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Frankel M, Bayya F, Munter G, Wolak A, Tolkin L, Barenhoz-Goultschin O, Asher E, Glikson M. Thyroid dysfunction and mortality in cardiovascular hospitalized patients. Cardiovasc Endocrinol Metab 2024; 13:e0299. [PMID: 38193023 PMCID: PMC10773777 DOI: 10.1097/xce.0000000000000299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024]
Abstract
Background Thyroid dysfunction (TD) is associated with increased cardiovascular morbidity and mortality. Early detection may influence the clinical management. Objective To determine the prevalence, predictors, and prognostic value of TD among hospitalized cardiac patients. Methods A retrospective analysis of a 12-year database consisting of nonselectively adult patients admitted to a Cardiology Department and who were all screened for serum thyroid-stimulation-hormone (TSH) levels . Statistical analysis of demographic and clinical characteristics, mortality and length of hospital stay (LOS) was performed. Results A total of 14369 patients were included in the study; mean age was 67 years, 38.3% females. 1465 patients (10.2%) had TD. The most frequent type of TD was mildly elevated TSH (5.4%) followed by mildly reduced TSH (2.1%), markedly elevated TSH (1.5%), and markedly reduced TSH (1.2%). Female gender, history of hypothyroidism, heart failure, atrial fibrillation, renal failure and amiodarone use were significantly associated with TD. During follow-up 2975 (20.7%) patients died. There was increased mortality in the mildly reduced TSH subgroup (hazard ratio [HR] =1.44), markedly elevated TSH subgroup (HR=1.40) and mildly elevated TSH subgroup (HR=1.27). LOS was longer for patients with TD; the longest stay was observed in the markedly elevated TSH subgroup (odds ratio=1.69). Conclusion The prevalence of TD in hospitalized cardiac patients is 10.2%. TD is associated with an increased mortality rate and LOS. Consequently, routine screening for thyroid function in this population is advisable, particularly for selected high-risk subgroups. Future studies are needed to determine whether optimizing thyroid function can improve survival in these patients.
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Affiliation(s)
- Meir Frankel
- Endocrinology Unit, Shaare Zedek Medical Center
- Hebrew University Medical School, Jerusalem, Israel
| | - Feras Bayya
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center
- Hebrew University Medical School, Jerusalem, Israel
| | - Gabriel Munter
- Endocrinology Unit, Shaare Zedek Medical Center
- Hebrew University Medical School, Jerusalem, Israel
| | - Arik Wolak
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center
- Hebrew University Medical School, Jerusalem, Israel
| | - Lior Tolkin
- Endocrinology Unit, Shaare Zedek Medical Center
- Hebrew University Medical School, Jerusalem, Israel
| | - Orit Barenhoz-Goultschin
- Endocrinology Unit, Shaare Zedek Medical Center
- Hebrew University Medical School, Jerusalem, Israel
| | - Elad Asher
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center
- Hebrew University Medical School, Jerusalem, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center
- Hebrew University Medical School, Jerusalem, Israel
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Tolkin L, Klein V, Frankel M, Altarescu G, Beeri R, Munter G. Variant Tyr 394Ser in the GCM2 Gene Is Rare in a Cohort of Ashkenazi Jews With Primary Hyperparathyroidism. J Endocr Soc 2023; 7:bvad086. [PMID: 37362385 PMCID: PMC10289514 DOI: 10.1210/jendso/bvad086] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Indexed: 06/28/2023] Open
Abstract
Context Various genes have been associated with familial and sporadic primary hyperparathyroidism (PHPT), including activating mutations of the glial cells missing transcription factor 2 (GCM2) gene. Objective The aim of this study was to assess the prevalence of the GCM2 p.Tyr394Ser variant in the Jerusalem Ashkenazi Jewish (AJ) population with PHPT, and to conclude whether routine genetic testing is justified. Methods The blood of 40 self-reported AJ patients with PHPT and 200 AJ controls was tested for the GCM2 p.Tyr394Ser variant. Demographic and medical information was extracted from the patients' charts and evaluated accordingly. Results Two (5%) PHPT patients and 3 (1.5%) controls were heterozygotes for the tested variant. Our patients were mostly (87.5%) sporadic cases. One of the heterozygote patients had familial PHPT; the other had 2 parathyroid adenomas, and the levels of his blood and urinary calcium were extremely high. Conclusion Our results suggest that in AJ patients with sporadic, single-gland PHPT, the likelihood of the tested variant is low and genetic testing should be limited to those with familial PHPT or multiglandular disease.
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Affiliation(s)
- Lior Tolkin
- Correspondence: Lior Tolkin, MD, Department of Internal Medicine Endocrine Unit, Shaare Zedek Medical Center Jerusalem affiliated with the Faculty of Medicine, Hebrew University, 12 Shmuel Bait St, PO Box 3235, Jerusalem 3235, Israel.
| | - Vanessa Klein
- Department of Internal Medicine Endocrine Unit, Shaare Zedek Medical Center Jerusalem affiliated with the Faculty of Medicine, Hebrew University, Jerusalem 3235, Israel
| | - Meir Frankel
- Department of Internal Medicine Endocrine Unit, Shaare Zedek Medical Center Jerusalem affiliated with the Faculty of Medicine, Hebrew University, Jerusalem 3235, Israel
| | - Gheona Altarescu
- Genetic Department, Shaare Zedek Medical Center Jerusalem affiliated with the Faculty of Medicine, Hebrew University, Jerusalem 3235, Israel
| | - Rachel Beeri
- Genetic Department, Shaare Zedek Medical Center Jerusalem affiliated with the Faculty of Medicine, Hebrew University, Jerusalem 3235, Israel
| | - Gabriel Munter
- Department of Internal Medicine Endocrine Unit, Shaare Zedek Medical Center Jerusalem affiliated with the Faculty of Medicine, Hebrew University, Jerusalem 3235, Israel
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Shapiro DS, Alexandrovich I, Sonnenblick M, Shavit L, Munter G, Friedmann R. Prospective determination of the incidence and severity of hyponatraemia in older hospitalised patients with acute urinary tract obstruction. Age Ageing 2022; 51:6430096. [PMID: 34850814 DOI: 10.1093/ageing/afab234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/26/2021] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION acute urinary tract obstruction (aUTO) is a common finding in older hospitalised patients. Anecdotal reports described hyponatraemia in patients with aUTO, which subsides rapidly with relief of the obstruction.The aim of this study was to determine the incidence, severity and subsequent correction of hyponatraemia in patients with aUTO. METHODS this is a prospective, single-centre, observational study including inpatients in the internal medicine and geriatric wards. A total of 204 patients were investigated, 104 with aUTO and 100 controls. The prevalence, severity and associations of hyponatraemia between aUTO and control patients were compared. RESULTS the incidence of hyponatraemia was similar in aUTO and control groups 28% versus 22%, respectively (P = 0.42). However, the incidence of severe hyponatraemia was significantly higher in the study group 7% versus 1% (P = 0.04). Mean sodium level was lower in hyponatremic patients with aUTO 127.7 ± 5.9 mEq/l versus 130.8 ± 3 mEq/l (P = 0.013). Serum sodium remained largely unchanged in the control group (∆Na 1.5 ± 2.3 mEq/l) but increased significantly within 48 hours following catheter insertion in patients with urinary retention (∆Na 5.3 ± 4.2 mEq/l overall in the aUTO group and 9.6 ± 3 mEq/l in those with urinary retention and severe hyponatraemia (P = 0.002)).
