Israel Medical Association Journal

Suicide is universal within the range of human behaviors and is not necessarily related to psychiatric morbidity, though it is considerably more prevalent among psychiatric patients. Considering the limitations of medical knowledge, psychiatrists cope with an unfounded and almost mythical perception of their ability to predict and prevent suicide. We set out to compose a position paper for the Israel Psychiatric Association (IPA) that clarifies expectations from psychiatrists when treating suicidal patients, focusing on risk assessment and boundaries of responsibility, in the era of defensive medicine. The final draft of the position paper was by consensus. The IPA Position Paper established the first standard of care concerning expectations from psychiatrists in Israel with regard to knowledge-based assessment of suicide risk, elucidation of the therapist's responsibility to the suicidal psychotic patient (defined by law) compared to patients with preserved reality testing, capacity for choice, and responsibility for their actions. Therapists will be judged for professional performance rather than outcomes and wisdom of hindsight. This paper may provide support for psychiatrists who, with clinical professionalism rather than extenuating considerations of defensive medicine, strive to save the lives of suicidal patients.
 

Background: Pediatric functional visual loss (FVL) is the loss of vision in a child that cannot be explained by an organic pathology. In the last decade, only a few studies on pediatric FVL have reported long-term patient follow-up.

Objectives: To report the characteristics of pediatric FVL with long-term follow-up in Israeli children.

Methods: We conducted a retrospective chart review of the medical records of patients with FVL from 2000 to 2010. Only children with adequate follow-up (at least 2 months) were included.

Results: Of the 12 patients identified, 9 were females. Mean patient age was 10.5 ± 4.4 years (range 3.5–17 years). Most children (75%) had bilateral visual loss. One patient had a history of psychiatric illness and in three patients a preceding psychosocial event/trauma was identified. Brain imaging and electrophysiology testing (if done) were normal in all cases. No medications were prescribed to any of the patients, and all were reassured that there was a high chance of spontaneous resolution. The follow-up time was 2–108 months (mean 23.8 months, median 6). During the follow-up period 9 of the 12 had complete resolution and 2 had relief of symptoms. Three patients reported a recurrence of symptoms. No organic disease was ever diagnosed in this group.

Conclusions: FVL may occur in all age groups, including children. In cases of visual loss, it is usually bilateral and can involve both acuity and visual field loss. In the present report most of the patients experienced normalization or relief of their symptoms without medical treatment.
 

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: In the past, carotid endarterectomy (CEA) was the only modality for invasive intervention in cases of carotid stenosis. Due to improvements in endovascular techniques (stenting), there is a growing debate regarding the preferred procedure for carotid intervention.

Objectives: To compare the 30 day complication rate after CEA and carotid angioplasty and stenting (CAS) in a tertiary medical center in Israel between the years 2008 and 2010.

Methods: We reviewed the medical charts of all the patients who underwent either CEA or CAS of the internal carotid artery due to symptomatic and asymptomatic stenosis during the period 2008–2010 (total of 128 patients).

Results: There was no difference between the groups in the rate of severe complications in the peri-procedural period. Mild complications were non-significantly more common in the CEA group (17%) compared to the CAS group (7.1%).

Conclusions: There was no significant difference in the mild and severe complications rate between CEA and CAS in the peri-procedural period.

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: Primary liver masses in children may require intervention because of symptoms or concern about malignant transformation.

Objectives: To review the management and outcomes of benign liver masses in children. Methods: We conducted a retrospective chart review of children with liver masses referred to our institution during the period 1997–2009.

Results: Benign liver masses were identified in 53 children. Sixteen of these children (30%) had hemangioma/infantile hepatic hemangioendothelioma (IHH) and 15 (28%) had focal nodular hyperplasia. The remainder had 6 cysts, 4 hamartomas, 3 nodular regenerative hyperplasia, 2 adenomas, 2 vascular malformations, and one each of polyarteritis nodosa, granuloma, hepatic hematoma, lymphangioma, and infarction. Median age at presentation was 6 years, and 30 (57%) were female. Masses were initially noticed on imaging studies performed for unrelated symptoms in 33 children (62%), laboratory abnormalities consistent with liver disease in 11 (21%), and palpable abdominal masses in 9 (17%). Diagnosis was made based on characteristic radiographic findings in 31 (58%), but histopathological examination was required for the remaining 22 (42%). Of the 53 children, 27 (51%) were under observation while 17 (32%) had masses resected. Medications targeting masses were used in 9 (17%) and liver transplantation was performed in 4 (8%). The only death (2%) occurred in a child with multifocal IHH unresponsive to medical management and prior to liver transplant availability.

Conclusions: IHH and focal nodular hyperplasia were the most common lesions. The majority of benign lesions were found incidentally and diagnosed radiologically. Expectant management was sufficient in most children after diagnosis, although surgical intervention including liver transplant was occasionally necessary.