Alan Jotkowitz

Syphilis and HIV co-infection.

Syphilis is a complex disease, which is sexually transmitted. The incidence of syphilis is rising all over the world, partly due to the increased transmission in HIV patients and other high risk groups such as men who have sex with men. Interestingly syphilis itself facilitates HIV infection in several ways. Great importance exists in recognition of both diseases and their complex interactions. This article will review the manifestations of syphilis in the context of HIV infected patients, and the challenging diagnosis and management of these patients.

Evidence-based medicine: assessment of knowledge of basic epidemiological and research methods among medical doctors

Background: An understanding of statistical methods and basic epidemiology are crucial for the practice of modern medicine. Aims: To assess (1) the knowledge of basic methods of conducting research and data analysis among residents and practicing doctors and (2) the effect of country of medical school graduation, professional status, medical article reading and writing experience on the level of this knowledge. Methods: Data were collected by means of a supervised self-administered questionnaire, which was distributed among doctors at Soroka Medical Center, Beer-Sheva, Israel. The questionnaire included 10 multiple-choice questions on basic epidemiology and statistics, and respondent demographical data. Results: Of the 260 eligible doctors, 219 (84.2%) returned completed questionnaires. Of the 219 doctors, 50% graduated more than 8.5 years ago, 39.7% were specialists and the remaining were residents. The most frequent specialty was internal medicine (37.4%). Israel was the most frequent country of graduation (45.7%), followed by the former Soviet Union (Eastern medical education; 38.4%). The median total score of knowledge was 4 of 10 questions (interquartile range 2–6). A higher score was associated with a Western medical education, being a specialist, shorter elapsed time since graduation, higher number of publications and self-reported reading of “methods” and “discussion” sections in scientific articles. Conclusion: This study found a low level of knowledge of basic principles of research methods and data analysis among doctors, and this knowledge considerably differed by country of medical school graduation.

Exertional heatstroke: clinical characteristics, diagnostic and therapeutic considerations.

BACKGROUND Exertional heat stroke (EHS) is a life threatening disease characteristically affecting young adults involved in strenuous physical activity. Delay in diagnosis and management may adversely affect outcome. The aim of this study was to summarize our experience with this syndrome and to identify factors associated with poor outcome. METHODS In this retrospective cohort study we enrolled thirty two patients who met the case definition of exertional heat stroke. RESULTS Of the 32 patients, 27 (84%) were male and their median age was 19 years. 26 patients were residents of the northern parts of the country spending less than 10 days in the area. Only 10 patients (31%) were correctly diagnosed and treated in the prehospital setting. Those in whom treatment was delayed had higher rates of multi-organ failure and longer hospitalizations. In 7 patients protracted systemic inflammatory response (SIRS) was observed. Of the 14 patients that had moderate to severe disease requiring ICU admission, eight (25%) were mechanically ventilated, two (6.3%) were dead on arrival. The other half of the cohort had a mild disease managed by the general wards. CONCLUSIONS Exertional heat stroke is a life threatening disease. Early diagnosis and appropriate management may improve outcome. Protracted SIRS may complicate the course of EHS.

A Case Against Justified Non-Voluntary Active Euthanasia (The Groningen Protocol)

The Groningen Protocol allows active euthanasia of severely ill newborns with unbearable suffering. Defenders of the protocol insist that the protocol refers to terminally ill infants and that quality of life should not be a factor in the decision to euthanize an infant. They also argue that there should be no ethical difference between active and passive euthanasia of these infants. However, nowhere in the protocol does it refer to terminally ill infants; on the contrary, the developers of the protocol take into account the future quality of life of the infant. We also note how the Nazi Euthanasie Programm started with the premise that there is some life not worthy of living. Therefore, in our opinion, the protocol violates the traditional ethical codes of physicians and the moral values of the overwhelming majority of the citizens of the world.

Truth-Telling in a Culturally Diverse World

Until recently physicians have been reluctant to disclose a poor prognosis to patients for fear of harming them with the bad news and/or taking away their will to live. In the last decades we have seen a reversal of practice among Western physicians, and most doctors readily disclose to their patients the full extant of their disease. This change is probably due to the emphasis on patient autonomy in the doctor-patient relationship and the lack of evidence that hearing the bad news impacts significantly on patient outcomes. This emphasis on complete honesty with patients might not reflect the practice in non-Western cultures. In disclosing a poor prognosis to a patient the physician must do so with cultural sensitivity, compassion and letting the patient decide how much he or she wants to know.

