A. Jotkowitz
Throughout history religious figures have been intimately involved in caring for the sick. Not only have they prayed for the welfare of the sick and arranged for their care but in many instances provided medical care as well. With the advent of scientific medicine, the responsibility for medical care was transferred to trained physicians. A new phenomenon has recently emerged in Israel that has threatened this ‘division of labor’ between physicians and rabbis, namely, the establishment of medical navigation organizations. Medical navigation can improve access to highly specialized care and help build trust between doctors and patients. However, this system is accompanied by numerous ethical and professional difficulties. For example, it is not clear how referrals are made and to what extent the system should be regulated. The phenomenon needs to be further studied to determine its prevalence in Israeli society as well as its impact on the practice of medicine from the perspective of both physicians and patients.
Y. Shilo, S. Efrati, Z. Simon, A. Sella, E. Gez, E. Fenig, M. Wygoda, A. Lindner, G. Fishlev, K. Stav, A. Zisman, Y.I. Siegel and D. Leibovici
Background: Hemorrhagic radiation cystitis (HRC) is a significant clinical problem that occurs after pelvic radiation therapy and is often refractory.
Objectives: To evaluate the efficacy and safety of hyperbaric oxygen therapy (HBO) for HRC.
Methods: Daily 90 minute sessions of HBO at 2 ATM 100% oxygen were given to 32 HRC patients with American Society of Therapeutic Radiology and Oncology (ASTRO) grades 3-4 hematuria.
Results: The median age was 72.5 (48–88 years). The median time interval between radiation therapy and HBO was 4 years (1–26 years). The patients received a median of 30 HBO sessions (3–53). Hematuria resolved in 27 patients (84%) and persisted in 5. Cystectomy was required in two, and ileal-conduit and bilateral percutaneous nephrostomies were performed in one and two patients, respectively. With a median follow-up of 12 months (5–74 months), the hematuria cleared completely in 16 patients (59%) and mild hematuria requiring no further treatment recurred in 10 others. Another patient with ASTRO grade 4 hematuria needed bladder irrigation and blood transfusions. Complications included eardrum perforation in four patients and transient vertigo and mild hemoptysis in one case each. None of them required HBO discontinuation.
Conclusions: HBO controlled bleeding in 84% of the patients. A durable freedom from significant hematuria was achieved in 96% of the patients. HBO seems to be an effective and safe modality in patients with HRC.
S. Hamoud, R. Mahamid, M. Halabi, J. Lessick, S. Abbadi, R. Shreter, Z. Keidar, D. Aronson,
H. Hammerman and T. Hayek
Background: Chest pain is one of the most common reasons for emergency department visits and hospital admissions. Chest pain units (CPU) are being incorporated in tertiary hospitals for rapid and effective management of patients with chest pain. In Israel prior to 2010, only one chest pain unit existed in a tertiary hospital.
Objectives: To report our first year experience with a CPU located in an internal medicine department as compared to the year before establishment of the CPU.
Methods: We retrospectively evaluated the medical records of consecutive patients who were admitted to our internal medicine department for the investigation of chest pain for 2 different years: a year before and a year after the establishment of the CPU in the department. We focused on the patients' characteristics and the impact of the CPU regarding the investigational modalities used and the length of in-hospital stay.
Results: In the year before establishment of the CPU, 258 patients were admitted to our department with chest pain, compared to 417 patients admitted to the CPU in the first year of its operation. All patients were followed for serial electrocardiographic and cardiac enzyme testing. All CPU patients (100%) underwent investigation compared to only 171 patients (66%) in the pre-CPU year. During the year pre-CPU, 164 non-invasive tests were performed (0.64 tests per patient) compared to 506 tests (1.2 tests/patient) in the CPU population. Coronary arteriography was performed in 35 patients (14%) during the pre-CPU year, mostly as the first test performed, compared to 61 patients (15%) during the CPU year, mostly as a second test, with only 5 procedures (1.1%) being the first test performed. The length of hospitalization was significantly shorter during the CPU year, 37.8 ± 29.4 hours compared to 66.8 ± 46 hours in the pre-CPU year.
Conclusions: Establishment of a CPU in an internal medicine department significantly decreased the need for invasive coronary arteriography as the first modality for investigating patients admitted with chest pain, significantly decreased the need for invasive procedures (especially where no intervention was performed), and significantly shortened the hospitalization period. CPU is an effective facility for rapid and effective investigation of patients admitted with chest pain.
R. Thein, S. Tenenbaum, O.Chechick, E. Leshem, A. Chechik and B. Liberman
Background: Hematogenous osteomyelitis of long bones is rare in adults, especially in the immune competent host. Only a few cases have been described to date.
