Israel Medical Association Journal

Background: Extensive necrosis is rare in primary renal cell carcinoma. This finding may reflect the biological characteristics of the carcinoma and therefore could be of prognostic and clinical value.

Objectives: To assess the incidence of necrosis in renal cell carcinoma and its potential prognostic value.

Methods: We conducted a consecutive retrospective study of 173 patients after radical nephrectomy for renal cell carcinoma. Clinical and pathological data were collected from hospital medical records and compiled into a computerized database.

Results: Extensive necrosis was found in 31 tumor specimens (17.9%). Univariate analysis showed that the specimens with extensive necrosis were significantly larger and manifested more perirenal and venous extension than the tumors without necrosis. The size of the renal tumor was the only parameter that remained significant in multivariate analysis (P=0.0001). Overall disease-free survival did not differ significantly between patients with necrotic tumors and those without (68% and 66% respectively).

Conclusions: The finding of extensive necrosis in renal cell carcinoma specimens does not seem to be related to tumor biology but rather may reflect the relation between size and vascularity of the tumor.

Background: The method of midline Iaparotomy incision and closure remains a complex surgical problem.

Objective: To compare the mechanical properties at the interface of midline laparotomy incision made by scalpel versus electrocutting current in rats.

Methods: A sharp midline laparotomy incision was made in 60 Wistar female rats using a scalpel or electrocautery to open the fascia. The fascial and skin wounds were closed separately with a continuous nylon. Fascial specimens were analyzed for mechanical properties at the midline incision using a loading machine. The load-extension curve was recorded during tensile loading at a steady extension rate of 15 mm/mm.

Results: There was no statistically significant difference between the two groups in either wound-bursting force (PPEAK) or the strain energy spent until the point of measured PPEAK. Each load-extension curve showed a characteristic pattern in all rats. Tissue stiffness was greater in the scalpel group than in the electrocautery group (P= 0.02). Correlations were found between tissue stiffness and strain energy, between tissue stiffness and bursting force, and between bursting force and strain energy.

Conclusions: While tissue stiffness was greater when a scalpel was used compared to electrocutting to incise the midline abdominal fascia in rats, there was no difference in the bursing force required to disrupt the wound.

Background: The association of carpal tunnel syndrome with occupational risk factors is well established. However, in clinical practice these factors are only rarely considered and evaluated. Managing these risk factors could prevent the occurrence of future cases and alleviate treatment of the afflicted individuals.

Objectives: To estimate the role of occupational risk factors in a large group of patients diagnosed by electro­physiological studies as suffering from CTS.

Methods: A group of 396 subjects (204 women, 165 men) who were tested in one laboratory by electrophysiological studies were further evaluated (by questionnaire) to determine the possible role of occupational and other risk factors in the etiology of their syndrome.

Results: Persons employed in high force — low repetitive or low force — high repetitive jobs, harbor an extra risk for developing CTS as compared with controls, OR=3.21 (95% C1 = 1.5-6.9) and OR=4.72 (95%C1 = 1.8-12.5), respectively. These jobs include typists/secretaries, nursing personnel, production workers and housewives.

Conclusion: Evaluation of a general group of examinees referred for electrophysiological studies on sympatology compatible with CTS may show that occupational risk factors play a substantial role in the development of symptoms. By increasing the awareness of clinicians and the public to these risk factors, appropriate preventive measures can be intro­duced and the burden of the disease reduced.

Background: Fixed dose combination therapy varies among countries.

Objective: To compare the list of fixed-dose combination therapies used in the USA, UK and Israel.

Methods: The total list of drugs and FDC drugs were counted manually from a list of generic names. We also counted the number of drugs in four characteristic subgroups:

cardiovascular, anti-infective, gastrointestinal, and dermatolo­gical. Data for drugs in the USA, UK and Israel were taken from the Physician’s Desk Reference (PDR 1997), the British National Formulary (BNF March 1997) and the Monthly Ethical Drug Indexed Compilation (MEDIC July 1997) respectively.

Results: The global percentage of FDC drugs in the USA and UK was higher than in Israel (20%, 25% and 15% respectively). A similar trend was found in all subclasses of FDC drugs except for the anti-infective category in which the percentage of FDC drugs was low and similar in all countries.

Conclusion: The list of FDC drugs varies greatly between the USA, UK and Israel. reflecting the differences in the outcome of debate between the pharmaceutical companies and the regulatory authorities.

Background: When encountering complaints of pain in the area of the Achilles tendon, the clinician seldom reaches a correct and precise diagnosis based solely on the grounds of physical examination and standard X-rays.

Objectives: To assess the usefulness of ultrasound in diagnosing pathologies of the Achilles tendon.

Methods: We conducted a retrospective review of patients presenting at our orthopedic clinics.

Results: Sonography was used to evaluate 41 patients with achillodynia. This modality enabled the diagnoses of 19 abnormal tendons (46%), peritendinous and other lesions a complete rupture in two patients (5%) a partial rupture of the Achilles tendon in 3 (7%) various degrees of calcification of the tendon in 7 (17%) and peritendinous lesions discerned by the tendon’s hypoechoic regions with disorganized arrange­ment of collagen fibrils in 4 patients (10%). Other lesions included tendonitis (3 patients, 7%), retrocalcaneal bursitis (3 patients, 7%), lipoma (1 patient, 2%), and foreign bodies (2 patients, 5%). The mean diameter of the pathological tendons was 10.4 +2.7 mm, while normal tendons measured 5.2 +0.8 mm (P<0.001).

Conclusion: As in many other soft tissue lesions, ultrasonography is a useful tool in the evaluation of the underlying pathology in patients presenting with achillodynia.

