Israel Medical Association Journal

Objective: To investigate hemodynamic variables, including small and large artery compliance, in cirrhotic patients during total paracentesis.

Methods: The study included 15 cirrhotic patients admitted for an episode of tense diuretic-resistant ascites. Hemodynamic variables including vascular compliance were measured using an HDI pulse wave cardiovascular profiling instrument CR-2000. The variables were measured in these patients before, immediately after and 24 hours following large volume (mean 5.6 L) paracentesis.

Results: Cardiac output increased immediately after paracentesis due to increment in stroke volume, with no change in heart rate. However, 24 hours later the cardiac output decreased to below the basal level. The fluctuation was statistically significant (P < 0.05). There was no change in large artery compliance, but small artery compliance increased after paracentesis (P < 0.05) and partially returned to the basal level after 24 hours. Systemic vascular resistance measurement showed the same pattern of change: vasodilatation occurred during paracentesis and was attenuated 24 hours later.

Conclusions: Large volume paracentesis with albumin replacement caused an accentuation of the vasodilatation (small but not large artery) already present in these patients. This may be the first sign of enhanced vasodilatation due to large volume paracentesis before the clinical expression of impaired hemodynamics and deterioration of renal function.

Objective: To establish the frequency of A. haemolyticum in throat cultures in a northern Israeli population and to estimate the clinical significance of this pathogen in patients with sore throat.

Methods: We examined suspected colonies for A. haemolyticum by gram stain, catalase test and reverse CAMP test in 518 throat cultures sent to the microbiologic laboratory of HaEmek Medical Center.

Results: Of the throat cultures tested, A. haemolyticum was recovered from one patient (0.2%). In contrast, group A Streptococcus (Streptococcus pyogenes) was recovered from 135 patients (26%).

Conclusion: A. hemolyticum is an uncommon pathogen implicated in acute pharyngitis, therefore routine screening in throat swabs is not required.

Objectives: To evaluate the extent and characteristics of CAM[1] use among cancer patients in northern Israel.

Methods: Telephone interviews were conducted with 2,176 newly registered cancer patients or their family members, at least 1 year following referral.

Results: The rates of CAM use varied significantly according to demographic characteristics and chemotherapy treatment, from 3% in the basically educated elderly group up to 69% of educated Israeli-born Jews younger than 70 years receiving chemotherapy. The overall rate of CAM use was 17%. The most influential factors determining CAM use were academic or high school education, chemotherapy treatment, Israel as country of birth, and age 41–50 years. All patients used CAM in addition to conventional therapies. Less than half of them reported it to their physicians. The most frequently used treatments were various chemical, biological, botanic and homeopathy remedies. Friends and relatives were the main recommenders of CAM. Most CAM users reported that they used CAM because they believed it “strengthens the immune system,” alleviates side effects of chemotherapy, improves quality of life and helps to overcome pain and stress, and 62% of them reported subjective beneficial effects.

Conclusions: A predicting module of CAM user patients was built, which may help physicians initiate conversations with their patients on CAM use. Expanding physicians' knowledge on CAM methods will encourage them to provide additional advice, promote the use of beneficial therapies, and inform patients about potentially harmful methods.

___________________

[1] CAM = complementary and alternative medicine

Objectives: To evaluate operative procedures, complications, early and late results and long-term functional outcome in FAP[1] patients operated in our department.

Methods: The study group included all patients with FAP who were operated between 1988 and 2003. Demographic data, length of follow‑up, complications, colorectal cancer, pouch function and extracolonic manifestations were recorded.

Results: Median age at surgery was 33 years (range 13–61 years). The final operative breakdown was: 48 proctocolectomies, 41 ileal pouch-anal anastomoses, 2 Kock’s pouch, 5 permanent ileostomies, and 2 colectomies with ileorectal anastomosis. There was no perioperative mortality. Early and late complications occurred in 20 and 9 patients, respectively. Twelve patients required re‑operation. Colorectal carcinoma was diagnosed in eight patients, three of whom were in an advanced stage. The mean follow‑up was 74 months (range 3–288 months). Four patients were lost to follow‑up. Extracolonic manifestations developed in 38 patients, including desmoid tumors (in 12), duodenal adenomas (in 9), pouch adenomas (in 5), and rectal stump adenomas (in 3). Two patients died (4%) because of desmoid tumor and malignant fibrous histiocytoma. At last follow‑up, 37 IPAA[2] patients have (median) six bowel movements/24 hours and good fecal control.

Conclusions: Restorative proctocolectomy can be performed with low mortality, acceptable morbidity, and good functional results. Patients should be closely followed after surgery for development of other manifestations of the syndrome. Relatives of the affected patients should be referred to a specialist multidisciplinary clinic.

____________________________

[1] FAP = familial adenomatous polyposis

[2] IPAA = ileal pouch-anal anastomosis

Background: Restorative proctocolectomy eliminates the risk of colorectal cancer in patients with familial adenomatous polyposis. Complications and extra‑intestinal manifestations are inherent to the procedure.

