Israel Medical Association Journal

Objectives: To evaluate the clinical course of four children with cricopharyngeal achalasia presenting to our clinic.

Methods: We conducted a 5 year retrospective chart review in a tertiary referral center.

Results: Four children were diagnosed with primary cricopharyngeal achalasia between 2006 and 2010. Diagnosis was established by videofluoroscopy and all underwent uneventful cricopharyngeal myotomy. Three children recovered completely and one child showed partial improvement. For residual UES spasm in a partially improved patient, botulinum toxin was injected into the UES which led to further improvement. Dysphagia recurred in one child who was successfully treated with botulinum toxin injection.

Conclusions: Cricopharyngeal myotomy is a safe procedure in infants and young children. Botulinum toxin injection of the UES was found to be effective in refractory cases. 

Objectives: To determine the effect of vitamin K on hip fracture patients treated with warfarin.

Methods: We retrospectively examined the management of 21 patients with hip fractures who were being treated with warfarin at the time of admission. Vitamin K was given to 11 of the 21 patients. A third group, which served as a control, consisting of 35 hip fracture patients who were not being treated with anticoagulants was also evaluated.

Results: Patients who received vitamin K took fewer days to reach target international normalized ratio (INR) (1.73 ± 0.90 vs. 4.30 ± 1.89, P < 0.001) and had less preoperative time (2.64 ± 1.12 vs. 5.10 ± 2.42 days, P < 0.008) when compared with patients who did not receive vitamin K. In addition, these patients had statistically significantly shorter hospitalization stays (9.4 ± 1.9 and 13.2 ± 4.9 days, one-sided P < 0.06). There was no difference in the amount of blood found in the wound drains (111.8 ± 68.5 vs. 103.0 ± 69.4 ml) or the number of blood units administered (1.45 ± 1.29 vs. 2.00 ± 2.75 units).

Conclusions: Treatment with vitamin K for hip fracture patients who receive warfarin shortens preoperative time, reduces the length of hospitalization and probably reduces morbidity and mortality.

 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: During the horrific war in the Democratic Republic of Congo during the years 1996–2007 the number of casualties is estimated to be 5.4 million. In addition, 1.8 million women, children and men were raped, many as a social weapon of war. Many of these women still suffer from post-traumatic stress disorder (PTSD) and mutilated genitals.

Objectives: To assess a short-term interventional team for the evaluation and treatment of sexual trauma victims.

Methods: The intervention program comprised four components: training the local staff, medical evaluation and treatment of patients, psychological evaluation and treatment of trauma victims, and evacuation and transport of patients with mutilated genitals. A diagnostic tool for post-traumatic stress disorder (PTSD) – the Impact Event Scale (IES) – was used. The psychological treatment was based on EMDR (eye movement desensitization and reprocessing) principles. Using questionnaires, the information was obtained from patients, medical staff and medical records.

Results: Three primary care clinics were chosen for intervention. Of the 441 women who attended the clinics over a period of 20 days, 52 women were diagnosed with severe PTSD. Psychological intervention was offered to only 23 women because of transport limitations.  The most common medical problems were pelvic inflammatory disease and secondary infertility. Nine patients had their genitals mutilated and were transferred for surgical correction. The 32 local nurses and 2 physicians who participated in the theoretical and practical training course showed improved knowledge as evaluated by a written test.

Conclusions: With the short-term interventional team model for sexual assault victims the combined cost of medical and psychological services is low. The emphasis is on training local staff to enhance awareness and providing them with tools to diagnose and treat sexual assault and mutilation.
 

Background: Chondrosarcoma of the larynx is a rare tumor. The most common symptom is hoarseness. Treatment is controversial.

Objectives: To describe six patients with laryngeal chondrosarcoma from a single center.

Methods: The medical records of a major tertiary hospital were reviewed for all patients with laryngeal chondrosarcoma diagnosed and treated from 1959 to 2010. Data on background, clinical treatment and outcome were collected.

Results: Six patients, all males with a mean age of 53.3 years, were identified. Partial laryngectomy was performed in three patients, and total laryngectomy, local excision, and partial cricoidectomy in one patient each. Four patients had a permanent tracheostomy after surgery. One patient required postoperative chemotherapy and one radiotherapy. Follow-up time was 12–216 months (mean 102 months). Recurrence developed in two patients 2 and 8 years after initial treatment and was treated by salvage surgery in both patients. One patient died during the follow-up from an unrelated cause. The others are currently alive.

Conclusions: This study supports earlier reports recommending initial treatment with partial or total laryngectomy for laryngeal chondrosarcoma. Long-term follow-up for recurrence is advised. We recommend preserving the larynx, if possible, even if a permanent tracheostomy is necessary.