Objectives: To investigate the incidence of splenic emboli treated in a single general internal medicine department over the last 3 years.

Methods: We examined the records of a 35 bed internal medicine department in a hospital in the center of Israel.

Results: Over a period of 3 years 13 patients admitted to one internal medicine department developed acute abdominal pain and areas of hypoperfusion in the spleen on contrast computed tomography imaging. The patients were treated with anticoagulants, their course was benign and there were no long-term sequelae.

Conclusions: Embolus to the spleen is not rare in an internal medicine department. Diagnosis can be easily made by contrast CT scanning and treatment with anticoagulants results in a good prognosis. 

Background: The model for end-stage liver disease is the best available predictor of waiting list mortality among liver transplant candidates.

Objectives: To validate the applicability of MELD[1] in Israel.

Methods: All candidates awaiting liver transplantation in our institution were followed prospectively since 2002. We measured the concordance (c-statistic) equivalent to the area under the receiver operating characteristic curve in order to assess the predictive power of MELD. Other independent mortality risk factors were identified by a separate multivariate analysis. Mortality rates within different MELD and Child‑Pugh‑Turcotte scores were compared to the original (United States) MELD data.

Results: Of 86 patients listed for transplantation, 40 were transplanted (36 in Israel and 4 abroad). Of the other 46 patients, 24 are alive and still listed, and 22 died (25%, ~7%/year). The area under the ROC[2] curve for MELD score was 0.79 (0.83 USA) compared to a CPT[3] score of 0.71 (O.76 USA). High MELD scores, occurrence of spontaneous bacterial peritonitis, and diagnosis of hepatocellular carcinoma were independent risk factors of mortality. Death rates per mid MELD score (20–29) were significantly higher than the USA results.

Conclusions: MELD is valid in Israel and superior to CPT in predicting waiting list mortality. Although longer waiting time due to organ scarcity is a key factor, death rates in the mid-range (10–29) MELD groups indicate further audit of the care of patients with end‑stage liver disease.

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.

Background: Virtual reality immersion has been advocated as a new effective adjunct to drugs for pain control. The attenuation of pain perception and unpleasantness has been attributed to the patient's attention being diverted from the real, external environment through immersion in a virtual environment transmitted by an interactive 3-D software computer program via a VR[1] helmet.

Objectives: To investigate whether VR immersion can extend the amount of time subjects can tolerate ischemic tourniquet pain.

Methods: The study group comprised 20 healthy adult volunteers. The pain was induced by an inflated blood pressure cuff during two separate, counterbalanced, randomized experimental conditions for each subject: one with VR and the control without VR exposure. The VR equipment consisted of a standard computer, a lightweight helmet and an interactive software game.

Results: Tolerance time to ischemia was significantly longer for VR conditions than for those without (P < 0.001). Visual Analogue Scale (0–10) ratings were recorded for pain intensity, pain unpleasantness, and the time thought about pain. Affective distress ratings of unpleasantness and of time thought about pain were significantly lower during VR as compared with the control condition (P < 0.003 and 0.001 respectively).

Conclusions: The VR method in pain control was shown to be beneficial. The relatively inexpensive equipment will facilitate the use of VR immersion in clinical situations. Future research is necessary to establish the optimal selection of clinical patients appropriate for VR pain therapy and the type of software required according to age, gender, personality, and cultural factors.

The adult human heart has limited regenerative capacity and, therefore, functional restoration of the damaged heart presents a great challenge. Despite the progress achieved in the pharmacological and surgical treatment of degenerative myocardial diseases, they are still considered a major cause of morbidity and mortality in the western world. Repopulation of the damaged heart with cardiomyocytes represents a novel conceptual therapeutic paradigm but is hampered by the lack of sources for human cardiomyocytes. The recent derivation of pluripotent human embryonic stem cell lines may provide a solution for this cell sourcing problem. This review will focus on the derivation of the hESC[1] lines, their mechanism of self-renewal, and their differentiation to cardiomyocytes. The possible signals and cues involved in the commitment and early differentiation of cardiomyocytes in this model will be discussed as well as the molecular, structural and electrophysiologic characteristics of the generated hESC-derived cardiomyocytes. Finally, the hurdles and challenges toward fully harnessing the potential clinical applications of these unique cells will be described.