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Affiliation(s)
- Dvorah S Shapiro
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; The geriatric Department, Shaare Zedek Medical Center, Israel
| | - Irina Alexandrovich
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; The geriatric Department, Shaare Zedek Medical Center, Israel
| | - Moshe Sonnenblick
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; The geriatric Department, Shaare Zedek Medical Center, Israel
| | - Linda Shavit
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; Institute of Nephrology, Shaare Zedek Medical Center, Israel
| | - Gabriel Munter
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; Medicine C and Endocrine Unit, Shaare Zedek Medical Center, Israel
| | - Reuven Friedmann
- Faculty of Medicine, Hebrew University of Jerusalem, Israel; The geriatric Department, Shaare Zedek Medical Center, Israel
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Mendlovic J, Zalut T, Munter G, Merin O, Yinnon AM, Katz DE. Mixed effect of increasing outflow of medical patients from an emergency department. Isr J Health Policy Res 2021; 10:59. [PMID: 34706781 PMCID: PMC8549409 DOI: 10.1186/s13584-021-00491-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 09/28/2021] [Indexed: 11/10/2022] Open
Abstract
Background and aim Since 2014, the annual number of patients entering our emergency department (ED) has increased significantly. These were primarily Internal Medicine (IM) patients, and of these, 25–30% were admitted. The present governmental policy presents a deterrent to adding IM beds for these patients, and Emergency and IM departments cope with ever-increasing number of IM patients. We describe a quality improvement intervention to increase outflow of IM patients from the ED to the IM departments. Methods We conducted a quality improvement intervention at the Shaare Zedek Medical Center from 2014 to 2018. The first stage consisted of an effort to increase morning discharges from the IM departments. The second stage consisted of establishing a process to increase the number of admissions to the IM departments from the ED. Results Implementation of the first stage led to an increased morning discharge rate from a baseline of 2–4 to 18%. The second stage led to an immediate mean (± SD) morning transfer of 35 ± 7 patients to the medical departments (8–12 per department), providing significant relief for the ED. However, the additional workload for the IM departments’ medical and nursing staff led to a rapid decrease in morning discharges, returning to pre-intervention rates. Throughout the period of the new throughput intervention, morning admissions increased from 30 to > 70%, and were sustained. The number of patients in each department increased from 36 to 38 to a new steady state of 42–44, included constant hallway housing, and often midday peaks of 48–50 patients. Mean length of stay did not change. IM physician and nurse dissatisfaction led to increased number of patients being admitted during the evening and night hours and fewer during the morning. Conclusion We describe a quality improvement intervention to improve outflow of medical patients from the ED in the morning hours. The new ED practices had mixed effects. They led to less ED crowding in the morning hours but increased dissatisfaction among the IM department medical and nursing staff due to an increased number of admissions in a limited number of hours. The present governmental reimbursement policy needs to address hospital overcrowding as it relates to limited community healthcare beds and an aging population.
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Affiliation(s)
- Joseph Mendlovic
- Shaare Zedek Medical Center, P.O. Box 3235, 91031, Jerusalem, Israel. .,Hadassah Faculty of Medicine, Hebrew University, Jerusalem, Israel.
| | - Todd Zalut
- Shaare Zedek Medical Center, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Gabriel Munter
- Division of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.,Hadassah Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Ofer Merin
- Shaare Zedek Medical Center, P.O. Box 3235, 91031, Jerusalem, Israel.,Hadassah Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.,Hadassah Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - David E Katz
- Division of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.,Hadassah Faculty of Medicine, Hebrew University, Jerusalem, Israel
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Jarjou'i A, Mendlovic J, Dadon Z, Sneineh MA, Tabi M, Kalak G, Jarallah YR, Yinnon AM, Munter G. Availability, timeliness, documentation and quality of consultations among hospital departments: a prospective, comparative study. Isr J Health Policy Res 2021; 10:19. [PMID: 33866967 PMCID: PMC8053423 DOI: 10.1186/s13584-021-00446-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/10/2021] [Indexed: 01/03/2023] Open
Abstract
Background Many in-patients require care from practitioners in various disciplines. Consultations most probably have significant implications for hospitalization outcomes. Purpose To determine key aspects of consultations provided by various departments to formulate an optimal policy. Methods This study comprised two methods: first, a questionnaire was completed in 2019 by 127 physicians interns, residents and senior doctors) from the medical and surgical departments (64 from the surgical wards, 43 from the medical wards and 22 from the emergency room and General ICU) regarding the availability, timeliness and documentation rate of the consultations they received from different disciplines. The investigators rounded through the various departments that were included in the study and they accosted a sample of interns, residents and attending physicians, who were then asked to fill the questionnaire. Overall compliance of filling the questionnaire was 95%. Residents accounted for 72% of the filled questionnaires, seniors and interns accounted for 15 and 13% respectively. Second, a convenience sample of 300 electronic records of hospitalized patients (135 from the surgical wards, 129 from the Medical wards and 36 from the emergency room and General ICU) of actually carried out consultations was reviewed for validated indicators of quality for both the consultation request and response. We used a 5-point Likert scale, ranging from poor (1) to superb (5), to grade the measured parameters. Results The availability, timeliness and documentation rate for medical consultations were 4 ± 0.9, 4.1 ± 0.9 and 4.3 ± 0.9 respectively, as compared with surgical consultations 3.2 ± 1.1, 3.4 ± 1.2 and 3.6 ± 1.2 respectively (P < 0.001). The mean time (in hours) from the consultation request till documentation (of the requested consultation) by consultants in the medical and surgical departments was 3.9 ± 5.9 and 10.0 ± 15.6, respectively (P < 0.001). The quality of requests of consultations from the medical and surgical departments was 3.4 ± 1.1 and 2.8 ± 1.2, respectively (P < 0.001). Two different models of consultations are employed: while each medical department adopts several departments for medical consultations, each day’s on-call surgeon provides all the hospital’s surgical consultations. Conclusion We detected significant differences in key aspects of consultations provided by the departments. The medical model of consultations, in which each medical department adopts several other wards to which it provides consulting services upon request, should probably be adopted as a major policy decision by hospitals directors to enhance inter-departmental consultations. Supplementary Information The online version contains supplementary material available at 10.1186/s13584-021-00446-0.
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Affiliation(s)
- Amir Jarjou'i
- Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel. .,Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.
| | - Joseph Mendlovic
- Deputy CEO, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Ziv Dadon
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.,Department of Cardiology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Marwan Abu Sneineh
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Meir Tabi
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.,Department of Cardiology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - George Kalak
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Yousef R Jarallah
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel.
| | - Gabriel Munter
- Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, Jerusalem, Israel.,Division of Internal Medicine, Shaare Zedek Medical Center, Affiliated with the Hadassah-Hebrew University School of Medicine, P.O. Box 3235, 91031, Jerusalem, Israel
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6
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Ben Shoham A, Munter G. The association between hallway boarding in internal wards, readmission and mortality rates: a comparative, retrospective analysis, following a policy change. Isr J Health Policy Res 2021; 10:8. [PMID: 33504368 PMCID: PMC7842011 DOI: 10.1186/s13584-021-00443-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/22/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Emergency department overcrowding is associated with adverse clinical outcomes and poor patients and staff experience. Full capacity protocols enabling hallway boarding in internal wards are instituted to relieve emergency room overcrowding. The effect of hallway boarding on the clinical outcomes of all inpatients in the internal wards has not been studied. Early in 2016, a decision to enable hallway boarding in the internal wing in our medical center came into effect, comprising an abrupt change to the medical center's policy. The objective of this study is to examine the effect of hallway boarding on patients who were hospitalized in the internal wards. METHODS General linear regression analysis, based on administrative data about admissions of patients, from January 2013 through September 2019, is used to compare in-hospital mortality, 30-day readmission and 30-day mortality rates, of inpatients hospitalized in two internal departments in our medical center, before and after the policy change. RESULTS Eight thousand five hundred eighty-three patients and 11,962 patients were admitted to internal departments A and B, before and after the policy change, respectively. Adjusted in-hospital mortality was lower after the policy change (OR 0.76, [CI, 0.65 to 0.90]), 30-day readmission was mildly higher (OR, 1.18 [CI, 1.00 to 1.40]) and no change in 30-day mortality was observed (OR 1.16 [CI, 0.88 to 1.53]). The results emanate from corresponding changes in department A. No apparent change was observed in the length of hospital stay in department A, while a shorter length of stay was observed in department B. CONCLUSION Enabling inpatient boarding in our medical center, effectively, had increased bed capacity and generated an increase in the volume of patients. It was associated with lower in-hospital mortality and an increased 30-day readmission, without increasing 30-day mortality. Since this is an observational study, conducted in a single center, further research is necessary to confirm and qualify these observations.
