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עמוד בית
Fri, 25.07.25

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July 2014
Ori Toker MD, Ariella Tvito MD, Jacob M. Rowe MD, Jacob Ashkenazi MD, Chezi Ganzel MD, Yuval Tal MD and Meir Shalit MD
June 2014
Ephraim Eviatar MD, Koby Pitaro MD, Haim Gavriel MD and Daniel Krakovsky MD

Background: Over the past 20 years, advances in endoscopic sinus surgery (ESS) techniques have led to widespread applications of this technology in both adult and pediatric populations with better results and lower morbidity.

Objectives: To update data regarding the rate of minor and major complications following ESS procedures that used powered instrumentation.

Methods: We retrospectively reviewed the charts of all patients who, with general anesthesia, underwent ESS utilizing powered instrumentation between January 1996 and December 2006. Age, gender, indication for surgery, length of hospitalization, and type and rate of surgical complications were recorded.

Results: A total of 1190 patients were included in our study (1309 surgeries). The male:female ratio was 1.7:1.0 and the average age was 39 years (range 4–86 years). The most common indication for surgery was chronic rhinosinusitis. The rate of major complications was 0.31% and that of minor complications 1.37%. The only major complication that occurred was cerebrospinal fluid leak. The minor complications included epistaxis, periorbital emphysema, ecchymosis and mucocele formation.

Conclusions: Compared to previously published series, the rate of major and minor complications in our study was low. The results indicate that the use of powered instruments during ESS is safe.

April 2014
Eyal Kramer MD, Oscar Herman MD, Jacob Frand MD, Lior Leibou MD, Letizia Schreiber MD and Hananya Vaknine MD
 Background: Basal cell carcinoma (BCC) is the most common malignancy in humans. Several factors have been associated with the biological behavior of these tumors, including histopathologic type, depth of tumor invasion, perineural invasion, and the expression of several biologic markers including Ki67, a proliferative marker. Previous studies assessing the relationship between the proliferative fraction, as expressed by Ki67, and the histologic variants of BCC as well as its association with the tendency to recur, failed to illustrate significant statistical correlation.

Objectives: To examine the proliferative index, as expressed by Ki67, in various subtypes of basal cell carcinoma, and to assess its relationship to various histological and clinical variables.

Methods: In this retrospective study 51 lesions of BCC were examined. In each case, the following data were gathered: demographic (age and gender), anatomic location, size of the lesion, and clinical follow-up.  Each case was stained immunohistochemically with anti-Ki67 antigen (MIB-1), and the proliferative index was determined. Histologic analysis was performed for the following data: presence of an ulcer, intensity of inflammatory infiltrate, histologic subtype, mitotic count, and the presence of perineural invasion.

Results: Basal cell carcinoma exhibited a wide variation of proliferative indices, ranging from 1% to 61%. A significant statistical correlation was observed between the proliferative index and the mitotic activity, tumor ulceration and brisk tumor-infiltrating lymphocytes.

Conclusions: The wide variation in the degree of proliferation (from almost no activity to highly proliferative tumors) suggests that basal cell carcinoma exhibits a wide spectrum of biological characteristics. Ulcerated lesions were characterized by high proliferative index. No true correlation was demonstrated between the proliferative index and the aggressive histologic subtypes, implying that other factors were more biologically significant. The degree of proliferation also showed significant statistical correlation with the degree of tumor infiltration by lymphocytes. The significance of this proliferation-associated increased immunogenicity needs to be further studied.

February 2014
Renata Faermann, Fani Sperber, Schlomo Schneebaum and Daphna Barsuk
Background: The surgical approach to breast cancer has changed dramatically in the past 20 years. The surgical objective today is to remove the tumor, ensuring negative margins and good cosmetic results, and preserving the breast when possible. Magnetic resonance imaging of the breast has become an essential imaging tool prior to surgery, diagnosing additional tumors and assessing tumor extent. Tumor-to-breast volume ratio, an important predictor of breast conservation, can be measured with MRI and may change the surgical decision.

Objectives: To measure the tumor-to-breast volume ratio using MRI in order to assess whether there is a correlation between this ratio and the type of surgery selected (breast-conserving or mastectomy).

Methods: The volumes of the tumor and the breast and the tumor-to-breast volume ratio were retrospectively calculated using preoperative breast MRI in 76 patients who underwent breast-conserving surgery or mastectomy.

Results: Breast-conserving surgery (lumpectomy) was performed in 64 patients and mastectomy in 12. The average tumor-to-breast volume ratio was 0.06 (6%) in the lumpectomy group and 0.30 (30%) in the mastectomy group (P < 0.0001).

