Shimon Weitzman

Determinants of Long-Term Satisfaction after Vertical Banded Gastroplasty

Background: The long-term usefulness of vertical banded gastroplasty (VBG) in achieving weight loss is controversial, and adverse effects related to the procedure may attenuate patient satisfaction. Our objective was to evaluate patient satisfaction, and to identify parameters that are related to such satisfaction, 3 to10 years after VBG. Methods: All consecutive patients who underwent VBG in one surgical ward were invited for a follow-up study 3 to 10 years after surgery. Questions relating to symptoms and quality of life were evaluated in a personal interview using a structured questionnaire. Results: Of the 122 patients who underwent VBG from 1986 to 1992, 75 patients were located and agreed to participate in the follow-up study. The average time since surgery was 5.4 ± 1.8 years. The average weight loss was 24.9 ± 12.4%, representing an excess body-weight loss of 58.6 ± 30.4%. Overall, 65% of the patients were satisfied with the results of surgery while 19% expressed dissatisfaction. Significant improvement was seen in respiratory difficulties, ability to perform physical exercise, and mental status. Successful weight loss and the frequency of respiratory difficulties were the only independent parameters associated with patient satisfaction. Although vomiting, gastroesophageal reflux and difficulty in swallowing occurred in over two-thirds of the patients, their presence was not correlated with patient dissatisfaction. Conclusion: Despite the presence of a multitude of adverse effects, the majority of our patients were satisfied with the long-term results of VBG. Successful weight loss and improvement in respiratory difficulties were the major determinants of patient satisfaction.

A new risk score predicting 1- and 5-year mortality following acute myocardial infarction: Soroka Acute Myocardial Infarction (SAMI) Project

BACKGROUND Risk stratification of patients following acute myocardial infarction (AMI), in order to identify patients whose clinical outcomes can be improved through specific medical interventions, is needed. OBJECTIVES Development and validation of a prognostic tool comprising a variety of non-cardiovascular co-morbidities, to predict mortality of hospital survivors after AMI. METHODS The study cohort included 2773 consecutive patients with AMI who were discharged live from the Soroka University Medical Center between 2002 and 2004. Two-thirds were used obtain the model (training set) and one-third to validate it (validation set). Data were collected from the hospitals routine computerized information systems. The primary outcome was post-discharge 1-year all-cause mortality. The weight of each variable in the final score was computed based on the odds ratio values of the multivariate model. Additionally, the ability of the index to predict 5-year mortality was assessed. RESULTS These are comprised of the following parameters: 4 points - age >75 years, abnormal echocardiography findings; 3 points - at least one of following: gastro-intestinal hemorrhage, COPD, malignancy, alcohol or drug addiction, neurological disorders, psychiatric disorders; 2 points - no echocardiography results, renal diseases, anemia, hyponatremia; -3 points for PCI or thrombolytic therapy; -6 points - CABG; -2 points - obesity. The c-statistics for 1-year all-cause mortality were 0.86 and 0.83 in the training and validation sets, respectively. The c-statistics for 5-year mortality was 0.858 for both sets combined. CONCLUSIONS The new score is a simple robust tool for predicting mortality in patients discharged alive following AMI.

Is diabetes an independent risk factor for mortality after myocardial infarction? The ARIC (Atherosclerosis Risk in Communities) Surveillance Study.

Abstract.We investigated the age-, gender- and race-specific 1-year case fatality rates of diabetic and non-diabetic individuals with a myocardial infarction. Data were obtained from the Atherosclerosis Risk in Communities (ARIC) Surveillance Study, which monitors both hospitalized myocardial infarction and coronary heart disease (CHD) deaths in residents aged 35–74 years in four communities in the USA. The study population comprised 3242 hospitalized myocardial infarctions (HMIs) in diabetic subjects and 9826 HMIs in non-diabetic individuals between 1987 and 1997. Age-adjusted and gender- and race-specific odds ratios (OR) for 1-year case fatality comparing diabetic to non-diabetic patients were 2.0 (95% CI, 1.6–2.4) for white men and 1.4 (95% CI, 1.1–1.8) for white women. Further adjustment for severity of HMI, history of previous MI, stroke and hypertension, and therapy variables showed significantly higher case fatality in white diabetic men than in non-diabetic white men (OR=1.5; 95% CI, 1.2–1.9), but no significant association in the other race-gender groups. The age-adjusted odds of out of hospital death was significantly higher among white diabetic men (OR=1.7; 95% CI, 1.2–2.3), white women (OR=2.3; 95% CI, 1.4–3.8), and African-American women (OR=2.9; 95% CI, 1.5–5.9) as compared to their non-diabetic counterparts. In conclusion, diabetes is an independent factor for mortality within one year following a myocardial infarction among white men, and following out-of hospital coronary death in white men and women and in African-American women. It is possible that these differences could be explained, at least in part, by a less than optimal medical management of the high cardiovascular risk profile of these patients after hospital discharge.

