Harefuah最新文献

Introduction: The Israeli health system is experiencing an ongoing manpower crisis that will deepen soon with the increase in the number of patients and the overcrowding in clinics and hospitals. The core of the crisis is the need to staff the hospitalization departments and clinics with quality manpower. Alongside the initial staffing, there is an obligation to ensure the survivability of the professional personnel in the system over the years, and this must be done while constantly preventing the process of professional burnout. In the present article, we propose to change the face of medicine by moving from relying on a single professional (physician) to the operation of a multidisciplinary team, while ensuring that the various professionals operate at the peak of their skill envelope. At the base of the team is a physician who devotes himself to direct contact with the patient and his family while applying analytical and humanistic thinking based on a body of knowledge accumulated during his training.

Introduction: Acute stress disorder (ASD) is a disorder that appears after exposure to a life-threatening event and lasts between three days and a month. In this article, we review therapeutic approaches to this disorder. The information collected, to date, has not demonstrated the effectiveness of drug therapy in preventing the development of post-traumatic stress disorder (PTSD), and therefore, there is no recommendation for providing drug therapy as a routine treatment for ASD. The only drug treatment that has proven to have prophylactic effectiveness is pain treatment given when the ASD is also accompanied by a painful physical injury. When symptomatic treatment of anxiety symptoms is required, it is recommended to use it in a limited way. The first line treatment is trauma-focused cognitive behavioral therapy (TF-CBT). It includes psychoeducation, cognitive construction and exposure. In armies around the world, the therapeutic approaches are characterized by the principles of proximity to the place of combat, immediacy in providing the therapeutic response and emphasizing the expectation to return to function (PIE). The effectiveness of psychological debriefing treatment has not been proven, and it is not recommended as a treatment for ASD. The authors of the article recommend building research systems that will allow quality research in this field. It is recommended to train therapists in the field of trauma-focused cognitive behavioral therapy (TF-CBT) in preparation for events on the scale of a national disaster.

Introduction: For millennia, the ethos of "First, Do No Harm", attributed to Hippocrates, has been a cornerstone of medicine. This principle emphasizes the responsibility and ethical commitment of the clinician to the benefit of their patient. Recently, the rapid development of artificial intelligence (AI) is transforming the medical world, significantly affecting not only diagnosis, treatment plans, research, medical education, and medical ethics, but also the way we think. To maximize the benefits of AI, understand its limitations, and prevent potential harm to patients, clinicians should be aware of the principles underlying artificial intelligence. Such familiarity will enable the clinician to correctly assess outputs generated by AI tools; from medical recommendations proposed by targeted systems (such as a decision-support system for the interpretation of chest radiography) to diagnoses and treatment plans proposed by non-specific AI tools such as large language models. Developments in computing power, algorithms, and data storage have enabled significant progress in the world of AI, including the emergence of generative AI. This review bridges fundamental medical research concepts with stages of AI development, encompassing neural networks, and deep learning principles. It offers a glossary of commonly used AI terms and provides insights into the development and functioning of large language models. The potential influence of AI on the patient-physician relationship is also discussed. Several proposals are presented for actionable items that may improve the integration of AI into clinical work while maintaining the basic ethical principles of beneficence, non-maleficence, justice, and autonomy. They include proper model training, regulation, and involvement of the medical community in the development and integration of these models into clinical practice. Such involvement will ensure that the ethical principles of medicine remain at the forefront, and are not compromised by the interests of the developing entities. Disclosures: Prof. Sharon Einav and Or Degany are employed by Medint Medical Intelligence.

Introduction: The terrorist attack by Hamas and other organizations on October 7th, 2023 surprised the State of Israel. The Western Negev region, where most of the damage occurred, is a conflict zone. In view of this fact, emergency plans were prepared, including for the response in the field of mental health. These plans included the provision of emotional support and mental health services by the regional resilience centers. Several factors led to the fact that the resilience centers were not able to provide full service to the evacuated population. In general, mental health services in the State of Israel on the eve of October 7th were significantly lacking and in non-optimal availability. The events of October 7th created a new reality in which it was no longer possible to rely on the resilience centers, which were also damaged by the events. Actually, tens of thousands of people were evacuated to widespread areas, requiring emergency preparedness by the Ministry of Health. On October 13th, 2023, the mental health medical centers were requested to respond to this need in a spatial distribution for 4 weeks until the recovery of the resilience centers or the response by the health funds ("Kupot Holim").

