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עמוד בית
Mon, 25.11.24

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December 2006
O. Bairey, R. Ruchlemer and O. Shpilberg

Background: Non-Hodgkin’s lymphoma of the colon is a rare and consequently poorly studied extranodal lymphoma. Most of the previous publications used old pathologic classifications and old diagnostic and treatment approaches.

Objective: To examine the clinical presentation, pathologic classification, treatment and outcome of patients with NHL[1] of the colon.


Methods: A retrospective study was performed of all patients with NHL and involvement of the colon in two medical centers. The patient group consisted of 17 patients over a 13 year period.


Results: Fourteen patients had primary involvement and 3 secondary. The ileocecal region and cecum were the most frequent sites of involvement, occurring in 76% of patients. Most patients had bulky disease: three had a diameter > 5 cm and eight a diameter > 10 cm. Aggressive histology was found in 12 patients: diffuse large B cell lymphoma in 11 and peripheral T cell lymphoma in 1. Three patients had mantle cell lymphoma and two had indolent lymphomas: mucosa-associated lymphoid tissue (n=1) and small lymphocytic (n=1). Eleven patients underwent hemicolectomy: right sided in 9 and left sided in 2, and 5 DLBCL[2] patients required emergency surgery for intestinal perforation. The median overall survival was 44 months (range 1–147). Disease stage influenced prognosis; six of seven patients with limited-stage DLBCL who received aggressive chemotherapy achieved complete remission and enjoyed prolonged survival, whereas patients with aggressive disseminated disease had resistant disease and poor survival (median 8 months).


Conclusions: Most colonic lymphomas are aggressive B cell lymphomas. Diagnosis is often delayed. Early diagnosis may prevent perforation. Those with limited-stage disease when treated with aggressive chemotherapy may enjoy prolonged survival. 

The role of elective hemicolectomy to prevent perforation should be examined in prospective trials.




[1] NHL = non-Hodgkin's lymphoma

[2] DLBCL = diffuse large B cell lymphoma  

A. Jotkowitz, A. Porath, A. Shotan, M. Mittelman, E. Grossman, R. Zimlichman, B.S. Lewis, A. Caspi, S. Gottlieb and M. Garty, for the Steering Committee of the Israeli Heart Failure National Survey 2003

Background: Despite significant advances in the therapy of heart failure, many patients still do not receive optimal treatment.

Objectives: To document the standard of care that patients hospitalized with HF[1] in Israel received during a 2 month period.

Methods: The Heart Failure Survey in Israel 2003 was a prospective 2 month survey of patients admitted to all 25 public hospitals in Israel with a diagnosis of HF.

Results: The mean age of the 4102 patients was 73 years and 43% were female. The use of angiotensin-converting enzyme/angiotensin receptor blockers and beta blockers both declined from NYHA class I to IV (68.8% to 50.6% for ACE[2]-inhibitor/ARB[3] and 64.1% to 52.9% for beta blockers, P < 0.001 for comparisons). The percentage of patients by NYHA class taking an ACE-inhibitor or ARB and a beta blocker at hospital discharge also declined from NYHA class I to IV (47.5% to 28.8%, P < 0.002 for comparisons). The strongest predictor of being discharged with an ACE-inhibitor or ARB was the use of these medications at hospital admission. Negative predictors for their usage were age, creatinine, disease severity class, and functional status.

Conclusions: Despite the dissemination of guidelines many patients did not receive optimal care for HF. Reasons for this discrepancy need to be identified and modified.






[1] HF = heart failure



[2] ACE = angiotensin-converting enzyme



[3] ARB = angiotensin receptor blocker


R. Avisar, R. Friling, M. Snir, I. Avisar and D. Weinberger

Background: The prevalence and incidence of blindness in Israel appear to be comparable to other western countries. Comparisons are difficult because of different definitions of blindness, and the uniqueness of the Israeli registry for the blind.

Objective: To characterize the population who were registered as Blind in Israel in the years 1998–2003 and estimate the prevalence and incidence of blindness by age and causes of blindness.

Methods: A retrospective review of the annual report of the National Registry for the Blind in Israel between 1998 and 2003 identified 21,585 blind persons who received a certificate for blindness. Blind persons are identified by ophthalmologists throughout Israel and referred to the Registry of the Blind if they have a visual acuity of 3/60 or worse, or a visual field loss of < 20 degrees in their better eye. This report includes prevalence data on 21,585 persons enrolled in this review still alive and living in Israel in 2003. We estimated the prevalence rate of blindness nationwide and the incidence rate for each cause of blindness for every year.

