive behavior.

Background: Tight glucose control has been shown to improve the outcome of patients with severe acute illnesses who are hospitalized in intensive care units and on intravenous insulin-based regimens.

Objectives: To clarify the attitudes of internists towards tight control of glucose levels in acutely ill patients hospitalized in general medical wards.

Methods: A questionnaire on intensive glucose control in acutely ill patients hospitalized in medical wards was mailed to each of the 100 heads of internal medicine departments in Israel.

Results: Fifty physicians responded. Of these, 80% considered tight glucose control to be a major treatment target, but only two-thirds had defined it as a goal in their ward. Furthermore, only about half had a defined protocol for such an intervention. Most physicians considered patients with acute coronary syndrome, stroke and infectious diseases as candidates for a tight glucose control protocol. The most frequently used modalities were multiple blood glucose measurements and repeated injections of short-acting subcutaneous insulin. The main reasons given for not having a defined protocol were lack of guidelines, no evidence of a clear benefit during hospitalization on a medical ward, and a shortage of adequately trained staff.

Conclusions: Inconsistencies in physicians’ attitudes and in treatment protocols regarding tight control of glucose levels in acutely ill patients hospitalized on a medical ward need to be addressed. Evaluation of the feasibility, effectiveness and side effects of a defined protocol is needed before any regimen can be approved by the heads of the internal medicine departments.
 

Background: Anti-ribosomal-P antibodies have been associated with central nervous manifestations of systemic lupus erythematosus. However, inconsistencies in their prevalence and clinical correlations have become an obstacle to their use as a diagnostic marker of the disease. This lack of consistency might stem from several factors, such as the lag period between clinical manifestations and the time blood was drawn, or the different methods used for antibodies detection.

Objectives: To evaluate three different enzyme-linked immunosorbent assay tests for the detection of anti-Rib-P Abs[1] in patients with SLE[2] and normal controls.

Methods: Sera from 50 SLE outpatients and 50 healthy subjects were tested with three ELISA[3] kits: Kit-1, which uses synthetic peptide comprising the 22 C-terminal amino-acids; Kit-2, which uses native human ribosomal proteins (P0, P1, P2); and Kit-3, which is coated with affinity-purified human ribosomal proteins. ELISA studies were performed according to the manufacturers' instructions.

Results: The prevalence of anti-Rib-P Abs in SLE patients and controls was 30% vs. 0%, 17% vs. 21%, and 30% vs. 14% in kits 1-3 respectively. Anti-Rib-P Abs detected by Kit-1 correlated with the SLEDAI score (SLE Disease Activity Index). No correlation between prior CNS[4] manifestations and anti-Rib-P Abs was observed.

Conclusions: A significant difference was documented between the ELISA kits used for the detection of anti-Rib-P Abs. A correlation was found between these antibodies (evaluated by Kit-1) and concurrent SLEDAI scores, in contrast to the lack of correlation with previous CNS manifestations. This supports the notion of "active serology" that is evaluated at the same time manifestations are present, as well as the need for standardization of laboratory assays in the future that enable a better assessment of anti-Rib-P Abs presence and clinical correlation. 

Background: The TANTALUS^™ System (MetaCure Ltd.) is a minimally invasive implantable device for the treatment of type 2 diabetes. The system detects food intake by sensing gastric electrical variations and applies electrical stimulation to the gut synchronized to natural gastric activity. The system is commercially available in Europe and Israel and is in clinical trials in the United States. It has been tested in 132 patients worldwide to date.

Objectives: To re-analyze previously reported data from different studies. This retrospective analysis of the type 2 diabetes subpopulation analyzed the expected benefit and characterize the significance of baseline A1c in the determination of the expected clinical outcome.

Methods: From the total cohort of 132 patients implanted with the TANTALUS device in 10 different centers in Europe and the U.S., 50 subjects (27 females, 23 males) who were obese with uncontrolled T2DM[1] on a stable regime of oral medication for 3 months prior to implant were identified. This population had similar inclusion/exclusion criteria as well as treatment protocols and were all treated for at least 24 weeks. The analysis was based on the A1c change compared to baseline.

Results: Data after 24 weeks demonstrate a reduction in A1c in 80% of the patients with average drop in A1c of 1.1 ± 0.1%. The average weight loss was 5.5 ± 0.7 kg.

Conclusions: The results suggest that the TANTALUS stimulation regime can improve glucose levels and induce moderate weight loss in obese T2DM patients.

Background: Dyslipidemia remains underdiagnosed and undertreated in patients with coronary artery disease. The Computer-based Clinical Decision Support System provides an opportunity to close these gaps.

Objectives: To study the impact of computerized intervention on secondary prevention of CAD[1].

Methods: The CDSS[2] was programmed to automatically detect patients with CAD and to evaluate the availability of an updated lipoprotein profile and treatment with lipid-lowering drugs. The program produced automatic computer-generated monitoring and treatment recommendations. Adjusted primary clinics were randomly assigned to intervention (n=56) or standard care arms (n=56). Reminders were mailed to the primary medical teams in the intervention arm every 4 months updating them with current lipid levels and recommendations for further treatment. Compliance and lipid levels were monitored. The study group comprised all patients with CAD who were alive at least 3 months after hospitalization.

