Screening for erectile dysfunction as part of periodic examination programs--concept and implementation.

Erectile dysfunction (ED) can be an early and first sign of an underlying systemic disease. A screening program is offered by the Israeli Defense Force for career servicemen at the staff periodic examination center (SPEC), the aim of which was early detection of morbidity. We introduced the Sexual Human Inventory for Males (SHIM) questionnaire, in order to detect examinees with ED, and offer them suitable treatment options. The purpose of this study is to introduce the concept of an ED questionnaire as part of a screening program, and to describe the first months of its implementation. A computerized questionnaire is used to collect the medical history. The SHIM questionnaire was incorporated into the medical questionnaire. Relevant data including compliance to reply, SHIM scores, age and accompanying diseases of patients were collected from the computerized database of SPEC. A total of 2182 patients reported to SPEC from 1/5/01 to 1/11/01, 1980 of whom were males. Of the males, 881 (44.5%) chose to fill the SHIM questionnaire (mean age 34.5 +/- 6.7 y), and 244 of them (27.7%) had a score of 21 or less (20.7% had 17-21, 5.7% 11-16, 1.4% 0-10). The prevalence of ED and its severity increases with age. An inverted linear correlation was found between age and SHIM score (r = -0.22, P<0.0001). Prevalence of hypertension and diabetes mellitus is higher in patients with SHIM score < or =16 compared to those with a score > or =22. Only 15% of men with ED refer themselves for medical help. The concept of adding an ED questionnaire to a screening program may encourage more men to seek treatment, not only for their ED, but also for the underlying disease. The platform of a periodic examination offers maximum privacy to the examinees, resulting in better cooperation.

Rehabilitation outcomes in patients with full weight-bearing hip fractures.

Evaluation of the functional outcome for hip fractured elderly patients has been controversial due to a typical casemix containing both weight bearing and non weight bearing postoperative fractures. The purpose of this study was to investigate factors associated with rehabilitation outcomes in patients who are able to fully weight bearing following surgical repair of femoral neck fracture. We studied 217 consecutive patients admitted for rehabilitation after surgery for hip fracture. Age, gender, marital status, type of fracture and admission Functional Independence Measure (FIM) were evaluated as possible predictors of rehabilitation outcome. Functional gains were evaluated according to FIM. Dependent outcome variables were calculated as absolute (total FIM gain and daily FIM gain) as well as relative (to potential). Results showed a significant improvement in absolute total and daily FIM gains (19.32+/-8.29, and 0.87+/-0.44, respectively). Relative total functional gain was 0.40+/-0.19. Absolute total functional gain did not depend on FIM admission, whereas all other parameters were significantly correlated with FIM scores on admission, indicating a relatively adverse rehabilitation in patients with an admission FIM of 40 points or lower. The majority (83.9%) of patients were discharged home. A significant association exists between the ability to go home and marital status (P=0.009), as well as with admission FIM (P<0.0001). We conclude that encouraging outcome results are achieved in the elderly with full weight bearing fractures. The absolute functional gains do not depend on FIM admission scores and argues for inclusion of patients with low admission FIM scores to rehabilitation programs. However, the relative gains are significantly better in patients with higher admission FIM scores, thus supporting inclusion of selected patients. This poses serious ethical issues for healthcare policy-makers.

Intravenous line diameter: is bigger really better?

OBJECTIVE: To determine whether the size of an intravenous catheter influences the cannulation success rate and procedure duration among military medics. METHODS: According to a prospective, randomized, controlled crossover study design, 114 military medic cadets were paired and inserted 14-gauge (14G) and 16G intravenous catheters into veins in the antecubital fossa. Success rate and procedure duration were determined. RESULTS: The overall success rate for 14G and 16G catheters was 80 and 86%, respectively. Average procedure duration was 33 +/- 14.7 and 35.2 +/- 14.9 seconds, respectively. No significant differences were found in either success rate or procedure duration between the examined catheter sizes. CONCLUSION: Successful intravenous cannulation was unaffected by catheter size. Therefore, 14G intravenous catheters are recommended for use by military medics on the battlefield.

[Our experience with the medical rehabilitation of homeless-disabled people].

