Israel Medical Association Journal

Background: The relationship between the amount of rehabilitation therapy and functional outcome in stroke patients has not been established.

Objectives: To evaluate the effectiveness of inpatient rehabilitation for post-acute stroke, and examine the relationship between intensity of therapies and functional status at discharge.

Methods: We evaluated 50 first-stroke patients, average age 63 years, in a prospective, descriptive study. The impairment and Functional Independence Measurement were assessed both at admission to rehabilitation and at discharge. Patients were monitored weekly during their stay by means of discipline-specific measures of activity level. Predictor variables included intensity of physical, occupational and speech therapies; demographic characteristics; length of stay; and time since the stroke.

Results: A significant reduction in impairment was observed at discharge. The predictors of gains and activity level at discharge as well as motor vs. cognitive components of the FIM[1] were neither consistent nor did they occur in the same trend of functional improvement. Greater FIM motor level at discharge was associated with younger age, higher admission motor and cognitive level, and receipt of any speech therapy, while greater FIM cognitive level was associated with higher cognitive level at admission, shorter interval from onset to admission, and more intense occupational therapy. More intense OT[2] was associated with greater and more cognitive improvement during the hospitalization.   

Conclusion: Since the sample was relatively small and heterogeneous in terms of the patients’ functional abilities, the findings cannot be generalized to the whole population of stroke patients. Further efforts to identify the best timing, modalities, intensity and frequency of the various treatments are needed to improve the cost-benefit equation of rehabilitation in stroke patients.

Background: Device replacement or revision may constitute 25% of pacemaker procedures. In patients needing pacemaker system replacement the usual approach is from the ipsilateral side of the previous system. In cases where the contralateral side is used the previous pulse generator is removed.

Objective: To test the feasibility of implanting a new system in the contralateral side without the removal of the old system.

Methods: We present 10 patients, age range 30–88 (median 73), with clinical indication of pacemaker replacement where the contralateral side was used. In eight patients the replacement was lead-related, and in the remaining two was due to other clinical indications. In all cases the ipsilateral approach was felt to be contraindicated because of local vein and/or pocket complications. Following the new pacemaker implantation the old system was reprogrammed at the lowest rate, lowest output and highest sensitivity.

Results: All patients underwent uneventful implantation. Post-surgery monitoring and Holter recordings failed to show any interference of the old system.

Conclusions: In clinically indicated cases it is feasible to implant a new device in the contralateral side without removing the old pulse generator, thereby avoiding an additional surgical procedure and reducing periprocedural complications.

The world now faces the dreadful possibility of biological weapons attacks by terrorists. Healthcare systems would have to cope with such emergencies should all preemptive measures fail. Information gained from the Global Mercury exercise and the SARS outbreak has shown that containing an outbreak at the start is more effective than reacting to it once it has spread and that containment should be treated both nationally and internationally. On the national level this entails developing rapid and effective methods to detect and identify infected cases, and implementing isolation and control measures to lower the risk of further transmission of the disease while assuring the safety of medical teams and laboratory workers. Strategic contingency plans should incorporate well-defined procedures for hospitalization and isolation of patients, providing regional backup of medical personnel and equipment and maintaining close cooperation between the various bodies in the healthcare system. Quarantine is an effective containment measure, especially if voluntarily imposed. Modern communication systems can help by sending professional teams timely instructions and providing the public with information to reduce panic and stress during quarantine procedures. Informing the public poses a dilemma: finding a balance between giving advance warning of an imminent epidemic outbreak and ascertaining the likelihood of its occurrence. Containment of international bioterrorist attacks depends entirely on close international cooperation to implement national and international strategic contingency plans with free exchange of information and recognition of procedures.

Background: The long-standing and ongoing controversy regarding administration of analgesia to patients with acute abdominal pain prior to final diagnosis has not yet been resolved, despite considerable research. Consequently, wide variations in clinical practice exist.

Objectives: To determine the motives, attitudes and practices of emergency physicians, internists and surgeons in Israeli emergency departments regarding the administration of analgesia before diagnosis in patients with acute abdominal pain.

Methods: Questionnaires were completed by 122 physicians in 21 EDs[1] throughout Israel and the replies were analyzed.

Results: Most EDs did not have a clear policy on analgesia for undifferentiated abdominal pain, according to 65% of the responders. More internists (75%) than surgeons (54%) (P = 0.02) and more emergency physicians (81%) than all other physicians (60%) (P = 0.05) held this opinion. Most respondents (64%) supported administration of analgesia pre-diagnostically. Support for analgesia was significantly stronger among internists (75%) compared to surgeons (52%) (P = 0.03). Despite this wide support, most respondents (68%) indicated that analgesia was rarely or never given pre‑diagnostically and, when it was, more surgeons (58%) than other physicians made that decision. Most internists (73%) and all surgeons reported that patients receive analgesia only after being examined by surgeons. Time allocated to the ED (part‑ or full‑time) significantly (P = 0.02) influenced decision-making, with 51% of part-time physicians vs. 25% of full-time opposing prompt administration of analgesia. Opinions on who should decide were divided according to medical specialty, with surgeons and internists almost opposed, as well as by physician age and percent of his/her time spent working in the ED. More surgeons than internists (P = 0.0005) reported that analgesia sometimes interfered with making a diagnosis. Most physicians (90%) stated that opiates impede diagnosis, to some extent. However, 58% of them supported the administration of opiates, more or less frequently. Intramuscular diclofenac was the most preferred analgesic, followed by intravenous morphine and pethidine; individual preferences extended beyond the list of actually administered drugs.

