Israel Medical Association Journal

Background: Optimil® is an infant formula, manufactured in Israel and introduced to the market in May 2008.

Objectives: To assess, for the first time, the effect of this formula on infant growth.

Method: The study group comprised 52 infants who for the first 6 months of life consumed Optimil, which constituted at least 25% of their total daily intake. Anthropometric data were collected from the records of the well-baby clinics. Weight, length and head circumference at baseline and 3 months thereafter were converted to gender and age-matched standard deviation Z-scores. As an exploratory uncontrolled analysis, questionnaires were sent to the caregivers to assess satisfaction with the formula and to note the rate of constipation, irritability and vomiting as well as apparent palatability.

Results: The baseline Z-scores of all three parameters were below zero but increased significantly after 3 months (-0.2 ± 0.88 to 0.12 ± 0.88, P = 0.013 for weight; -0.44 ± 0.87 to 0.10 ± 0.72, P < 0.001 for length; and -0.58 ± 0.78 to -0.1 ± 0.76, P < 0.001 for head circumference). There was a significant dose-response effect of the formula with weight gain. The formula was generally well accepted, with 8% constipation, 8% vomiting and 6% significant irritability.

Conclusions: This study provides the first evidence that infants consuming Optimil under age 6 months have adequate growth. Nonetheless, breastfeeding during this period should be preferred in almost all cases.

Background: The criteria for tonsillectomy for recurrent tonsillitis were established by prospective studies in the pediatric population and are applied to adults as well. No studies have been conducted to assess whether these guidelines are followed. 

Objectives: To examine the eligibility for tonsillectomy of tonsillectomized patients who were referred because of recurrent acute tonsillitis.

Methods: A retrospective case series in an ambulatory military otolaryngology clinic was conducted, and the medical records of 44 tonsillectomized patients who suffered from throat infections in the year before surgery were analyzed. The number of tonsillar infections that met the referral criteria was counted.

Results: The average number of throat infections that met the referral criteria was 1.89 per year. The average number of visits to the clinic due to upper respiratory tract infection was 12.92 (range 2–36) per year. The average number of visits for any cause was 45.13 (range 6–64) per year. One patient with eight documented throat infections met the criteria of more than six infections in the last year.

Conclusion: Although the referral criteria were not strictly met, we speculate that surgery was probably beneficial. This study shows that the indications for tonsillectomy referral are not strictly followed, and that new criteria for referral of adults for tonsillectomy need to be established.

Background: Inserting a transjugular intrahepatic portosystemic shunt by means of interventional radiology has become the procedure of choice for decompression of portal hypertension. The indications and criteria for patient selection have been expanded and refined accordingly.

Objectives: To review our experience with TIPS[1] and analyze the results with emphasis on patient selection and indication (conventional vs. atypical).

Methods: In this retrospective analysis in a single center all cases were managed by a multidisciplinary team (comprising liver surgery and transplantation, hepatology, imaging, interventional radiology and intensive care).

Results: Between August 2003 and December 2009, 34 patients (mean age 51, range 27–76 years) were treated with TIPS. The cause of portal hypertension was cirrhosis (23 cases), hypercoagulabilty complicated by Budd-Chiari syndrome (n=6), and acute portal vein thrombosis (n=5). Clinical indications for TIPS included treatment or secondary prevention of variceal bleeding (10 cases), refractory ascites (n=18), mesenteric ischemia due to acute portal vein thrombosis (n=5), and acute liver failure (n=1). TIPS was urgent in 18 cases (53%) and elective in 16. Three deaths occurred following urgent TIPS. The overall related complication rate was 32%: transient encephalopathy (6 cases), ischemic hepatitis (n=2), acute renal failure (n=2) and bleeding (n=1). Long-term results of TIPS were defined as good in 25 cases (73%), fair in 4 (12%) and failure in 5 (15%). In three of five patients with mesenteric ischemia following acute portal vein thrombosis, surgery was obviated. Revision of TIPS due to stenosis or thrombosis was needed in 7 cases (20%).

