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: 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: The growing numbers of H1N1 "swine influenza" cases should prompt national health systems to achieve dual preparedness: preparedness of clinicians to recognize and treat cases of human H1N1 flu, and national preparedness for an influenza pandemic. This is similar to recent contingency planning for an avian flu pandemic.

Objectives: To evaluate hospital personnel's knowledge on avian flu (zoonotic, sporadic, pandemic), comparing among nurses, residents and faculty, and between those who attended lectures or other educational modalities targeted at avian flu and those who did not.

Methods: A 14 item multiple choice questionnaire was designed to test crucial points regarding preparedness for human avian flu. The directors of 26 general hospitals were instructed by the Ministry of Health to improve knowledge of and preparedness for different avian flu scenarios, and to expect an official inspection. As part of this inspection, we distributed the questionnaires to nurses, residents and senior physicians.

Results: Altogether, 589 questionnaires were collected from the 26 hospitals. Examinees who participated in training modules (course, lecture or any training provided by the hospital) did somewhat better (scoring 78 points out of 100) than those who did not attend the training (70 points) (P < 0.05). Differences in nurses’ knowledge were even more striking: 66 points for the non-attendants compared to 79 for nurses who attended the lecture (P < 0.05).  Residents had significantly lower scores compared to nurses or senior physicians: 70 compared to 77 and 78 respectively (P < 0.05).

The features of infective endocarditis include both cardiac and non-cardiac manifestations. Neurologic complications are seen in up to 40% of patients with infective endocarditis and are the presenting symptom in a substantial percentage. We describe in detail the clinical scenarios of three patients admitted to our hospital, compare their characteristics and review the recent literature describing neurologic manifestations of infective endocarditis. Our patients demonstrate that infective endocarditis can develop without comorbidity or a valvular defect. Moreover, our patients were young and lacked the most common symptom of endocarditis: fever. The most common neurologic manifestations were focal neurologic deficits and confusion. We conclude that infective endocarditis should always be considered in patients presenting with new-onset neurologic complaints, especially in those without comorbidities or other risk factors. A prompt diagnosis should be reached and antibiotic treatment initiated as soon as possible.

Background: Guidelines are frequently under-implemented in older patients with heart failure. Octogenerians are often excluded from clinical trials.

Objectives: To characterize the clinical profile of the oldest-old (age ≥ 80 years) heart failure patients hospitalized in a subacute geriatric hospital and to evaluate their management and 1 year outcome.

Methods: Patient characteristics and in-hospital course were retrospectively collected. Diagnosis of heart failure was based mainly on clinical evaluation in addition to chest X-ray results and echocardiographic findings when available.

Results: The study population comprised 96 consecutive unselected heart failure patients hospitalized from January to June 2003. The patients were predominantly women (67%), aged 85 ± 5 years, fully dependent or frail with a high rate of comorbidities. Adherence to guidelines and recommended heart failure medications was poor. Their 1 year mortality was 57%. According to logistic regression analysis, predictors of 1 year mortality were lower body mass index (odds ratio 0.86, 95% confidence interval 0.78–0.96) and high urea levels (OR[1] 1.04, 95% CI[2] 1.02–1.06).

Conclusions: Our study confirms that the management of oldest-old heart failure patients hospitalized in a subacute geriatric hospital was suboptimal and their mortality was exceptionally high.

Background: Clinical and epidemiologic features of coronary heart disease may not be explained solely by established risk factors. The role of infectious pathogens in the development and rupture of atherosclerotic plaques remains elusive but an association between Chlamydia pneumoniae, Mycoplasma pneumoniae and CHD[1] has been previously reported

Objectives: To determine whether there is an association between mycoplasmal infections and CHD.

Methods: We conducted a prospective cohort analysis of 150 consecutive hospitalized patients with CHD (85 with acute coronary syndrome and 65 admitted for unrelated reasons) and 98 healthy blood donors. Antibody titers for Mycoplasma pneumoniae, M. fermentans, M. hominis and Ureaplasma urealyticum were measured with the agglutination test or specific enzyme-linked immunosorbent assay in all three groups of patients.

Results: Analysis of the antibody titers did not reveal any significant difference in the presence of mycoplasmal antibodies between the patients with ACS[2], patients with known stable CHD hospitalized for non-CHD reasons, and healthy blood donors.

Conclusions: Determination of specific antibodies did not reveal a significant association among different types of mycoplasmal infection and CHD.





[1] CHD = coronary heart disease

[2] ACS = acute coronary syndrome

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: There is controversy as to which is the preferred treatment for distal radius intra-articular fractures – anatomic reduction or external fixation.

Objectives: To evaluate the radiologic and functional outcome following external fixation of these fractures.

Methods: Between January 2003 and March 2005, 43 patients with distal radius intra-articular fractures were treated using a mini-external AO device. Follow-up of 38 of the patients included X-rays at 1 week, 6 weeks and 6 months postoperatively. The Visual Analogue Scale was used to assess pain levels, and the Lidstrom criteria scale to evaluate functional outcome and wrist motion. Clinical and radiographic results were correlated.

Results: According to the Lidstrom criteria, the results were excellent in 31%, good in 61% and fair in 5.5%; 2.5% had a poor outcome. The results of the VAS[1] were good. Thirty-five patients gained a good range of wrist movement, but 3 had a markedly reduced range. We found statistical correlation between the radiographic and clinical results, emphasizing the value of good reduction. There was no correlation between fracture type (Frykman score) and radiologic results or clinical results.

Conclusions: External fixation seems to be the preferred method of treatment for distal radius intra-articular fractures, assuming that good reduction can be achieved. The procedure is also quick, the risk of infection is small, and there is little damage to the surrounding tissues.