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Frankel M, Feldman I, Levine M, Frank Y, Bogot NR, Benjaminov O, Kurd R, Breuer GS, Munter G. Bilateral Adrenal Hemorrhage in Coronavirus Disease 2019 Patient: A Case Report. J Clin Endocrinol Metab 2020; 105:5879684. [PMID: 32738040 PMCID: PMC7454653 DOI: 10.1210/clinem/dgaa487] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/28/2020] [Indexed: 01/04/2023]
Abstract
CONTEXT Bilateral adrenal hemorrhage is a rare condition with potentially life-threatening consequences such as acute adrenal insufficiency. Early adrenal axis testing, as well as directed imaging, is crucial for immediate diagnosis and treatment. Coronavirus disease 2019 (COVID-19) has been associated with coagulopathy and thromboembolic events. CASE DESCRIPTION A 66-year-old woman presented with acute COVID-19 infection and primary adrenal insufficiency due to bilateral adrenal hemorrhage (BAH). She also had a renal vein thrombosis. Her past medical history revealed primary antiphospholipid syndrome (APLS). Four weeks after discharge she had no signs of COVID-19 infection and her polymerase chain reaction test for COVID-19 was negative, but she still needed glucocorticoid and mineralocorticoid replacement therapy. The combination of APLS and COVID-19 was probably responsible of the adrenal event as a "two-hit" mechanism. CONCLUSIONS COVID-19 infection is associated with coagulopathy and thromboembolic events, including BAH. Adrenal insufficiency is life threatening; therefore, we suggest that early adrenal axis testing for COVID-19 patients with clinical suspicion of adrenal insufficiency should be carried out.
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Affiliation(s)
- Meir Frankel
- Endocrinology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Itamar Feldman
- Rheumatology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Michal Levine
- Department of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yigal Frank
- Department of Radiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Naama R Bogot
- Department of Radiology, Shaare Zedek Medical Center, Jerusalem, Israel
- Hadassah Hebrew University School of Medicine, Jerusalem, Israel
| | - Ofer Benjaminov
- Department of Radiology, Shaare Zedek Medical Center, Jerusalem, Israel
- Hadassah Hebrew University School of Medicine, Jerusalem, Israel
| | - Ramzi Kurd
- Department of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Gabriel S Breuer
- Rheumatology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Department of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
- Hadassah Hebrew University School of Medicine, Jerusalem, Israel
| | - Gabriel Munter
- Endocrinology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
- Department of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
- Hadassah Hebrew University School of Medicine, Jerusalem, Israel
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Tolkin L, Vidberg M, Munter G. Basal serum cortisol levels predict a normal response to the Synacthen stimulation test in hospitalised patients. Intern Med J 2020; 52:105-109. [PMID: 32833270 DOI: 10.1111/imj.15033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 07/30/2020] [Accepted: 08/10/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND The short Synacthen test (SST) is widely used to assess the hypothalamus-pituitary-adrenal axis in the outpatient setting. However, in the inpatient setting, technical difficulties to adhere to the protocol may pose a challenge for using this test. AIMS To find the most suitable basal serum cortisol (BSC) cut-off for predicting an adequate response to the SST in non-critically inpatients without conducting the actual test. METHODS Information was retrieved retrospectively from medical files of 197 patients who had had a 250 μg SST between the years 2000 and 2016 at the Shaare Zedek Medical Center. BSC, electrolytes, creatinine, thyroid-stimulating hormone, blood counts and blood pressure values were evaluated for a correlation with the results of the SST. RESULTS A BSC cut-off of 280 nmol/L provides a negative predictive value of 94% for adrenal insufficiency (AI). Using a cut-off of 380 nmol/L increases the sensitivity to 96% and yields a negative predictive value of 95.8%. CONCLUSIONS In this study, we found two suitable BSC cut-offs for predicting an adequate response to the SST in hospitalised patients. We suggest using the lower cut-off (280 nmol/L) for patients with a low level of suspicion for AI and using the higher cut-off (380 nmol/L) for patients with a higher level of suspicion. A BSC above this cut-off makes the diagnosis of AI very unlikely and precludes the need for a Synacthen test.
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Affiliation(s)
- Lior Tolkin
- Department of Internal Medicine and Endocrine Unit, Shaare Zedek Medical Center, affiliated with the Faculty of Medicine, Hebrew University, Jerusalem, Jerusalem, Israel
| | - Michal Vidberg
- Department of Internal Medicine and Endocrine Unit, Shaare Zedek Medical Center, affiliated with the Faculty of Medicine, Hebrew University, Jerusalem, Jerusalem, Israel
| | - Gabriel Munter
- Department of Internal Medicine and Endocrine Unit, Shaare Zedek Medical Center, affiliated with the Faculty of Medicine, Hebrew University, Jerusalem, Jerusalem, Israel
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Feldman I, Feldman L, Shapiro DS, Munter G, Yinnon AM, Friedman R. Characteristics and outcome of elderly patients admitted for acute Cholecystitis to medical or surgical wards. Isr J Health Policy Res 2020; 9:23. [PMID: 32741359 PMCID: PMC7397574 DOI: 10.1186/s13584-020-00383-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 04/27/2020] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Elderly patients admitted because of acute cholecystitis are usually not operated during their initial admission and receive conservative treatment. To help formulate a new admission policy regarding elderly patients with acute cholecystitis we compared the demographic and clinical characteristics and outcome of patients > 65 with acute cholecystitis admitted to medical or surgical wards. METHODS This retrospective study included all patients > 65 years admitted for acute cholecystitis between January, 2009 and September, 2016. Data were retrieved from the electronic health records. RESULTS A total of 187 patients were detected, 54 (29%) in medical departments and 133 (71%) in surgical wards. The mean age (±SD) was 80 ± 7.5 and was higher among those in medical than surgical wards (84 ± 7 versus 79 ± 7, p < 0.05). Patients hospitalized in medical departments had more comorbidity, disability and mental impairment. However, there was no difference in mortality between the two groups, 1 (2%) and 6 (4%) respectively. Independent predictors for hospitalization in medical departments were chronic obstructive pulmonary disease (OR = 9.8, 95% C. I 1.6-59) and the Norton Scale score (NSS)(OR = 0.7, 95% C. I 0.7-0.8). Impaired mental condition was the only predictor for hospitalization > 1 week. The strongest predictor for having cholecystostomy was admission to the surgical department (OR = 14.7, 95% C. I 3.9-56.7). Linear regression showed a negative correlation between NSS and length of hospitalization (LOH; Beta = - 0.5). CONCLUSION Elderly patients with acute cholecystitis who require conservative management, especially those with severe functional and mental impairment can be safely hospitalized in medical departments. Outcome was not inferior in terms of mortality and LOH. These results have practical policy implications for the placement of elderly patients with acute cholecystitis in medical rather than surgical departments.
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Affiliation(s)
- Itamar Feldman
- Department of Geriatrics, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Lena Feldman
- Department of Geriatrics, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Dvorah S Shapiro
- Department of Geriatrics, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Gabriel Munter
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, P.O. Box 3235, 91031, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, P.O. Box 3235, 91031, Jerusalem, Israel.
| | - Reuven Friedman
- Department of Geriatrics, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Wiener-Well Y, Hadeedi M, Schwartz Y, Yinnon AM, Munter G. Prospective Audit of Empirical Antibiotic Therapy for Septic Patients. Isr Med Assoc J 2020; 22:378-383. [PMID: 32558445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Antibiotic stewardship programs are necessary to test the appropriateness of local guidelines for empirical antibiotic treatment by audits. OBJECTIVES To assess whether compliance to local guidelines achieved a higher rate of appropriate antibiotic treatment and reduced morbidity and mortality, and whether infectious disease counseling improved the rate of appropriate treatment. METHODS Our cohort comprised 294 patients with proven bacteremia. Data were retrieved from medical records including diagnosis, empiric antibiotic treatment, and outcomes. RESULTS The empirical treatment was consistent with bacterial susceptibility in 227 patients (77%), and matched in 64% of the time to the first line, and another 24% to the second line of institutional guidelines. A strong correlation was found between appropriate empiric treatment according to bacterial susceptibility and reduced mortality (odds ratio [OR] 0.403, P = 0.007). A similar correlation was found with the choice of appropriate antibiotics according to local guidelines (OR 0.392, P = 0.005). Infectious disease consultation was related to an increase in the rate of appropriateness of treatment according to guidelines (85% vs.76%, P = 0.005). A tendency to increased appropriateness was related to microbial susceptibility (87% vs. 74%, P = 0.07). CONCLUSIONS In this study, initiation of appropriate empiric antibiotic therapy, according to the hospital's guidelines, was found associated with reduced mortality in patients with bacteremia.
