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ABSTRACT: Diabetic ketoacidosis (DKA) is 1 of the most common and serious complications of diabetes, and is a significant cause of morbidity and mortality. There is a paucity of data regarding gender-related differences in clinical characteristics and outcomes of patients hospitalized for DKA.
The purpose of this study was to assess whether gender plays a role in clinical characteristics and outcome of DKA.
We performed a retrospective cohort study of patients hospitalized with DKA between January 1, 2003 and January 1, 2010. The outcomes of male and female patients were compared. The primary outcome was in-hospital all-cause mortality. The secondary outcomes were 30-day all-cause mortality and rate of complications: sepsis, respiratory failure, multiple organ failure, stroke, and myocardial infarction.
Eighty-nine men and 131 women with DKA were included in the study. Male patients had higher rates of chronic renal failure compared with women (16.9% vs 3.1%; P = 0.001), whereas more women than men received oral hypoglycemic therapy (19.8% vs 9.0%; P = 0.046); women also had higher glycosated hemoglobin levels before admission (11.9% [1.7%] vs 9.9% [2.2%]; P = 0.025). The in-hospital mortality rate was not significantly different for both genders (4.5% in the male group vs 3.8% in the female group; P = 1.0). We did not find significant differences between the 2 groups in the 30-day mortality rate (4.5% vs 6.1%; P = 0.7) or the rate of complications (5.6% vs 6.9%; P = 0.9). Advanced age, mechanical ventilation, and bedridden state were independent predictors of 30-day mortality.
In our study we did not find statistically significant differences in the in-hospital mortality, 30-day all-cause mortality, or rate of complications between men and women hospitalized with DKA. However, women with poorly controlled type 2 diabetes mellitus receiving oral hypoglycemic therapy required particular attention and might benefit from earlier introduction and intensification of insulin therapy to avoid DKA.
Gender Medicine 11/2011; 8(6):372-7. · 2.10 Impact Factor
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ABSTRACT: Swearing to a medical oath is a common practice in medical schools today. Students at the Medical School for International Health (MSIH) participate in an elaborate physician's oath ceremony held in the first year of studies. At this ceremony, students read a code of ethics written by their class, the content of which includes the ethical principles the class as a whole deems significant.
9 codes of ethics, written by students at the MSIH between 1998 and 2006, as well as the oaths of Hippocrates and Maimonides, were collected and the principles contained within them were analyzed and compared. The oaths were broken up into preamble, covenant, code, and peroration sections, each encompassing various content domains.
Principles discussed in both the oaths of Hippocrates and Maimonides, as well in two-thirds or more of the student-written codes, included loyalty to one's colleagues, the profession, and one's teachers, as well as acting with beneficence. Attributes including compassion, integrity, and honesty, were mentioned in two-thirds or more of the student-written codes but neither the oath of Hippocrates nor Maimonides. Controversial issues, such as abortion and discussing God were not included in codes written by students.
Ethical codes written by students at the MSIH contained some similar principles to those contained within the traditional oaths; however, there was more emphasis on attributes that establish a good physician-patient relationship in the codes written by students. Future studies need to examine the content of other student-written codes.
European Journal of Internal Medicine 10/2009; 20(5):e101-4. · 2.00 Impact Factor
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European Journal of Internal Medicine 08/2009; 20(4):337-8. · 2.00 Impact Factor
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ABSTRACT: Israel, like many other countries, is struggling with numerous bioethical dilemmas due to its cultural and religious diversity. Until recently there was no legal guidance for how to deal with end-of-life issues. However, in 2005 a law was passed regulating the treatment of dying patients. Its most controversial aspect is the distinction it makes between withholding therapy (which is allowed) and withdrawing continuous therapy (which is not allowed). In this formulation, the law attempted to strike a balance between respecting the autonomy of the patient and respecting the sanctity of life. The law respects autonomy by establishing the right of the patient to refuse treatment; it respects the sanctity of life by prohibiting active euthanasia and physician-assisted suicide. However, this compromise was not acceptable to all members of the public advisory body that framed the law. Some argued that there was no moral basis for the distinction between withholding and withdrawing treatment.