Results: The main leading causes of blindness in Israel in 1998 were (in percent of the total number of newly registered patients): age-related macular degeneration (20.1%), glaucoma (13.8%), myopic maculopathy (12%), cataract (10.4%), diabetic retinopathy and maculopathy (10.1%), and optic atrophy (7.9%), and in 2003, 28%, 11.8%, 7.4%, 6.5%, 14.4% and 6.5% respectively.

Conclusions: The results indicate that the incidence of age-related macular degeneration, diabetic retinopathy and maculopathy in Israel is increasing, while that of glaucoma, myopic maculopthy, optic atrophy and cataract is decreasing.

November 2006
R. Segal, A. Furmanov and F. Umansky
 Background: The recent occurrence of a spontaneous intracerebral hemorrhage in Israel’s Prime Minister placed the scrutiny of local and international media on neurosurgeons as they made therapeutic decisions. In the ensuing public debate, it was suggested that extraordinary measures (surgical treatment) were undertaken only because of the celebrity of the patient.

Objectives: To evaluate the criteria used to select surgical versus medical management for SICH.

Methods: We retrospectively reviewed the files of 149 consecutive patients admitted with SICH[1] from January 2004 through January 2006 to our medical center. Their mean age was 66 (range 3–92 years), and 62% were male. SICH localization was lobar in 50% of patients, thalamus in 23%, basal ganglia in 15%, cerebellum in 13%, intraventricular in 6%, and pontine in 1%. Mean admission Glasgow Coma Score was 9 (range 3–15). Risk factors included hypertension in (74%), diabetes mellitus (34%), smoking (14%) and amyloid angiopathy (4%). Fifty percent of patients were on anticoagulant/antiplatelet therapy, including enoxaparin (3%), warfarin (7%), warfarin and aspirin (9%), or aspirin alone (34%).      

Results: Craniotomy was performed in 30% of patients, and ventriculostomy alone in 3%. Rebleed occurred in 9% of patients. Six months after the treatment 36% of operated patients were independent, 42% dependent, and 13% had died. At 6 months, 37% of non-operated patients were independent, 15% dependent, and 47% had died.

Conclusions: One-third of the SICH patients, notably those who were experiencing ongoing neurologic deterioration and had accessible hemorrhage, underwent craniotomy. The results are good, considering the inherent mortality and morbidity of SICH.


 





[1] SICH = spontaneous intracerebral hemorrhage


October 2006
J-N. Zhou, D-Z. Wang, X-E. Huang, F-P Xu, J-Q. Shang and R-M. Gu
 Background: The combination of high dose preoperative radiotherapy and transanal abdominal transanal with radical proctosigmoidectomy and colo-anal anastomosis as a sphincter-preserving method has never been performed in mainland China.

Objectives: To assess the feasibility and efficacy of high dose preoperative radiotherapy and TATA[1] as a sphincter-preserving method in Jiangsu, an economically well-developed region of China with a population of 70 million people.

Methods: From September 1994 to September 2000, 25 consecutive patients with pathologically confirmed distal rectal adenocarcinoma were treated preoperatively with a total dose of 45–46 Gy at 1.8–2.0 Gy per fraction during 5 weeks. Sphincter-preserving surgery by TATA was performed 4–6 weeks after radiotherapy. 

Results: Acute toxicity of preoperative radiotherapy was tolerable. Eight percent of the patients presented pathologic complete tumor response after preoperative radiotherapy. All patients underwent TATA as scheduled. During a median follow-up of 70 months, the 5 year survival rate was 88%. The 5 year survival rate for those tumors down-staged to pathological T0 or to pT1 was 100%.

Conclusions: High dose preoperative radiotherapy and TATA as a sphincter-preserving method was feasible and efficient in Chinese patients with distal rectal cancer. In this study, the subset of patients with a good response to radiotherapy had a better clinical outcome.


 





[1] TATA = transanal abdominal transanal


V.H. Eisenberg, D. Raveh, Y. Meislish, B. Rudensky, Y. Ezra, A. Samueloff, A.I. Eidelman and M.S. Schimmel
 Background: Previous assessments of maternal group B Streptococcus carrier rates in women delivering at Shaare Zedek Medical Center ranged between 3.5 and 11% with neonatal sepsis rates of 0.2–0.9/1000 live births. Because of low colonization and disease rates, routine prenatal cultures of GBS[1] were not recommended, and intrapartum prophylaxis was mainly based on maternal risk factors.

Objectives: To determine whether this policy is still applicable. 

