Israel Medical Association Journal

Objectives: To evaluate health utilization patterns in two primary care clinics in southern Israel: one under continuous attacks of Qassam rockets as compared with a similar clinic not under a rocket threat.

Methods: We conducted a retrospective cross-sectional study in two primary care clinics in southern Israel, with 11,630 persons listed in the two clinics during the entire study period. The primary outcome measures were total annual number of visits per person to the clinic and for specific diagnoses, and the number of drug prescriptions issued, emergency room (ER) visits, hospitalization days, cardiac catheterizations and coronary bypass surgeries.

Results: In both clinics there was an increase over time in the mean annual number of visits per person. During the years of severe attacks there was an increase in visits with a chief complaint of depression and anxiety and an increase in the number of anxiolytic prescriptions in the study clinic compared with the control. During the same period there was a decrease in the number of ER visits in the study clinic compared with the control.

Conclusions: The population under continuous life-threatening events showed more depression and anxiety problems. Under severe bombardment, the residents prefer not to leave home, unless necessary.

Objectives: To investigate current smoking trends among Israeli physicians.

Methods: All practicing physicians at a tertiary university-affiliated medical center in central Israel were invited to complete a Web-based questionnaire on smoking habits and smoking-related issues via the institutional email. Findings were compared to those in the general population and between subgroups.

Results: Of the 90 responders (53 male, 88 Jewish), 54 (60%) had never smoked, 21 (23.3%) were past smokers, and 15 (16.7%) were current smokers. The rate of current smokers was lower than in the general population. The proportion of current smokers was higher among residents than attending physicians and among physicians in surgical compared to medical specialties. Past smokers accounted for 17.9% of the residents (average age at quitting 26.2 years) and 28.1% of the attending physicians (average age at quitting 33.0 years). Non-smokers more frequently supported harsh anti-smoking legislation.

Conclusions: The rate of smoking is lower in physicians than in the general population but has not changed over the last 15 years. Anti-smoking programs should particularly target physicians in surgical specialties. 

Background: The number of patients treated with intravitreal injections has increased significantly over the past few years, mainly following the introduction of anti-vascular endothelial growth factor antibody intraocular medications. Bevacizumab is mostly used in this group of medications.

Objectives: To describe persistent elevation of intraocular pressure (IOP) following intravitreal injection of bevacizumab.

Methods: We reviewed consecutive cases of persistent IOP elevation after intravitreal bevacizumab injection for exudative age-related macular degeneration (AMD). A total of 424 patients (528 eyes) met the inclusion criteria and received 1796 intravitreal injections of bevacizumab. Persistent IOP elevation was found in 19 eyes (3.6%, 19/528) of 18 patients (4.2%, 18/424) with IOP elevated 30–70 mmHg, 3–30 days after injection.

Results: Mean IOP was 42.6 mmHg (range 30–70); IOP elevations occurred after an average of 7.8 injections of bevacizumab (range 3–13). Injected eyes (19/528) had a significantly higher incidence of elevated IOP than uninjected eyes (fellow eyes), 1/328, P < 0.001.

 Conclusions: Like other anti-vascular endothelial growth factor (VEGF) substances reported in a few recent studies, intravitreal injection of bevacizumab for neovascular AMD may be associated with persistent IOP elevation. Providers should be aware that significant IOP elevation might occur after repeated treatments. 

Objectives: To define preoperative predictors for MPC in prostatectomy specimens and to examine the accuracy of such prediction.

Methods: Data collected on 1526 consecutive radical prostatectomy patients operated in a single center between 2003 and 2008 included: age, body mass index, preoperative prostate-specific antigen level, biopsy Gleason score, clinical stage, percentage of positive biopsy cores, and maximal core length (MCL) involvement. MPC was defined as < 5% of prostate volume involvement with organ-confined Gleason score ≤ 6. Univariate and multivariate logistic regression analyses were used to define independent predictors of minimal disease. Classification and Regression Tree (CART) analysis was used to define cutoff values for the predictors and measure the accuracy of prediction.

Results: MPC was found in 241 patients (15.8%). Clinical stage, biopsy Gleason`s score, percent of positive biopsy cores, and maximal involved core length were associated with minimal disease (OR 0.42, 0.1, 0.92, and 0.9, respectively). Independent predictors of MPC included: biopsy Gleason score, percent of positive cores and MCL (OR 0.21, 095 and 0.95, respectively). CART showed that when the MCL exceeded 11.5%, the likelihood of MPC was 3.8%. ;Conversely, when applying the most favorable preoperative conditions (Gleason ≤ 6, < 20% positive cores, MCL ≤ 11.5%) the chance of minimal disease was 41%.