Journal of palliative care 01/2009; 25(4):284-8. · 0.93 Impact Factor
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ABSTRACT: Hyperlipidemia remains a major cause of morbidity in Western countries. The objective of this study was to document the percentage of adults who underwent periodical LDL measurement, and the percentage of patients with diabetes and post-angioplasty who were treated to goal.
Using a national database, data were obtained on the percentage of adults who had an LDL performed and the percentage of adults with an LDL at pre-specified levels. We also assessed the attainment of target LDL levels in diabetic and post-angioplasty patients. Data were also collected from patients with an acute coronary syndrome (ACS) admitted to seven hospitals within a 5 year period (2000-2004).
Primary prevention: In 2005, 64.6% of the total population of 754,910 aged 35-44 had at least one record of LDL cholesterol measurement documented. This figure was 79.6% in the 717,617 adults aged 45-54. Secondary prevention: Of 253,233 diabetics in 2005, 220,023 (86.9%) have undergone at least one annual LDL measurement. The percentage of patients on statin therapy 3 and 12 months after an ACS admission increased significantly during the years 2000-2004 and reached 87%. Of the 42,292 patients who underwent PTCA during 2005, 34,346 (81.2%) have purchased at least 3 prescriptions of statins during 2005, 35,261 (83.4%) have performed at least one LDL measurement and 57.8% attained an LDL level of <100 mg/dl.
We have shown an improvement in primary and secondary preventions of CV disease as documented by LDL measured and attainment of treatment goals, but further efforts are needed.
European Journal of Internal Medicine 07/2008; 19(5):356-61. · 2.00 Impact Factor
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The Israel Medical Association journal: IMAJ 06/2008; 10(5):390-1. · 1.02 Impact Factor
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Alan B Jotkowitz
The American journal of bioethics: AJOB 03/2007; 7(2):41-2. · 4.00 Impact Factor
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ABSTRACT: Despite significant advances in the therapy of heart failure, many patients still do not receive optimal treatment.
To document the standard of care that patients hospitalized with HF in Israel received during a 2 month period.
The Heart Failure Survey in Israel 2003 was a prospective 2 month survey of patients admitted to all 25 public hospitals in Israel with a diagnosis of HF.
The mean age of the 4102 patients was 73 years and 43% were female. The use of angiotensin-converting enzyme/angiotensin receptor blockers and beta blockers both declined from NYHA class I to IV (68.8% to 50.6% for ACE-inhibitor/ARB and 64.1% to 52.9% for beta blockers, P < 0.001 for comparisons). The percentage of patients by NYHA class taking an ACE-inhibitor or ARB and a beta blocker at hospital discharge also declined from NYHA class I to IV (47.5% to 28.8%, P < 0.002 for comparisons). The strongest predictor of being discharged with an ACE-inhibitor or ARB was the use of these medications at hospital admission. Negative predictors for their usage were age, creatinine, disease severity class, and functional status.
Despite the dissemination of guidelines many patients did not receive optimal care for HF. Reasons for this discrepancy need to be identified and modified.
The Israel Medical Association journal: IMAJ 12/2006; 8(12):875-9. · 1.02 Impact Factor
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ABSTRACT: Mentoring is a relationship aimed at fostering the development of the less experienced person. The internal medicine community has recently recognized the importance of this relationship in the advancement of careers in the profession. Preliminary evidence points to the importance of mentoring in achieving the mentee's goals without much suggestion that it could be harmful. It can be particularly helpful to women and minority junior faculty. We encourage academic institutions to help forge these relationships by developing their own formal systems of mentoring and to evaluate and report their efforts.
European Journal of Internal Medicine 11/2006; 17(6):399-401. · 2.00 Impact Factor
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ABSTRACT: The objective of the study was to assess the influence of socioeconomic status (SES) on the care of patients with diabetes.
Quality indicators for patients who were taking medication for diabetes were established. Overall compliance with the quality indicators, as well as prevalence of diabetes by age, were obtained from a national database. Patients with national tax exemptions (used as a marker for low SES) were compared to those without.
