Israel Medical Association Journal

Background: The marijuana plant cannabis is known to have therapeutic effects, including improvement of inflammatory processes. However, no report of patients using cannabis for Crohn’s disease (CD) was ever published.

Objectives: To describe the effects of cannabis use in patients suffering from CD.

Methods: In this retrospective observational study we examined disease activity, use of medication, need for surgery, and hospitalization before and after cannabis use in 30 patients (26 males) with CD. Disease activity was assessed by the Harvey Bradshaw index for Crohn’s disease.

Results: Of the 30 patients 21 improved significantly after treatment with cannabis. The average Harvey Bradshaw index improved from 14 ± 6.7 to 7 ± 4.7 (P < 0.001). The need for other medication was significantly reduced. Fifteen of the patients had 19 surgeries during an average period of 9 years before cannabis use, but only 2 required surgery during an average period of 3 years of cannabis use.

Conclusions: This is the first report of cannabis use in Crohn’s disease in humans. The results indicate that cannabis may have a positive effect on disease activity, as reflected by reduction in disease activity index, and in the need for other drugs and surgery. Prospective placebo-controlled studies are warranted to fully evaluate the efficacy and side effects of cannabis in CD.
 

Background: Glioblastoma multiforme (GBM) is an ultimately fatal disease that affects patients of all ages. Elderly patients (65 years and older) constitute a special subgroup of patients characterized by a worse prognosis and frequent comorbidities.

Objectives: To assess the efficacy of different treatment modalities in terms of survival in elderly patients with GBM¹.

Methods: Using retrospective analysis, we extracted, anonymized and analyzed the files of 74 deceased patients (aged 65 or older) treated for GBM in a single institution.

Results: Mean survival time was 8.97 months and median survival time 7.68 months. Patients who underwent tumor resection had a mean survival of 11.83 months, as compared to patients who underwent no surgical intervention or only biopsy and had a mean survival of 5.22 months (P < 0.0001). Patients who underwent full radiation treatment had a mean survival of 11.31 months, compared to patients who received only partial radiotherapy or none at all and had a mean survival of 4.09 months (P < 0.0001). Patients who underwent chemotherapy had a mean survival 12.4 months, compared to patients who did not receive any chemotherapy and had a mean survival of 5.89 months (P < 0.001).

Conclusions: Age alone should not be a factor in the decision on which treatment should be given. Treatment should be individualized to match the patient’s overall condition and his or wishes, while taking into consideration the better overall prognosis expected with aggressive treatment.
 

Background: Esophageal perforations and postoperative esophageal leaks are associated with substantial morbidity and mortality and pose a difficult therapeutic challenge. 

Objectives: To evaluate the outcome of removable self-expanding metallic stents (SEMS) as a treatment for postoperative leaks and perforations of the esophagus and stomach.

Methods: We conducted a retrospective study of all patients in one medical center who underwent temporary insertion of a covered plastic stent for postoperative leaks and perforations of the esophagus and stomach from June 2009 to February 2010. Data were retrieved from hospital and outpatient clinical data charts. Data included indication for insertion, post-insertion outcome including stent complications, and follow-up after stent removal.

Results: The indications for stent insertion were postoperative leak in four patients and postoperative esophagopleural fistula in one patient. Three of the patients had a leak at the gastro-esophageal junction following laparoscopic sleeve gastrectomy. In all cases the stent insertion was completed successfully. In three patients the stent migrated distally. In two of these three it was repositioned or replaced endoscopically, and in the third it was excreted in the feces. Stents were removed electively after 6 to 7 weeks. All patients recovered fully and were discharged from the hospital.

Conclusions: SEMS insertion may have an important role in the management of postoperative leaks and perforations of the esophagus and stomach and should be considered in such cases.
 

Background: Increased cardiovascular morbidity has become a leading cause of mortality in rheumatoid arthritis (RA). Tumor necrosis factor-alpha (TNFα) inhibitors may influence flow-mediated vasodilation (FMD) of the brachial artery, common carotid intima-media thickness (ccIMT) and arterial stiffness indicated by pulse-wave velocity (PWV) in RA.

Objectives: To assess the effects of adalimumab treatment on FMD[1], ccIMT[2] and PWV[3] in early RA[4].

Methods: Eight RA patients with a disease duration ≤ 1 year received 40 mg adalimumab subcutaneously every 2 weeks. Ultrasound was used to assess brachial FMD and ccIMT. PWV was determined by arteriograph. These parameters were correlated with C-reacive protein, vonWillebrand factor (vWF), immunoglobulin M (IgM)-rheumatoid factor (RF), anti-CCP levels and 28-joint Disease Activity Score (DAS28).

