Israel Medical Association Journal

Objectives: To assess the implementation of intravenous rt-PA[1] in routine clinical care at our center after its formal approval in Israel, and the therapeutic and logistic implications for reperfusion therapy for acute ischemic stroke in Israel.

Methods: Patients with acute ischemic stroke, admitted between January 2005 and June 2006, who were treated with intravenous rt-PA or endovascular-based reperfusion were reviewed. Implementation, timing, safety and clinical outcomes were assessed.

Results: Forty-six patients received reperfusion therapy (37 with intravenous rt-PA and 9 with endovascular-based therapy), corresponding to 4.0% of ischemic stroke patients in 2005 and a projection of 6.2% in 2006. Mean age of intravenously treated patients was 67 years (range 22–85 years), median baseline NIHSS score was 14 (range 10–18, 25–75%) and the median ‘onset to drug time’ was 150 minutes (range 120–178, 25–75%). Symptomatic intracerebral hemorrhage and orolingual angioedema each occurred in one patient (2.7%). Significant clinical improvement occurred in 54% of treated patients and 38% of patients were independent at hospital discharge.

Conclusions: Use of reperfusion therapy for acute ischemic stroke has increased in our center after the formal approval of rt-PA therapy to over 5%, with ‘onset to drug time’, safety and outcome after intravenous rt-PA treatment comparing favorably with worldwide experience. A prerequisite for the implementation of effective reperfusion therapy and expansion of the proportion of patients treated nationwide is the establishment of a comprehensive infrastructure.

Objectives: To describe patients with initially misdiagnosed PTP[1] and to emphasize the diagnostic pitfalls of this disorder.

Patients and Results: During a period of 11 years we have diagnosed six patients with PTP, four women and two men. The incidence of PTP was approximately 1:24,000 blood components transfused. We present the detailed clinical course of three of the six patients in whom the diagnosis was particularly challenging. The patients were initially misdiagnosed as having heparin-induced thrombocytopenia, systemic lupus erythematosus complicated by autoimmune thrombocytopenia, and disseminated intravascular coagulation. A history of recent blood transfusion raised the suspicion of PTP and the diagnosis was confirmed by appropriate laboratory workup.

Conclusions: PTP seems to be more frequent than previously described. The diagnosis should be considered in the evaluation of life threatening thrombocytopenia in both men and women with a recent history of blood transfusion.

Background: Anti-influenza vaccination has proven cost-effective for society. In Israel, however, vaccination rates remain relatively low in comparison to other countries.

Objectives: To analyze the socioeconomic and health status factors affecting the decision to be vaccinated against flu and to compare these factors to results from other countries in order to determine which segments of the adult population should be targeted for increased coverage in influenza vaccination programs.

Methods: Our source was the 1999/2000 Health Survey of the Central Bureau of Statistics for the group aged 25 and above, comprising 16,033 individuals. We used statistical methods such as the Probit regression model to estimate the effects of socioeconomic and health status variables on the decision to get a flu shot. The variables included gender, age, marital status, education, ethnic origin, religious affiliation and housing density, as well as chronic illnesses, smoking, hospitalizations, membership in health management organizations and kibbutz membership.

Results: Our findings indicate that being a post-1990 immigrant from the former Soviet Union, living in a densely populated house, being unmarried and smoking heavily are important factors in predicting the decision not to be vaccinated. In contrast, chronic illness, previous hospitalizations, older age, and kibbutz membership have a positive effect on the decision to take the vaccine.

Conclusions: It is necessary to identify the socioeconomic and health variables marking population sectors that are less likely to be vaccinated in order to design a suitable policy to encourage vaccination.

Objectives: To assess the prevalence of reversible and treatable cardiovascular risk factors among 26’477 healthy Israeli adults: 23’339 men and 3138 women aged 25-55 years.

Methods: We collected data during routine examinations performed as part of a screening program for Israel Defense Force personnel.

Background: The degree of left ventricular dysfunction determines the prognostic outcome of patients with acute myocardial infarction.

Objectives: To define the clinical, angiographic and procedural variables related to LV[1][1] dysfunction in patients with  with anterior wall AMI[1][2] referred for primary percutaneous coronary intervention.

Methods: The sample included 168 patients treated by primary PCI[1][3] for first anterior wall AMI. Clinical, demographic and medical data were collected prospectively into a computerized registry, and clinical outcome (death, reinfarction, major cardiovascular event) were evaluated during hospitalization and 30 days after discharge. Patients were divided into three groups by degree of LV dysfunction (mild, moderate, severe) and compared for clinical, angiographic and procedural variables.

Results: LV dysfunction was associated with pre-PCI renal failure (serum creatinine > 1.4 mg/dl), peripheral vascular disease, high peak creatine kinase level, longer door to balloon time, low TIMI flow grade before and after PCI, and use of an intraaortic balloon pump. On multivariate analysis adjusted for baseline differences, peak creatine kinase level (r = 0.3, P = 0.0001) and door to needle time (r = 0.2, P = 0.008) were the most significant independent predictors of moderate or severe LV dysfunction after anterior AMI.

Conclusion: Abnormal LV function after first anterior AMI can be predicted by door to balloon time and the size of the infarction as assessed by creatine kinase levels. Major efforts should be made to decrease the time to myocardial reperfusion.

[1][1] LV = left ventricular

[1][2] AMI = acute myocardial infarction

[1][3] PCI = percutaneous coronary intervention