Medical Tourism in a Socialized Health Care System—The Need for Strict Systemic Supervision

Medical tourism is defined by the active act of traveling from a patient’s country of origin to a different country, specifically to receive medical treatment. Globalization has made a tremendous change in the field of medical tourism. Medical tourism statistics revealed an anticipated growth of the industry from about $40 billion in 2004 to$100 billion by 2012, as estimated by the McKinsey Company (Shetty, 2010). The size of the global medical tourism market increased about 2.5 times from 2004 to 2012 by approximately USD 10 billion, and it is expected to reach approximately USD 33 billion by 2019 (Seo & Park, 2018). Israel has emerged as a medical tourism destination due to the advantages it can offer. Israel’s facilities are recognized throughout the world, and provide high quality of care at reasonable prices. But, Israel has a socialized health care system. This means that the national health insurance program is financed mainly by the government from public sources, such as health insurance tax that is collected by the general payroll and other general tax revenues, but also directly from the public through out-of-pocket money and private complementary health insurances. In comparison to OECD countries, Israel’s hospitals are characterized by a very low bed to population ratio, an extremely low average length of stay, a high rate of admissions per 1000 population, and a high occupancy rate, which means this is already a very “lean” and effective system, that is on the verge of collapse due to a lack of funding. In relation to this medical tourism raises a lot of ethical, moral and economic issues for the Israeli health system. In the current article we try to shed some light upon these problems and suggest feasible solutions for them.We suggest that countries should adopt an ethical code and health policy, which will be used by local hospitals to maintain the delicate balance between medical services to the local population and medical tourism

Bouveret Syndrome in an Elderly Female

ABSTRACT Introduction: A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Herein we present a case of an elderly woman with an impacted gallstone in duodenum and discuss its' management. Patient description: A 96-year-old woman was admitted to our department due to a gastric outlet obstruction. Initial gastroscopy revealed a gastric bezoar. An attempt for its extraction failed. She underwent a laparotomy in which a cholecystoduodenal fi stula and a large impacted stone were found. Separation of the fi stula, including closure of the duodenum side, cholecystectomy and removal of the obstructing gallstone were performed. Additional stones were found and retrieved during common bile duct (CBD) exploration. Surgery was fi nalized by duodenoplasty, closure and T-tube drainage of the CBD. Post-operative course was prolonged and uneventful. Discussion and Conclusions: Bouveret syndrome is a rare cause of gastric outlet obstructions. In this case, unsuccessful endoscopic treatment necessitated surgery for removal of impacted gallstone in the duodenum

The NlpD Lipoprotein Is a Novel Yersinia pestis Virulence Factor Essential for the Development of Plague

Yersinia pestis is the causative agent of plague. Previously we have isolated an attenuated Y. pestis transposon insertion mutant in which the pcm gene was disrupted. In the present study, we investigated the expression and the role of pcm locus genes in Y. pestis pathogenesis using a set of isogenic surE, pcm, nlpD and rpoS mutants of the fully virulent Kimberley53 strain. We show that in Y. pestis, nlpD expression is controlled from elements residing within the upstream genes surE and pcm. The NlpD lipoprotein is the only factor encoded from the pcm locus that is essential for Y. pestis virulence. A chromosomal deletion of the nlpD gene sequence resulted in a drastic reduction in virulence to an LD50 of at least 107 cfu for subcutaneous and airway routes of infection. The mutant was unable to colonize mouse organs following infection. The filamented morphology of the nlpD mutant indicates that NlpD is involved in cell separation; however, deletion of nlpD did not affect in vitro growth rate. Trans-complementation experiments with the Y. pestis nlpD gene restored virulence and all other phenotypic defects. Finally, we demonstrated that subcutaneous administration of the nlpD mutant could protect animals against bubonic and primary pneumonic plague. Taken together, these results demonstrate that Y. pestis NlpD is a novel virulence factor essential for the development of bubonic and pneumonic plague. Further, the nlpD mutant is superior to the EV76 prototype live vaccine strain in immunogenicity and in conferring effective protective immunity. Thus it could serve as a basis for a very potent live vaccine against bubonic and pneumonic plague

Host sequence motifs shared by HIV predict response to antiretroviral therapy

<p>Abstract</p> <p>Background</p> <p>The HIV viral genome mutates at a high rate and poses a significant long term health risk even in the presence of combination antiretroviral therapy. Current methods for predicting a patient's response to therapy rely on site-directed mutagenesis experiments and <it>in vitro </it>resistance assays. In this bioinformatics study we treat response to antiretroviral therapy as a two-body problem: response to therapy is considered to be a function of both the host and pathogen proteomes. We set out to identify potential responders based on the presence or absence of host protein and DNA motifs on the HIV proteome.</p> <p>Results</p> <p>An alignment of thousands of HIV-1 sequences attested to extensive variation in nucleotide sequence but also showed conservation of eukaryotic short linear motifs on the protein coding regions. The reduction in viral load of patients in the Stanford HIV Drug Resistance Database exhibited a bimodal distribution after 24 weeks of antiretroviral therapy, with 2,000 copies/ml cutoff. Similarly, patients allocated into responder/non-responder categories based on consistent viral load reduction during a 24 week period showed clear separation. In both cases of phenotype identification, a set of features composed of short linear motifs in the reverse transcriptase region of HIV sequence accurately predicted a patient's response to therapy. Motifs that overlap resistance sites were highly predictive of responder identification in single drug regimens but these features lost importance in defining responders in multi-drug therapies.</p> <p>Conclusion</p> <p>HIV sequence mutates in a way that preferentially preserves peptide sequence motifs that are also found in the human proteome. The presence and absence of such motifs at specific regions of the HIV sequence is highly predictive of response to therapy. Some of these predictive motifs overlap with known HIV-1 resistance sites. These motifs are well established in bioinformatics databases and hence do not require identification via <it>in vitro </it>mutation experiments.</p