Objectives: To evaluate operative procedures, complications, early and late results and long-term functional outcome in FAP[1] patients operated in our department.

Methods: The study group included all patients with FAP who were operated between 1988 and 2003. Demographic data, length of follow‑up, complications, colorectal cancer, pouch function and extracolonic manifestations were recorded.

Results: Median age at surgery was 33 years (range 13–61 years). The final operative breakdown was: 48 proctocolectomies, 41 ileal pouch-anal anastomoses, 2 Kock’s pouch, 5 permanent ileostomies, and 2 colectomies with ileorectal anastomosis. There was no perioperative mortality. Early and late complications occurred in 20 and 9 patients, respectively. Twelve patients required re‑operation. Colorectal carcinoma was diagnosed in eight patients, three of whom were in an advanced stage. The mean follow‑up was 74 months (range 3–288 months). Four patients were lost to follow‑up. Extracolonic manifestations developed in 38 patients, including desmoid tumors (in 12), duodenal adenomas (in 9), pouch adenomas (in 5), and rectal stump adenomas (in 3). Two patients died (4%) because of desmoid tumor and malignant fibrous histiocytoma. At last follow‑up, 37 IPAA[2] patients have (median) six bowel movements/24 hours and good fecal control.

Conclusions: Restorative proctocolectomy can be performed with low mortality, acceptable morbidity, and good functional results. Patients should be closely followed after surgery for development of other manifestations of the syndrome. Relatives of the affected patients should be referred to a specialist multidisciplinary clinic.

Background: Restorative proctocolectomy with ileal pouch-anal anastomosis has become the surgical procedure of choice for patients with ulcerative colitis and familial adenomatous polyposis.

Objectives: To evaluate the long-term functional outcome of patients who underwent this surgical procedure.

Methods: We performed this observational study in 174 consecutive patients: 146 with UC[1] and 28 with FAP[2]. The patients, 91 males and 83 females with a mean age of 34.1 ± 10.6 years (range 6–67 years), underwent the procedure between January 1984 and January 2004 (mean follow-up 64.8 months, range 1–240 months). The indications for surgery were intractable disease in 124 patients (71%), dysplasia in 36 (21%), severe bleeding in 8 (5%), and perforation in 6 (3%).

Results: A protective ileostomy was performed in 140 patients (96%) with UC and 12 (43%) with FAP. An urgent three-stage procedure was necessary in 14 patients (8.4%). A mucosal proctectomy was performed in 94 (54%), and a double stapling technique in 80 (46%). Mean length of hospital stay was 9.4 ± 6.6 days (range 5–34 days, median 8). Complications included pelvic sepsis in 7 patients (4.2%), anastomotic leakage in 8 (4.8%), bowel obstruction in 22 (13.2%), incisional hernia in 12 (7.2%), anastomotic stenosis that usually responded to manual dilatation in 46 (27.6%), pouchitis in 106 (61%), recto-vaginal fistula in 3 (1.8%), retrograde ejaculation in 3 (1.8%), and impotence in 2 (1.2%). There was no mortality in this group of patients. The median number of bowel movements per 24 hours was six in UC patients and five in FAP patients, with at least one bowel movement during the night. Complete daytime and night-time continence was documented in 124 patients (71%). Overall satisfaction was 95%.

Conclusions: Restorative proctocolectomy with ileal pouch-anal anastomosis confers a long-term good quality of life to both UC and FAP patients, and the majority of patients are fully continent with five to six bowel movements per day. 

Background: Bladder exstrophy is a severe congenital defect that requires a multidisciplinary treatment approach. Soft tissue repair may be successful during the first few days after birth but a combination of pelvic osteotomies and bladder reconstruction is necessary later in life. The combination of externally fixed anterior and posterior osteotomies has biomechanical advantages over previous techniques for achieving primary bladder closure.

Objectives: To describe our experience with a combined vertical and horizontal pelvic osteotomy approach for the repair of bladder exstrophy.

Methods: Four children underwent bladder exstrophy closure; the mean age at surgery was 19 months (range 9–33 months)... We stabilized the osteotomies with a small Synthes AO external fixator, 4.0 mm rod diameter.

Results: All four patients had successful bladder repair with no dehiscence; two of them achieved partial continence, and bladder neck reconstruction is planned for the other two. Three of the four patients sustained neurologic injury; two completely recovered, and the third continues to suffer from right drop foot. The average follow-up was 39 months (range 10–60 months).

Conclusions: Vertical and horizontal pelvic osteotomies stabilized by external fixator and bladder repair is an effective treatment for bladder exstrophy.

Background: Head lice move easily from head to head. The lack of safe, effective repellents leads to reinfestation.

Objectives: To test the efficacy of a slow-release citronella formulation as a repellent against the head louse.

