Israel Medical Association Journal

Background: Food allergies in children are often very serious and can lead to anaphylactic reactions. Observations that camel milk ameliorates allergic reactions were noted over the years. The effect of the camel milk is probably related to its special composition.

Objectives: To investigate the effect of camel milk in several children with severe food (mainly milk) allergies.

Methods: We studied eight children with food allergies who did not benefit from conventional treatment. Their parents, or their physicians, decided to try camel milk as a last resort. The parents were advised by the authors – who have considerable experience with the use of camel milk – regarding how much and when the children should drink the milk. The parents reported daily on the progress of their children.

Results: All eight children in this study reacted well to the milk and recovered fully from their allergies.

Conclusions: These encouraging results should be validated by large-scale clinical trials.

Objective: To establish population-based standards of birth weight of singletons in Israel.

Methods: Data on birth weight and gestational age were obtained from the registries of the Israel Ministry of Health and Ministry of the Interior. During the 8 year study period there were 1,074,122 infants delivered in Israel; 787,710 (73%) were included in this analysis.

Results: In this study we provide data of birth weight by gestational age of live infants born in Israel between 1993 and 2001. Ranges of birth weight by gestational age are also depicted for singleton and multiple pregnancies. Fetuses in multiple pregnancies grow in a similar manner to singletons until 30 weeks of gestation, after which their growth slows down.

Conclusions: Use of these data as a standard for “intrauterine” growth better represents the Israeli neonatal population than the American standards. In addition, curves of multiple pregnancies are significantly different from those of singleton pregnancies and might be more appropriate in these pregnancies.

Objective: To identify risk factors and associated conditions that may cause TdP[1] in patients on chronic amiodarone treatment.

Methods: We reviewed the data of six consecutive patients on chronic amiodarone treatment who were admitted to the intensive cardiac care unit due to syncope and TdP.

Results: The patients’ median age was 73.5 years, and five were women. Concomitantly, loratadine was given to two patients and trazodone to one patient. Associated and attributing conditions to the development of TdP were hypokalemia in three patients, drug-induced bradycardia in one and reduced left ventricular function in four.

Conclusions: TdP associated with chronic amiodarone treatment may occur when amiodarone is co-administered with drugs that may potentially prolong QT interval. Additional risk factors for amiodarone-associated TdP include female gender, hypokalemia, reduced left ventricular function and bradycardia.

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[1] TdP = torsade de pointes

Objective: To present our algorithm of urgent and elective donor selection.

Methods: Urgent selection is expeditious and protocol‑based. Elective selection permits a comprehensive process. Both include medical, psychosocial and surgical-anatomic evaluations. Liver volumes and vascular anatomy are evaluated with computerized tomographic angiography. Informed consent is obtained after painstaking explanations. Independent institutional committees review and approve all cases.

Results: Between July 2003 and June 2004 we evaluated 43 potential live donors for 12 potential recipients (fulminant hepatic failure, n=5; chronic end-stage liver disease, n=6); primary graft non-function, n=1). Thirty-three candidates (76%) were excluded due to blood type incompatibility (n=14, 42%), incompatible anatomy (n=8, 24%) – including problematic volume distribution (n=2) or vascular anatomy (n=6) – psychosocial issues (n=4, 12%), or medical co-morbidity (n=7, 22%). Five recipients (FHF[1], n=4; chronic ESLD[2], n=1) were successfully transplanted from living donors. In the acute setting, two patients (FHF, PGNF[3]) died in the absence of an appropriate donor (cadaveric or living donor). In the elective group, one patient died of unexpected variceal bleeding and one received a cadaveric graft just before the planned living donor transplantation was performed. One candidate was transplanted overseas and two cases are scheduled. The ratio of compatibility for donation was 34% (10/29) for blood type-compatible candidates.

Conclusions: Donor selection for living donor liver transplantation is a complex, labor-intensive multidisciplinary process. Most exclusions are due to blood type incompatibility or anatomic details. Psychosocial aspects of these donations warrant special attention.

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[1] FHF = fulminant hepatic failure

[2] ESLD = chronic end-stage liver disease

[3] PGNF = primary graft non-function

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.