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Affiliation(s)
- Yonit Wiener-Well
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Mustafa Hadeedi
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Yuval Schwartz
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Amos M Yinnon
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
| | - Gabriel Munter
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University Hadassah Medical School, Jerusalem, Israel
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Schwartz Y, Weigert N, Cohen A, Steinmetz Y, Ioscovich A, Yinnon AM, Munter G. [INTERVENTIONS TO IMPROVE THE QUALITY OF THE INTERNSHIP YEAR]. Harefuah 2019; 158:630-634. [PMID: 31576706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
AIMS To describe three interventions that have improved the quality of the internship. BACKGROUND All medical school graduates are required to take a one year internship, rotating through various hospital departments. By various objective and subjective measures, the quality, benefit and efficacy of the internship varies significantly between departments and hospitals and also depends on where the interns studied. METHODS The interventions were: First, all graduates of foreign medical schools (FMG) were required to interview and present a patient, demonstrating practical knowledge of spoken and written Hebrew and basic medical terminology prior to the start of the internship. Second, on the first day of their internship in internal medicine the new interns participate in an orientation day, addressing multiple clinical, administrative and other components. Third, upon the completion of their rotation in internal medicine, the interns participate in an interactive session to help them prepare for their future career. RESULTS First, during the first 3 years after introducing the Hebrew test, 101 FMGs took the test, 89 (88%) passed the first time, the remainder passed the 2nd or 3rd test after another 1-3 months of studying Hebrew. Of 31 women, 30 (97%) passed the first time, compared to 59/70 (84%) of the men (p=0.065); 27/28 (96%) of Jewish interns passed the first time compared to 62/73 (85%) non-Jewish interns (p=0.99). Physicians report on the significantly increased ability of FMGs to participate in all activities from the onset of their internship. Second, upon completion of the orientation, 137 interns provided feedback of its 12 components; satisfaction was marked on a Likert scale (ranging from 1 [low] to 5 [high]) and ranged from 4.2±0.1 to 4.7±0.6; high/very high satisfaction with the various components ranged from 79% to 96%. Third, feedback was provided by 96 interns after participating in the interactive session helping to prepare for the future; satisfaction with the 5 components of the session ranged from 3.8±0.8 (on the acquired insight into the possibilities, scope and limitations regarding their future career) to 4.5±0.7 (regarding the relevance of such sessions). Sub-analysis revealed several statistically significant differences between male and female interns (male interns indicated these sessions to be more important to them than females, p<0.01), and FMG (as compared to graduates from Israeli medical schools) indicated that they had acquired relevant information more often (p<0.001). CONCLUSIONS Various interventions positively impact the quality, benefit and efficacy of the internship as observed by physicians working with the residents, as well as perceived by the interns themselves.
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Affiliation(s)
- Yuval Schwartz
- Department of Internal Medicine C, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Nir Weigert
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Asaf Cohen
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Yoed Steinmetz
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Alexander Ioscovich
- Department of Anesthesiology, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
- Internship Committee of Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
- Internship Committee of Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Gabriel Munter
- Department of Internal Medicine C, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Szterenlicht YM, Jarjoui A, Kurd R, Levy L, Munter G. A Peculiar Case of Purpura. Am J Med 2019; 132:934-935. [PMID: 30904505 DOI: 10.1016/j.amjmed.2019.02.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 02/27/2019] [Accepted: 02/28/2019] [Indexed: 11/18/2022]
Affiliation(s)
- Yael M Szterenlicht
- Department of Internal Medicine C, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Amir Jarjoui
- Department of Internal Medicine C, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Ramzi Kurd
- Department of Internal Medicine C, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Ludmila Levy
- Department of Internal Medicine C, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Gabriel Munter
- Department of Internal Medicine C, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel.
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Hadelsberg UP, Doviner V, Frankel M, Gonen L, Munter G, Margalit N. A rare brain tumor encountered: Phosphaturic mesenchymal tumor. Case report and review of the literature. Interdisciplinary Neurosurgery 2019. [DOI: 10.1016/j.inat.2018.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
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Katz DE, Shanek O, Raveh-Brawer D, Yinnon AM, Munter G. [SELECTING A SPECIALTY BY INTERNS IN A CHANGING PERIOD: A MULTI-YEAR AND SINGLE-CENTER EXPERIENCE]. Harefuah 2018; 157:356-360. [PMID: 29964373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
AIMS To collect data on the expectations of interns at the onset of their internship regarding their professional future and the actual realization of these expectations of medical graduates who completed their internship in one medical center during the years 2010-2015. BACKGROUND The internship year may have great importance in the decision-making process regarding selection of future residency. Previous research conducted 10-20 years ago involved graduates of Israeli medical schools. In the current era up to 50% of interns are foreign medical graduates (FMG), and it is not clear whether all of these professionals find a residency or employment according to their wishes. METHODS Our hospital's database includes demographic details of all 237 graduates of the aforementioned years, according to gender (64% male); medical school (Israeli 50%); and ethnicity (Jewish, 66%). The aim of the study was to call all graduates according to the telephone numbers in the database and obtain relevant information on the basis of a pre-arranged script and with a standardized questionnaire to achieve uniform collection of data. RESULTS Of 237 graduates, 151 (64%) responded, of whom 101 (64%) were male, 90 (60%) were Jewish, and 80 (54%) were FMG. Most interns had decided on a future career at the onset of their internship (114, 75%), but at its completion this rate had decreased to 88 (59%). Their preferences included surgical specialties 40 (36%), pediatrics 34 (30%), internal medicine 22 (19%), family practice 9 (8%), and other specialties 8 (7%). At the conclusion of the internship 108 (75%) immediately started a residency program; the remainder started employment in the community not within the context of a residency. A high degree of satisfaction was examined for three factors: personal relations and ethics - 114 (76%), professional learning - 108 (72%) and counseling regarding their professional future - 46 (31%). At the onset of their internship,) 75 77%( of the men and 46 )75%( of the women had decided upon their future career, without major change by the year's end. In reality, 43 (84%) of the women started a residency, but only 63 (65%) of the men (p=0.013). At the start of the year 67 (77%) of the Jewish interns and 46 (75%) of the Arab interns had decided on a future career; at the end of the year, the rate for Jewish interns had increased to 74 (85%) and it had decreased to 31 (67%) for Arab interns (p=0.026). Of the Jewish sector 74 (85%) had actually started a residency, as compared to 33 (54%) of the Arab sector (p<0.001) and 26 (43%) Arab graduates started work in the community not within the context of a residency. The rate of Israeli graduates who at onset of their internship had decided on their future choice was similar to that of FMG, 55 (82%) as compared to, respectively, 58 (73%) (Non significant), but at the end of the year a significant gap had opened up, 47 (86%) vs. 40 (52%), respectively (p=0.04). In addition, and not surprisingly, there were significant differences in the three measures of satisfaction between the Israeli and foreign graduates. CONCLUSIONS During the internship year significant differences emerge between the interns, according to gender, ethnic background or the country they had studied medicine. Improved counseling could possibly help interns to secure optimal employment, especially for foreign medical graduates.
