Israel Medical Association Journal

Background: Even operative deliveries defined as “urgent” show marked diurnal variation with a significant increase during regular working hours.

Objective: To investigate the diurnal variation of urgent operative deliveries and its potential implications on the outcome of newborns.

Methods: We conducted a retrospective study of all deliveries in a public hospital from 1 January 1990 to 31 December 1998. Delivery mode variables analyzed were spontaneous vaginal delivery, urgent cesarean section and operative vaginal delivery. Deliveries were stratified hourly throughout the day. The rate of operative deliveries was calculated and the analysis was then performed according to the daily routine shifts of the medical staff. Birth weight and Apgar scores at 1 and 5 minutes were retrieved as outcome measures.

Results: The rate of urgent cesarean deliveries increased significantly between 8 a.m. and 2 p.m. (150%–230%) from that predicted. The lowest rate of urgent cesarean sections was found between 5 a.m. and 6 a.m. (5.3%). Mean birth weight in spontaneous deliveries was higher in the morning hours than during the night shift (3,293 ± 520 g vs. 3,277 ± 510 g, respectively, P < 0.005). Apgar scores of newborns delivered by urgent cesarean section during the morning were higher compared to those delivered during night shifts and the rate of low Apgar scores was lower in the morning than in evening and night shifts.

Conclusions: Our results indicate a marked diurnal variation in urgent operative deliveries, caused perhaps by varying definition of “urgency” according to the time of day.
 

Background: Understanding discharge instructions is crucial to optimal healing but may be compromised in the hectic environment of the emergency department.

Objectives: To determine parents’ understanding of ED[1] discharge instructions and factors that may affect it.

Methods: A convenience sample of parents of children discharged home from the ED of an urban tertiary care pediatric facility (n=287) and a suburban level II general hospital (n=195) completed a 13-item questionnaire covering demographics, level of anxiety, and quality of physician’s explanation. Parents also described their child’s diagnosis and treatment instructions and indicated preferred auxiliary methods of delivery of information. Data were analyzed using the BMPD statistical package.

Results: Full understanding was found in 72% and 78% of the parents at the respective centers for the diagnosis, and in 82% and 87% for the treatment instructions (P  = NS between centers). There was no statistical correlation between level of understanding and parental age, gender, education, level of anxiety before or after the ED visit, or time of day. The most contributory factor to lack of understanding was staff use of medical terminology. Parents suggested further explanations by a special discharge nurse and written information as auxiliary methods.

Conclusions: Overall, parental understanding of ED discharge instructions is good. However, there remains a considerable number (about 20%) who fail to fully comprehend the diagnosis or treatment directives. This subset might benefit from the use of lay terminology by the staff, institution of a special discharge nurse, or use of diagnosis-specific information sheets.

Background: Decreased elasticity of the aorta is associated with aging and several risk factors of atherosclerosis. The data regarding this phenomenon in patients with familial hypercholesterolemia are rather sparse.

Objectives: To evaluate non-invasively the elasticity of the proximal ascending aorta of 51 heterozygous FH[1] patients compared to 42 normal age and gender-matched controls.

Methods: Aortic elasticity was estimated by transthoracic echocardiography using the “pressure-strain” elastic modulus and aortic strain formulas.

Results: The elastic modulus score was higher in the FH group than in the controls (1.12 ± 0.91 10⁶ dynes/cm² vs. 0.65 ± 0.46 10⁶ dynes/cm² respectively, P = 0.01). This was consistent in both the pediatric (0.5 ± 0.2 10⁶ dynes/cm² vs. 0.4 ± 0.1 10⁶ dynes/cm² respectively, P = 0.009) and adult subgroups (1.3 ± 1.0 10⁶ dynes/cm² vs. 0.8 ± 0.5 10⁶ dynes/cm² respectively, P = 0.0004). Aortic strain was significantly lower in patients with FH than in controls (6 ± 4% vs. 9 ± 5% respectively, P = 0.0002). These findings reflected decreased elasticity of the proximal ascending aorta in the FH patients. In multivariate analysis, age, serum cholesterol level and serum triglycerides level were the independent predictors of the elastic modulus score, whereas age was the predictor of aortic strain.

Conclusions: The elasticity of the proximal ascending aorta is decreased in heterozygous FH patients.

Background: Treatment of hyperlipidemia is important for secondary prevention in patients suffering from coronary heart disease. It has been proven that “young elderly” (patients aged 65–75 years) can benefit from the treatment at least as much as younger patients.

Objective: To assess the adequacy of treatment as part of secondary prevention in “young elderly” and younger patients.

Methods: In this prospective study, 389 patients discharged from the hospital with the diagnosis of coronary heart disease were divided according to age groups. Data were collected regarding lipid profile examinations, dietary and drug therapy, and results of lipid profiles.