Results: Adalimumab therapy successfully ameliorated arthritis as it decreased CRP[5] levels (P = 0.04) and DAS28[6] (P < 0.0001). Endothelial function (FMD) improved in comparison to baseline (P < 0.05). ccIMT decreased after 24 weeks, indicating a mean 11.9% significant improvement (P = 0.002). Adalimumab relieved arterial stiffness (PWV) after 24 weeks. Although plasma vWF[7] levels decreased only non-significantly after 12 weeks of treatment, an inverse correlation was found between FMD and vWF (R = -0.643, P = 0.007). FMD also inversely correlated with CRP (R = -0.596, P = 0.015). CRP and vWF also correlated with each other (R = 0.598, P = 0.014). PWV and ccIMT showed a positive correlation (R = 0.735, P = 0.038).

Conclusions: Treatment with adalimumab exerted favorable effects on disease activity and endothelial dysfunction. It also ameliorated carotid atherosclerosis and arterial stiffness in patients with early RA. Early adalimumab therapy may have an important role in the prevention and management of vascular comorbidity in RA.

Background: Survival in T cell lymphoblastic lymphoma has improved over the past 30 years, largely due to treatment protocols derived from regimens designed for children with acute lymphoblastic leukemia.

Objectives: To assess the outcome of the NHL-BFM-95 protocol in children and adolescents hospitalized during the period 1999–2006.

Methods: We conducted a retrospective multi-institutional, non-randomized study of children and adolescents up to age 21 with T cell lymphoma admitted to pediatric departments in six hospitals in Israel, with regard to prevalence, clinical characteristics, pathological characteristics, prognostic factors, overall survival (OS) and event-free survival (EFS). All patients had a minimal follow-up of one year after diagnosis. The study was based on the NHL[1]-BFM[2]-95 protocol.

Results: At a median follow-up of 4 years (range 1–9 years), OS and EFS for all patients was 86.5% and 83.8%, respectively. OS was 86.7% and 83.3% for patients with stage III and stage IV, respectively, and EFS was 83.3% and 83.3%, respectively. EFS was 62.5% for Arab patients and 89.7% for Jewish patients (P = 0.014). Patients who did not express CD45 antigen showed superior survival (P = 0.028). Five (13.5%) patients relapsed, four of whom died of their disease. Death as a consequence of therapy toxicity was documented in one patient while on the re-induction protocol (protocol IIA).

Conclusions: Our study shows that OS and EFS for all patients was 86.5% and 83.8%, respectively.

Background: Uterine sarcoma constitutes a highly malignant group of uterine tumors. It accounts for 2–6% of uterine malignancies and its incidence is 1.7 in 100,000 women. The three most common variants of uterine sarcoma are endometrial stromal sarcoma, leiomyosarcoma and carcinosarcoma. Based on relatively small case series, the literature provides little information on the risk factors, the natural course of the disease and the preferred treatment.

Objectives: To evaluate uterine sarcoma patients treated in a tertiary referral center in Israel over a 20 year period (1980–2005).

Methods: We conducted a retrospective review of the charts of 40 uterine sarcoma patients, including their tumor characteristics, stage at diagnosis, treatment modalities, follow-up and survival.

Results: The patients’ mean age was 53 years (range 32–76); 30% of the patients had carcinosarcoma, 55% had leiomyosarcoma and 15% had ESS[1]. Half of the patients presented with stage I disease, 23% stage II, 10% stage III and 15% stage IV. Thirty-nine patients were treated by surgery. Adjuvant radiotherapy was administered to 39% of the patients, adjuvant chemotherapy to 21% and combined radiotherapy and chemotherapy to 9%. The mean follow-up period was 44 months, at which time disease had recurred in 44% of the patients. The disease stage was correlated with the 5-year survival rate, which was 73.1% for stages I-II and 22.2% for stages III- IV.

Conclusions: In accordance with other larger studies our data show that the only prognostic factor that was significantly correlated with prognosis was the stage of the disease at diagnosis. Despite advances in diagnosis and treatment, survival has not improved over the last 25 years.

Background: For health professionals who interact professionally with children, adequate awareness and training regarding the clinical indicators of child abuse and neglect, as well as subsequent reporting and procedures, are essential.

Objectives: To study Israeli health professionals’ experiences with identification and reporting of suspected cases of child abuse and neglect, and their perceived training needs in this area.

Methods: The study group was a convenience sample comprising 95 Israeli health professionals (physicians, nurses, social workers, psychologists, etc.) attending workshops on medical aspects at a national conference on child abuse and neglect. The study was a cross-sectional survey. The health professionals were asked to complete an anonymous structured questionnaire on their experience with child abuse and neglect and on their training needs.

Results: The participants in the survey had relatively high levels of involvement with child protection. Nevertheless, they strongly expressed their need for training, especially in mastering practice skills. The need for training was greater for professionals with less experience in child protection, and there were different needs according to profession.

Conclusions: Despite their prior extensive experience in dealing with child abuse and neglect, most of the health professionals participating in the conference reported the need for training in various areas.

Background: Kikuchi-Fujimoto disease is a benign and self-limited disease, first reported in Japan in 1972. The characteristic features of this disorder include lymphadenopathy and fever.

Objectives: To summarize our experience with Kikuchi disease with regard to clinical manifestations and outcome.