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Affiliation(s)
- David E Katz
- Department of Medicine D, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Osama Shanek
- Department of Medicine D, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - David Raveh-Brawer
- Department of the Bio-Informatics Unit, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Gabriel Munter
- Department of Medicine C, Shaare Zedek Medical Center, affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Dadon Z, Cohen A, Szterenlicht YM, Assous MV, Barzilay Y, Raveh-Brawer D, Yinnon AM, Munter G. Spondylodiskitis and endocarditis due to Streptococcus gordonii. Ann Clin Microbiol Antimicrob 2017; 16:68. [PMID: 28978355 PMCID: PMC5628438 DOI: 10.1186/s12941-017-0243-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 09/26/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Streptococcus gordonii is an infrequent cause of infective endocarditis (IE); associated spondylodiskitis has not yet been described in the literature. PURPOSE We describe 2 patients who presented with new-onset, severe back pain; blood cultures revealed S. gordonii bacteremia, which led to the diagnosis of spondylodiskitis and IE. We review our 2-decade experience with S. gordonii bacteremia to describe the clinical and epidemiological characteristics of these patients. RESULTS In our hospital over the last 20 years (1998-2017), a total of 15 patients with S. gordonii bacteremia were diagnosed, including 11 men and 4 women, and the mean age was 65 ± 22 (range 23-95). The most common diagnosis was IE (9 patients), spondylodiskitis (the presented 2 patients, who in addition were diagnosed with endocarditis), necrotizing fasciitis (1), sternitis (1), septic arthritis (1) and pneumonia (1). The 11 patients with IE were treated with penicillin ± gentamicin, or ceftriaxone for 6 weeks, 5 required valve surgery and 10/11 (91%) attained complete cure. The 2 patients with diskitis required 2-3 months of intravenous antibiotics to achieve complete cure. CONCLUSION Spondylodiskitis was the presenting symptom of 2/11 (18%) patients with S. gordonii endocarditis. Spondylodiskitis should probably be looked for in patients diagnosed with S. gordonii endocarditis and back pain as duration of antibiotic treatment to achieve complete cure may be considerably longer.
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Affiliation(s)
- Ziv Dadon
- Department of Internal Medicine A, Shaare Zedek Medical Medicine, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Assaf Cohen
- Department of Internal Medicine C, Shaare Zedek Medical Medicine, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Yael M Szterenlicht
- Department of Internal Medicine C, Shaare Zedek Medical Medicine, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Marc V Assous
- Clinical Microbiology and Immunology Laboratory, Shaare Zedek Medical Medicine, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Yair Barzilay
- Spine Unit of the Department of Orthopedics, Shaare Zedek Medical Medicine, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - David Raveh-Brawer
- Infectious Disease Unit, Shaare Zedek Medical Medicine, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Medicine, Affiliated with the Hebrew University-Hadassah Medical School, P.O. Box 3235, 91031, Jerusalem, Israel.
| | - Gabriel Munter
- Department of Internal Medicine C, Shaare Zedek Medical Medicine, Affiliated with the Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Munter G, Brivik Y, Freier-Dror Y, Zevin S. Nicotine Addiction and Withdrawal among Orthodox Jews: the Effect of Sabbath Abstinence. Isr Med Assoc J 2017; 19:25-29. [PMID: 28457110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Cigarette smoking is a widespread problem around the world. In Israel, the prevalence of smoking is 23%. Smokers who are Orthodox abstain from smoking during the Sabbath, i.e., from sundown Friday to sundown Saturday, due to a religious prohibition. The prevalence of smoking among Orthodox men is 13%. However, there are no data on patterns of smoking or on the addiction profiles in this population. OBJECTIVES To explore the smoking patterns, motivation for smoking and nicotine addiction among Orthodox Jewish men, compared to non-Orthodox men, as well as the differences in the urge to smoke and withdrawal symptoms on Saturday versus weekdays in the Orthodox group. METHODS The participants completed the Fagerstrom test for nicotine dependence, questionnaires on reasons for smoking and smoking patterns, as well as two brief questionnaires on the urge to smoke and withdrawal symptoms after overnight abstinence on a weekday and after the end of the Sabbath. RESULTS Both groups were strongly addicted to nicotine and there were no differences in the reasons for smoking, withdrawal symptoms and nicotine craving after an overnight abstinence on weekdays. However, religious smokers had low levels of craving for nicotine and few withdrawal symptoms during Sabbath abstinence when compared to weekdays. CONCLUSIONS Although we found no difference in the baseline characteristics with regard to nicotine addiction, smoking motivation, urge to smoke and withdrawal symptoms between religious and non-religious groups, the former are able to abstain from smoking during 25 hours of the Sabbath every week with significantly fewer withdrawal symptoms compared to week days.
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Affiliation(s)
- Gabriel Munter
- Department of Internal Medicine C, Shaare Zedek Medical Center, affiliated with Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - Yehuda Brivik
- Department of Internal Medicine, Bikur Cholim Hospital, Jerusalem, Israel
| | | | - Shoshana Zevin
- Department of Internal Medicine B, Shaare Zedek Medical Center, affiliated with Hadassah-Hebrew University Medical School, Jerusalem, Israel
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Abramovitch A, Friedmann R, Zevin S, Munter G, Yinnon AM, Raveh-Brawer D. Operating a Monitoring Unit in the Geriatric Department: Effects on Outcomes. J Am Geriatr Soc 2016; 65:427-432. [PMID: 28032889 DOI: 10.1111/jgs.14592] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To compare the effect of a five-bed geriatric monitoring unit (MU) on in-hospital mortality and length of stay with the effect of usual care in a geriatric hospital department and a medical MU. DESIGN Prospective, case-control, noninterventional study. PARTICIPANTS All individuals hospitalized for 24 hours or longer in the geriatric MU (n = 89, aged 53-101, mean age 82.2 ± 9.6) over a period of 5 months (January-May 2015); individuals admitted to the geriatric department (n = 178, aged 55-100, mean age 83.2 ± 9.8), matched at a ratio of 1:2 according to sex, age ±5 years, and need for mechanical ventilation; and individuals admitted to a similar five-bed medical MU (n = 95, aged 35-90, mean age 68.2 ± 14.4) during the same period. MEASUREMENTS Primary outcome was in-hospital mortality. RESULTS The predicted death rate was 49 ± 26 for participants in the geriatric MU, 39.6 ± 27 for those in the medical MU (P = .02), and 36.7 ± 27 for those in the geriatric department (P < .001). Observed in-hospital mortality was higher for geriatric MU participants (n = 40, 44.9%) than for the department control group (n = 48, 27%) (P = .002), although the mortality ratios (actual divided by predicted death rates) of these two groups were similar, indicating that the more severely ill participants in the geriatric MU did better than control participants in the departments, in particular those requiring hemodynamic pressure support and those with acute renal failure. CONCLUSION For elderly, severely ill adults, care in a geriatric MU was associated with lower in-hospital mortality than care in the hospital geriatric ward and a longer stay and may be an alternative to medical MU admission.
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Affiliation(s)
- Abram Abramovitch
- Department of Geriatrics, Shaare Zedek Medical Center, affiliated with the Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Reuven Friedmann
- Department of Geriatrics, Shaare Zedek Medical Center, affiliated with the Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Shoshana Zevin
- Department of Medicine B, Shaare Zedek Medical Center, affiliated with the Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Gabriel Munter
- Department of Medicine C, Shaare Zedek Medical Center, affiliated with the Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hadassah Medical School, Hebrew University, Jerusalem, Israel
| | - David Raveh-Brawer
- Bioinformatics Unit, Shaare Zedek Medical Center, affiliated with the Hadassah Medical School, Hebrew University, Jerusalem, Israel
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Goldberg SA, Neykin D, Henshke-Bar-Meir R, Yinnon AM, Munter G. Assessment and Improvement of Medical Histories: Impact of Focused Feedback. Isr Med Assoc J 2016; 18:479-483. [PMID: 28471580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Medical history-taking is an essential component of medical care. OBJECTIVES To assess and improve history taking, physical examination and management plan for hospitalized patients. METHODS The study consisted of two phases, pre- and post- intervention. During phase I, 10 histories were evaluated for each of 10 residents, a total of 100 histories. The assessment was done with a validated tool, evaluating history-taking (maximum 23 points), physical examination (23 points), assessment and plan (14 points) (total 60 points). Subsequently, half of these residents were informed that they were assessed; they received their scores and were advised regarding areas needing improvement. Phase II was identical to phase I. The primary endpoint was a statistically significant increase in score. RESULTS In the study group (receiving feedback after phase I) the physical examination improved from 9.3 ± 2.4 in phase I to 10.8 ± 2.2 in phase II (P < 0.001), while in the control group there was no change (11.3 ± 1.9 to 11.5 ± 1.8 respectively, P = 0.59). The assessment and plan component improved in the study group from 6.4 ± 2.7 in phase I to 7.4 ± 2.6 in phase II (P = 0.05), while no change was observed in the control group (8.2 ± 2.7 and 7.8 ± 2.3, P = 0.43). Overall performance improved in the study group from 30.4 ± 5.1 in phase I to 32.9 ± 4.5 in phase II (P = 0.01), a 10% improvement, while no change was observed in the control group (35.5 ± 6.0 to 34.6 ± 4.1, P = 0.4). CONCLUSIONS A review of medical histories obtained by residents, assessed against a validated score and accompanied by structured feedback may lead to significant improvement.