Objectives: To present a case series of femoral hematogenous osteomyelitis in adults, a rare condition that is difficult to diagnose and may cause major morbidity and mortality.
Methods: We reviewed three cases of femoral hematogenous osteomyelitis that occurred between 2007 and 2009. The course of the disease, physical findings, imaging modalities, laboratory analysis, culture results and functional outcomes were recorded.
Results: In all cases the diagnosis was delayed after symptoms were first attributed to radicular-like pain or lateral thigh pain due to an inflammatory non-infectious source. In all cases infection was caused by an unusual or fastidious bacterium. The pathogen was Haemophilus aphrophilus in one case, and Streptococcus specimens were found in the other two. Pathological fracture occurred in two of the cases despite culture-specific antibiotic treatment and a non-weight bearing treatment protocol. It took five surgical interventions on average to reach full recovery from infection, but residual disability was still noted at the last follow-up.
Conclusions: Clinicians should be aware that although femoral hematogenous osteomyelitis is a rare condition in adults, its ability to mimic other pathologies can result in delayed diagnosis and major morbidity. In our series the pathogen was different in each case and was cultured only from the infected site. Pathological fracture is a devastating complication but we do not recommend prophylactic stabilization at this point.
T. Steinberg, I. Tamir, S. Zimmerman-Brenner, M. Friling and A. Apter
Background: Tic disorders are common causes of morbidity in Israel but their prevalence in this country needs further study.
Objectives: To assess the prevalence of mental disorders in Israeli youth including tic disorders, as part of the Israel Survey of Mental Health among Adolescents (ISMEHA).
Methods: The ISMEHA was conducted in a representative sample of 957 adolescents aged 14–17 and their mothers during 2004–2005. We interviewed the adolescents and their mothers in their homes and collected demographic information about the use of services. We also administered a psychiatric interview, the Development and Well-Being Assessment inventory (DAWBA), which included a question on tic disorder. The prevalence of tic disorders was calculated based on the adolescents’ and maternal reports. The relationships among demographic data, comorbidity rates, help-seeking behaviors and tic disorder are presented.
Results: The prevalence of tics was 1.3% according to maternal reports and 4.4% according to adolescents’ reports. The prevalence correlated with externalizing disorders and learning disabilities A higher prevalence of tics was found in the Arab population compared with Jewish adolescents
Conclusions: The prevalence of tic disorders in Israel, as measured by a direct question in this epidemiological study, and associated comorbidities concurs with previous reports. The complexities of prevalence estimations, comorbidities, demographic correlates, and help-seeking behaviors are discussed.
O. Halshtok Neiman, S. Sadetzki, A. Chetrit, S. Raskin, G. Yaniv and C. Hoffmann
Background: MRI differentiation between metastases and high grade gliomas is a challenging task. Contrast enhancement and size of edema do not provide clear-cut differentiators. The differences in the properties of the peritumoral edema between these tumor types may be exploited to distinguish between them, using MRI perfusion sequences, which are capable of imaging edema in the clinical setting and may be a reliable method to make this differentiation.
Objectives: To assess the ability of perfusion-weighted imaging to differentiate between high grade gliomas and brain metastases.
Methods: During 5 months, 21 patients (age 40–85, median age 61, 16 males and 5 females) with either glioblastoma multiforme (GBM) or metastasis (pathology proven), underwent MRI for assessment of the tumor prior to surgery. Most of the scans were done at 3 Tesla. The scans included perfusion-weighted imaging sequences. Perfusion in the tumor, in the peritumoral edema and in normal tissue were assessed using Functool® software. The ratios of tumor perfusion and peritumoral edema perfusion to normal tissue perfusion were calculated and compared.
Results: Bleeding artifact precluded perfusion assessment in four patients. There was no statistically significant difference between the tumor perfusion ratios of high grade gliomas and those of metastases. The edema perfusion ratios were higher in GBM than in metastases (P = 0.007).
Conclusions: Perfusion-weighted imaging of peritumoral edema can help to differentiate between GBM and metastases.
E. Ashkenazi, Y. Kovalev and E. Zuckerman
Portal hypertension is the leading cause of morbidity and mortality in liver cirrhosis. Complications of portal hypertension in cirrhotic patients include esophageal and gastric varices, portal hypertensive gastropathy, ascites, hepatorenal syndrome, hepatopulmonary syndrome and portopulmonary hypertension. The hepatic venous pressure gradient should be at least 10 mmHg for esophageal varices to appear, and more than 12 mmHg for acute esophageal variceal bleeding. This article reviews the pathophysiology responsible for portal hypertension and its complications, and the treatments used for esophageal varices in the setting of primary and secondary prophylaxis and during active bleeding.