Conclusions: TIPS is safe and effective. While its benefit for patients with portal hypertension is clear, the role of TIPS in treatment of portal-mesenteric venous thrombosis needs further evaluation. Patient selection, establishing the indication and performing TIPS should be done by a multidisciplinary dedicated team.

Background: ST-elevation myocardial infarction is caused by occlusive coronary thrombosis where antecedent plaque disruption occurs. When treating STEMI[1] the main goal is to achieve prompt reperfusion of the infarction area. Several studies have demonstrated the efficacy of an aspiration device before percutaneous coronary intervention in patients with acute myocardial infarction.

Objectives: To determine the added value of thrombus aspiration prior to primary PCI[2] by comparing AMI[3] patients with totally occluded infarct-related artery treated with routine primary PCI to those treated with extraction device prior to primary PCI.

Methods: The study group comprised 122 consecutive patients with AMI and a totally occluded infarct artery (TIMI flow 0) who underwent primary PCI. The patients were divided into two groups: 68 who underwent primary PCI only (control group) and 54 who underwent primary thrombus extraction with an extraction device before PCI (extraction group). Baseline clinical and lesion characteristics were similar in both groups. Final TIMI grade flow and myocardial blush as well as 1 year mortality, target lesion revascularization, recurrent myocardial infarction, unstable angina and stroke were compared between the two groups.

Results: Primary angiographic results were better for the extraction group versus the control group: final grade 3 TIMI flow was 100% vs. 95.6% (P = 0.03) and final grade 3 myocardial blush grade 50% vs. 41.18% (although P was not significant). Long-term follow-up total MACE[4] showed a non-significant positive trend in the extraction group (12.96% vs. 24.71%, P = 0.26).

Conclusions: The use of extraction devices for intracoronary thrombectomy during primary PCI in patients with totally occluded infarct artery significantly improved epicardial reperfusion in the infarct-related vessel and showed a trend for more favorable long-term outcome.

Background: Infiltrating ductal carcinoma and infiltrating lobular carcinoma account for more than 90% of all invasive breast cancer histological types. The rate of ILC[1] is reported to be increasing steadily in the United States and Europe.

Objectives: To describe the trend in the incidence of ILC in a large cohort of patients who underwent surgery in a single institution over an 18 year period.

Methods: Our comprehensive database of 2175 consecutive patients with invasive breast cancer diagnosed during the period 1992–2009 served for the analysis. Several potential factors associated with lobular carcinoma as compared with ductal carcinoma were evaluated.

Results: During this period, a 2.4-fold increase in the incidence of pure ILC was noted, from 4.6% in the years 1992–1994 to 10.9% in 2004–2006, followed by a modest decrease to 8.7% in 2007–2009. A significant association of lobular malignancies with external hormonal use was noted, including hormone replacement therapy exposure in patients diagnosed at age 50–64, and ovarian overstimulation during in vitro fertilization in those diagnosed at age 50 or less.  

Conclusions: Better diagnostic tools – such as the liberal use of ultrasound and magnetic resonance imaging – and more accurate pathological definition for ILC type appear to influence the changes in the incidence of ILC in the subgroups of invasive breast cancer.

Background: On-site cardiac surgery is not widely available in developing countries despite a high prevalence of coronary artery disease.

Objectives: To analyze the safety, feasibility and cost-effectiveness of transradial percutaneous coronary intervention without on-site cardiac surgery in a community hospital in a developing country.

Methods: Of the 174 patients who underwent PCI[1] for the first time in our center, we analyzed two groups: stable coronary disease and acute myocardial infarction. The primary endpoint was the rate of complications during the first 24 hours after PCI. We also analyzed the length of hospital stay and the rate of hospital readmission in the first week after PCI, and compared costs between the radial and femoral approaches.