Background: Breast cancer is one of the most prevalent malignancies in women, yet one of the most treatable. Early detection is essential to obtain the desired remission and longevity. Numerous studies have shown that periodic screen­ing for breast cancer can reduce mortality by 20-30%.

Objective: To assess the rates, compliance, character­istics as well as barriers in women regarding mammography screening.

Methods: The study group comprised a random sample of 702 women aged 50 or older from 5914 eligible women in two teaching clinics in southern Israel. Phone interviews using structured questionnaires were conducted.

Results: The mean age of the study population was 61 years. The vast majority of the women were not born in Israel. Sixty-three percent of the women had undergone a mammo­graphy screening, 48% in the past 2 years. Monthly self-breast examinations were performed by 12% of the women in the last 2 years. Significant factors associated with undergoing mammography were: more than 7 years since immigration, married, a higher education level, adequate knowledge about breast cancer and mammography, presence of past or current cancer, and cancer in relatives. The main reasons for not being screened was no referral (54%) and a lack of knowledge about breast cancer and mammography (19%) - conditions easily remedied by physician counseling.

Conclusion: The study suggests that promotional efforts should be concentrated on new immigrants and on less educated and unmarried women.

Background: Complementary medicine incorporates several methods of treatment, all of which aim to promote the health and quality of life of the patient. Public interest and demand for complementary medicine services have increased in recent years in Israel, as they have throughout the western world.

Objective: To characterize patients attending the Com­plementary Medicine Clinic in southern Israel at the completion of its first 2 years of operation.

Methods: Data for 398 patients selected at random from 4,400 patients treated in the clinic were collected retroactively from the patientsq' charts.

Results: Of those who visited the clinic, 68% were women with an average age of 49 years. Patients attending the clinic had higher rates of hypertension (20%), diabetes (6%) and heart disease (7%) than the general population of patients insured at the Clalit Health Services in the southern region. In addition to musculoskeletal problems (47%), the other most common complaint was emotional problems (13%) such as tension and anxiety. Acupuncture and Shiatsu were the most commonly used types of treatment (61%). Homeopathy was used by 7%. Among patients with musculoskeletal problems, there were significantly more men than women (P= 0.02). The mean age was higher (P= 0.07). And more of them were referred by friends or family (P= 0.06) than those with other problems.

Conclusions: Characterizing patients attending a com­plementary medicine clinic is imporant for the planning of marketing and resource management, and can assist primary care physicians in decisions regarding the referral of patients to this type of healthcare.

Although a depressive state is known to occur following the resolution of an acute psychotic episode, little research has investigated its etiology, course, prognosis and treatment. Very often the depression is mistaken for an extrapyramidal­like syndrome — the secondary effect of antipsychotic medica­tion - as a sense of inevitability assails both the patient and therapist. Post-psychotic depression, far from being an obscure and undefined clinical picture, has the characteristics of a clear-cut syndrome. Nevertheless, it was only recently referred to as a distinct entity in psychiatric classification systems. As a result, different researchers used varying criteria for the definition of the phenomenon, and the data collected in the different studies are therefore difficult to compare. We present a critical review of the data published to date, with emphasis on the importance of early recognition and treatment of post-psychotic depression.

Background: It is not clear to what extent the drug economy in Israel's health maintenance organizations is responsive to major healthcare reforms.

Objective: To provide information on how drug expendi­tures, revenues, net costs and drug utilization have changed in the wake of the 1995 National Health Insurance Law in Israel.

Methods: This study compares trends in aggregate sick fund expenditures, revenues (patient co-payment) and net costs (expenditures less revenues) in Israel's four health maintenance organizations for the 3 year period 1992-1994 prior to the introduction in 1995 of the NHI Law, with that of the 4 year period 1995-1998 following its introduction. This analysis is similarly carried out for Israel’s largest HMO, Clalit Health Services, and for the three smaller HMOs combined.

Results: The pace of growth in the pre-NHI era in drug expenditures and particularly in drug revenues was drastically reduced in the NHI era - whether measured as totals or as per insured person (age-adjusted) or in real terms at constant medicine prices. These trends were mirrored to a large extent in

Conclusions: The impact of the NHI Law on the HMO drug economy has been substantial. The evidence suggests a decline in both the qualitative (basket of drugs consumed) and quantitative (volume of drugs consumed) elements of growth. These changes in expenditure and revenue trends are discussed in the light of the evolving involvement of the Israel Ministry of Health in drug policy within the framework of the NHI, with emphasis on the basket of drugs reimbursed and co­payments for prescriptions.

Objectives: To assess mortality causes and trends over time and identify target groups with excessive mortality rates among Israeli youth aged 10-24, in order to formulate an intervention policy for prevention of adolescent mortality.

Methods: Mortality data for Israeli residents aged 10-24 were extracted from the Central Bureau of Statistics compu­terized death certificate file for the period 1984-95. Trends were evaluated by cause of death and demographic char­acteristics.

Results: The crude mortality rate among Israeli youth aged 10-24, during 1993-1995, was 39.6 per 100000. Rates were 2.7 times higher among males, increased with age, and reached a peak among 18-21 year olds. Rates were 1.4 times higher among Arabs than among Jews. The sharp increase in mortality among Jewish males of military service age (18-21 years) was due mainly to motor vehicle crashes and suicide. Although overall mortality decreased by 9.4% from 1984-86 to 1993-95, the gap between the subgroups increased. MVC­related mortality increased over time by 100% among Arab males. The rate of completed suicide among Jewish males increased by 110%. Although injury-related mortality is lower in Israel compared with the U.S., similar demographic differen­tials and trends were found in both countries.

Conclusions: Suicide among Jewish males of military service age, as well as MVC fatalities among Arab males, present a growing public health issue. Intervention strategies should therefore be targeted towards these subgroups in order to minimize the rates of preventable death.