Israel Medical Association Journal

Background: One of the ominous complications following proximal gastrectomy or total gastrectomy is a leak from the esophagogastric or esophagojejunal anastomosis. An upper gastrointestinal swallow study is traditionally performed to confirm the anastomotic patency and lack of any leak before oral feeding can be initiated.

Objectives: To challenge the routine use of UGISs[1] following proximal or total gastrectomy in order to check the integrity of the gastroesophageal or jejunoesophageal anastomosis.

Methods: The charts of 99 patients who underwent PG[2] or TG[3]  for malignant pathology were retrospectively reviewed. UGISs were performed on day 6 following surgery using a water-soluble material.

Results: The UGISs were normal in 95 patients, with none displaying any complication related to the gastroesophageal or jejunoesophageal anastomosis. All four patients who experienced a leak from the anastomosis had an early stormy postoperative course.

Conclusions: Routine use of an UGIS to detect a leak following PG or TG is not justified. UGIS should be performed whenever signs of abdominal sepsis develop following this type or surgery.

Background: Trans-aortic pressure gradient in patients with aortic stenosis and left ventricular systolic dysfunction is typically low but occasionally high.

Objectives: To examine the distribution of trans-aortic PG[1] in patients with severe AS[2] and severe LV[3] dysfunction and compare the clinical and echocardiographic characteristics and outcome of patients with high versus low PG.

Methods: Using the echocardiographic laboratory database at our institution, 72 patients with severe AS (aortic valve area ≤ 1.0 cm²) and severe LV dysfunction (LV ejection fraction ≤ 30%) were identified. The characteristics and outcome of these patients were compared.

Results: PG was high (mean PG ≥ 35 mmHg) in 32 patients (44.4%) and low (< 35 mmHg) in 40 (55.6%). Aortic valve area was slightly smaller in patients with high PG (0.63 ± 0.15 vs. 0.75 ± 0.16 cm² in patients with low PG, P = 0.003), and LV ejection fraction was slightly higher in patients with high PG (26 ± 5 vs. 22 ± 5% in patients with low PG, P = 0.005). During a median follow-up period of 9 months 14 patients (19%) underwent aortic valve replacement and 46 patients (64%) died. Aortic valve replacement was associated with lower mortality (age and gender-adjusted hazard ratio 0.19, 95% confidence interval 0.05–0.82), whereas trans-aortic PG was not (P = 0.41).

Conclusions: A large proportion of patients with severe AS have relatively high trans-aortic PG despite severe LV dysfunction, a finding partially related to more severe AS and better LV function. Trans-aortic PG is not related to outcome in these patients.

Background: The existence of "ophthalmoltonic consensual reaction," a contralateral change in intraocular pressure in the fellow eye induced by treatment of the first eye only, was suggested in 1924. Since then, the validity of this mechanism has been controversial.

Objectives: To assess intraocular pressure changes in the contralateral fellow eyes of patients treated with IOP[1]-lowering medication in one eye, and investigate the existence of an ophthalmotonic consensual reaction.

Methods: The study population included 38 patients with newly diagnosed bilateral ocular hypertension or early open angle glaucoma. One eye of each patient was randomly treated with one of five compounds: prostaglandin analogues, beta-blockers, alpha-2 agonists, carbonic anhidrase inhibitors and a combination therapy: dorzolamide hydrochloride–timolol maleate (Cosopt®, Sharpe & Dohme). The eye with the higher baseline IOP was selected to be the treated eye. After 3 weeks a masked examiner measured the IOP in both the treated and untreated eye.

Results: Mean IOP of the treated eyes at baseline was 26.1 ± 4.2 mmHg and at follow-up 20.2 ±2.9 mmHg, a reduction of IOP from baseline of -6 ± 3.8 mmHg, a mean percent reduction of -22 ± 10.1%. In the contralateral eyes, the mean IOP at baseline was 24.2 ± 3 mmHg and 23.1 ± 3.1 mmHg at follow-up; IOP reduction from baseline was -1.2 ± 1.8 mmHg, or mean percent reduction -4.7 ± 7.1%. A major contralateral IOP decrease was seen only in the beta-blockers and the combination (Cosopt®) treatment groups (-6.1 ± 8.3% and -12.3 ± 8.3% mean percent reduction, respectively, P < 0.05). The contralateral eyes in the prostaglandin analogues, CAI[2] or α2-agonist groups showed only a small change in IOP (-2.6 ± 4.6%, -3.2 ± 2.6%, +0.7 ± 3.3%, mean percent reduction, respectively, P < 0.05).