Work satisfaction, quality of life, and leisure time of neonatology fellows and senior neonatologists in Israel

<p>Abstract</p> <p>Objectives</p> <p>To examine work satisfaction, quality of life, and leisure time of neonatology fellows and senior neonatologists in Israel.</p> <p>Methods</p> <p>A validated questionnaire was delivered during the second half of 2008 to all the neonatology fellows and senior neonatologists in Israel. Descriptive analysis, parametric Student’s <it>t</it>-test, and aparametric Mann Whitney and χ2 tests were conducted.</p> <p>Results</p> <p>Of 114 practicing neonatologists in that period in Israel (including both seniors and fellows), 112 (98.25%) participated in the study. The majority of neonatologists were male (53.2%), married (91.7%), 40–60 years old (69.7%), and studied in Israeli medical schools (62.0%). Most did their pediatric residencies and fellowships in Israel (97.2% and 75.7%, respectively). The average number of night/on-call shifts of fellows and senior neonatologists was 8.8 per month (SD ± 3.425) and the number of active on-call shifts was 4.04 (SD ± 3.194). The satisfaction level of neonatologists in Israeli medical centers with patient care, self-reward, work relations, and quality of life was high, but their satisfaction level with workload, income and prestige, and leisure time was low. The general index of work satisfaction and the general index of indices were both high in relation to the mid-range values. The majority of neonatologists stated that they would choose to practice medicine again. Most of them would encourage medical students to choose the same specialty they had chosen. Only a few neonatologists were contemplating changing their choice of specialty. Most neonatologists want to continue practicing medicine; however, a significant number will not recommend that their children do so.</p> <p>Conclusions</p> <p>The satisfaction level of neonatologists in Israel is high, mainly due to satisfaction with their work. High satisfaction levels promise high quality patient care, as well as high satisfaction levels of patients and their families. However, satisfaction with leisure time was low and it will require greater attention and focused steps to correct this.</p

Bouveret Syndrome in an Elderly Female

Introduction: A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Herein we present a case of an elderly woman with an impacted gallstone in duodenum and discuss its&rsquo; management. Patient description: A 96-year-old woman was admitted to our department due to a gastric outlet obstruction. Initial gastroscopy revealed a gastric bezoar. An attempt for its extraction failed. She underwent a laparotomy in which a cholecystoduodenal fistula and a large impacted stone were found. Separation of the fistula, including closure of the duodenum side, cholecystectomy and removal of the obstructing gallstone were performed. Additional stones were found and retrieved during common bile duct (CBD) exploration. Surgery was finalized by duodenoplasty, closure and T-tube drainage of the CBD. Post-operative course was prolonged and uneventful. Discussion and Conclusions: Bouveret syndrome is a rare cause of gastric outlet obstructions. In this case, unsuccessful endoscopic treatment necessitated surgery for removal of impacted gallstone in the duodenum

The Effect of Bariatric Surgery upon Diabetes Mellitus: A Proof of Concept by Using the Case of the Mid-Term Effect of Lap Adjustable Gastric Banding (LAGB) on Patients with Diabetes

Obesity is a worldwide epidemic, with numbers on the rise in the world. Obesity is strongly correlated with increased morbidity and mortality. One of the major factors affecting this increase is comorbid diseases such as diabetes mellitus (DM), which is strongly associated with and dependent on the degree of obesity. Thus, it is not surprising that when efficient surgical treatments were found to battle obesity, researchers soon found them to be relevant and effective for battling DM as well. Laparoscopic Adjustable Gastric Banding (LAGB) is a common surgical treatment for morbid obesity. LAGB has the potential to improve control of the comorbidities of morbid obesity, primarily diabetes mellitus (DM). Our hypothesis was that patients treated with LAGB would have a long-term improvement in the control of DM and that due to its unique mechanism of action, this can lend us a better understanding of how to battle diabetes in an efficient and effective way. This was a cohort study based on patients who underwent LAGB surgery in our institution 4 to 7 years previously and had DM type 2 at the time of surgery. Data were collected from patient&rsquo;s charts and a telephone interview-based questionnaire including demographics, health status, and quality-of-life assessment (Bariatric Analysis and Reporting Outcome System [BAROS]). Seventy patients participated in the current study. The average follow-up time was 5.1 &plusmn; 0.9 years post-surgery. The average weight prior to surgery was 122.0 &plusmn; 20.2 kg, and on the day of the interview it was 87.0 &plusmn; 17.6 kg (p &lt; 0.001). The average body mass index before surgery was 43.8 &plusmn; 5.1, and on the day of the interview it was 31.2 &plusmn; 4.8 (p &lt; 0.001). On the day of the interview, 47.1% of the participants were cured of DM (not receiving treatment, whether dietary or pharmacologic). The sum of ranks for diabetes was lower after the surgery (p &lt; 0.001), as was HTN and its treatment (p &lt; 0.001). We have shown in this study that LAGB is an effective treatment for morbid obesity, as well as two comorbidities that come with it&mdash;DM type 2 and Hypertension (HTN)&mdash;in a longer period than previously shown, and with a unique look at the underlying mechanism of action of this procedure. There is a need for further studies to consolidate our findings and characterize which patients are more prone to enjoy these remarkable surgical benefits