The Case of Samuel Golubchuk and the Right to Live

Samuel Golubchuk was unwittingly at the center of a medical controversy with important ethical ramifications. Mr. Golubchuk, an 84-year-old patient whose precise neurological level of function was open to debate, was being artificially ventilated and fed by a gastrostomy tube prior to his death. According to all reports he was neither brain dead nor in a vegetative state. The physicians directly responsible for his care had requested that they be allowed to remove the patient from life support against the wishes of the patients family. Concurrently the Manitoba College of Physicians and Surgeons released a statement which states that the final decision to withdraw life support lies with the physician. In our opinion the statement is ethically problematic for a number of reasons. 1. It is an affront to the guiding principles of Western medical ethics: patient autonomy and human freedom. 2. The position of Samuel Golubchuks physicians and the new statement lack cultural sensitivity towards other traditions. 3. In modern society there exists an erosion of a basic attitude towards the value of life. 4. The ability of physicians to predict life expectancy in terminally ill patients has been shown repeatedly to be quite limited.

Comparison of Diabetic Ketoacidosis in Patients With Type-1 and Type-2 Diabetes Mellitus

Background:Diabetic ketoacidosis (DKA) occurs most often in patients with type 1 diabetes, however patients with type 2 diabetes are also susceptible to DKA under stressful conditions. The aims of our study were to evaluate and compare the clinical and biochemical characteristics and outcomes of type 1 versus type 2 diabetes mellitus (DM) patients with DKA. Methods:A retrospective cohort study of adult patients hospitalized with DKA between January 1, 2003, and January 1, 2010. The clinical and biochemical characteristics of DKA patients with type-1 DM were compared with those of patients with type-2 DM. The primary outcome was in-hospital all-cause mortality. Results:The study cohort included 201 consecutive patients for whom the admission diagnosis was DKA: 166 patients (82.6%) with type-1 DM and 35 patients (17.4%) with type-2 DM. The patients with DKA and type-2 DM were significantly older than patients with type-1 DM (64.3 versus 37.3, P < 0.001). Significantly more patients with severe forms of DKA were seen in the group with type-2 DM (25.7% versus 9.0%, P = 0.018). The total in-hospital mortality rate of patients with DKA was 4.5%. The primary outcome was significantly worse in the group of patients with type-2 DM. Conclusions:DKA in patients with type-2 DM is a more severe disease with worse outcomes compared with type-1 DM. Advanced age, mechanical ventilation and bed-ridden state were independent predictors of 30-day mortality.

A Jewish response to the Vatican's new bioethical guidelines.

The Vatican recently published directives (Dignitas Personae) regarding “beginning of life” issues that explain the Catholic Churchs position regarding new technologies in this area. We think that it is important to develop a response that presents the traditional Orthodox Jewish position on these same issues in order to present an alternative, parallel system. There are many points of commonality between the Vatican document and traditional Jewish thought as well as several important issues where there is a divergence of opinion. The latter include the status of the zygote as produced during in vitro fertilization (IVF), the acceptable of procreation in a method other than through the conjugal act, and the permissibility of deriving benefit from the products of an illicit act. These points of agreement and disagreement are discussed in detail in this article.

Reduction in sex-based mortality difference with implementation of new cardiology guidelines.

BACKGROUND Mortality from acute coronary syndrome has historically been higher in women as compared with men. We hypothesized that adoption of a more sensitive definition for the diagnosis of acute myocardial infarction and managing patients according to the 2000 European Society of Cardiology and American College of Cardiology guidelines would reduce this difference. METHODS A retrospective cohort study was conducted of all acute coronary syndrome admissions to 7 regional tertiary hospitals in Israel during 1999-2004. The primary end point was all-cause 1-year mortality. Differences in risk between men and women were assessed using Cox proportional hazards regression. RESULTS The number of patients admitted with acute coronary syndrome was 20,206 and 15,583 before and after adoption of the guidelines, respectively. An invasive strategy during the index hospitalization was more frequent in men in both the pre- (47.6% vs 33.6, P <.001) and post- (55.7% vs 40.9%, P <.001) transition periods. Secondary prevention was intensified in the post-transition period in both sexes. Multivariate analysis adjusting for differences in baseline clinical characteristics between men and women and invasive strategy demonstrated that female sex was associated with increased 1-year mortality during the pretransition period (hazard ratio 1.34, 95% confidence interval, 1.24-1.45), but was not a significant factor in the post-transition period (hazard ratio 1.04, 95% confidence interval, 0.94-1.14). CONCLUSIONS The transition to the 2000 European Society of Cardiology and American College of Cardiology guidelines was associated with a reduction in the sex-based mortality difference in patients with acute coronary syndrome despite the fact that an early invasive strategy and secondary prevention continued to be underutilized in female patients in both periods.

The use of personal digital assistants among medical residents

The purpose of this study was to determine residents’ perception of the utility of personal digital assistants (PDAs) and their influence on clinical practice at two teaching hospitals, one of which subsidized resident purchase of a PDA. A total of 21 residents in the unsubsidized group (32%) and 24 residents in the subsidized group (96%) owned a PDA. Medical residents who were provided with PDAs perceived them to be less useful than residents who were not provided with them. Palm owners in both groups responded that they used these devices to organize their record keeping and the most frequently used programs were pharmacopoeias, medical reference and clinical calculators. Residents quickly adapted PDA to clinical care and further research is needed to assess their impact on resident education and patient outcomes.