Methods: We performed prospective sampling and follow-up of women admitted for labor and delivery between February 2002 and July 2002. Vaginal and rectal cultures were obtained before the first pelvic examination. GBS isolation was performed using selective broth medium, and identified by latex agglutination and serotyping. Demographic data were collected by means of a standardized questionnaire. Data on the newborns were collected throughout 2002.

Results: Of the 629 sampled women, 86 had a positive culture and a carrier rate of 13.7%. A borderline significantly higher carriage rate was observed among mothers of North American origin (21% vs. 13.1%, P = 0.048), and a higher attack rate in their infants (3.8/1000 compared with 0.5/1000 live births in our general maternal population, P = 0.002). Eight newborns had early-onset neonatal GBS sepsis (a rate of 0.8/1000 live births), but none of them benefited from intrapartum antibiotic prophylaxis.

Conclusions: An increased neonatal disease rate was observed in a population with a higher colonization rate than previously seen. In lieu of the higher carrier rates, we now recommend routine prenatal screening for GBS in our perinatal population.


 





[1] GBS = group B Streptococcus


H. Berkenstadt, A. Ziv, N. Gafni and A. Sidi
 Background: The Israeli Board of Anesthesiology Examination Committee added a simulation-based Objective Structured Clinical Evaluation (OSCE) component to the board examination process. This addition was made in order to evaluate medical competence and considers certain domains that contribute to professionalism. This unique and new process was in a need to be validated.

Objectives: To validate and evaluate the reliability and realism of incorporating simulation-based OSCE into the Israeli Board Examination in Anesthesia.

Methods: Validation was performed before the exam regarding Content Validity using the modified Delphi technique by members of the Task Force of the Israeli Board Examination Committee in Anesthesiology.

Results: The examination has been administered six times in the past 3 years to a total of 145 examinees. The pass rate ranged from 62% (trauma) to 91% (regional anesthesia). The mean inter-rater correlations for the total score (all items), for the Critical checklist items score, and for the Global (General) rating were 0.89, 0.86 and 0.76, respectively. The inter-correlations between the five OSCE stations scores were significant (P < 0.01) only between Trauma & Ventilation for the Total score (r = 0.32, n=63), and between Resuscitation & Regional and OR-crisis for the Global score (r = 0.42 and 0.27, n=64 and 104, respectively). The correlation between the OSCE examination score and the success rate at each of the eight different clinical domains of the oral board examination did not reach statistical significance. Most participants (70–90%) found the difficulty level of the examination stations reasonable to very easy. All major errors, which were identified in the initial two exam periods, disappeared later in the next two exam periods.

Conclusions: The exam has gradually progressed from being an optional part of the oral board examination to a prerequisite component of this test. Other anesthesiology programs or medical professions can adopt the model described here.

September 2006
D. Chemtob, B. Damelin, N Bessudu-Manor, R. Hassman, Y. Amikam, J.M. Zenilman and D. Tamir

Background: Israel, as a country of immigration, has a heterogeneous distribution of risk for human immunodeficiency virus. Therefore, general population-based surveys of sexual behaviors among young adults may be useful for guiding prevention policy. To the best of our knowledge, the present survey is the first one among Israeli adults ever published.

Objectives: To survey knowledge, attitudes and practices regarding sexually transmitted infections in Israeli adults in order to target the future AIDS public campaigns for the general population.

Methods: A national sample of 800 individuals, aged 18–45, was interviewed telephonically in September 2000.

Results: The average number of sexual partners reported in the previous 3 months was 1.3. Accurate knowledge on HIV[1] transmission modes was expressed by 99% of respondents for unprotected sexual intercourse, 97% for re-use of needles and syringes, and 85% for mother-to-child infection. However, incorrect notions on transmission were also prevalent (34% for insect bites, 29% for kissing and 21% for public toilets). Prevention of STIs[2] and prevention of pregnancy were the most common reasons for using condoms (72–73%); HIV prevention was the motivation for 39%. Fifty percent of single individuals without steady partners always/usually used condoms. It was decided that women need empowerment to negotiate condom use.

Conclusions: Gaps were found between knowledge (at high level), attitudes (perceiving greater risk for others than themselves) and behavioral practices (combining low level of partner exchange with widespread disregard for safe sex). Promptly implemented, these findings will serve as a baseline for further surveys.






[1] HIV = human immunodeficiency virus



[2] STI = sexually transmitted infection


R. Yerushalmi, E. Fenig, D. Shitrit, D. Bendayan, A. Sulkes, D. Flex and M.R. Kramer

Background: Endobronchial stents are used to treat symptomatic patients with benign or malignant airway obstructions.

