Israel Medical Association Journal

Background: Reports from Europe and North America indicate that significant changes have occurred in the practice of cardiac surgery in the last two decades.

Objectives: To examine the trends and case-mix in cardiac surgery in Israel and their relationship with changes in invasive cardiology.

Methods: We analysed data collected by the Ministry of Health from all cardiac centers in Israel from 1985 to 2002.

Results: Three periods were identified: the 1980s, when a relatively small number of operations were performed; 1990–1994, characterized by a dramatic rise in the number of operations; and 1994–present, characterized by a small decline and stabilization in the rate of operations. The percentage of valve procedures increased significantly from 15% of all cardiac surgeries in 1991 to 21% in 2002 (P = 0.002). In addition, the chance of a diagnostic coronary angiography being followed, in the same patient, by an interventional procedure such as percutaneous transluminal coronary angioplasty or by a coronary artery bypass graft increased dramatically from 42% in 1991 to 69% in 2002. At Rabin Medical Center, there was a constant decline in the percent of repeated CABGs[1] out of the total CABGs performed, from 6.7% in 1996 to 1.3% in 2002.

Conclusions: Despite the rise in the rate of percutaneous coronary interventions since 1991, there has been no significant decline in the rate of CABGs performed. However, there is a significant shift to more complex operations. The number of repeated CABG operations has significantly decreased and, in view of the growing use of arterial grafts and further improvements in invasive cardiology techniques, we expect this decline to continue.

Background: Hypertrophic pyloric stenosis classically presents as projectile vomiting during the third to fourth week of life associated with good appetite. Additional classical presenting findings include palpation of the pyloric tumor, described as olive-shaped, a visible gastric peristaltic wave after feeding, and hypochloremic, hypokalemic metabolic alkalosis. It was recently claimed that this presentation has changed due to the easier access to gastrointestinal imaging.

Objective: To validate this contention and discuss possible reasons.

Methods: We conducted a retrospective chart review of all patients who underwent pyloromyotomy for HPS[1] between 1990 and 2000. Only patients with confirmed HPS at the time of surgery were included. We also performed a comprehensive review of older studies for comparison.

Results: Seventy patients underwent pyloromyotomy over the 10 year period. Overall, 81% of patients were male infants and the mean age at diagnosis was 40 days. The mean duration of symptoms was 8 days. A firstborn child was noted in 43% of the cases. The classical symptom of projectile vomiting was absent in one-third of the patients, a pyloric tumor was not palpated in one-half of the cases, bicarbonate was higher than 28 mEq/L in 20% and a pH of above 7.45 was present in 25% of patients. Hypochloremia was noted in about one-third. We found a good correlation between ultrasonographic width and length of the pylorus and the intraoperative findings. Pylorus length ≥ 24 mm correlated with significantly longer duration of symptoms. When compared with previous studies, the main findings were not significantly different; namely, mean age at diagnosis, percentage of male gender and duration to diagnosis. The decrease in the number of pyloric tumors palpated paralleled the increase in the use of upper gastrointestinal series and ultrasonography in particular.

Conclusions: The clinical presentation of HPS has not actually changed despite the easier accessibility of GI imaging studies. However, the one significant change is the low percentage of pyloric tumors palpated, probably due to declining clinical skills, accompanied by earlier utilization of imaging studies. The use of imaging and laboratory studies did not change the age at diagnosis but may have shortened the time for diagnosis and reduced the postoperative stay. Imaging and laboratory studies may be helpful for the subgroup with a non-classical clinical presentation.

Background: In Israel, preventive services for mothers and children are provided mainly by the Ministry of Health through a network of Maternal and Child Health clinics, and partly by municipalities and health maintenance organizations. Utilization of the MCH[1] clinics for prenatal care has declined during the last decades.

Objective: To study the utilization and satisfaction with prenatal care services following the introduction of the National Health Insurance Law.

Methods: The study population comprised a national sample of Jewish and Arab women who were interviewed by telephone regarding the following: main service utilized for prenatal care, physician and nursing visits, satisfaction with care, and demographic and other characteristics. The response rate was 92% among Jewish women and 88% among Arab women.

Results: Twenty percent of the Jewish and 52% of the Arab women selected MCH clinics as the main service for prenatal care. The great majority of the study population attended the HMO[2] services (clinics, independent physicians, women’s health centers), while 7% of the Jewish and 4% of the Arab women visited a private clinic. The predisposing factors affecting the women's choice were educational level, ethnic group, religiosity, district of residence, and type of HMO. The mean number of physician visits was more than the eight visits recommended. Forty percent of the sample visited with three or more physicians at different services. More than 50% of the women had no appointment with a nurse, mainly those who chose the services of an HMO clinic, independent physician, or private physician. Satisfaction with the physician, nurse, and physical structure of the main service chosen for prenatal care was high.