Conclusions: Biopsy Gleason score, the percent of positive cores and MCL are independently associated with MPC. While preoperative prediction of significant prostate cancer was accurate, clinical prediction of MPC was incorrect 59% of the time. Caution is necessary when implementing clinical data as selection criteria for active surveillance. 

Objectives: To examine prospectively the feasibility of vessel sealing in tracheostomy.

Methods: A vessel-sealing device was used in 24 consecutive patients undergoing tracheostomy. There were no exclusion criteria for enrolling the patients. No other hemostatic technique was used for dividing the isthmus.

Results: There were no bleeding events throughout the postoperative period. The operating time savingwas 5–10 minutes.

Conclusions: Use of the vessel sealer was found to be straightforward, efficacious, rapid and safe. 

Objectives: To assess the current practice in acute flexor tendon repair among Israeli hand surgeons.

Methods: A five-question survey was conducted among certified hand surgeons in Israel regarding their preferred materials and method for performing acute flexor tendon repair.

Results: Forty-eight hand surgeons participated in the survey. The most widely used core suture in zone 2 (58.3%), as well as in zones 3 and 4 (62.5%), was the modified Kessler type. The most widely used suture material was nylon. All surgeons incorporated epitendinous sutures to augment their core sutures. 

Conclusions: The modified Kessler core suture technique is the most widely used technique among Israeli hand surgeons for repairing acute flexor tendon lacerations in zones 2, 3 and 4. This finding agrees with worldwide data and with emerging data attesting to the lower risk of adhesion formation and postoperative tendon ruptures with this method. The core suture technique initially popularized by the late Prof. Isidor Kessler, who headed our department during the years 1973–92, remains the most practiced acute flexor tendon repair technique among hand surgeons in Israel. 

Objectives: To present the feasibility and safety of DSMR in Israel.

Methods: Thirty patients with suspected or known CAD were studied. DSMR images were acquired during short breath-holds in three short axis views and four-, two-, and three-chamber views. Patients were examined at rest and during a standard dobutamine-atropine protocol. Regional wall motion was assessed in a 16-segment model and the image quality was evaluated using a four-point scale for the visibility of the endocardial border.

Results: In 28 patients (93.4%) DSMR was successfully performed and completed within an average of 55 ± 6 minutes. One patient could not be examined because of claustrophobia and another patient, who was on beta-blockers, did not reach the target heart rate. Image quality was excellent and there was no difference between the rest and stress images in short axis (3.91 ± 0.29 vs. 3.88 ± 0.34, P = 0.13, respectively) and long axis (3.83 ± 0.38 vs. 3.70 ± 0.49, P = 0.09, respectively) views. Segmental intra-observer agreement for wall motion contractility at rest and stress cine images was almost perfect (κ = 0.88, 95% confidence interval = 0.93–0.84, and κ = 0.82, 95% CI = 0.88–0.76) respectively. No serious side effects were observed during DSMR.

Conclusion: The present study confirms the feasibility, safety and excellent image quality of DSMR for the diagnosis of coronary artery diseases.

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 assess intakes of Mg and Ca from water, other beverages, and food in communities with different water supplies, and assess the proportion of individuals with intakes below the estimated average requirement (EAR).

Methods: Telephone interviews were conducted using a food frequency questionnaire to assess Mg and Ca intakes by adults in four communities. The proportion of individuals with Mg and Ca intakes below the EAR were evaluated based on current intakes and on potential intakes assuming that desalinated water had been introduced countrywide.

Results: The proportion of individuals with Mg intake below the EAR was higher in Kibbutz Maagan Michael (30.6%), an agricultural settlement supplied with desalinated water, than in Hadera (16.7%), a city supplied by the National Water Carrier (NWC) (P < 0.01). The proportion of individuals with Ca intake below the EAR was higher in Maagan Michael (15.3%) than in the communities supplied with water from the NWC or mixed water (27.7%–33.8%), P < 0.02.

Conclusions: Returning Mg and Ca to desalinated water may be beneficial for raising intakes in Israeli communities supplied with desalinated water. Individuals with intake of Mg and/or Ca below the EAR may be at risk for cardiac abnormalities and other medical conditions.