Objectives: To evaluate the safety and outcome of airway stent insertion for the treatment of malignant tracheobronchial narrowing.

Methods: The files of all patients with malignant disease who underwent airway stent insertion in our outpatient clinic from June 1995 to August 2004 were reviewed for background data, type of disease, symptoms, treatment, complications, and outcome.

Results: Airway stents were used in 34 patients, including 2 who required 2 stents at different locations, and one who required 2 adjacent stents (total, 37 stents). Ages ranged from 36 to 85 years (median 68). Primary lung cancer was noted in 35% of the patients and metastatic disease in 65%. Presenting signs and symptoms included dyspnea (82%), cough (11.7%), hemoptysis (9%), pneumonia (5.9%), and atelectasis (3%). The lesions were located in the left mainstem bronchus (31%), trachea (26%), right mainstem bronchus (26%), subglottis (14.3%), and bronchus intermedius (2.9%). Conscious sedation alone was utilized in 73% of the patients, allowing for early discharge. Eighteen patients (50%) received brachytherapy to the area of obstruction. Complications included stent migration (one patient) and severe or minimal bleeding (one patient each). Ninety-four percent of the patients reported significant relief of their dyspnea. Three of the four patients who had been mechanically ventilated before the procedure were weaned after stent insertion. Median survival from the time of stent placement was 6 months (range 0.25–105 months).

Conclusion: Stent placement can be safely performed in an outpatient setting with conscious sedation. It significantly relieves the patient's symptoms and may prolong survival.
 

D. Nitzan Kaluski, E. Barak, Z. Kaufman, L. Valinsky, E. Marva, Z. Korenman, Z. Gorodnitzki, R. Yishai, D. Koltai, A. Leventhal, S. Levine, O. Havkin and M.S. Green

Contamination of food with streptococci could present with unusual outbreaks that may be difficult to recognize in the early stages. This is demonstrated in a large food-borne outbreak of streptococcal pharyngitis that occurred in 2003 in a factory in Israel. The outbreak was reported to the public health services on July 2 and an epidemiologic investigation was initiated. Cases and controls were interviewed and throat swabs taken. An estimated 212 cases occurred within the first 4 days, the peak occurring on the second day. There was a wave of secondary cases during an additional 11 days. The early signs were of a respiratory illness including sore throat, weakness and fever, with high absenteeism rates suggesting a respiratory illness. As part of a case-control study, cases and controls were interviewed and throat swabs taken. Illness was significantly associated with consumption of egg-mayonnaise salad (odds ratio 4.2, 95% confidence interval 1.4–12.6), suggesting an incubation period of 12–96 hours. The initial respiratory signs of food-borne streptococcal pharyngitis outbreaks could delay the identification of the vehicle of transmission. This could be particularly problematic in the event of deliberate contamination.

August 2006
E. Leibovitz, Y. Gerber, M. Maislos, E. Wolfovitz, T. Chajek-Shaul, E. Leitersdorf, U. Goldbourt and D. Harats for the HOLEM study group
 Background: Obesity is an independent risk factor for ischemic heart disease and affects the status of other risk factors for cardiovascular disease.

Objective: To study the attitude of physicians to obesity by examining discharge letters of overweight patients with ischemic heart disease.

Methods: We used the HOLEM database for this analysis. The HOLEM project was designed to study the NCEP (National Cholesterol Education Program) guideline implementation among patients with IHD[1] at hospital discharge. We documented the recording of risk factors and treatment recommendations for IHD by reviewing the discharge letters of 2994 IHD patients admitted to four central hospitals in Israel between 1998 and 2000. A follow-up visit was held 6–8 weeks after discharge, at which time the diagnosis of IHD was verified, risk factor status was checked, height and weight were measured and drug treatment was reviewed.

Results: Mean body mass index was 28.3 kg/m2 and 32% were obese (BMI[2] ³ 30 kg/m2). Only 39.6% of the obese patients and 65.8% of the morbidly obese patients (BMI ³ 40 kg/m2) had "obesity" noted in their discharging letters, and weight loss recommendation was written in only 15% of the obese patients' discharge letters. Acute episodes like acute myocardial infarction and unstable angina did not influence the notation of obesity, and only BMI and the number of additional risk factors were positively correlated with the notation of this risk factor.

Conclusions: Despite the importance of obesity, weight status was not noted and weight loss was not recommended in most of the discharge letters of obese IHD patients.


 





[1] IHD = ischemic heart disease

[2] BMI = body mass index


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