Gestational diabetes among Bedouins in southern Israel: comparison of prevalence and neonatal outcomes with the Jewish population.

Differences in the prevalence of gestational diabetes mellitus (GDM) have recently been reported between various ethnic populations. In the Negev region of Israel, a universal free screening programme for GDM was implemented in 1985. Between 1 March 1987 and 31 July 1988 11 003 deliveries occurred at the Soroka Medical Center, which provides free delivery and postnatal care to the whole Jewish and Bedouin population of the region. GDM was found in 5.7% of Jewish and in 2.4% of Bedouin women (odds ratio 2.3, 95% confidence interval (CI) 1.8–2.9;P<0.0001). Ethnicity was unrelated to maternal outcome, perinatal mortality or to any of the examined morbidity conditions of the newborn. The incidence of major congenital malformations was significantly higher in Jewish than in Bedouin infants of GDM women (Fishers Exact Test,P<0.03). Conversely, Jewish infants had fewer minor congenital anomalies (odds ratio 0.26, 95% CI0.09–0.73). In a multivariate logistic regression model, gestational age, mode of delivery and insulin requirement during pregnancy were the only factors independently associated with neonatal morbidity. The results of this study suggest that in our health care system, among women with GDM ethnicity is not associated with an excess of unfavourable maternal or infant outcomes.

Soroka acute myocardial infarction (SAMI) score predicting 10-year mortality following acute myocardial infarction

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Gender and ethnic disparities in outcome following acute myocardial infarction among Bedouins and Jews in Southern Israel

BACKGROUND Previous studies have documented gender-ethnic disparities in outcomes following acute myocardial infarction (AMI). This study evaluates such disparities in the Negev, Israel, and reviews potentially responsible mechanisms. METHODS Patients discharged with AMI were classified into young (<70 years), elders (≥70 years) and gender-ethnicity groups: Female Bedouins (FB), Female Jews (FJ), Male Bedouins (MB) and Male Jews (MJ). The primary outcome was 1-year all-cause mortality. Prognosis was assessed using Kaplan-Meier approach. Multivariable analyses assessing hazard ratios (HRs) for mortality were performed using the Cox proportional hazards regression models in two steps controlling for (i) the Ontario Acute Myocardial Infarction Mortality Prediction Rules (OAMIMPRs) and (ii) the OAMIMPR and additional potential confounders. RESULTS Of 2669 subjects, 45.8% were elders, 66.2% male and 10.9% Bedouin. The mortality rate was 12.3% (young 4.6%, elders 22%). Survival was significantly lower in FB compared with MB in the elderly stratum (P = 0.025). Multivariate analyses demonstrated similar risks for dying among the young. In the elders, the first multivariate analysis showed greater risk for mortality in FB. Using FB as the reference group, the HRs were as follows: HR((MB)) = 0.36 [95% confidence interval (CI): 0.14-0.9]; HR((FJ)) = 0.5 (95% CI: 0.27-0.9) and HR((MJ)) = 0.5 (95% CI: 0.28-0.91). In the second analysis, the HRs were as follows: HR((MB)) = 0.37 (95% CI: 0.14-0.93); HR((FJ)) = 0.58 (95% CI: 0.32-1.07) and HR((MJ)) = 0.56 (95% CI: 0.31-1.03). CONCLUSIONS Elderly FB have poor 1-year prognosis following AMI compared with MB, MJ and FJ when controlling for the OAMIMPR model, yet when controlling for other potential confounders the differences are of borderline significance in relation to Jewish subjects. A culturally and economically sensitive programme focusing on tertiary prevention in these patients is warranted.