Introduction: Coping with illness or physical disability and its consequences, including a decrease in daily function, is a stressful situation that poses various challenges for the person and the family. Rehabilitation is a complex ongoing process targeting to help return to functioning as close as possible to the status prior to the illness. There are different styles of coping with disease/disability, which affect the rehabilitation process and its success.

Objectives: This article aims to conceptualize and prepare a framework for coping of patients with physical disabilities in order to assist rehabilitative teams in providing care for these patients.

Methods: Clinical observations were conducted at the rehabilitation clinic in the central district of Maccabi, for mapping styles of coping with physical disability. Between February 2020 and July 2022, 240 patients who were suitable for the current study were examined. The sample included patients in the sub-acute phase, after the end of the diagnostic phase and the curative treatment of a medical condition, which caused a functional decline.

Results: Clinical observations indicate that the most effective coping style is flexibility, which allows a person to receive the assistance provided under the rehabilitation program and to adjust his or her lifestyle to the current functional status.

Conclusions: It is important for professionals to be familiar with coping styles to help patients move between them. Acceptance and Commitment Therapy (ACT) may help increase a person's psychological flexibility. It is recommended to combine it as part of the multi-professional rehabilitation to maximize the results of the rehabilitation.

Introduction: Up to 5% of patients with newly diagnosed celiac disease have negative serology. Although seronegative celiac, is the most common cause for villous atrophy, there are other differential diagnoses that should be ruled out when we find villous blunting without positive serology for celiac disease. The aetiologies are usually divided into 5 categories: immune-mediated, infectious, iatrogenic, inflammatory and infiltrative. We hereby report a case of 39 years old male, with end-stage renal failure and pancreatic insufficiency. He was treated with peritoneal dialysis and was a candidate for combined kidney-pancreas transplantation. Hyperphosphatemia is a common complication in patients with end-stage renal disease. In order to reduce his serum phosphate levels, he was treated with a high dose of lanthanum carbonate, one of the most effective and safe non-calcium-based phosphate binders. During weight loss investigation, he underwent gastroscopy that demonstrated duodenal denudated mucosa with villous blunting. Biopsy showed complete villous atrophy and accumulation of foreign material in mucosal histiocytes. Von Kossa staining, that was performed, emphasized the depositions of the foreign material that has been identified as lanthanum. Consequently, the treatment with lanthanum was stopped and replaced by another phosphate binder. This case illustrates a rare differential diagnosis of villous atrophy typical for end-stage renal disease patients, that can be categorized as an iatrogenic and infiltrative aetiology for villous atrophy. Since the long-term consequences of lanthanum deposition in tissue are unknown, this case also emphasizes the need for a multidisciplinary approach for treating dialysis patients, in order to understand which phosphate binder was provided.

Introduction: Hypoglycemia may be related to malnutrition or treatment of diabetes. An association between treatment with medical food and lower incidence of hypoglycemia among patients with diabetes and hypoalbuminemia has recently been shown.

Aims: To study the association between hypoglycemia incidence and medical and nutrition treatment for diabetes.

Methods: In this observational study, data was collected from electronic medical records. Included were patients with type 2 diabetes, admitted to internal medicine "E" at the Edith Wolfson Medical Center between 1.6.2016-31.5.2017. Logistic regression was implemented to assess the association between treatment for diabetes and hypoglycemia. Linear regression models were built to examine the association between treatment for diabetes and the number of hypoglycemic events.

Results: Included were 221 patients (62.4% females, mean age 77.4 ± 12.0 years), 52 of them (23.5%) had hypoglycemia. The proportion of patients on medical food was 69.5±37.1%. According to logistic regression model, age (OR 1.034, CI 1.002-1.068, p=0.038), male sex (OR 2.941, CI 1.454-5.945, p=0.003) and treatment with insulin (OR 3.778, CI 1.831-7.794, p<0.001) were associated with hypoglycemia, while treatment with medical food was associated with less hypoglycemia (OR 0.352, CI 0.145-0.857, p=0.022). The linear regression model showed that metformin was associated with fewer hypoglycemic events (beta=-0.352 CI -1.391- -0.704, p<0.001). Nutrition was not found to be associated with the number of hypoglycaemic events.