Conclusions: Since the majority of women preferred the HMO services, the merging of prenatal care with curative care provided by the HMOs has to be considered. Public health nurses should be integrated in the service, and their specific role needs to be defined.

Background: Eyes scheduled for posterior segment surgery may have cataract, which obscures the visualization of the retina. Surgery may be carried out either by a two-step procedure: i.e., removal of the cataract followed later by posterior segment surgery; or it may be done in a single session: i.e., combined surgery of both the anterior and posterior segments.

Objective: To evaluate the outcomes of combined surgery by phacoemulsification and vitrectomy.

Methods: We retrospectively reviewed the records of 42 patients with coexisting cataract and vitreoretinal disease who underwent combined surgery by phacoemulsification and pars plana vitrectomy at one session.

Results: Indications for surgery were vitreous hemorrhage in 71.4%, retinal detachment in 11.9%, macular hole in 11.9%, and epiretinal membrane in 4.8%. There were no significant intraoperative complications.The main early postsurgical complications were fibrinous formation in 11.9%, elevated intraocular pressure in 23.8%, and recurrent vitreous hemorrhage in 9.5%. There were a few late complications related to phacoemulsification: posterior synechia in 9.5%, posterior capsular opacification in 7.1%, and dislocating intraocular lens in 4.8%. Recurrent retinal detachment occurred in five eyes and rubeoisis iridis in one. Visual acuity was improved in 85.8%, stable in 7.1% and worse in 7.1%.

Conclusions: Phacoemulsification performed at the time of posterior segment surgery enables good visualization during the vitrectomy, facilitates surgery, and is associated with only minor complications. In cases with cataract and vitreoretinal diseases, combined surgery by phacoemulsification and vitrectomy in one session may be considered.
 

Background: The highly tissue-specific trafficking of normal and malignant lymphocytes to particular organs is mediated by adhesion molecules, or “homing receptors.” Among our patients with B cell chronic lymphocytic leukemia 15% demonstrate predominantly splenic manifestations and are classified as stage II(S).

Objective: To investigate whether expression of cell surface adhesion molecules can distinguish stage II(S) patients from stage 0 or stage 0 and I CLL[1] patients.

Methods: Expression of adhesion molecules belonging to different families was studied in CD19-positive cells isolated from the blood of 42 patients by dual color flow cytometry. The families included: immunoglobulin superfamily (CD54, CD58), integrin family (β1, β2 and β3 chains, CD11a, CD11c CD49d), selectin family (L-selectin), and lymphocyte homing receptor family (CD44).

Results: The average percentage of leukemic cells expressing CD11c in the 23 patients with stage II(S) was 25.7 compared with 13.2% in the 14 patients with stage 0 disease (P = 0.047). The average percentage of leukemic cells expressing CD44 in patients with stage II(S) was 90.5 compared with 77.2% in patients with stage 0 (P = 0.007) and 80% in patients with stages 0 and I together (n=19, P = 0.008). Other adhesion molecules tested did not show a statistically significance difference in expression between the different disease stages.

Conclusions: The higher expression of CD44 and CD11c in cells of CLL patients with predominantly splenic manifestations may account for the tendency of their lymphocytes to home to the spleen.

Background: Arterial involvement in Behçet's syndrome is rare. Aneurysms are common among the arterial lesions, affecting various arteries but mostly the abdominal aorta. Surgical interposition graft insertion is the treatment of choice for large aneurysms. However, vasculitis in these patients is the reason for the notorious surgical complications that result in up to 50% false aneurysms in anastomotic sites. Recently, endovascular repair for abdominal aortic aneurysms has been established.

Objectives: To learn more about vascular Behçet and, specifically, to compare the results of surgical treatment and endovascular repair of AAA[1] in patients with Behçet's syndrome.

Methods: We retrieved the medical records of all 53 patients with Behçet disease admitted to Rambam Medical Center during the years 1985 and 2001 and analysed the results and follow-up of open surgery versus endovascular repair of AAA in patients with known Behçet's syndrome.