During the last two years, 11 homeless-disabled people were treated at our rehabilitation ward. All of the patients were Jewish, six were new immigrants from Russia, their age ranged between 34 to 60 years, most of these patients had completed at least high school education, and all had managed to have a "normal" social-working life until the crisis which led them to the street. Six became alcoholics and one was a narcotic-drug user. None of these patients suffered from malnutrition or mental disorder, and after the rehabilitation process was over, they became independent, performing the activities of daily living. Most of them decided to return to their previous street--living place, despite their disabilities. This new combination of relatively young disabled-homeless people at our rehabilitation facility demands novel and different rehabilitation approaches.

[Changes in structure and process components of trauma care in emergency departments in Israel--Part I].

In recent years there have been tremendous efforts to improve primary trauma care. The Ministry of Health and other authorities have invested in new trauma facilities in various hospitals. A nationwide survey with regard to structure and function of emergency departments was carried out. Compared to a similar survey conducted in 1992, significant progress in quality and quantity of equipment at various emergency departments was demonstrated. However, there are still differences between various hospitals. A drive to standardize trauma care will undoubtedly contribute to improvement in care of the injured.

Conversion motor paralysis disorder: overview and rehabilitation model.

It is important to consider a differential diagnosis between paralysis on an organic basis and paralysis and disability due to psychological mechanisms in people with physical impairment secondary to trauma, without evidence of organic etiology. We review the most dramatic type of conversion disorder (CD)-'Conversion Motor Paralysis'. Recent important medical literature concerning the accepted treatment and rehabilitation management will be reviewed and discussed. The inter-disciplinary in-patient team management approach in a rehabilitation setting offers the benefits of a comprehensive assessment and treatment. The diagnosis is temporary and conditional, since there may be a long delay until the appearance of organic findings. A complete medical assessment is essential in order to rule out any possibility of an organic etiology. In as many as 25% to 50% of patients diagnosed as conversion, an organic medical diagnosis was found.

Acute acalculous cholecystitis as a complication of spinal cord injury.

Acute acalculous cholecystitis (AAC) is an uncommon, but serious, and potentially lethal complication that may occur among patients suffering severe trauma, including surgical trauma, burns, and bacterial sepsis. Because clinical findings are often nonspecific or misleading, AAC causes a particular diagnostic problem when occurring after unrelated surgery or trauma. We report two patients who suffered AAC following spinal cord injury (SCI). We review the etiology, diagnosis, and management of this disorder. Increased awareness of this problem by the physiatrist and rehabilitation community is important, because of the apparent increasing occurrence of AAC and the potential for significant morbidity and possible mortality when not promptly diagnosed.

Conversion motor paralysis disorder: analysis of 34 consecutive referrals.

STUDY DESIGN: We present our cumulative experience with patients sustaining the most dramatic type of Conversion Disorder (CD) - Conversion Motor Paralysis. SETTING: Rehabilitation departments, Reuth Medical Center, Tel-Aviv and Sheba Medical Center, Tel-Hashomer, Israel. METHODS: During the period 1973-2000, 34 patients with neurological symptoms without any anatomical or physiological basis were admitted to both rehabilitation departments. This number consists of less than 1% of the total acute traumatic and non-traumatic spinal cord disorders admitted annually to these centers. RESULTS: Twenty-five of the subjects were men (mean age of 30 years) and nine were women (mean age of 31.4 years). Neurological symptoms included: paraplegia (complete or incomplete) (18), hemiplegia or hemi paresis (11), tetraplegia (complete or incomplete) (three), monoplegia (one), triplegia (one). The final diagnosis on discharge was CD in 30 of the 34 cases, the remaining four being diagnosed as malingering. Functionally, nine patients had a complete recovery, 10 a partial recovery and 15 remained unchanged. CONCLUSION: Disabled people who experienced traumatic events resulting in various disabilities are admitted usually to a rehabilitation center. However, some of them are later diagnosed as having Conversion Disorder or malingering. We believe that their participation in active regular and integrative rehabilitation process is beneficial to most of them. Most of these patients gain functional independence and return to the main stream of life.

Gynecomastia following spinal cord disorder.