Results: Follow-up was available for 7448 patients with CAD (median 19.8 months, range 6–36 months). Overall, 51.7% of patients were adequately screened, and 55.7% of patients were compliant with treatment recommended to lower lipid level. A significant decrease in low density lipoprotein levels was observed in both arms, but was more pronounced in the intervention arm: 121.9 ± 34.2 vs. 124.3 ± 34.6 mg/dl (P < 0.02). A significantly lower rate of cardiac rehospitalizations was documented in patients who were adequately treated with lipid-lowering drugs, 37% vs. 40.9% (P < 0.001).

Conclusions: This initial assessment of our data represent a real-world snapshot where physicians and CAD patients often do not adhere to clinical guidelines, presenting a major obstacle to implementing effective secondary prevention. Our automatic computerized reminders system substantially facilitates adherence to guidelines and supports wide-range implementation.

Background: The Palestinian Poison Control and Drug Information Center was established in 2006 to provide up-to-date information on medications and to help in the early diagnosis and management of poisoning cases.

Objectives: To summarize the activities carried out by the PCDIC[1] in the past 2 years.

Methods: Documented inquires received at the PCDIC were analyzed and the Center's activities were extracted from the files.

Results: During the first 2 years of the Center's existence, 323 inquiries were received, mainly (67.2%) from physicians; 70% of the calls were from the city of Nablus. Unintentional poisoning was the leading type of call (62.8%) followed by suicidal poisoning (20.7%). Medications were the major category of toxicants encountered (48.9%), followed by pesticides (23.5%). In 67.9% of the cases, the calls were initiated before any treatment was provided. The advice provided by the PCDIC was based on the nature of the call. During these 2 years the PCDIC has conducted several academic and non-academic activities. The Center introduced the concept of poison prevention weeks in Palestine and has conducted two so far. The PCDIC has published several articles in the fields of toxicology, rational drug use, complementary and herbal therapy, pharmacoepidemiology, and self-medication.

Conclusions: Documentation of all inquiries is mandatory for analysis, evaluation, comparative purposes, and quality assurance. More information campaigns are needed to encourage people to use the services provided by the PCDIC.

Background: Women frequently suffer perineal trauma while giving birth. Interventions to increase the possibility for an intact perineum are needed.

Objectives: To evaluate the effectiveness of antenatal perineal massage in increasing the likelihood of delivering with an intact perineum.

Methods: This single blinded prospective controlled trial included 234 nulliparous women with a singleton fetus. Women allocated to the study group were instructed to practice a 10 minute perineal massage daily from the 34th week of gestation until delivery. Primary outcome measures included the episiotomy rate; first, second, third and fourth-degree perineal tear rates; and intact perineum. Secondary outcomes were related to specific tear locations and the amount of suture material required for repair.

Results: Episiotomy rates, overall spontaneous tears and intact perineum rates were similar in the study and control groups. Women in the massage group had slightly lower rates of first-degree tears (73.3% νs. 78.9%, P = 0.39) and slightly higher rates of second-degree tears (26.7% νs. 19.3%, P = 0.39), although both of these outcomes did not reach statistical significance. The rates of anterior perineal tears were significantly higher in the massage group (9.5% vs. 3%, P = 0.05), whereas internal lateral tears rates were slightly lower but without statistical significance (11.5% νs.13.1%, P = 0.44).

Conclusions: The practice of antenatal perineal massage showed neither a protective nor a detrimental significant effect on the occurrence of perineal trauma.
 

Background: The introduction of more potent statins such as atorvastatin and rosuvastatin in Israel was accompanied by massive advertising about their superiority.

Objectives: To assess the need for switching therapy from older statins to more potent ones among diabetic patients with uncontrolled hypercholesterolemia.

Methods: Data on all diabetic patients over 30 years old attending two urban clinics were extracted and analyzed. For each patient we checked the last low density lipoprotein-cholesterol measurements for the year 2006, the brand and the dose of cholesterol-lowering medications, prescriptions and actual purchasing over a 4 month period prior to the last LDL-C[1] measurement, and whether treatment changes were necessary to achieve the LDL-C target (100 mg/dl or 70 mg/dl).

Results: The study population comprised 630 patients, age 66.7 ± 12.6 years, of whom 338 (53.6%) were women. Of the 533 (84.6%) patients whose LDL-C was measured in 2006, 45 (8.1%) had levels < 70 mg/dl and 184 (33.3%) had levels of 70 mg/dl < LDL-C < 100 m/dl.  The reasons for LDL-C > 100 mg/dl were patients not prescribed cholesterol-lowering drugs (38.3%), partial compliance (27.2%), and under-dosage of statins (15.4%); only 7.7% needed to switch to a more potent statin. Reasons for LDL-C > 70 mg/dl were patients not prescribed cholesterol-lowering drugs (34.3%), partial compliance (22.0%), and under-dosage of statins (26.6%); only 8.7% needed to switch to a more potent statin.

Conclusions: Only a small minority of diabetic patients with uncontrolled hypercholesterolemia need one of the potent statins as the next treatment step. More emphasis on compliance and dose adjustment is needed to achieve the target LDL-C level.