Methods: The patients included in the study were those diagnosed with Kikuchi disease during the years 2005–2008 in two departments of internal medicine at Sheba Medical Center.

Results: We identified five patients with Kikuchi disease; four of them were women and the mean age was 22.6 years. All the patients had cervical lymphadenopathy; three had other sites of lymphadenopathy. Four of the patients had fever higher than 39ºC. Two of them had splenomegaly and three reported weight loss. Three of the five patients experienced a relapse of the disease and were treated with steroids or non-steroidal anti-inflammatory agents. The diagnosis was confirmed in all the patients by an excisional biopsy of lymph node.

Conclusions: Kikuchi disease must be considered in every young patient with fever and lymphadenopathy. The disease usually has a benign course.

Background: In compliance with public health measures initiated by the Israel Ministry of Health following an outbreak of influenza, amantadine was administered to all patients in the psychogeriatric department of Lev Hasharon Mental Health Center to reduce transmission and illness severity in this susceptible population.

Objectives: To evaluate the potential beneficial effects of amantadine on elderly hospitalized patients with persistent schizophrenia.

Methods: We conducted a retrospective case review of the treatment effects of amantadine on the mental, cognitive and clinical states of elderly chronic schizophrenic patients who received concomitant amantadine treatment and were routinely evaluated with the Positive and Negative Syndrome Scale, the Mini Mental State Examination, and Sandoz Clinical Assessment Geriatric Scale.

Results: No significant differences before and after amantadine treatment were noted. Conclusion: Amantadine did not influence the mental, cognitive and clinical states of elderly schizophrenia patients and thus can be considered as an anti-influenza preventive measure for this population, when indicated.

survey. A tailor-made CME program may have contributed to the improvement in skills and quality of care.

Background: The existence of "ophthalmoltonic consensual reaction," a contralateral change in intraocular pressure in the fellow eye induced by treatment of the first eye only, was suggested in 1924. Since then, the validity of this mechanism has been controversial.

Objectives: To assess intraocular pressure changes in the contralateral fellow eyes of patients treated with IOP[1]-lowering medication in one eye, and investigate the existence of an ophthalmotonic consensual reaction.

Methods: The study population included 38 patients with newly diagnosed bilateral ocular hypertension or early open angle glaucoma. One eye of each patient was randomly treated with one of five compounds: prostaglandin analogues, beta-blockers, alpha-2 agonists, carbonic anhidrase inhibitors and a combination therapy: dorzolamide hydrochloride–timolol maleate (Cosopt®, Sharpe & Dohme). The eye with the higher baseline IOP was selected to be the treated eye. After 3 weeks a masked examiner measured the IOP in both the treated and untreated eye.

Results: Mean IOP of the treated eyes at baseline was 26.1 ± 4.2 mmHg and at follow-up 20.2 ±2.9 mmHg, a reduction of IOP from baseline of -6 ± 3.8 mmHg, a mean percent reduction of -22 ± 10.1%. In the contralateral eyes, the mean IOP at baseline was 24.2 ± 3 mmHg and 23.1 ± 3.1 mmHg at follow-up; IOP reduction from baseline was -1.2 ± 1.8 mmHg, or mean percent reduction -4.7 ± 7.1%. A major contralateral IOP decrease was seen only in the beta-blockers and the combination (Cosopt®) treatment groups (-6.1 ± 8.3% and -12.3 ± 8.3% mean percent reduction, respectively, P < 0.05). The contralateral eyes in the prostaglandin analogues, CAI[2] or α2-agonist groups showed only a small change in IOP (-2.6 ± 4.6%, -3.2 ± 2.6%, +0.7 ± 3.3%, mean percent reduction, respectively, P < 0.05).

Conclusions: The existence of an ophthalmoltonic consensual reaction was not supported.

Background: There is controversy as to which is the preferred treatment for distal radius intra-articular fractures – anatomic reduction or external fixation.

Objectives: To evaluate the radiologic and functional outcome following external fixation of these fractures.

Methods: Between January 2003 and March 2005, 43 patients with distal radius intra-articular fractures were treated using a mini-external AO device. Follow-up of 38 of the patients included X-rays at 1 week, 6 weeks and 6 months postoperatively. The Visual Analogue Scale was used to assess pain levels, and the Lidstrom criteria scale to evaluate functional outcome and wrist motion. Clinical and radiographic results were correlated.

Results: According to the Lidstrom criteria, the results were excellent in 31%, good in 61% and fair in 5.5%; 2.5% had a poor outcome. The results of the VAS[1] were good. Thirty-five patients gained a good range of wrist movement, but 3 had a markedly reduced range. We found statistical correlation between the radiographic and clinical results, emphasizing the value of good reduction. There was no correlation between fracture type (Frykman score) and radiologic results or clinical results.

Conclusions: External fixation seems to be the preferred method of treatment for distal radius intra-articular fractures, assuming that good reduction can be achieved. The procedure is also quick, the risk of infection is small, and there is little damage to the surrounding tissues.