Results: Of the 53 patients with Behçet's disease 18 had vascular manifestations (34%). AAAs were encountered in 8 patients (15%) and 5 were treated. Open surgery (group 1), under general anesthesia, lasted less than 3 hours with an average aortic clamping time of 34 minutes (range 26–41 min) after which the patients were transferred to the intensive care unit for 24–48 hours. Endovascular treatment (group 2), although lasting about the same time without the need for intensive care, necessitated contrast media and fluoroscopy. The length of hospital stay was considerably shorter for patients after endovascular repair compared to open surgery (3 days vs. 6 days). Combined mortality and morbidity was higher in patients who underwent open surgery compared to endovascular repair (one death, one major amputation and three anastomotic pseudoaneurysms compared to one temporary contrast-induced nephropathy).

Conclusions: Vasculo-Behçet patients with AAA are better candidates for endovascular treatment than atherosclerotic patients. Combined morbidity (especially anastomotic pseudoaneurysms) and mortality of Behçet patients after endovascular repair is considerably lower than after open surgery.

Background: Primary pulmonary hypertension is a rare disorder, characterized by progressive pulmonary hypertension and right heart failure. It may be familial or sporadic. Mutations in bone morphogenetic protein receptor II (BMPR2), a member of the transforming growth factor-beta receptor superfamily of receptors, underlie many cases of the disorder.

Objectives: To perform molecular analysis of a patient with familial PPH[1] and provide her and her family with suitable genetic counseling.

Methods: DNA was extracted from 10 ml whole blood, and the BMPR2 gene was screened for mutations. Individual exons were amplified by polymerase chain reaction and sequenced. Mutation confirmation and molecular characterization of additional family members was performed using restriction enzyme analysis followed by appropriate genetic counseling.

Results: We identified a novel T to C missense mutation expected to result in substitution of arginine for a conserved cysteine in the ligand-binding domain of BMPR2. Screening of family members demonstrated the presence of the mutation in the father and a younger asymptomatic sister of the index patient.

Conclusions: Molecular diagnosis in PPH allows for identification of at-risk family members and raises the option of earlier diagnosis and possibly instituting earlier treatment in affected individuals. However, molecular screening of asymptomatic family members raises difficult ethical questions that can only be resolved by conducting large multicenter prospective studies in BMPR2 carriers.

Patients with graft-versus-host disease suffer from xerostomia, oral infections and mucosal pathologies. The continuous increase in the number of patients treated worldwide with bone marrow transplants, combined with improved survival statistics result in a concomitant increase in the number of GVHD[1] patients. the pathogenesis of GVHD is based on donor graft T lymphocytes that recognize antigenic disparities between donor and recipient, and on the disregulation of a broad panel of cytokines. Consequently, various tissues and organs, including the mucosa of the oral and gastrointestinal tract, are damaged via cytotoxicity caused by infiltrating T cells. Since the salivary glands are a known major target of GVHD and their secretions significantly contribute to preserving mucosal integrity, this mucosal insult is further enhanced by the reduced quantity and altered quality of saliva. GVHD occurs in 40–70% of patients treated by bone marrow and peripheral blood stem cell transplantation. limited studies suggest that a large percentage of GVHD patients are affected and that the induced salivary dysfunction occurs rapidly following transplantation, affecting both major and minor salivary glands and reflecting the severity of the disease. Moreover, profound sialochemical alterations may be diagnostic of GVHD. an additional reason for the vast amount of research is that GVHD, as an autoimmune-like disease, seems to be an appropriate model for studying a much more prevalent, well-known and studied autoimmune disease involving salivary glands, namely, sjögren’s syndrome. The present review describes the GVHD-related sialometric and sialochemical data available in the literature for both major and minor salivary glands in both human and rodent models, and discusses a possible mechanism.

The Israel Health Ministry is preparing legislation that would allow a person to receive monetary compensation in exchange for donating a kidney for a lifesaving transplant. Such a bill would be the first of its kind, and would seem to establish a policy that is in contrast with both existing international professional ethics and major Christian and Islamic religious ethics. In an attempt to investigate the extent to which such a bill would be consistent with traditional Jewish ethics, we reviewed the opinions of major traditional Jewish ethicists/halakhists, with emphasis on contemporary opinions, and found that compensating an organ donor for his or her time, discomfort, inconvenience, and recovery is fully consistent with traditional Jewish law and ethics.  While non-altruistic sale of kidneys might be theoretically ethical from a Jewish perspective, ultimately its ethical status is inextricably connected to solving a series of pragmatic issues, such as creating a system that insures that potential vendors/donors are properly informed and not exploited; controlling and supervising medical screening and support of the donors to insure that their health is not permanently endangered; protecting minors and incompetents; and regulating payments so that they reasonably reflect compensation for pain and suffering.