Background: There are no national data on the burden and management of acute cerebrovascular disease in Israel.

Objectives: To delineate the burden, characteristics, management and outcomes of hospitalized patients with acute cerebrovascular disease in Israel, and to examine adherence to current guidelines.

Methods: We prospectively performed a national survey in all 28 hospitals in Israel admitting patients with acute cerebrovascular events (stroke or transient ischemic attacks) during February and March 2004.

Results: During the survey period 2,174 patients were admitted with acute cerebrovascular disease (mean age 71 ± 13 years, 47% women; 89% ischemic stroke or TIA[1], 7% intracerebral hemorrhage and 4% undetermined stroke). Sixty-two percent of patients were admitted to departments of Medicine and a third to Neurology, of which only 7% were admitted to departments with a designated stroke unit. Head computed tomography was performed during hospitalization in 93% of patients. The overall rate of urgent thrombolytic therapy for acute ischemic stroke was 0.5%. Among patients with ischemic stroke or TIA, 94% were prescribed an antithrombotic medication at hospital discharge, and among those with atrial fibrillation about half were prescribed warfarin. Carotid duplex was performed in 30% and any vascular imaging study in 36% of patients with ischemic events. The mean length of hospital stay was 12 ± 27 days for ICH[2] and 8 ± 11 days for ischemic stroke. Among patients with ICH, 28% died and 66% died or had severe disability at hospital discharge, and for ischemic stroke the corresponding rates were 7% and 41% respectively. Mortality rates within 3 months were 34% for ICH and 14% for ischemic stroke.

Conclusions: This national survey demonstrates the high burden of acute stroke in Israel and reveals discordance between existing guidelines and current practice. The findings highlight important areas for which reorganization is imperative for patients afflicted with acute stroke.

Background: Phototherapy is considered the standard of care for neonatal jaundice. However, its short term cardiorespiratory effects have not been studied thoroughly.

Objectives: To assess the cardiorespiratory effect of phototherapy during sleep in term infants with physiologic jaundice.

Methods: We performed two polysomnography studies during 3 hours sleep in 10 healthy term infants with physiologic jaundice; each infant served as his/her own control. The first study was performed just prior to phototherapy and the second study during phototherapy 24 hours later. Heart and respiratory rates, type and duration of apneas, and arterial oxygen saturation were analyzed during active and quiet sleep.

Results: Term infants (gestational age 38.6 ± 1.4 weeks, birth weight 3.2 ± 0.5 kg) underwent the two polysomnography studies within a short time interval and had a comparable bilrubin level (3.6 ± 0.8 and 4.5 ± 0.8 days; 14.5 ± 1.4 and 13.8 ± 2.1 mg/dl, P = NS, respectively). There was no difference in sleeping time or the fraction of active and quiet sleep before or during phototherapy. During active sleep under phototherapy there was a significant decrease in respiratory rate and increase in heart rate (54.3 ± 10.3 vs. 49.1 ± 10.8 breaths/minute, and 125.9 ± 11.7 vs. 129.7 ± 15.3 beats/minute, respectively, P < 0.05), as well as a decrease in respiratory effort in response to apnea. These effects were not found during quiet sleep. Phototherapy had no significant effect on oxygen saturation, apnea rate or periodic breathing in either sleep state. No clinical significant apnea or bradycardia occurred.

Conclusions: Phototherapy affected the cardiorespiratory activity during active sleep but not during quiet sleep in term infants with physiologic jaundice. These effects do not seem to have clinical significance in "real-life" conditions.

