Israel Medical Association Journal

The incidence of invasive uterine cervical cancer in Israeli Jewish women is persistently lower than in many other countries, although the frequency of premalignant lesions is similar to that in other populations. Most characteristics, except certain traditional habits, are similar to those in other populations. The incidence among women born in North Africa and their Israeli born descendants is significantly higher than in those born in other continents, possibly due to genetic factors. In view of the similarities to other populations the reason for the low incidence in Israel remains obscure, and whether it may be attributed to genetic reasons or to some traditional habits remains to be confirmed
 

Background: An outbreak of respiratory illness caused by a novel swine-origin influenza virus (influenza A/H1N1 2009) that began in Mexico was declared a global pandemic by the World Health Organization in June 2009. The pandemic affected many countries, including Israel.

Objectives: To compare the course of chest radiographic and computed tomography findings in patients who survived and those who died following admission to the intensive care unit (ICU) or intubation due to severe laboratory-confirmed swine-origin influenza A/H1N1 2009.

Methods: We retrospectively reviewed the patient records (267 radiographs, 8 CTs) of 22 patients (10 males, 12 females) aged 3.5–66 years (median 34) with confirmed influenza A/H1N1 2009, admitted to the ICU and/or intubated in five major Israeli medical centers during the period July–November 2009. We recorded demographic, clinical, and imaging findings –including pattern of opacification, extent, laterality, distribution, zone of findings, and presence/absence of nodular opacities– at initial radiography and during the course of disease, and compared the findings of survivors and non-survivors. Statistical significance was calculated using the Wilcoxon (continuous variables) and Fisher's exact tests (categorical variables).

Results: The most common findings on the initial chest radiography were airspace opacities, which were multifocal in 17patients (77%) and bilateral in 16 (73%), in the lower or lower and middle lung zones in 19 patients (86%). Large airspace nodules with indistinct margins were seen in 8 patients (36%). Twelve patients survived, 10 died. Patients who died had multiple background illnesses and were significantly older than survivors (P = 0.006). Radiologic findings for the two groups were not significantly different.

Conclusion: Airspace opacities, often with nodular appearance, were the most common findings among patients with severeinfluenza A/H1N1 2009. The course of radiologic findings was similar in patients with severe influenza A/H1N1 2009 whosurvived and those who died.

Background: In the past, carotid endarterectomy (CEA) was the only modality for invasive intervention in cases of carotid stenosis. Due to improvements in endovascular techniques (stenting), there is a growing debate regarding the preferred procedure for carotid intervention.

Objectives: To compare the 30 day complication rate after CEA and carotid angioplasty and stenting (CAS) in a tertiary medical center in Israel between the years 2008 and 2010.

Methods: We reviewed the medical charts of all the patients who underwent either CEA or CAS of the internal carotid artery due to symptomatic and asymptomatic stenosis during the period 2008–2010 (total of 128 patients).

Results: There was no difference between the groups in the rate of severe complications in the peri-procedural period. Mild complications were non-significantly more common in the CEA group (17%) compared to the CAS group (7.1%).

Conclusions: There was no significant difference in the mild and severe complications rate between CEA and CAS in the peri-procedural period.

Background: Staphylococcus aureus infection is a major cause of morbidity and mortality worldwide. Clindamycin is widely used in the treatment of staphylococcal infections; however, it is our impression that in the last few years, inducible clindamycin resistance (ICR) has become more prevalent.

Objective: To assess the prevalence of ICR[1] in methicillin-sensitive Staphylococcus aureus (MSSA) infections among pediatric patients in Israel.

Methods: We reviewed the files of children diagnosed with MSSA[2] infections during the period January 2006 to June 2007 for full antibiogram (including the D-test for ICR), phage typing and randomly amplified polymorphic DNA.

Results: Altogether, 240 MSSA isolates were recovered, mainly from wounds and abscesses. ICR was detected in 62 of 68 erythromycin-resistant/clindamycin-sensitive strains (91%); the ICR rate for the total number of isolates was 26% (62/240). Phage type analysis demonstrated that 38 of 61 ICR isolates

(62%) were sensitive to group 2, compared to 42 of 172 isolates (24%) that did not express ICR (P < 0.01). On randomly amplified polymorphic DNA, phage type 2 isolates expressing ICR belonged to the same clone, which was different from ICR isolates sensitive to other phages and from isolates not expressing ICR.

Conclusions: Inducible clindamycin resistance is common among methicillin-sensitive Staphylococcus aureus in Israeli children. The D-test should be performed routinely in all isolates of MSSA.

Background: Exacerbations of chronic obstructive pulmonary disease (COPD) are a major problem worldwide and are usually the main indication for mechanical ventilation (MV), especially in the intensive care unit (ICU). The rate of weaning failure is also high and prolonged MV leads to complications of intubation. The goal is to wean these patients as soon as possible.