Results: Less than one-third of the patients achieved target low density lipoprotein levels. More patients in the older age group achieved the treatment goals. The goals were achieved despite the fact that the percentage of patients treated with lipid-lowering drugs was lower in the older age group.

Conclusion: The percentage of patients treated for hyperlipidemia as part of a secondary prevention plan in Israel is similar to that in other developed countries. The fact that more “young elderly” patients achieve adequate lipid profiles compared to younger patients indicates that there is no age discrimination towards this patient group. The finding that less than one-third of the patients reach the treatment goals should prompt physicians to treat hyperlipidemia more aggressively.

Background:  After the introduction of endoscopic techniques to other surgical fields, like general surgery, gynecology and thoracic surgery, cardiac surgeons sought their own methods of using minimally invasive techniques.

Objectives:  To examine whether this approach is less invasive and yields better results, more desirable cosmetic results, and a more rapid and complete rehabilitation, maintaining safety, efficacy, and outcome equivalent to those of more established procedures, such as median sternotomy.

Methods:  From January 2000 to July 2001, 22 patients underwent video-assisted port-access mitral or aortic valve repair or replacement with the Heartport system in our department, and one underwent closure of atrial septal defect.

Results:  Intraoperative transesophageal echocardiography revealed excellent functional results. Total operating room time, perfusion time, and cross-clamp time in this technique decreased with our growing experience, and remains stable. There were no intraoperative reversals to mid-steronomy, no mortalities, and only one complication 24 hours after surgery.

Conclusions:  Thoracoscopic assisted cardiac surgery (via port access) provides all the advantages of minimally invasive surgery, accelerates recovery, decreases pain, and maintains overall surgical efficacy, while avoiding the complications and pathology of mid-sternotomy.  For appropriate patients, this is the method of choice in our department.

Background: Onchocerciasis results from infestation by the nematode Onchocerca volvulus, and is characterized clinically by troublesome itching, skin lesions and eye manifestations. Since 1992, approximately 9,000 immigrants have arrived in Israel from the Kuwara province of northwest Ethiopia where the prevalence of onchocerciasis is particularly high.

Objectives: To determine whether onchocerciasis is the cause of cutaneous and ocular symptoms among recent immigrants from the Kuwara province in Ethiopia

Methods: We examined 1,200 recent immigrants from the Kuwara province residing at the Mevasseret Zion immigration center outside Jerusalem. Among them, patients with cutaneous signs suggestive of onchocerciasis underwent a skin-snip biopsy and a thorough eye examination.

Results: In the detailed skin examination performed in 83 patients, the most common skin finding was chronic papular onchodermatitis, found in more than 46 patients (55%);depigmentation and atrophy was found in 13 (15%) and 12 (14%), respectively. In 40 patients (48%), living microfilaria were detected in their skin snips. Of the 65 patients who underwent a thorough eye examination, 45 patients (66%) had ocular complaints. Corneal abnormalities were found in 55 of the 130 eyes (42%), active anterior segment intraocular inflammation and live microfilariae were found in 4 eyes (3%) and lens changes in 16 eyes (1 %). Eleven eyes (9%) showed retinal or choroidal changes.

Conclusions: Skin and eye manifestations associated with onchocerciasis are prevalent among symptomatic Ethiopian immigrants to Israel from the Kuwara province.

Background: Radiofrequency ablation has recently become a viable treatment option for unresectable primary or secondary lesions confined to the liver.

Objective: To study the local therapeutic efficacy, side effects and complications of radiofrequency ablation for the treatment of hepatocellular carcinoma and liver metastases This is the first reported experience of radiofrequency ablation for treating malignant hepatic tumors in Israel.

Methods: Fifteen consecutive patients, aged 53–73 years, with 23 lesions (8 patients with HCC[1] and 7 with secondary liver tumors) underwent radiofrequency ablation under general anesthesia. RITA nine-array 5 cm thermal ablation catheter and the model 1500 generator were used. The mean diameter of all tumors was 4.28 cm (range 1–10 cm). Three lesions were 1–3 cm in diameter (small), 17 lesions measured 3.1–5 cm (medium), and 3 measured 5.1–10 cm (large).

Results: Complete necrosis was found in 8 (66%) of 12 HCCs by computed tomography scan. Of the remainder, diffuse tumor recurrence was demonstrated in three lesions (25%) after lipiodol injection and there was one local tumor recurrence. In the metastases group complete necrosis was found in 5 of 11 lesions (45%). One major complication (peritonitis) was treated with antibiotics and four (26%) minor complications (right pleural effusion, small subcapsular hematoma) were monitored.

Conclusions: Radiofrequency ablation appears to be an effective, safe and relatively simple procedure for the treatment of liver tumors.