Methods: During 4 months in 2003 a randomized, placebo-controlled double-blind clinical study was conducted in four elementary schools; 103 children were treated with the test formulation and 95 with a placebo.

Results: A significant difference was observed during the second examination 2 months later, when 12.0% of the children treated with the test repellent and 50.5% of those treated with placebo were infested with lice. A significant difference was also observed at the third examination 2 months later, when 12.4% of the children treated with the test repellent and 33.7% treated with placebo were infested. Overall, there were significant differences between those treated with the repellent and those treated with the placebo (15.4% and 55.1% respectively, P < 0.0001). Side effects were observed in 4.4% of children who disliked the odor of the formulation, and an additional 1.0% who complained of a slight itching and burning sensation.

Conclusions: Use of an effective repellent could significantly lower the incidence of reinfestations, which would lower expenditure on lice control, including pediculicides, combs and products for nit removal, and the time spent on treatment and removal of the nits.

Background: The long-standing and ongoing controversy regarding administration of analgesia to patients with acute abdominal pain prior to final diagnosis has not yet been resolved, despite considerable research. Consequently, wide variations in clinical practice exist.

Objectives: To determine the motives, attitudes and practices of emergency physicians, internists and surgeons in Israeli emergency departments regarding the administration of analgesia before diagnosis in patients with acute abdominal pain.

Methods: Questionnaires were completed by 122 physicians in 21 EDs[1] throughout Israel and the replies were analyzed.

Results: Most EDs did not have a clear policy on analgesia for undifferentiated abdominal pain, according to 65% of the responders. More internists (75%) than surgeons (54%) (P = 0.02) and more emergency physicians (81%) than all other physicians (60%) (P = 0.05) held this opinion. Most respondents (64%) supported administration of analgesia pre-diagnostically. Support for analgesia was significantly stronger among internists (75%) compared to surgeons (52%) (P = 0.03). Despite this wide support, most respondents (68%) indicated that analgesia was rarely or never given pre‑diagnostically and, when it was, more surgeons (58%) than other physicians made that decision. Most internists (73%) and all surgeons reported that patients receive analgesia only after being examined by surgeons. Time allocated to the ED (part‑ or full‑time) significantly (P = 0.02) influenced decision-making, with 51% of part-time physicians vs. 25% of full-time opposing prompt administration of analgesia. Opinions on who should decide were divided according to medical specialty, with surgeons and internists almost opposed, as well as by physician age and percent of his/her time spent working in the ED. More surgeons than internists (P = 0.0005) reported that analgesia sometimes interfered with making a diagnosis. Most physicians (90%) stated that opiates impede diagnosis, to some extent. However, 58% of them supported the administration of opiates, more or less frequently. Intramuscular diclofenac was the most preferred analgesic, followed by intravenous morphine and pethidine; individual preferences extended beyond the list of actually administered drugs.

Conclusions: There is no consensus on the administration of analgesia for undiagnosed acute abdominal pain in EDs in Israel. Physicians’ attitudes are influenced by training, experience, and percent of personal time allocated to work in the ED.

Background: Left main coronary artery disease is considered a surgical indication in most centers. However, in some cases prohibited from surgery or in patients with prior bypass grafting, there is a need for percutaneous coronary intervention in LMCA[1] disease scenarios.

Objectives: To assess the clinical outcomes among patients undergoing stent-based LMCA angioplasty.

Methods: We identified 34 consecutive patients who underwent PCI[2] in LMCA at our institution. Procedural data and clinical outcomes were obtained for all patients.

Results: The mean age was 71 ± 12 years. There were 27 elective and 7 emergent procedures performed on 23 “protected” LMCA and 11 “unprotected” LMCA. In emergent procedures, the prevalence of cardiogenic shock (29% vs. 0%, P = 0.04) in patients with prior coronary bypass (29% vs. 8.5%, P = 0.007) was significantly higher compared to elective cases. Procedural success in emergent procedures was significantly lower than in elective procedures (71 vs. 100%, P = 0.04). In emergent versus elective procedures, the in-hospital mortality rate was higher (43 vs. 0%, P = 0.006). The rate of cumulative major adverse cardiac events at 1 and 6 months was 43% and 71% in emergent cases versus 0% and 33% in elective cases (P < 0.05 for both comparisons). In patients with “unprotected” LMCA the overall major cardiac events at 1 month was higher compared to “protected” LMCA patients (27 vs. 0%, P = 0.02). Multivariate analysis revealed emergent procedure as an independent predictor for mortality and adverse cardiac events (odds ratio 6.7; 95% confidence interval 1.2–36; P = 0.02).

Conclusions: Percutaneous interventions in LMCA are feasible and relatively safe in carefully selected cases. Procedural outcomes and clinical prognosis is highly dependent on the nature of disease prior to angioplasty (e.g., elective vs. emergent procedure) as well as on protection of the LMCA by patent grafts.