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Affiliation(s)
- Shimon A Goldberg
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Diana Neykin
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Ruth Henshke-Bar-Meir
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Amos M Yinnon
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
| | - Gabriel Munter
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with Hebrew University-Hadassah Medical School, Jerusalem, Israel
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Ben-Chetrit E, Weiner-Well Y, Katz DE, Rosenman D, Munter G. Ventricular Septal Defect Associated Right-sided Infective Endocarditis Complicated by Septic Pulmonary Emboli. Am J Med Sci 2016; 352:107-8. [PMID: 27432043 DOI: 10.1016/j.amjms.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
Affiliation(s)
- Eli Ben-Chetrit
- Division of Infectious Diseases, Shaare Zedek Medical Center, Hadassah-Hebrew University Medical School, Jerusalem, Israel.
| | - Yonit Weiner-Well
- Division of Infectious Diseases, Shaare Zedek Medical Center, Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - David E Katz
- Division of Infectious Diseases, Shaare Zedek Medical Center, Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - David Rosenman
- Division of Infectious Diseases, Shaare Zedek Medical Center, Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - Gabriel Munter
- Division of Infectious Diseases, Shaare Zedek Medical Center, Hadassah-Hebrew University Medical School, Jerusalem, Israel
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Breuer GS, Reinus K, Nesher G, Munter G. Recurrent Unilateral Orchitis as a Presenting Symptom of Polyarteritis Nodosa. Isr Med Assoc J 2015; 17:585-586. [PMID: 26625554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Wiener-Well Y, Kaloti S, Hadas-Halpern I, Munter G, Yinnon AM. Ultrasound diagnosis of Clostridium difficile-associated diarrhea. Eur J Clin Microbiol Infect Dis 2015; 34:1975-8. [PMID: 26173691 DOI: 10.1007/s10096-015-2439-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/26/2015] [Indexed: 01/05/2023]
Abstract
Clostridium difficile colitis is diagnosed using an immunoassay or polymerase chain reaction (PCR) assay for toxins A/B. Since ultrasound is frequently used as a screening test for hospitalized patients suffering from different abdominal morbidities, we searched for sonographic indicators of C. difficile infection (CDI). In a prospective and blinded case-control study, abdominal ultrasound was performed on hospitalized patients for whom stool samples were sent for C. difficile toxin immunoassay. All patients with positive toxin were included as the case group and patients with negative toxin comprised the control group. Sonographic parameters of both groups were compared. Demographic variables of the 67 patients in the toxin-positive group were similar to those of the 71 patients in the toxin-negative group. The sonographic parameters which were found to be associated with CDI included colonic wall thickening, appearing in 61 (91%) patients of the toxin-positive group versus 15 (21%) patients of the toxin-negative group (p < 0.001), and also internal ring (24 versus 0%, p < 0.001), external ring (15 versus 0%, p < 0.001), ascites (24 versus 10%, p < 0.001), and diminution of large bowel content (16 versus 1%, p < 0.001). Bowel wall thickening had high positive and negative predictive values (0.80 and 0.90, respectively), while the other features had only high positive predictive values (0.7-1.0). Abdominal ultrasound may contribute to the diagnosis of C. difficile colitis in patients developing hospital-acquired diarrhea.
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Affiliation(s)
- Y Wiener-Well
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, P.O. Box 3235, Jerusalem, 91031, Israel.
| | - S Kaloti
- Radiology Department, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - I Hadas-Halpern
- Radiology Department, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - G Munter
- Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
| | - A M Yinnon
- Infectious Disease Unit, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, P.O. Box 3235, Jerusalem, 91031, Israel.,Division of Internal Medicine, Shaare Zedek Medical Center, affiliated with the Hadassah-Hebrew University Medical School, Jerusalem, Israel
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Munter G, Levi-Vineberg T, Sylvetsky N. Vitamin D deficiency among physicians: a comparison between hospitalists and community-based physicians. Osteoporos Int 2015; 26:1673-6. [PMID: 25634772 DOI: 10.1007/s00198-015-3028-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2014] [Accepted: 01/04/2015] [Indexed: 10/24/2022]
Abstract
UNLABELLED Physicians are indoor workers with low sun exposure. The aim of this study was to compare serum 25-hydroxyvitamin D(25(OH)D) levels among hospitalists and community-based physicians. 25(OH)D levels among hospitalist physicians were significantly lower than those among community-based physicians. Hospitalist physicians should be considered for vitamin D deficiency screening and replacement. INTRODUCTION Vitamin D deficiency is now recognized as a widespread phenomenon, even in a sunny, Mediterranean country such as Israel. Physicians may be vulnerable to low vitamin D levels due to long work hours and lack of sun exposure. METHODS Forty-three physicians employed in a hospital and 38 physicians who work in the community in Jerusalem were enrolled. Their serum 25(OH)D levels were measured, and a questionnaire was filled to assess the risk of vitamin D deficiency. RESULTS Mean serum levels of 25(OH)D among hospitalist physicians were significantly lower than those among community-based physicians (15 ± 6 vs. 19.7 ± 6 ng/ml, respectively; p < 0.00 l). Arab physicians had a lower 25(OH)D level compared to Jewish physicians (18.2 ± 6.6 vs. 11.4 ± 2.7 ng/ml; p < 0.001). After exclusion of Arab physicians from the analysis, 25(OH)D levels remained higher in hospitalist compared to community-based physicians (15.9 ± 6 vs. 20.4 ± 6 ng/ml; p < 0.004). The variables that were significantly linked to low mean serum levels of 25(OH)D were as follows: age, night shifts, daily sun exposure, and ethnic origin. CONCLUSION Hospitalist physicians are at greater risk for low vitamin D levels than community-based physicians.
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Affiliation(s)
- G Munter
- Department of Internal Medicine and Endocrine Unit, Shaare Zedek Medical Center, Jerusalem, Israel.
- Faculty of Medicine, Hebrew University, POB 3235, 91031, Jerusalem, Israel.
| | - T Levi-Vineberg
- Department of Ophthalmology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - N Sylvetsky
- Department of Internal Medicine and Endocrine Unit, Shaare Zedek Medical Center, Jerusalem, Israel
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Szalat A, Shahar M, Shpitzen S, Nachmias B, Munter G, Gillis D, Durst R, Mevorach D, Leitersdorf E, Meiner V, Rosen H. Calcium-sensing receptor sequencing in 21 patients with idiopathic or familial parathyroid disorder: pitfalls and characterization of a novel I32 V loss-of-function mutation. Endocrine 2015; 48:444-53. [PMID: 25091521 DOI: 10.1007/s12020-014-0370-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 07/19/2014] [Indexed: 12/22/2022]
Abstract
The calcium-sensing receptor (CaSR) is a G-protein-coupled receptor with a crucial role in calcium homeostasis. Mutations in the CaSR gene may lead to specific parathyroid disorders due to either gain-of-function (autosomal dominant hypercalciuric hypocalcemia; ADHH) or loss-of-function (familial hypocalciuric hypercalcemia; FHH). Our aim was to evaluate CaSR mutations as a cause of disease in selected patients. We identified and recruited patients with phenotypes suggestive of CaSR-related parathyroid disorders. DNA was extracted, and CaSR gene was sequenced. Live-ratiometric measurements of intracellular [Ca(2+)] and Western blot assays for evaluation of MAPK phosphorylation in response to changes in extracellular [Ca(2+)] were performed in transiently transfected HEK-293T cells to functionally characterize mutants. A total of 21 patients were evaluated, seven of them with idiopathic hypoparathyroidism (suspected ADHH) and 14 with hyperparathyroidism (suspected FHH). In the latter group two patients were found to harbor missense mutations: a novel heterozygous I32 V mutation in a female index case and a sporadic known R185Q mutation in a 1-year-old girl. In-vitro functional studies showed that I32 V is an inactivating mutation. In our study, most patients had normal CaSR sequencing. This suggests that phenotypic pitfalls may occur at time of patients' selection for CaSR sequencing. In one patient with strong positive pre-test probability based on both familial history and appropriate phenotype, a novel I32 V mutation leading to FHH was identified and characterized. In cases of familial parathyroid disorders, CaSR sequencing should be performed, but if negative, one should consider involvement of alternative genes or mechanisms.