Conclusions: The existence of an ophthalmoltonic consensual reaction was not supported.

Background: Continuous use of combined oral contraceptives is currently attracting growing interest as a means of improving menstrual related symptoms and reducing the number of bleeding days.

Objectives: To evaluate bleeding patterns, menstrual symptoms and quality of life with an extended 84/7 oral contraceptive regimen versus 21/7 cycles.

Methods: In two consecutive run-in cycles, 30 µg ethinyl estradiol and 3 mg drospirenone tablets taken on days 1–21 were followed by a tablet-free period from days 22 to 28 of each cycle and then by two 84 day cycles of pill use with a 7 day tablet-free interval. The primary outcome was the total number of bleeding/spotting days. Secondary outcomes were severity of daily symptoms, general well-being determined by the PGWBI questionnaire, and overall treatment satisfaction.

Results: Of the 137 women invited to participate in the study 109 (aged 18–40 years) were enrolled. The number of bleeding days decreased by about one-third from a calculated 31.8 days of bleeding under a cyclic 21/7 regimen to an expected total of 21.8 days for the extended 84/7 regimen. The incidence of menorrhagia, intermenstrual bleeding, dysmenorrhea, abdominal bloating, breast tenderness, depressive moods and irritability – when compared at enrollment and at the end of the second extended study period – was significantly lower (P < 0.005) among women on the continuous pill regimen. The median (range) global PGWBI scores were not substantially different before and after the extended use cycles: 78.2 (39.1–96.4) and 77.3 (30.9–96.4), respectively. Body weight and skin condition also remained constant. At the completion of the study: 65.5% of the women were either highly satisfied (41.4%) or satisfied (24.1%) with the extended regimen.

Conclusions: The extended 84/7 regimen was found to be satisfactory for the majority of participants and was associated with a decrease in the number of bleeding days and an improvement in menstrual symptoms compared to 21/7 cycles. 

Background: Osler taught that splenic infarction presents with left upper abdominal quadrant pain, tenderness and swelling accompanied by a peritoneal friction rub. Splenic infarction is classically associated with bacterial endocarditis and sickle cell disease.

Objectives: To describe the contemporary experience of splenic infarction.

Methods: We conducted a chart review of inpatients diagnosed with splenic infarction in a Jerusalem hospital between 1990 and 2003.

Results: We identified 26 cases with a mean age of 52 years. Common causes were hematologic malignancy (six cases) and intracardiac thrombus (five cases). Only three cases were associated with bacterial endocarditis. In 21 cases the splenic infarction brought a previously undiagnosed underlying disease to attention. Only half the subjects complained of localized left-sided abdominal pain, 36% had left-sided abdominal tenderness 31% had no signs or symptoms localized to the splenic area, 36% had fever, 56% had leukocytosis and 71% had elevated lactate dehydrogenase levels. One splenectomy was performed and all patients survived to discharge. A post hoc analysis demonstrated that single infarcts were more likely to be associated with fever (20% vs. 63%, p < 0.05) and leukocytosis (75% vs. 33%, p = 0.06)

Conclusions: The clinical presentation of splenic infarction in the modern era differs greatly from the classical teaching, regarding etiology, signs and symptoms. In patients with unexplained splenic infarction, investigation frequently uncovers a new underlying diagnosis. 

Background: An accurate preoperative definition of tumor and lymph node status is needed for reaching the correct decision regarding rectal cancer treatment. Transrectal ultrasonography is the most commonly used diagnostic modality for the local staging of rectal cancer.

Objectives: To determine the accuracy of TRUS[1] in the staging of rectal cancer.

