Israel Medical Association Journal

Background: Low back pain has been the leading cause for disability worldwide for several decades, and clinical guidelines for its management clearly emphasize a multifactorial approach. Yet, current guidelines are still not well implemented by clinicians.

Objectives: To explore the attitudes of family medicine residents regarding low back pain and to determine whether they positively correlate with their treatment approaches. To test if these attitudes can be affected by the Enhanced Transtheoretical Model Intervention (ETMI), a guideline-based workshop.

Methods: Participants completed an online questionnaire regarding their attitudes toward low back pain and clinical habits, after which they attended an online ETMI educational workshop. One month later all participants were asked to complete the questionnaire a second time. Statistical analysis was conducted to explore the attitudes of the residents and clinical approaches, as well as any associations between them, as well as possible differences pre- and post-intervention.

Results: The participants exhibited highly psychologically oriented attitudes. Correlations between the attitudes and treatment did not show consistent coherency. Results regarding the participants clinical approaches were revealed to have two distinct and opposed inclinations: biomedically and biopsychosocially. Last, results for the re-activation subscale were significantly higher post-intervention.

Conclusions: Family medicine residents seem to be highly psychologically oriented regarding low back pain; however, they do not necessarily treat their patients accordingly. Their clinical choices seem to follow two different approaches: guideline-consistent and non-guideline-consistent. An ETMI guideline-based workshop may sway their attitudes toward re-activation of patients. Further research is needed to determine whether similar results would arise in larger physician populations.

Objective: To investigate the effectiveness of preoperative chemoradiation in increasing the resectability rates of rectal cancer and increasing the anal sphincter preservation rate.

Methods: The study group included 66 patients aged 33–84 years with T₂–T₃ rectal carcinoma who were treated in our institute from 1997 to 2002 with preoperative chemoradiation followed by surgery 6 weeks later. All patients underwent preoperative transrectal endoscopic ultrasound for tumor staging and localization. The duration of follow-up was 25 months.

Results: Chemoradiation led to tumor downstaging in 61 patients (92.4%), all of whom underwent low anterior resection. Only 11.4% of this group needed a temporary (6 weeks) loop colostomy/ileostomy. None of the 16 patients with post-treatment T₀ tumors had evidence of malignant cells on pathologic study. Five patients (7.6%) failed to respond to chemoradiation and underwent APR[1]. There were no major complications, such as leakage, and no deaths.

Conclusions: Neoadjuvant chemoradiation is an effective modality to downstage advanced rectal cancer, improving patient quality of life by significantly reducing the need for a terminal permanent colostomy, or even a temporary one.

Background: The mortality rate for cholecystectomy for acute cholecystitis in the elderly is 10% in low risk patients and increases threefold in high risk patients. Ultrasound-guided percutaneous transhepatic cholecystostomy may serve as a rapid and relatively safe tool to relieve symptoms of sepsis and decrease gallbladder distension.

Objective: To determine the safety and effectiveness of PTC[1] in the treatment of acute cholecystitis in elderly debilitated high risk patients.

Methods: The study sample included 10 patients aged 63–88 (mean 77.6 years) with clinical and sonographic signs of acute cholecystitis for more than 48 hours (fever, white blood cells > 12,000/mm³, positive Murphy sign and distended gallbladder) who underwent ultrasound guided PTC. All had severe underlying disease (coronary heart disease, renal failure, chronic obstructive pulmonary disease, and others) that places them at high risk for surgical intervention.

Results: Eight patients showed rapid regression of the clinical symptoms following PTC drainage. One patient, with bacterial endocarditis, was febrile for 5 days after catheter insertion, but with rapid resolution of the biliary colic and sepsis. One patient died from perforation of the gallbladder and small bowel. PTC catheters were withdrawn 3–25 days after the procedure, and the patients remained free of biliary symptoms. Two patients underwent successful elective cholecystectomy 3 weeks later.

Conclusion: PTC may be a safe and effective treatment for high risk elderly patients with acute cholecystitis. It can be followed by elective cholecystectomy if the underlying condition improves, as soon as the patient stabilizes and no sepsis is present, or by conservative management in high surgical-risk patients.