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Affiliation(s)
- Auryan Szalat
- Endocrinology and Metabolism Service, Department of Internal Medicine, Hadassah-Hebrew University Medical Center, POB 24035, 91240, Jerusalem, Israel,
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Yinnon AM, Munter G, Friedmann R, Katz D, Nesher G, Tichler T, Zevin S. [Shaare Zedek Medical Center's model of an integrated division of internal medicine]. Harefuah 2014; 153:159-239. [PMID: 24791555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND The specialty and practice of internal medicine have been subject to serious challenges in the last two decades. METHODS We describe the integrative model of internal medicine as developed in our hospital, providing solutions to some major challenges. RESULTS Major components include: (1) Senior physicians and residents are employed by the Division rather than individual Departments of Medicine, allowing for balanced distribution of professional capabilities. (2) Two medical departments specialize in geriatric medicine, while the other departments take care of younger, more intellectually challenging patients. Senior and junior staff members rotate through these departments, allowing for exposure to different patient populations and professional expertise. (3) The backbone of senior physicians is rewarded by a set of incentives, including dedicated time for research. (4) Senior staff from the subspecialties contributes annually 1-2 months as senior physicians in the departments and receive academic and other compensation for their efforts. (5) In cases where medical departments elsewhere are flooded with corridor admissions (a source of frustration and burnout), a short admission unit in the emergency department relieves internal medicine pressures and shortens evaluation and therapy for many patients. CONCLUSION Our integrative model of internal medicine allows for improved patient and staff distribution, greater satisfaction among patients and family members, greater professional satisfaction among physicians, while resident vacancies are filled with competent residents.
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Ben-Chetrit E, Chen-Shuali C, Zimran E, Munter G, Nesher G. A simplified scoring tool for prediction of readmission in elderly patients hospitalized in internal medicine departments. Isr Med Assoc J 2012; 14:752-756. [PMID: 23393714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Frequent readmissions significantly contribute to health care costs as well as work load in internal medicine wards. OBJECTIVE To develop a simple scoring method that includes basic demographic and medical characteristics of elderly patients in internal medicine wards that would allow prediction of readmission within 3 months of discharge. METHODS We conducted a retrospective observational study of 496 hospitalized patients using data collected from discharge letters in the computerized archives. Univariate and multivariate logistic regression analyses were performed and factors that were significantly associated with readmission were selected to construct a scoring tool. Validity was assessed in a cohort of 200 patients. RESULTS During a 2 year follow-up 292 patients were readmitted at least once within 3 months of discharge. Age 80 or older, any degree of impaired cognition, nursing home residence, congestive heart failure, and creatinine level > 1.5 mg/dl were found to be strong predictors of readmission. The presence of each variable was scored as 1. A score of 3 or higher in the derivation and validation cohorts corresponded with a positive predictive value of 80% and 67%, respectively, when evaluating the risk of rehospitalization. CONCLUSIONS We propose a practical, readily available five-item scoring tool that allows prediction of most unplanned readmissions within 3 months. The strength of this scoring tool, as compared with previously published scores, is its simplicity and straightforwardness.
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Affiliation(s)
- Eli Ben-Chetrit
- Department of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.
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Affiliation(s)
- Eli Ben-Chetrit
- Department of Internal Medicine, Shaare Zedek Medical Center, Hebrew University School of Medicine, Jerusalem, Israel.
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27
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Shapiro DS, Sonnenblick M, Munter G. Reply. Intern Med J 2011. [DOI: 10.1111/j.1445-5994.2011.02430.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Winchester Behr T, Sonnenblick M, Nesher G, Munter G. Hyponatraemia in older people as a sign of adrenal insufficiency: a case-control study. Intern Med J 2010; 42:306-10. [DOI: 10.1111/j.1445-5994.2010.02306.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Shapiro DS, Sonnenblick M, Galperin I, Melkonyan L, Munter G. Severe hyponatraemia in elderly hospitalized patients: prevalence, aetiology and outcome. Intern Med J 2010; 40:574-80. [PMID: 20298512 DOI: 10.1111/j.1445-5994.2010.02217.x] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hyponatraemia is the commonest electrolyte disorder in the elderly. Data on severe hyponatraemia and the prevalence of cerebral salt wasting syndrome (CSWS) in elderly hospitalized patients are lacking. We studied the incidence, frequency of various aetiologies, outcome and the possible role of CSWS in severe hyponatraemia in elderly medical patients. METHODS A prospective, observational, non-interventional study conducted over a 5-month period in medical wards. Eighty-six patients aged over 65 years with serum sodium levels < or =125 mEq/L were included. All patients were examined by one of the authors, who also evaluated potential contributing factors. Demographic, clinical and outcome data were extracted from the medical records. RESULTS The mean age of the patients was 82.1 + 8.7 years. The prevalence of hyponatraemia was 6.2% (8.1% women and 4.0% men (P < 0.001)). There was no increase in incidence of hyponatraemia with age. The leading cause of hyponatraemia was the syndrome of inappropriate antidiuretic hormone secretion (SIADH), whose aetiology could be determined in only 46% of cases. Aetiology was multifactorial in 51% of patients (1.7 aetiological factors per patient). All patients with thiazide-induced hyponatraemia had other contributing factors. Hyperglycaemia and hypoalbuminaemia were predictors of neurological manifestations of hyponatraemia. Overall in-hospital mortality was 19%. Only hypoalbuminaemia was found as an independent risk factor for death. In none of the patients was the hyponatraemia due to CSWS. CONCLUSION Severe hyponatraemia in elderly hospitalized medical patients is more frequent in women and of multifactorial aetiology in 50% of cases. It is most commonly caused by SIADH; CSWS is an unlikely cause.
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Affiliation(s)
- D S Shapiro
- Department of Geriatrics, Shaare-Zedek Medical Center Jerusalem, Israel.
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30
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Melamud B, Shilo S, Munter G. Life-threatening hypoglycemia due to false measurement of glucose in a peritoneal dialysis patient. Isr Med Assoc J 2010; 12:125-126. [PMID: 20550042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Affiliation(s)
- Bernardo Melamud
- Department of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel
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Ulbrichova D, Mamet R, Munter G, Martasek P, Schoenfeld N. Novel human pathological mutations. Gene symbol: HMBS. Disease: Acute intermittent porphyria. Hum Genet 2010; 127:114. [PMID: 20108425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Dana Ulbrichova
- Department of Pediatrics and Center for Applied Genomics, 1st School of Medicine, Charles University, Prague, Czech Republic.
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32
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Altarescu G, Renbaum P, P BB, Margalioth EJ, Chetrit AB, Munter G, Levy-Lahad E, Eldar-Geva T. Successful polar body-based preimplantation genetic diagnosis for achondroplasia. Reprod Biomed Online 2008; 16:276-82. [DOI: 10.1016/s1472-6483(10)60586-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
BACKGROUND Extreme leukocytosis in the absence of haematological disease, is a topic about which little is known, although it may be associated with increased mortality among patients admitted to the intensive care department. The significance of extreme leukocytosis in patients presenting to hospital is uncertain. AIM To study the correlates and prognostic significance of extreme leukocytosis, in patients admitted to an emergency department. DESIGN Observational study. METHODS Consecutive adult patients with extreme leukocytosis (>25 x 10(9)/l, n=54) presenting to the emergency department of a university-affiliated hospital were compared to age-matched controls (+/-5 years) with moderate leukocytosis (12-25 x 10(9)/l, n=118) presenting to the same department. Data were collected on demographic features, emergency room findings and hospital course. RESULTS Patients with extreme leukocytosis were more likely to suffer from infectious disease (74% vs. 48%, p<0.01), to be hospitalized (100% vs. 80%, p<0.001), and to die (32.1% vs. 12.7%, p<0.01), and had a longer median length of stay (7.5 vs. 4.0 days, p<0.005). There was no significant difference in vital signs between the two groups. DISCUSSION In our patients, extreme leukocytosis appeared to be predominantly caused by infectious disease, and was associated with a high case fatality rate. The degree of leukocytosis may provide prognostic information beyond that reflected in traditional vital signs.