Of 4,110,852 citizens aged 18-74, 210,988 (5.1%) were receiving medication for diabetes. The prevalence of diabetes reached 19.9% in people aged 65-74. 495,392 citizens had an exemption, and they had a higher prevalence of diabetes that those who did not (15.4% vs. 3.7%). Patients with an exemption had a higher rate of having a yearly HbA1c done, a yearly LDL level done, a yearly eye exam, a yearly urinary protein exam, of being treated with insulin for an elevated HbA1c than those without an exemption. In patients with an exemption there was a lower percentage with an HbA1c less than 7%, a higher percentage with an HbA1c greater than 9%, and a lower percentage with an LDL less than 130. Multivariate analysis showed that exemption status was a predictor of better performance on process measures (LDL test done, OR-1.03, 95% CI 1.01-1.06, HbA1c test done, OR 1.03, 95% CI- 1.01-1.05) and of worse outcomes (high LDL, OR 0.92, 95% CI, 0.90-0.95 and high HbA1c, OR, 0.85, 95% CI, 0.83-0.87).
In a country with universal healthcare, patients from a lower SES had an increased prevalence of diabetes and had greater adherence to preventive healthcare measures However, they were less successful in meeting target treatment goals.
The American journal of medicine 09/2006; 119(8):665-9. · 4.47 Impact Factor
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ABSTRACT: Urinothorax is an unexpected cause of transudative pleural effusion associated with obstructive uropathy. We present a case of urinothorax in a patient with congestive heart failure who had undergone percutaneous nephrolithotomy. The diagnosis was made after an unexpected enlargement of the pleural effusion after treatment with diuretics.
European Journal of Internal Medicine 08/2006; 17(4):300-2. · 2.00 Impact Factor
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European Journal of Internal Medicine 01/2006; 16(8):543-4. · 2.00 Impact Factor
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ABSTRACT: Acetaminophen is the most common drug employed in deliberate self-poisoning (DSP) in many countries and can lead to acute liver failure. The purpose of the present study was to compare DSP with acetaminophen with DSP with other medications.
From January 2001 to December 2002, all patients admitted after DSP to Soroka University Hospital in Beer-Sheva, Israel, were identified. Demographic data and medical history were obtained retrospectively.
There were 282 incidences of DSP in the study period. The mean age of 94 patients with an acetaminophen overdose was lower than that of patients who had attempted DSP with other medications (24.8 vs. 34.6 years, p<0.001). There was no gender or ethnic difference between the groups. Patients with DSP with acetaminophen were less likely to make recurrent attempts (23.4% vs. 39.9% p=0.006), less likely to have psychiatric disorders (32% vs. 59% p<0.001), and had a shorter hospital stay (1.7 vs. 2.1 days, p=0.05). The acetaminophen group had less of an impairment in level of consciousness (84% vs. 52.1% p<0.001) and had less need for ICU care (6.4% vs. 14.9%, p=0.04). Serum levels were checked in 68 (72.3%) of the patients in the acetaminophen group and they were found to be high in 6 (8.8%) of them (95% CI 2.1-15.5%).
Taking an overdose of acetaminophen is a common method of DSP, with patients tending to have a more benign presentation and shorter hospital stay than those who attempt DSP with other medications. Further research on the optimal care of these patients and multi-disciplinary approaches to DSP prevention are needed.
European Journal of Internal Medicine 12/2005; 16(8):585-9. · 2.00 Impact Factor
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Jorge Delgado,
Ami D Sperber,
Victor Novack,
Bertha Delgado,
Leslie Edelman,
Nava Gaspar,
Pavel Krugliak,
Shmuel Odes, Alan B Jotkowitz,
Mark Faszczyk,
Alex Fich
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ABSTRACT: The epidemiology of primary biliary cirrhosis has changed significantly over the last decade, with a trend towards increasing prevalence in many places around the world.
To determine the overall prevalence of PBC in southern Israel and the specific rates for different immigrant groups between January 1993 and October 2004.
Multiple case-finding methods were used to identify all cases of PBC in the study region. Age-adjusted prevalence rates were compared among the different immigrant groups.
A total of 47 cases of PBC were identified with an overall prevalence of 55 cases per million. All patients were women, and all except for a Bedouin Arab were Jewish. Foreign-born patients comprised 70% of our PBC cohort even though they represent only 45.4% of the regional population. This predominance of immigrants did not change when the rates were adjusted for age (P < 0.001). The prevalence rates were 40, 177, and 58 cases per million for those born in Israel, North Africa or Asia, and Eastern Europe, respectively. The age-specific prevalence rate for women older than 40 years varied from 135 cases per million among those born in Israel to 450 among immigrants from Eastern Europe and the former USSR to 700 cases per million among immigrants from North Africa and Asia.