Postoperative analgesia with tramadol and indomethacin for diagnostic curettage and early termination of pregnancy

BACKGROUND The postoperative analgesic effects of rectal indomethacin and tramadol were compared in patients undergoing elective termination of first trimester pregnancy and diagnostic dilatation and curettage. METHODS Eighty-one American Society of Anesthesiologists class I and II women undergoing first trimester termination of pregnancy or diagnostic dilation and curettage were randomly allocated to receive rectal suppositories of either tramadol 100 mg (n=41) or indomethacin 100 mg (n=40) 90 min before induction of anesthesia. Pain scores and side effects were evaluated until discharge. Intraoperative anesthetic and postoperative analgesic consumption was also recorded. Intravenous metamizole 1 g was employed for postoperative rescue analgesia. RESULTS When compared to the indomethacin group, the tramadol group required less intraoperative propofol [136 mg ±28 vs. 160 mg ±35 (P=0.001)], less rescue analgesia [2.4% vs. 22% (P=0.005)] and lower visual analogue pain scores [2.4 ±8 vs. 23 ±22 (P=0.005)]. The incidence of postoperative nausea and vomiting was similar in both groups. CONCLUSION When compared to indomethacin 100 mg, preoperative administration of tramadol 100 mg provides superior postoperative analgesia with minimal adverse effects.

Transient Neurological Symptoms After Isobaric Subarachnoid Anesthesia with 2% Lidocaine: The Impact of Needle Type

BACKGROUND:The reported incidence of transient neurological symptoms (TNS) after subarachnoid lidocaine administration is as high as 40%. We designed this clinical trial to determine the incidence of TNS with two different pencil-point spinal needles: one-orifice (Atraucan) and two-orifice (Eldor) spinal needles. METHODS:Ninety-nine ASA physical status I or II patients undergoing surgical procedures of the urinary bladder or prostate were prospectively allocated to receive spinal anesthesia with 40 mg, 2% isobaric lidocaine plus fentanyl injected through either a 26-gauge Atraucan (n = 52) or a 26-gauge Eldor (n = 47) spinal needle. During the first three postoperative days, patients were observed for postoperative complications, including TNS. The primary end-point for this trial was the percentage of TNS in both double- and single-orifice spinal needle procedures. RESULTS:The incidence of TNS was higher when spinal anesthesia was done through the Atraucan needle (28.8% vs 8.5%, P = 0.006). Fifty percent of the patients in the double-orifice group versus 100% of the single-orifice group developed TNS after surgery in the lithotomy position (P = 0.014). The relative risk for developing TNS with the Eldor needle was 0.29 (95% CI: 0.07–0.75) compared with the Atraucan needle. CONCLUSIONS:The use of a double-orifice spinal needle was associated with a lower incidence of TNS, which may have been due to the needle design.

Ethnic Variation in the Association of Hypertension With Type 2 Diabetes

Lifestyle changes occurring with urbanization increase the prevalence of both type 2 diabetes mellitus (T2DM) and hypertension (HTN). Yemenites who have immigrated to Israel have demonstrated a dramatic increase in T2DM but the prevalence of HTN in diabetic Yemenites is unclear. In a cross‐sectional study, the authors evaluated the prevalence of HTN and lifestyle patterns in Israelis with T2DM of Yemenite (Y‐DM) and non‐Yemenite (NY‐DM) origin. Y‐DM (n=63) and NY‐DM (n=120) had similar age (63±7 vs 64±7 years, P=.5), diabetes duration, diet adherence, and exercise patterns. Y‐DM had a lower prevalence of HTN (63%) than NY‐DM (83%) (P<.01). Furthermore, Yemenite origin was independently associated with lower prevalence of HTN (odds ratio, 0.3; 95% confidence interval, 0.12–0.71). Blood pressure was well controlled with fewer antihypertensive medications in Y‐DM than NY‐DM (P<.01). Even though lifestyle patterns were similar in the two groups, Y‐DM had a lower prevalence of HTN compared with NY‐DM and required fewer antihypertensive medications.