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[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: Various medical centers in Israel have recently incorporated electronic medical record systems. Knowing the EMR[1] systems’ features and pattern of use is an essential step for developing locally and nationally integrated systems.

Objectives: To evaluate the status of EMR systems in all major general hospitals in Israel in terms of the applications used and the patterns of use.

Methods: Structured questionnaires were sent to hospital directors and directors of medical informatics units of 26 general and pediatric hospitals serving the vast majority of the population in Israel. The qheuestionnaire included questions pertaining to the EMR systems, their usage and the attitude of the participants to data security issues.

Results: Of the 26 general hospitals 23 (88.4%) returned the questionnaires. Of these, 21 (91.3%) use EMR systems. Twenty-seven different types of systems are in use in Israeli hospitals, and generally more than one type is used in a hospital. [YD1] Physicians work with EMR systems in over 98% of the departments. Also, the EMR systems are used for clinical admission and discharge in over 90% of the departments and for medical daily follow-up in about 45%.

Conclusions: Most of the hospitals in Israel use EMR systems but there is no standard data model. Physicians are the main users but the amount of data entered is still limited. Adoption of standards is essential for integration of electronic patient records across Israeli healthcare organizations.

Background: Preoperative radiotherapy is standard treatment for rectal cancer and is often combined with 5-fluorouracil-based chemotherapy. UFT, a new oral 5FU[1] derivative, given daily during a course of radiotherapy mimics the effect of continuous-infusion 5FU.

Objectives: To determine the maximum tolerated dose of oral UFT and leucovorin with preoperative pelvic irradiation for rectal cancer, and assess tumor response.

Methods: In this phase 1 trial, 16 patients aged 42–79 years with tumors within 12 cm of the anal verge received radiotherapy, 45 Gy over 5 weeks, an escalating dose of oral UFT, and a fixed dose of 30 mg/day leucovorin. UFT and leucovorin were given for 28 consecutive days concomitant with the first 4 weeks of radiotherapy. Surgery was scheduled for 4–6 weeks after completion of radiotherapy. The surgical procedure was determined by the surgeon at the time of surgery.

Results: No grade III toxicity was seen at 200 mg/m²/day UFT. Of eight patients who received 240 mg/m²/day UFT, one developed grade IV diarrhea; of four patients who received 270 mg/m²/day UFT, one was hospitalized with grade IV diarrhea and leukopenic fever and died during hospitalization. Of the 15 evaluable patients, 9 had pathologic tumor down-staging including 4 patients with complete response. Only one patient required a colostomy.
Conclusions: The MTD[2] of UFT together with leucovorin and preoperative radiotherapy for rectal cancer is 240 mg/m². The major toxicity was diarrhea. Down-staging was noted in 60% of patients, allowing sphincter-preserving surgery even in patients with low tumors.

Background: The appearance of pericarditis following insertion of a permanent pacemaker is not widely acknowledged in the literature.

Objectives: To describe our experience with pericarditis following 395 permanent pacemaker implantations over 2 years.

Methods: We retrospectively reviewed the medical records of 395 consecutive patients in whom new pacing systems or pacemaker leads had been implanted over a 2 year period. We searched the records for pericarditis that developed within 1 month after pacemaker implantation according to the ICD-9 code. The incidence, clinical picture, response to treatment and relationship to lead design and location were studied.

Results: Eight cases (2%) of pericarditis following implantation were detected. Clinical manifestations in all patients were similar to those of post-pericardiotomy syndrome and included chest pain (n=7), friction rub (n=1), fever (n=2), fatigue (n=2), pleural effusion (n=2), new atrial fibrillation (n=2), elevated erythrocyte sedimentation rate (n=4) and echcardiographic evidence of pericardial effusion (n=8). All affected patients had undergone active fixation (screw-in) lead implantation in the atrial position. The incidence of pericarditis with screw-in atrial leads was 3% compared to 0% in other cases (P < 0.05).

Conclusions: Pericarditis is not uncommon following pacemaker implantation with active fixation atrial leads. Special attention should be paid to identifying pericardial complications following pacemaker implantation, especially when anticoagulant therapy is resumed or initiated. The use of passive fixation leads is likely to reduce the incidence of pericarditis but this issue should be further investigated.