Gynecomastia, an excessive development of the mammary glands in men, is a known phenomenon among patients with spinal cord disorder, yet in the last 50 years it has not been fully described in relation to spinal cord disorder. Over a period of 2 years, six patients with spinal cord disorder (4 secondary to a traumatic injury, 1 to decompression sickness, and 1 to transverse myelitis) manifested gynecomastia. The onset of gynecomastia occurred between 1 to 6 months after injury. These patients are presented along with a review of the possible causes for gynecomastia and a suggested workup routine. A clinical examination for the presence of gynecomastia should be performed for every patient with spinal cord disorder and a thorough endocrinological workup should follow to rule out malignancy and reassure the anxious patient undergoing a disruption of his body image.

Cognitive status at admission: does it affect the rehabilitation outcome of elderly patients with hip fracture?

OBJECTIVES: To determine the effect of cognitive status at admission on functional gain during rehabilitation of elderly hip-fractured patients. DESIGN: Cohort study. SETTING: A hospital geriatric rehabilitation department. PATIENTS: Two hundred twenty-four elderly patients admitted consecutively for rehabilitation after surgery for hip fracture. MEASUREMENTS: Cognitive status was assessed by the Mini-Mental State Examination and the cognitive subscale of the Functional Independence Measure (cognFIM); functional status was assessed by the motor subscale of FIM; absolute functional gain was determined by the motor FIM gain (deltamotFIM); and relative functional gain (based on the potential for improvement) by the Montebello rehabilitation factor score (MRFS). RESULTS: A significant increase in FIM scores (19.7) occurred during rehabilitation, mainly due to motor functioning (19.1). When the relative functional gain (as measured by both motor MRFS efficacy [r = .591] and efficiency [r = .376] was compared with the absolute gain (as measured by deltamotFIM [r = .304]), a stronger association between cognFIM and the relative measures was found. In addition, motor FIM efficacy and efficiency were significantly lower in the cognitively impaired patients (p<.01). A better rehabilitation outcome was seen in patients with higher admission cognitive status, adjusting for the effects of age, sex, length of stay, and type of fracture (odds ratio = 2.2, 95% confidence interval 1.5-3.7). CONCLUSIONS: Impaired cognitive status at admission lowered the rehabilitation outcome of elderly hip fracture patients. Cognitive impairment was strongly and directly associated with functional gain in these patients. Absolute motor gain appeared to be independent of cognitive status, whereas the relative motor gain depended on it. These findings support the implementation of comprehensive rehabilitation for selected cognitively impaired elderly hip fracture patients.

Structure and process components of trauma care services in Israeli acute-care hospitals.

In recent years a vigorous effort has been made to improve primary trauma care in Israel. The Ministry of Health and other authorities have invested in new facilities in various hospitals which are engaged in trauma care. A survey was conducted in order to identify deficiencies in organization, personnel and equipment required to provide optimal trauma care. A cross-country survey was conducted by using a questionnaire that dealt with structure and process components of trauma care. The questionnaire was submitted to medical directors of emergency departments in all 24 acute-care hospitals in Israel. Additional information was obtained by a telephone poll when required. Inter-hospital variation concerning structure of trauma services, protocols and qualification of manpower responsible for primary care of the injured was found. The conclusions are that an increase in homogeneity in the field of trauma care is still needed. A continuous effort should be made in order to structurally and functionally further develop independent trauma units in all hospitals in Israel. Methods should be found to encourage young physicians to enter the field of trauma care. The establishment of a nationwide trauma registry system will undoubtedly contribute to future improvement in the initial care of the injured in Israel.

Treatment of male infertility due to spinal cord injury using rectal probe electroejaculation: the Israeli experience.