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Affiliation(s)
- Y R Lawrence
- Department of Internal Medicine, Shaare Zedek Medical Center, Jerusalem, Israel.
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Steiner-Birmanns B, Munter G, Benasouli Y, Perl B, Itzchaki M, Korn Lubetzki I. Opercular syndrome due to non-convulsive status epilepticus in an adult. J Neurol Neurosurg Psychiatry 2006; 77:1198-9. [PMID: 16980661 PMCID: PMC2077542 DOI: 10.1136/jnnp.2005.085282] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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35
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Gross DJ, Munter G, Bitan M, Siegal T, Gabizon A, Weitzen R, Merimsky O, Ackerstein A, Salmon A, Sella A, Slavin S. The role of imatinib mesylate (Glivec) for treatment of patients with malignant endocrine tumors positive for c-kit or PDGF-R. Endocr Relat Cancer 2006; 13:535-40. [PMID: 16728580 DOI: 10.1677/erc.1.01124] [Citation(s) in RCA: 121] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Imatinib mesylate (IM), a small molecule that is a selective inhibitor of the ABL, platelet derived growth factor receptor (PDGFR-R) and stem cell ligand receptor (c-kit) tyrosine kinases (TK). IM was also found to inhibit the TK activity of BCR/ABL fusion protein produced in chronic myelogenous leukemia, with marked clinical activity against the disease. Since both PDGF-R and c-kit both having a putative role in tumorigenesis, we investigated the efficacy and safety of the use of IM in patients with endocrine tumors unresponsive to conventional therapies that expressed c-kit and/or PDGF-R (within the framework of a comprehensive phase II multi-center study of IM in patients with solid tumors). IM was initiated at a dose of 400 mg/day, with possible dose escalation within 1 week to 600 mg/day and an option to raise the dose to 800 mg/day in the event of progression and in the absence of safety concerns for a period of up to 12 months. Between September 2002 and July 2003, 15 adult patients with disseminated endocrine tumors were recruited as follows: medullary thyroid carcinoma (MTC, n = 6); adrenocortical carcinoma (ACC, n = 4); malignant pheochromocytoma (pheo, n = 2); carcinoid (non-secreting, n = 2), neuroendocrine tumor (NET, n = 1). No objective responses were observed. MTC--disease progression in 4 patients, and treatment discontinuation in 2 patients due to adverse events; ACC--disease progression in 3 patients, and treatment discontinuation in 1 patient due to severe psychiatric adverse event; Pheo--disease progression in 2 patients; Carcinoid--stable disease in 1 patient (6.5 months), and disease progression in 1 patient; NET--disease progression in 1 patient. IM does not appear to be useful for treatment of malignant endocrine tumors, also causing significant toxicity in this patient population.
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Affiliation(s)
- David J Gross
- Endocrinology and Metabolism Service, Department of Medicine, Hadassah University Hospital, P.O.B 12000, Jerusalem, Israel 91120.
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Mayan H, Munter G, Shaharabany M, Mouallem M, Pauzner R, Holtzman EJ, Farfel Z. Hypercalciuria in familial hyperkalemia and hypertension accompanies hyperkalemia and precedes hypertension: description of a large family with the Q565E WNK4 mutation. J Clin Endocrinol Metab 2004; 89:4025-30. [PMID: 15292344 DOI: 10.1210/jc.2004-0037] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Familial hyperkalemia and hypertension (FHH; pseudohypoaldosteronism type II) is an autosomal dominant disorder characterized by hyperkalemia, hypertension, and low renin. WNK1 kinase overexpression and WNK4 kinase inactivating missense mutations cause FHH. When expressed in frog oocyte, WNK4 inhibits Na-Cl cotransporter surface expression, and WNK1 relieves this inhibition. We have reported hypercalciuria in subjects with the WNK4 Q565E mutation. In contrast, in subjects with WNK1 overexpression, normocalciuria was found. Here we report a major extension of our previously described kindred that contains 34 subjects, 18 of them affected by the mutation. Hypertension was diagnosed in 13 affected subjects at the age of 31 +/- 12 yr. Five of the affected or obligatory affected subjects had stroke, in four at the age of 50-62 yr. Seven subjects with FHH were diagnosed 27 yr previously. All four subjects who were normotensive at diagnosis became hypertensive during follow-up. The mean time between detection of hyperkalemia and appearance of hypertension was 13 yr. In the extended kindred, compared with the unaffected subjects, affected subjects had hyperkalemia, low transtubular potassium gradient, hyperchloremia, low bicarbonate, higher aldosterone, and marked suppression of renin. Urinary calcium levels in affected and unaffected subjects were 0.85 +/- 0.27 and 0.28 +/- 0.12 mmol/mmol creatinine, respectively (P < 0.0001). Hypercalciuria was accompanied by lower serum calcium levels [9.44 +/- 0.15 vs. 9.81 +/- 0.31 mg/dl (2.36 +/- 0.04 vs. 2.45 +/- 0.08 mmol/liter); P = 0.01], supporting a mechanism of renal calcium leak. The six affected, currently normotensive subjects had the same degree of hyperkalemia, hypercalciuria, and low renin as the affected hypertensive subjects. We conclude that in FHH with WNK4 mutations, with time all affected subjects will apparently develop hypertension. Hypercalciuria accompanies hyperkalemia, and both precede hypertension. Based on the recent findings that WNK4 regulates the renal outer medullary potassium channel as well as epithelial Cl(-)/base exchanger and the Na(+)-K(+)-2Cl(-) cotransporter, we suggest that WNK4 interacts with a calcium channel or transporter.
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Affiliation(s)
- Haim Mayan
- Department of Medicine E, Sheba Medical Center, Sackler School of Medicine, Tel Aviv University, Tel Hashomer 52621, Israel
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Abstract
Acute liver failure due to hepatic involvement by haematological malignancies is very rare, and usually has a rapidly fatal prognosis. We describe the case of a man who was treated for diffuse large B-cell lymphoma, and achieved a complete remission after eight courses of chemotherapy. He then presented with acute liver failure. Transjugular liver biopsy revealed massive infiltration by lymphomatous cells, with extensive necrosis. A CT scan did not show any evidence of extrahepatic lymphoma. The patient recovered from the liver failure following combined immuno-chemotherapy. Recurrence of the disease should be included in the differential diagnosis of patients with haematological malignancies and acute liver failure, even without evidence of extrahepatic involvement.
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Affiliation(s)
- G A Morali
- Department of Gastroenterology, Shaare Zedek Medical Centre, Jerusalem, Israel
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Munter G, Hershko C. Increased warfarin sensitivity as an early manifestation of occult prostate cancer with chronic disseminated intravascular coagulation. Acta Haematol 2001; 105:97-9. [PMID: 11408712 DOI: 10.1159/000046542] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Increased sensitivity to warfarin anticoagulation is usually attributed to liver disease, vitamin K deficiency, or drug interactions. We describe a patient with unexplained sensitivity to warfarin and mildly elevated prostate-specific antigen levels in whom subsequent developments indicated that warfarin sensitivity was the first manifestation of occult prostatic cancer. A review of all published cases of coagulopathy associated with cancer of the prostate shows that, unlike other solid tumors with secondary disseminated intravascular coagulation (DIC), in prostate cancer increased bleeding is more common than thrombotic phenomena. Chronic DIC due to occult prostate cancer should be included in the differential diagnosis of excessive prothrombin time prolongation in patients receiving anticoagulants.
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Affiliation(s)
- G Munter
- Department of Medicine A, Shaare Zedek Medical Center, Jerusalem, Israel
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