The prevalence of PBC in southern Israel is similar to that reported from some European countries. The rate is much higher among Jews than Arabs and among immigrants to Israel compared to native Israelis.
The Israel Medical Association journal: IMAJ 11/2005; 7(11):717-21. · 1.02 Impact Factor
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ABSTRACT: Primary aortoenteric fistula is a rare but catastrophic cause of gastrointestinal bleeding. The diagnosis of primary aortoenteric fistula is difficult to make and is usually accompanied by a very high level of clinical suspicion. It should be considered in any elderly patient presenting with upper gastrointestinal bleeding in the context of a known abdominal aortic aneurysm. Prompt surgical intervention is necessary. We present the case of a 78-year-old man with a history of atherosclerotic abdominal aortic aneurysm which is presented with massive upper gastrointestinal bleeding due to a primary aortoduodenal fistula. Initial misdiagnosis led to a delay in treatment and the patient succumbed to the illness.
European Journal of Internal Medicine 10/2005; 16(5):363-5. · 2.00 Impact Factor
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ABSTRACT: Patients with dementia and their families can face many difficult and agonizing ethical dilemmas over the course of the illness. An awareness of the Jewish ethical response to some of these issues can help clinicians in treating patients of the Jewish faith and also serve as an example of how one ethical system addresses these questions. The Jewish response is grounded in a profound respect and value for human life in all its forms and man's responsibility to preserve it, but Judaism rejects unproven therapies and recognizes the limitations of modern medicine. Jewish law also codifies normative obligations that children have toward their elderly parents. With these principles in the forefront, this article analyzes a Jewish ethical response to various problems in the care of the demented patient such as truth telling, transfer to a nursing home, artificial nutrition, and end-of-life care, taking into account modern concepts of the doctor-patient relationship and ancient Jewish tradition.
Journal of the American Geriatrics Society 06/2005; 53(5):881-4. · 3.74 Impact Factor
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ABSTRACT: Patients, their families and even physicians themselves have commented on the lack of communication skills, empathy and concern for the psychosocial aspect of patient care among doctors of today. The call by many in the medical community for a renewed commitment to professionalism is partially in response to these concerns. Recently, medical ethics has focused on technical legal issues but ethics also has much to contribute on issues relating to the doctor-patient relationship. By analyzing traditional religious attitudes toward this relationship one can develop universal insights that still have much relevance to modern medicine for physicians and patients of all faiths.
European Journal of Internal Medicine 05/2005; 16(2):95-96. · 2.00 Impact Factor
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ABSTRACT: BACKGROUND: Screening for various diseases is now being offered to the public in settings other than their physicians' office, often using expensive and sophisticated technology. Little is known about how patients decide to participate in such programs, whether they understand the implications of a positive or negative test, or if their primary care physician is involved in the decision to screen. METHODS: We surveyed a cohort of patients who participated in a free carotid artery screening using Doppler ultrasound at a tertiary care academic medical center. RESULTS: One hundred twenty-four patients participated and underwent the ultrasound exam. Their mean age was 68.8 (+/-9.8) years and 54% were female. Some 117 patients (94%) completed the survey. Five patients (4%) tested positive for significant carotid artery stenosis. Sixty-two percent (95% CI: 53-71%) of the patients learned about the program through a newspaper advertisement. Eighty-eight percent (95% CI: 82-94%) of the subjects stated that their primary physician had not suggested that they have the test, and 59% (95% CI: 50-68%) did not know that carotid artery surgery is often recommended for patients who test positive. CONCLUSIONS: This study of one group of patients who voluntarily took a screening test for carotid artery stenosis raises some important questions since most subjects did not understand the implications of a positive result, nor did they involve their physicians in their decision to take the test. Further studies are needed to evaluate whether providing patients with more information about the implications of a screening test would change their desire to have the test and about the nature of the informed consent required before such screening is carried out.
European Journal of Internal Medicine 03/2005; 16(1):34-36. · 2.00 Impact Factor
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Journal of palliative care 02/2005; 21(1):57-8. · 0.93 Impact Factor
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The Israel Medical Association journal: IMAJ 12/2004; 6(11):661-4. · 1.02 Impact Factor