Results: The study group comprised 131 patients with stable coronary disease and 43 with acute MI[2]. Among the patients with stable coronary disease 8 (6.1%) had pulse loss, 12 (9.16%) had on-site hematoma, and 3 (2.29%) had bleeding at the site of the puncture. Among the patients with acute MI, 3 (6.98) had pulse loss and 5 (11.63%) had bleeding at the site of the puncture. There were no cases of atriovenous fistula or nerve damage. In the stable coronary disease group, 130 patients (99%) were discharged on the same day (2.4 ± 2 hours). In the acute MI group, the length of stay was 6.6 ± 2.5 days with at least 24 hours in the intensive care unit. There were no hospital readmissions in the first week after the procedure. The total cost, which includes equipment related to the specific approach and recovery room stay, was significantly lower with the radial approach compared to the femoral approach (US$ 500 saving per intervention).

Conclusions: The transradial approach was safe and feasible in a community hospital in a developing country without on-site cardiac surgery backup. The radial artery approach is clearly more cost effective than the femoral approach.

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: Previous pregnancies may influence the success of medical termination of pregnancy.

Objectives: To determine the effect of parity and gravidity on the successful termination of pregnancy using mifepristone and misoprostol.

Methods: The medical files of all patients attending a department of obstetrics and gynecology during the years 2006 and 2007 for the purpose of medical termination of pregnancy at ≤ 49 days of gestation were analyzed retrospectively. The medical history, previous pregnancies and deliveries were recorded. Mifepristone was administered orally followed by 400 mg of misoprostol 48 hours later. A second dose of misoprostol was offered 2 weeks later if uterine content thickness was more than 15 mm. Then, after 24 hours, if uterine content thickness was more than 15 mm the uterus was evacuated by dilation and curettage.

Results: Of 403 women, 349 (86.6%) aborted following the basic regime; 207 (51.4%) (group A) were primiparous while 196 (48.6%) (group B) had at least one prior pregnancy. Uterine curettage was performed in 17 patients (8.2%) in group A and in 37 (18.9%) in group B (P = 0.002). When patients with a history of a previous abortion were excluded from group B, 32 of 143 (22.4%) required curettage (P < 0.001). When patients without a history of previous cesarean section were excluded, 10 of 52 (19.2%) underwent curettage (P = 0.038).

Conclusions: Previous pregnancies negatively affect the success of medical termination of pregnancy, especially in women with a previous term pregnancy. This information is important when counseling women about the method of pregnancy termination.
 

Background: A pandemic (H1N1) influenza A virus was identified in 2009.

Objectives: To investigate predictors for pandemic (H1N1) 2009 virus infection among hospitalized patients with a flu-like illness and to identify parameters suggesting a severe clinical course.

Methods: We analyzed a cohort of all patients hospitalized during a 2 month period with a flu-like syndrome who were tested for pandemic (H1N1) 2009 infection. Demographic, clinical and laboratory, along with outcome parameters, were recorded and compared between pandemic (H1N1) 2009 virus-positive and negative hospitalized patients.

Results: Of the 179 examined hospitalized patients suspected of having pandemic (H1N1) 2009 infection 65 (36%) were found positive. These patients tended to be younger and had significantly fewer comorbidities. In addition, they had a significantly higher frequency of fever (94%), cough (86%) and myalgia (29%). Furthermore, age < 65 years and cough were independent predictors for pandemic (H1N1) 2009 virus positivity in a multivariate regression analysis. Notably, 14 of the 65 positive patients (21.5%) had acute respiratory insufficiency requiring treatment in the intensive care unit. These patients were neither older nor previously sicker than patients with non-severe disease, but were distinguished by augmented inflammatory markers, significant lymphopenia associated with disease severity, and overall mortality of 21.4%.

Conclusions: Pandemic (H1N1) 2009 virus-positive hospitalized patients tend to be younger and have fewer comorbidities as compared to compatible negative patients. A significant number of relatively young and previously healthy positive patients might develop severe disease associated with a robust inflammatory reaction and significant lymphopenia.