Objective: To determine the optimal time necessary to start the weaning process.

Methods: In an attempt to determine the length of MV and stay in the ICU, we compared the length of MV, weaning, re-intubations and discharge during a 10 month period. This study included 122 patients on MV due to severe exacerbation of COPD who were not suitable for non-invasive ventilation. For each patient serial arterial blood gases were measured at admission and during hospitalization. PeCO₂ (mixed expired CO₂) was tested using a Datex S/5 instrument at follow-up.

Results: The study population comprised all patients who required MV; of these 122, 108 were ventilated from 6 to 140 hours (average 48 ± 42), 9 needed more than 168 hours, and 5 died due to severe ventilation-associated pneumonia. No correlation was found between pH, PCO₂ and length of MV; these findings did not contribute to evaluation of the patient’s condition nor did they enable us to predict the length of treatment necessary.

Conclusion: Most of the patients (93%) ventilated for acute respiratory failure due to COPD required MV for only 6–90 hours.

Background: Percutaneous angioplasty (PTA) and stenting is an established procedure for the treatment of hypertension caused by atherosclerotic renal artery stenosis. However recently, the decision whether or not to perform this procedure has raised considerable debate.

Objectives: To examine the association between the basic clinical and radiological characteristics of candidates for renal artery PTA and the clinical outcome of the procedure in terms of improvement of blood pressure control and renal function.

Methods: We conducted a retrospective cohort study of all patients who underwent percutaneous transluminal renal artery angioplasty (PTRA) and stent implantation in a tertiary medical center during the period 2000–2007. The clinical and radiological data were extracted from the medical file of each patient. Blood pressure measurements and creatinine level were recorded before the procedure and 1 month, 6 months, 12 months and 18 months after PTRA.

Results: Thirty-two patients were included in the final statistical analysis. The mean age of the study population was 66.6 ± 8.8 years old and 75% were men. There was a significant reduction in both systolic and diastolic blood pressure 1 month after the procedure: 160.5 ± 24.7 vs. 141.8 ± 23.6 mmHg and 83.8 ± 12.9 vs. 68.8 ± 11.8 mmHg respectively (P < 0.001). The reduction in blood pressure was constant throughout the follow-up period and was evident 18 months after the procedure: 160.5 ± 24.7 vs. 135.0 ± 35.1 mmHg and 83.8 ± 12.9 vs. 71.3 ± 16.5 mmHg respectively (P < 0.001). However, no improvement in renal function was observed at any time during the follow-up period. We could not demonstrate an association between clinical or radiological features and the clinical outcome after PTRA.

Conclusions: Our findings show that PTRA[1] can be considered an effective procedure for improving blood pressure control in patients with atherosclerotic renal artery stenosis (ARAS) and resistant hypertension. This research, together with previous studies, strengthens the knowledge that the decline in glomerular filtration rate seen in many patients with ARAS is non-reversible and is not improved by PTRA.

Background: Several studies have suggested that iron deficiency may be related to the pathophysiology of attention deficit hyperactivity disorder (ADHD) due to the role of iron in the production of dopamine and noradrenaline.

Objectives: To evaluate the status of iron deficiency in ADHD children, using ferritin levels, a reliable measure of iron storage in body tissue, as an iron status marker, and to investigate a possible correlation between ferritin levels and the diagnosis of ADHD.

Methods: The study group included 113 newly referred ADHD children aged 5–15 years (mean age 8.8 ± 2.7).

Results: Ferritin levels were below 20 ng/ml in 67 children (59%) and above 20 ng/ml in 45 (41%). There was a very low inverse statistical correlation between scores on Conners’ Rating Scale and ferritin levels, probably without clinical significance. 

Conclusions: Our findings suggest that low iron stores may be related to ADHD pathophysiology; therefore, ferritin should be included in the overall evaluation of children with ADHD.

Background: Gastric stump cancer is often described as a tumor with a poor prognosis and low resectability rates.

Objectives: To compare the pathological characteristics of gastric stump cancer patients with those of patients with proximal gastric cancer.

Methods: This retrospective study was based on the demographic and pathological data of patients diagnosed with gastric cancer and treated at Assaf Harofeh Medical Center during an 11 year period. The patients were divided into two groups: those undergoing proximal gastrectomy for proximal gastric cancer and those undergoing total gastrectomy for gastric stump cancer.

Results: Patients with gastric stump cancer were predominantly male, older (P = 0.202, not significant), and had a lower T stage with less signet-ring type histology, fewer harvested and fewer involved lymph nodes (P = 0.03, statistically significant) and less vascular/lymphatic involvement than patients with proximal gastric cancer.

Conclusions: The lower incidence of involved lymph nodes and lymphovascular invasion in gastric stump cancer as compared to proximal gastric cancer in this study may imply that the prognosis of gastric stump cancer may be better than that of proximal gastric cancer. However, to verify this assumption a study comparing patient survival is required.