Israel Medical Association Journal

Objectives: To review our experience with laparoscopic repair of GDH, emphasizing preoperative investigation, technical aspects, and outcome.

Methods: We conducted a retrospective review of patients operated on for GDH who were diagnosed when at least half the stomach was found in the mediastinum at surgery. Technical aspects and surgical outcomes were evaluated.

Results: Fifty patients underwent laparoscopic GDH repair during an 8 year period. Four patients admitted with acute symptomatic volvulus of the stomach were initially treated by endoscopic decompression followed by surgery during the same admission. Two cases were converted to open surgery. Initial surgery was successful in 45 patients; 3 had an immediate recurrence, 1 was reoperated for dysphagia during the same admission, and 1 had a mediastinal abscess. During long-term follow-up, six patients required reoperation for recurrent hernias. Another four patients had asymptomatic partial herniation of the stomach. The main reason for failure was incomplete reduction of the hernia sac, especially the posterior component. No correlation was found between the type of repair and surgical failure. Most patients who did not undergo an anti-reflux procedure had postoperative reflux unrelated to their preoperative workup.

Conclusions: Laparoscopic repair of GDH is challenging, but practical and safe. It should be the treatment of choice for this potentially life-threatening condition. Careful attention to pitfalls, such as the posterior element of the sac, and routine performance of an anti-reflux procedure are crucial.

Objectives: To evaluate the feasibility of induction chemotherapy with docetaxel-cisplatin-5-flurouracil (TPF) followed by external beam radiotherapy (EBRT) with concomitant chemotherapy (CRT) or cetuximab (ERT) in the treatment of patients with advanced SCCHN.

Methods: We reviewed the data of all patients with advanced SCCHN, stage III and IV, treated in 2007–2010. Tolerability was assessed and scored according to the proportion of patients completing the planned study protocol. Toxicity was scored using the U.S. National Cancer Institute Common Toxicity Criteria (version 4) for classification of adverse events.

Results: The study included 53 patients. TPF was initiated at a reduced dose in 13 patients (25%). Twenty-two patients (41.5%) received primary prophylaxis with granulocyte colony-stimulating factor (GCSF) and 42 (77%) completed treatment according to schedule. During the induction phase one patient (2%) died and 24 (45%) had one or more grade 3-4 complications. The number of patients who developed neutropenia was lower in the group that received primary GCSF prophylaxis. Secondary dose reductions were required in 21% of the patients.

Conclusions: Induction TPF was associated with grade 3-4 toxicity. Prophylaxis with GCSF should be part of the treatment regimen.

 Background: Patients with transient ischemic attack (TIA) at a high risk of stroke can be identified and should be managed urgently.

Objectives: To investigate whether recognized recommendations are being implemented in Israel.

Methods: An Israeli nationwide registry on patients admitted with stroke and TIA was conducted in all acute care hospitals (NASIS registry) within 2 successive months during 2004, 2007 and 2010. A revised ABCD² score was applied retrospectively. Patients with TIA were divided into a low risk group (LRG, 0–3 points) and a high risk group (HRG, 4–6 points) and were compared to patients with minor ischemic strokes (MIS, NIHSS score ≤ 5 points).

Results: A total of 3336 patients were included (1023 with TIA: LRG 484, HRG 539, and MIS 2313). LRG patients were younger and had lower rates of most traditional risk factors as compared with HRG and MIS patients. Brain imaging was performed in almost all the patients. Ancillary tests (vascular and cardiac) were overall underused, yet were performed more in LRG (53.2% and 26.9% respectively) than in HRG patients (41.6%, 18.9%). Between periods there was no change in usage of ancillary tests for the LRG and a modest increase in both HRG and MIS patients. For performance of vascular investigations overall, the odds ratio was 1.69 (95% confidence interval 1.42–2.00) comparing 2010 with 2004, but 0.7 (95% CI 0.5–0.9) comparing HRG with LRG. Between periods an increase in statin usage was observed in all groups (OR 2.69, 95% CI 2.25–3.21) but was more marked in MIS patients (OR 3.06, 95% CI 2.47–3.8). 

Conclusions: The approach to TIA risk stratification and management in Israeli hospitals does not follow standards set by current guidelines. Standardized protocols for TIA should be used to assure effective management.

 Background: Burn injuries are extremely common and may impose a serious load on public health around the world.

 Objectives: To compare mortality rates and length of hospitalization according to the identified risk factors, extent of burn, gender and age.