Background: Ischemic mitral regurgitation is associated with reduced survival after coronary artery bypass surgery.

Objectives: To compare long-term survival among patients undergoing coronary surgery for reduced left ventricular function and severe ischemic MR[1] in whom the valve was either repaired, replaced, or no intervention was performed.

Methods: Eighty patients with severe left ventricular dysfunction and severe MR underwent coronary bypass surgery. The mean age of the patients was 65 years (range 42–82), and 63 (79%) were male. Sixty-three (79%) were in preoperative NYHA functional class III-IV (mean NYHA 3.3), and 26 (32%) were operated on an urgent/emergent basis. Coronary artery bypass surgery was performed in all patients. The mitral valve was repaired in 38 and replaced in 14, and in 28 there was no intervention. The clinical profile was similar in the three groups, although patients undergoing repair were slightly younger.

Results: Operative mortality was 15% (8%, 14%, and 25% for the repair, replacement and no intervention respectively; not significant). Long-term follow up was 100% complete, for a mean of 38 months (range 2–92). Twenty-nine patients (57%) were in NYHA I-II (mean NYHA 2.3). Among the surgery survivors, late survival was improved in the repair group compared to the other groups (P < 0.05). Predictors for late mortality were non-repair of the mitral valve, residual MR, and stroke (P = 0.005).

Conclusions: Patients with severe ischemic cardiomyopathy and severe MR undergoing coronary bypass surgery should have a mitral procedure at the time of surgery. Mitral valve repair offers a survival advantage as compared to replacement or no intervention on the valve. Patients with residual MR had the worst results.

Background: The cause of cerebral palsy remains unknown in most cases. Factor V Leiden mutation, a common cause of hereditary thrombophilia, has been associated with CP[1].

Objectives: To analyze the prevalence of factor V Leiden (G1691A), prothrombin (G20210A), and methylenetetrahydrofolate reductase (C677T) mutations in children with CP.

Methods: Sixty-one children with CP were studied for the presence of the three gene mutations associated with thrombophilia.

Results: We found that 41% of the children with CP and 33% of the controls carry one or more of the studied mutations (P = 0.348). The prevalence of the factor V mutation was 27.9% in CP and 16.4% in controls (P = 0.127). The frequency of the other two genetic factors was even less significant. The FVL[2] mutation was found in 35% of the Arab CP patients (15/42) and in 22% of the controls from the same population (9/40) (P = 0.067).

Conclusions: Each of the genetic factors studied was shown to be related to CP. Despite the high frequency of FVL among the studied patients, we were unable to prove a significant correlation between FVL and CP, mainly because this factor is frequent in the Arab control group. In this population a trend toward significance can be seen (P = 0.067). Larger studies are needed to validate the significance of these results.

Objectives: To determine the effectiveness of a neuroreflexology-based screening test, specifically the Medex device (Medex Screen Ltd.), for diagnosing patients undergoing conventional internal organ assessment, in a hospital setting.

Methods: Patients admitted to an internal medicine department, who met the inclusion criteria and agreed to participate, underwent conventional medical evaluation that included past medical history and physical examination. Another examination was conducted by a second physician using the Medex device to determine internal organ pathologies. A third researcher compared the actual “conventional” diagnosis with the Medex device output using standard statistical analysis.   

Results: Overall, 150 patients participated in the study. Correlation was significant for all categories (P < 0.01) except for blood and lymphatic disease. A high sensitivity (>70%) was measured for cardiovascular, respiratory, gastrointestinal and genitourinary diseases. The highest measure of agreement, as represented by the Cohen-Kappa factor, was found for respiratory disease (0.57).

Conclusions: Although the exact mechanism is not entirely clear, measurement of electroskin impedance of dermal-visceral zones has the potential to serve as a screening tool for inner organ pathologies. Further research should be conducted to create more evidence to support or dispute the use of this technique as a reliable diagnostic tool.