Conclusions: Treatment with oral nutrition supplements and metformin is associated with reduced incidence of hypoglycemia.

Discussion: Oral nutrition is crucial for preventing hypoglycaemia during hospitalizations, regardless of the treatment for glucose control. Metformin is also beneficial.

Introduction: The winning works of the Scientific Council of the Israel Medical Association (IMA) Award for Excellence in Basic Sciences for 2024.

Aims: The identification of brain structures that are critical for upper limb residual motor function following stroke is an essential step towards the development of advanced treatment modalities for improving rehabilitation outcomes among brain-injured patients, such as non-invasive brain stimulation techniques, which aim to induce neuroplasticity in motor-critical brain regions. In the current study we attempted to identify the critical brain regions for upper limb motor function among stroke patients, using three different methods of lesion-symptom mapping (LSM).

Methods: Brain imaging data and Fugl-Meyer Assessment for upper-limb (FMA) scores for 107 patients admitted to the neurological rehabilitation department at Loewenstein Rehabilitation Medical Center, were analyzed using 3 LSM methods: Voxel-based Lesion-Symptom Mapping (VLSM), Region-based Lesion-Symptom Mapping (RLSM), and Multi-perturbation Shapley-value Analysis (MSA).

Results: In left-hemispheric damaged (LHD) patients only a relatively small number of brain regions were found, in comparison with right-hemispheric damaged (RHD) patients. For LHD, two regions important for movement planning were found to be critical - the supplementary motor area and the premotor area. For RHD, parts of the temporal, frontal and insular cortices, as well as the cingulate gyrus were exclusively detected as critical. Sub-cortical brain structures (basal ganglia, corona radiata, internal capsule and superior longitudinal fasciculus) were detected in both hemispheres.

Conclusions: Despite the variability between different LSM methods, all methods have consistently shown a difference between the critical brain-regions for upper-limb function following LHD vs. RHD. These findings support previous works suggesting that the left (motor-dominant) hemisphere is more inter-connected, thus it has higher redundancy and decreased vulnerability to focal damage.

Introduction: Spinal cord lesions (SCL) are usually followed by neurological and functional improvement. The neurological improvement is natural and improves the functional potential of the patients, while rehabilitation improves the realization of that potential. The functional change depends on the neurological change, and usually does not represent the contribution of rehabilitation alone to the functional improvement.

Aims: To evaluate the net contribution of inpatient rehabilitation in Israel to functioning after SCL, and the ability to predict this contribution, which reflects the success of rehabilitation.

Methods: Demographic and clinical data of SCL patients admitted to rehabilitation between 2011 and 2020 were collected retrospectively. The data were used to calculate Spinal Cord Injury Ability Realization Measurement Index (SCI-ARMI) scores, isolating the effect of neurologic status on functioning, its change during rehabilitation, and factors affecting it. Data were analyzed using t-tests, Pearson correlations, ANOVA, and ANCOVA.

Results: A total of 1,433 patients were included in the study. Their age was 54±17 years, 32% were females, and 37.2% had traumatic injuries. American Spinal Injury Association Impairment Scale (AIS) grades were A in 11% of the patients, B in 4.8%, C in 17.3% and D in 65.9%. SCI-ARMI was 52±24 at admission to rehabilitation, and 73.5±19 at discharge (41% improvement, p<0.001). Likewise, the neurological motor status and function significantly improved. SCI-ARMI improvement increased with lower admission SCI-ARMI values (r=-0.654, p<0.001) and younger age (r=-0.122, p<0.001), and correlated with longer stay in rehabilitation (r=0.261, p<0.001).

Conclusions: Inpatient rehabilitation in Israel made a substantial contribution to functional improvement. Lower realization of the functional potential at admission to rehabilitation predicted greater success in the process of SCL rehabilitation.