Methods: We conducted a retrospective study on 95 patients evaluated by TRUS. The rectum was subdivided into two parts (lower and upper).

Results: Sixty patients underwent radical surgery. Of these, 34 received no preoperative chemo-irradiation owing to µT1, µT2 tumor or the patient’s choice (neo-adjuvant treatment was suggested to patients with adenocarcinoma that proved to be µT3). The overall accuracy rate was 80% for T stage. Overstaging was found in 13.3% and understaging in 6.7%.The N-stage was correctly assessed in 70%. The overall accuracy rate for tumors was 73.9% in the lower part and 90.9% in the upper. A trend towards a lower accuracy rate for low-lying tumors compared to high-located rectal tumors was found (P = 0.532), which did not reach statistical significance.

Conclusions: TRUS gave better results for T1 and T3 stage rectal tumors but was inaccurate for stage T2, indicating the possible need for local excision in order to base the final treatment for T2 tumors on pathologic staging.
[1] TRUS = transrectal ultrasonography
 

Background: High frequency oscillatory ventilation based on optimal lung volume strategy is one of the accepted modes of ventilatory support for respiratory distress syndrome in very low birth weight infants. In 1999 it was introduced in our unit as the primary ventilation modality for RDS[1].

Objectives: To evaluate if the shift to HFOV[2] influenced the outcome of ventilated VLBW[3] infants in the neonatal intensive care unit of Carmel Medical Center.

Methods: Data were obtained from the medical charts of VLBW infants born at Carmel Medical Center, and late mortality data were taken from the Israel Ministry of Internal Affairs records. A retrospective analysis and a comparison with a historical control group ventilated by the conventional method were performed.

Results: A total of 232 VLBW infants with RDS were mechanically ventilated, from 1995 to 2003: 120 were ventilated using HFOV during the period 1999–2003 and 102 infants using CV[4] during 1995–1999. The mean gestational age of survivors was 27.4 ± 2 weeks in the HFOV group and 28.4 ± 2 in the conventional ventilation group (P = 0.03). The sub-sample of infants with birth weights <1000 g ventilated with HFOV showed higher survival rates than the infants in the conventional ventilation group, 53 vs. 25 (64.6% vs. 44.6%) respectively (P < 0.05). A trend for lower incidence of pulmonary interstitial emphysema was observed in the HFOV group.

Conclusions: The introduction of HFOV based on optimal lung volume strategy proved to be an efficient and safe method of ventilation support for VLBW infants in our unit.

Background: Professional drivers have been found to be at high risk for developing low back pain. However, the exact reasons are poorly understood.

Objectives: To assess the prevalence of LBP[1] among Israeli professional urban bus drivers, and evaluate the association between LBP in drivers and work-related psychosocial and ergonomic risk factors.

Methods: A total of 384 male full-time urban bus drivers were consecutively enrolled to this cross-sectional study. Information on regular physical activity and work-related ergonomic and psychosocial stressing factors was collected during face-to-face interviews. The prevalence of LBP was assessed using the Standardized Nordic Questionnaire.

Results: From the total cohort, 164 bus drivers (45.4%) reported experiencing LBP in the previous 12 months. Ergonomic factors associated with LBP were uncomfortable seat (odds ratio 2.6, 95% confidence interval 1.4–5.0) and an uncomfortable back support (OR[2] 2.5, 95% CI[3] 1.4–4.5). In the group of drivers with LBP, 48.5% reported participation in regular physical activities vs. 67.3% in the group without LBP (P < 0.01). The following psychosocial stressing factors showed significant association with LBP: “limited rest period during a working day” (1.6, 1.0–2.6), “traffic congestion on the bus route” (1.8, 1.2–2.7), “lack of accessibility to the bus stop for the descending and ascending of passengers” (1.5, 1.0–1.5), and “passengers' hostility” (1.8, 1.1–2.9).

Conclusions: Work-related ergonomic and psychosocial factors showed a significant association with LBP in Israeli professional urban bus drivers. Prevention of work-related stress, organizational changes targeted to reduce stressful situations, improvement in seat comfort, and encouraging regular sports activity need to be evaluated as prevention strategies for LBP in professional bus drivers.