Methods: In this retrospective study, data from 558 archive files of hospitalization due to burns as the diagnosis in patients of all ages, between the years 2001 and 2002, were analyzed to identify the risk factors for mortality and length of hospitalization.

Results: Males comprised 62.4% of the hospitalized burn patients. The mortality rate was 3.2% (n=18) and among them 55.6% were women. Fifty percent of the fatality cases were over 48 years old, with statistically significant correlation of mortality rate and age. Most of the fatality cases (66.7%) had burns with total burn surface area (TBSA) larger than 40%. The multiple logistic regression model showed that leukocyte count on admission, TBSA, and age are the most important predictors of mortality. Smoke inhalation was not found to be an independent risk factor.

Conclusions: Using a statistical model for estimating the mortality rate, this study found that white blood cell count at admission, TBSA, and age were the most significant predictors of mortality. 

Objectives: To evaluate the course and management of visual and pregnancy outcomes of consecutive pregnancies with IIH.

Methods: The medical records of women with IIH in consecutive pregnancies were reviewed for neuro-ophthalmological findings, management, and visual and pregnancy outcomes.

Results: The study group comprised eight women with at least two consecutive pregnancies (mean age 27.3 ± 5.3 years). The mean duration of IIH prior to the first pregnancy was 3.4 ± 3.16 years. One woman with IIH pre-pregnancy symptoms and three women with clinical features of IIH during the second trimester of pregnancy (gestational week 21.7 ± 4.04) were treated with acetazolamide (250 mg every 8 hours). Symptoms resolved, resulting in uncomplicated first deliveries for all four. The first deliveries of four other women were by cesarean section due to obstetric indications. Only one woman developed symptoms and signs of IIH during her second pregnancy and was thus treated with acetazolamide. Two women who completed three pregnancies had no IIH symptoms during their pregnancies. The course and outcome of those pregnancies were normal.

Conclusions: IIH apparently does not worsen or even become symptomatic in consecutive pregnancies. The appropriate management of IIH in pregnant women is similar to management for non-pregnant women; neither the course nor the obstetric outcome of first and consecutive pregnancies is influenced by the presence of IIH.

Objectives: To investigate these injuries with respect to type, incidence and modes of prevention.

Methods: A retrospective study of medical records was performed for all patients admitted to Assaf Harofeh Medical Center due to horse-related injury between January 1984 and December 2008. A telephone questionnaire was used to complete the data.

Results: Eighty-nine subjects (267 injuries) were included in the study. Most of them were not professional horse riders or horse handlers. Helmet use was reported in only 28% of the participants. The number of subjects with horse-related injuries and the percentage of pediatric involvement increased during the study period. Falling from a horse was the most frequent cause of injury (60.67%), followed by being kicked (13.4%). Head and extremities were the most affected areas. On admission, 33.7% had a potential severe injury score. Forty-two participants (47%) had underlying fractures, mostly in the upper extremities. In the pediatric population, 16.2% (vs. 0% adults) rode horses for therapeutic reasons. Seventeen subjects reported having long-term consequences.

Conclusions: The findings are similar to those described in other parts of the world. Horseback riding-related injuries are increasing, which emphasizes the need for safety education programs in Israel.

Objectives: To describe the types of endothelial cell organelles involved in vascular permeability in drug-induced acute urticaria (DIAU).

Methods: Seven patients with DIAU were enrolled in the study. Biopsies of urticarial lesions and apparently normal skin were performed. The 14 collected fragments were processed with immunogold electron microscopy using single stains for tryptase and factor XIIIa (FXIIIa) and double immunogold labeling for both tryptase and FXIIIa.

Results: Some sections demonstrated mast cells in the degranulation process, in both anaphylactic and piecemeal degranulation. After double immunogold staining, 10 nm (FXIIIa) and 15 nm (tryptase) gold particles were both present, covering the granules in the mast cells, indicating that both tryptase and FXIIIa were localized within the granules of these cells. Interestingly, we found strong evidence of the presence of caveolae and vesico-vacuolar organelles (VVOs) in the endothelial cells of the biopsies. In addition to these findings, we were able to demonstrate the presence of tryptase and FXIIIa in the endothelial cells, in urticarial lesions and in apparently normal skin.

Conclusions: VVOs are present in the endothelial cells of post-capillary venules in DIAU. This is the first report on the expression of FXIIIa and tryptase in the cytoplasm of endothelial cells in urticaria.