Conclusions: There is no consensus on the administration of analgesia for undiagnosed acute abdominal pain in EDs in Israel. Physicians’ attitudes are influenced by training, experience, and percent of personal time allocated to work in the ED.

Background: Until recently trimethoprim-sulfamethoxazole was the drug recommended in the Leumit Health Fund for the empiric treatment of uncomplicated urinary tract infection in women. However, due to increased uropathogen resistance to this drug, the fund has designated nitrofurantoin as its new drug of choice.

Objectives: To evaluate the potential economic impact of implementing this new pharmaco-policy.

Methods: Using data derived from the electronic patient records of the Leumit Health Fund we identified all non-recurrent cases of women aged 18–49 with a diagnosis of acute cystitis or UTI[1] without risk factors for complicated UTI and empirically treated with antibiotics throughout 2003. The final sample comprised 5,489 physician-patient encounters. The proportion of cases treated with each individual drug was calculated, and the excess expenditure due to non-adherence to the new guideline from the perspective of the health fund was evaluated using 5 days of therapy with nitrofurantoin as the reference treatment.

Results: Ofloxacin was the most frequently prescribed drug (30.24%), followed by TMP-SMX[2] (22.43%), cephalexin (15.08%), and nitrofurantoin (12.59%). The observed net aggregate drug expenditure was 2.3 times greater than expected had all cases been treated with nitrofurantoin according to the guideline duration of 5 days. The cost of treatment in 53% of the cases exceeded the expected cost of the guideline therapy.

Conclusions: Successful implementation of the new drug policy will likely improve quality of care and reduce costs to the health fund.

Objectives: To assess patient satisfaction, subjective long-term continence and complications after AMS 800 artificial urinary sphincter implantation.

Methods: The medical records of 34 patients who underwent artificial urinary sphincter implantation for radical prostatectomy (n=23), simple prostatectomy (n=9) or neurogenic disease (n=2) between 1995 and 2003 were studied retrospectively. Median follow-up was 49 months (range 3–102 months). Records were analyzed for urinary sphincter survival and complications. Quality of life and continence assessment was done by mailing an impact questionnaire.

Results: In 4 of the 34 patients (11.7%) the device was removed due to infection. One of the four had surgical revision elsewhere, and the other three were not interested in re-implantation of the device. Two patients (5.9%) underwent revisions due to mechanical failure. One patient died and three patients were not located. Twenty-seven out of a possible 30 patients (88%) completed the questionnaire; 22 (85%) achieved social continence (0–2 pads daily), and one patient had subjective difficulty activating the device. Subjective improvement and patient satisfaction was rated as 4.22 and 4.11, respectively (scale 0 to 5).
Conclusions: Artificial urinary sphincter implantation is an efficacious option for sphincter-related incontinence. This study documents the positive impact of artificial urinary sphincter implantation on quality of life with acceptable complications; these results are comparable to other published studies.

Background: Laron Syndrome, first described in Israel, is a form of dwarfism similar to isolated growth hormone deficiency caused by molecular defects in the GH[1] receptor gene.

Objective: To characterize the molecular defects of the GH-R[2] in Laron syndrome patients followed in our clinic.

Methods: Of the 63 patients in the cohort, we investigated 31 patients and 32 relatives belonging to several ethnic origins. Molecular analysis of the GH-R gene was performed using the single strand conformation polymorphism and DNA sequencing techniques.

Results: Eleven molecular defects including a novel mutation were found. Twenty-two patients carried mutations in the extracellular domain, one in the transmembrane domain, and 3 siblings with typical Laron syndrome presented a normal GH-R. Of interest are, on one hand, different mutations within the same ethnic groups: W-15X and 5, 6 exon deletion in Jewish-Iraqis, and E180 splice and 5, 6 exon deletion in Jewish-Moroccans; and on the other hand, identical findings in patients from distinct regions: the 785-1 G to T mutation in an Israeli-Druze and a Peruvian patient. A polymorphism in exon 6, Gly168Gly, was found in 15 probands. One typical Laron patient from Greece was heterozygous for R43X in exon 4 and heterozygous for Gly168Gly. In addition, a novel mutation in exon 5: substitution of T to G replacing tyrosine 86 for aspartic acid (Y86D) is described.

Conclusions: This study demonstrates: a) an increased focal incidence of Laron syndrome in different ethnic groups from our area with a high incidence of consanguinity; and b) a relationship between molecular defects of the GH-R, ethnic group and geographic area.