Background: The incidence of congenital heart defects, reported to be 5–8/1000 in term infants, is not well established in very low birth weight infants.

Objectives: To establish the incidence of congenital heart defects in VLBW[1] infants in the neonatal intensive care unit of our institution.

Methods: A retrospective analysis of the population in the NICU[2] at our institution was performed. VLBW (BW ≤ 1500 g) infants born between 2001 and 2006 who survived more than 48 hours were included in the study. Infants with clinical signs of heart disease underwent echocardiography.

Results: During the study period 437 VLBW live-born infants met the inclusion criteria. Of these, 281 (64.3 %) underwent echocardiography. CHD[3] was detected in 19 infants (4.4%, 95% confidence interval 2.4–5.4%), significantly higher than the incidence of 5–8/1000 in the general population (P < 0.0001). In the subgroup of 154 infants with BW < 1000 g there were 10 (6.5%) with CHD. In the subgroup of 283 infants with BW 100–-1500 g there were 9 (3.2 %, P = 0.19 vs. VLBW) with CHD.

Conclusions:  Our observations show an increased incidence of CHD in VLBW neonates, as compared to the general population. Since not all infants underwent echocardiography, and minor cardiac defects may have been missed in our VLBW infants, the true incidence may be higher than reported here.

Background: Low back pain is a common problem managed by primary care physicians and orthopedic specialists.

Objectives: To evaluate the outcome of new LBP[1] episodes in patients who chose to visit either an orthopedist or a general practitioner.

Methods: All patients visiting the orthopedist or physician during the study period were screened for a new complaint of LBP. After the initial visit the patients were interviewed by phone by means of a structured questionnaire, with a follow-up interview one month later. The study was performed at Clalit Health Services primary care and consultation clinics. A random sample of 125 GPs[2] and 17 orthopedists were chosen. Consecutively recruited were 166 patients who visited the GP and 75 the orthopedist. The main outcome measures evaluated were perceived complaint severity and degree of disturbance to everyday functioning, problem resolution, and health services utilization.

Results: Patients who decided to first visit the orthopedist indicated a higher disturbance to everyday functioning (75% vs. 70%, P < 0.01), were invited for further follow-up visits (6% vs. 51%, P < 0.05) and had more computed tomography and bone scans (20 vs. 3%, P < 0.001 and 9 vs. 2%, P < 0.05, respectively). Health status after one month showed that patients who chose the GP were more likely to have their problem solved (36 vs. 17%, P < 0.05).

Conclusions: Symptom resolution for a new LBP complaint was significantly higher in patients who decided on the GP, even when controlling for severity of illness and degree of disturbance to everyday functioning.

Background: Although febrile urinary tract infections are very common in young children, the need for antimicrobial prophylaxis and evaluation following a first event is controversial.

Objectives: To assess the approach of leading pediatric specialists throughout Israel.

Methods: A questionnaire regarding the approach to antibiotic prophylaxis and diagnostic evaluation following a first event of febrile UTI[1], according to age and underlying renal abnormality, was sent to all 58 directors of departments of pediatrics, units of pediatric infectious diseases and pediatric nephrology in Israel.

Results: Fifty-six directors (96%) responded. Most prescribed prophylactic antibiotics after UTI. Heads of infectious disease departments prescribed less prophylaxis following UTI at the age of 18 months than heads of pediatrics or heads of pediatric nephrology units (34% vs. 72–75%, P = 0.018), but more often in cases of severe vesico-ureteral reflux without UTI. Cephalosporins were used prophylactically more often by directors of pediatrics compared to heads of pediatric nephrology units (71% vs. 38%, P = 0.048); the latter used non-beta-lactam prophylaxis (61% vs. 23%, P = 0.013) more often. Most pediatricians used renal sonography for evaluation; renal scan was used more commonly by pediatric nephrologists.

Conclusions: The administration of prophylactic antibiotics after UTI is still common practice among pediatric opinion leaders, although the specific approach differs by subspecialty. According to up-to-date evidence-based data, educational efforts are needed to formulate and implement judicious guidelines.