STUDY DESIGN: Male infertility caused by anejaculation is common among patients with spinal cord injury (SCIP). The fertility options for SCIP have improved impressively over the past 10 years. We present the Israeli experience in the treatment of infertility in a large series of SCIP. The issues which are addressed include the treatment of ejaculatory dysfunction, seminal quality and fertility management in SCIP. SETTING: Sexual rehabilitation clinic, Neuro-Rehabilitation department, Sheba Medical Center, Israel. METHODS: Between June 1992 and May 1998, a total of 84 consecutive SCIP were treated in our clinic with electro-ejaculation (EEJ), representing a sample of the SCIP population, composed mostly of young men traumatically injured. The patients have sustained different levels and completeness of spinal injury. Among the patients 33 were interested in achieving pregnancy (39.3%), while the rest were interested in determining fertility potential for family. With EEJ, a low-current stimulation of the ejaculatory organs via a rectal probe is done. The collected semen is used for fertility determination or for fertilization. RESULTS: Eighty-four patients were treated by EEJ. Mean age was 31.3 and mean age at injury was 21.7. There were 29 cervical, 50 thoracic and five lumbar lesions. Sixty-three had complete injury (ASIA A) and 21 incomplete (ASIA B -15, ASIC C -5, ASIA D -1). Fifty-nine had upper motor neuron lesions, and 25 had lower motor neuron. A total of 355 stimulations were performed. Ejaculate was obtained in all patients in 350 stimulations (98.6%), and sperm was present in 74 patients (88.1%) in 296 of the stimulations (83.4%). Fairly good numbers of spermatozoa were obtained, whereas sperm motility and morphology of spermatozoa were low in most cases. A significant difference in sperm count, motility and morphology was noted between antegrade and retrograde samples. No significant improvement in sperm quality after four repeated consecutive stimulations was noted in 38 SCIP. Side effects were minor and encountered in 16 patients (19.1%). Out of 33 couples who wished to achieve pregnancy, 26 reached the stage of insemination. Four pregnancies were achieved after 33 cycles of In-Uterine-Insemination (pregnancy rate 28.6% per couple), and 15 after 68 cycles of In-Vitro-Fertilization (micromanipulation) (pregnancy rate of 68.75% per couple). In all, of 101 conception attempts 23 were successful, resulting in pregnancies in 18 couples, and accounting for an overall pregnancy rate of 70% per couple. CONCLUSION: The high percentage of pregnancies imply that, despite the typically poor sperm motility noted in EEJ, rectal probe EEJ combined with assisted reproductive techniques, and performed by a team approach, is an efficient and safe technique for treating infertility among SCIP.

Interhospital patient transfer: a quality improvement indicator for prehospital triage in mass casualties.

The need for interhospital patient transfer after mass casualties may be a consequence of triage errors. Indications for interhospital patient transfer following seven suicidal bus bombings in Israel were reviewed to identify possible errors in triage at the scene. Medical records of victims arriving to hospitals were analyzed for age, injury description, injury Severity Score (ISS), and indication and destination of interhospital transfer. A total of 473 victims were involved, 74 of whom died at the scene (15.6%). Mean victim age was 29 +/- 16 (SD) years. Interhospital transfer was necessary for 29 patients. Indications for transfer included (1) mandatory lifesaving procedures on route to trauma center (n = 14), (2) underdiagnosis at the scene (n = 1), (3) insufficient local resources (n = 9), and (4) triage-related errors (n = 5). The ratio between interhospital transfer due to triage errors and the victim population who may need to be transferred is suggested as quality assurance (QA/QI) indicator for triage.

Blast injuries: bus versus open-air bombings--a comparative study of injuries in survivors of open-air versus confined-space explosions.

OBJECTIVES: To compare injury patterns resulting from explosions in the open air versus within confined spaces. METHODS: Medical charts of 297 victims of four bombing events were analyzed. Two explosions occurred in the open air and two inside buses. Similar explosive devices were applied in all four incidents. The incidence of primary blast injuries, significant penetrating trauma (Abbreviated Injury Scale score > or = 2), burns, Injury Severity Score, Revised Trauma Score, and mortality were compared between the two populations. RESULTS: A total of 204 casualties were involved in open-air bombings, 15 of whom died (7.8%). Ninety-three victims were involved in bus bombings, 46 of whom died (49%). The difference in mortality rate was highly significant, p < 0.00001. Primary blast injuries were observed in 25 and 31 victims (34.2% and 77.5% of admitted victims), respectively (p = 0.00003). Median Injury Severity Score was 4 versus 18, respectively (p < 0.0001). CONCLUSION: Explosions in confined spaces are associated with a higher incidence of primary blast injuries, with more severe injuries and with a higher mortality rate in comparison with explosions in the open air.