Background: Fat tissue mediates the production of inflammatory cytokines and oxidative products, which are key steps in the development of type 2 diabetes and atherosclerosis. Antioxidant-rich diets protect against chronic diseases, but antioxidants may interfere with pro-inflammatory signals.

Objectives: To investigate the effect of the potent tomato-derived antioxidant carotenoid, lycopene, on plasma antioxidants (carotenoids and vitamin E), inflammatory markers (C-reactive protein, interleukin-6, tumor necrosis factor-alpha), and oxidation products (conjugated dienes).

Methods: Eight obese patients (body mass index 37.5 ± 2.5 kg/m²) were compared with a control group of eight lean, age and gender-matched subjects (BMI[1] 21.6 ±  0.6 kg/m²), before and after 4 weeks of lycopene supplementation (tomato-derived Lyc-O-Mato) (30 mg daily).

Results: Plasma carotenoids were significantly reduced in the obese compared to control subjects (0.54 ± 0.06 vs. 0.87 ± 0.08 mg/ml, P < 0.01). CRP[2] levels were significantly higher (6.5 vs. 1.1 mg/L, P = 0.04) in obese vs. controls, as were IL-6[3] and conjugated dienes (3.6 and 7.9-fold, respectively). CRP, IL-6 and conjugated dienes correlated with BMI, while IL-6 and conjugated dienes correlated inversely with carotenoids (P < 0.05). Following lycopene treatment, a significant elevation of plasma carotenoids (1.79 vs. 0.54 ug/ml) and specifically lycopene (1.15 vs 0.23 ug/ml) (P < 0.001) occurred in the treatment vs. placebo group, respectively. Markers of inflammation and oxidation products were not altered by lycopene.
Conclusions: Obese patients showed abnormally higher markers of inflammation and oxidation products and lower plasma carotenoids. The lack of reduction of pro-inflammatory markers could be attributed to the short period of the study and the small number of participants. More studies are needed on the protective qualities of natural antioxidant-rich diets against obesity-related co-morbidities.

Background: Critical limb ischemia is an increasingly common condition that has high surgical morbidity and limited non-surgical options.  

Objectives: To evaluate the use of silicon carbide-coated Motion stents, as compared to reported data for bare metal stents, in elderly patients with infrapopliteal artery stenoses causing critical limb ischemia after failed or complicated percutaneous transluminal angioplasty.

Methods: Between January 2003 and March 2004, 41 stents were inserted into 17 consecutive patients (11 males, 6 females, mean age 82 years, range 75–93) following unsuccessful or complicated PTA[1]. Seven patients had one-vessel run-off, six had two-vessel and four had three vessel run-off. All patients suffered from CLI[2], had up to three lesions and more than one co-morbid condition, and were considered at high surgical risk. Silicon carbide-coated Motion coronary stents, 2.5–4 mm diameter and 25 and 30 mm length, were used. Pre-intervention assessment included clinical condition, ankle brachial index, Doppler ultrasound and digital subtracted angiography. Post-intervention evaluation included clinical condition, ABI[3], and Doppler ultrasound at 3, 6 and 12 months.

Results: The technical success rate per lesion was 100% (41/41). Two patients died of unrelated causes after 2 and 8 months respectively. Primary patency rates with duplex ultrasound were 68.7% (11/16) at 3 months, 43.7% (7/16) at 6 months and 40% (6/15) after 12 months. Nine patients developed complete occlusion in 13 stents; three of these patients underwent a below-knee amputation and two patients a partial foot amputation. Re-intervention (PTA only) was performed in 7 patients (43.7%). Secondary patency rate was 81.2% (13/16) at 6 months and 60% (9/15) at one year. Mean ABI index had improved at 6 months from 0.32 to 0.67, and to 0.53 at one year. Clinical improvement was evident in 87.5% (14/16) at 6 months and in 66.6% (10/15) at one year.

Conclusions: Silicon carbide-coated stents are comparable to bare metal stents after 6 and 12 months in infrapopliteal interventions in CLI when stenting is indicated.