Conclusion: The tumor-to-breast volume ratio correlated with the type of surgery. As measured on MRI, this ratio is an accurate means of determining the type of surgery best suited for a given patient. It is recommended that MRI-determined tumor-to-breast volume ratio become part of the surgical planning protocol for patients diagnosed with breast cancer.

January 2014
Johad F. Khoury, Myriam Weyl Ben-Arush, Michael Weintraub, Elisha Waldman, Boris Futerman, Eugene Vlodavsky and Sergey Postovsky
 Background: In osteosarcoma the histological response, measured by the percentage of tumor necrosis, constitutes one of the most significant predictive factors, with better survival in patients whose tumor necrosis is ≥ 90%.

Objectives: To determine if the decrease rate of serum alkaline phosphatase (SAP) levels during the first month of neoadjuvant chemotherapy could serve as a predictive indicator of tumor necrosis and clinical outcome.

Methods: We analyzed the medical files of 53 osteosarcoma patients (19 females, 34 males) (median age 16 years, range 8–24); the disease was metastatic in 12 and localized in the other 41.

Results: The histological responses were good in 38 patients (71.7%) and poor in 15 (28.3%). At a median follow-up of 50 months, 34 patients (64.2%) had no evidence of disease and 19 (35.8%) had died from the disease. High levels of SAP at diagnosis correlated with worse survival (P = 0.002). There was no difference in overall survival between patients whose SAP decrease rate was > 25% and those with a rate < 25% (P = 0.14). Among female patients, "rapid" SAP responders had better survival than "slow" responders (P = 0.026). In patients with metastases the SAP decrease rate was positively correlated with survival (P = 0.042).

Conclusions: There was no evidence that "rapid" SAP responders had a higher percentage of tumor necrosis than "slow" responders, although female "rapid" SAP responders had a better prognosis than "slow" responders. Patients with metastases at presentation and "rapid" SAP response had better prognoses.

Joao L. P. Vaz, Mirhelen M. Abreu and Roger A. Levy
 Background: The presence of anti-citrullinated peptide/protein antibody (ACPA) has a high specificity and predictive value for the development of rheumatoid arthritis (RA). Some studies have shown decreased titers of this antibody after treatment with infliximab.

Objectives: To assess the changes in ACPA titers in patients with RA after treatment with infliximab as a first biological agent, and to correlate these variations with non-infusion-related adverse effects.

Methods: In a prospective multicenter observational study involving 48 research centers, we assessed 139 patients with established moderate-to-severe RA diagnosed according to American College of Rheumatology criteria. Samples were collected before and 6–12 months after treatment.

Results: The mean age of the study patients was 50.6 years old, and 118 were female (84.9%). Statistically significant variations in ACPA titers were noted in 47 patients (before and after treatment) (P = 0.012). Overall, ACPA titers were decreased in 32 (65.3%) and increased in 15 (34.7%). No correlation was found between severe or mild adverse effects in patients presenting variations in ACPA titers.

Conclusions: The present study showed that infliximab affected ACPA titers, promoting mainly a decrease; however, this was not related to the occurrence of non-infusion-related adverse effects.

December 2013
Yael Milgrom, Gideon Goldman, Alex Gileles Hillel, Pojurovsky Svetlana and Zvi Ackerman
November 2013
I. Strauss, T. Jonas-Kimchi, Z. Lidar MD, D. Buchbut, N. Shtraus, B. W. Corn and A. A. Kanner
 Background: Radiation treatment of spinal and paraspinal tumors has been limited by the tolerance of the spinal cord. As such, therapeutic options are restricted to surgically accessible lesions or the use of suboptimal dosing of external beam irradiation.

Objectives: To evaluate the safety and applicability of the Elekta Synergy-S radiation unit for the treatment of spinal tumors.

Methods: We retrospectively reviewed all patients treated with stereotactic radiosurgery to spinal tumors between November 2007 and June 2011.

Results: Thirty-four patients were treated for 41 lesions. Treatment indications were local tumor control and pain palliation. The mean follow-up was 10.8 ± 11.6 months (range 0.5–38 months). No acute radiation toxicity or new neurological deficits occurred during the follow-up period. Local tumor control was achieved in 21 of the 24 lesions (87.5%) available for radiological follow-up at a median of 9.8 months (range 3–32 months). Good analgesia was achieved in 24/30 lesions (80%) that presented with intractable pain.

Conclusions: The safety and feasibility of delivering single and multiple-fraction stereotactic spinal irradiation was demonstrated and became a standard treatment option in our institution. 

September 2013
A. Kadar MD, R. Ankory, H. Sherman, I. Eshed, N. Shasha, A. Gold, M. Aharon and M. Salai

Background: The articular surface replacement (ASR) total hip arthroplasty (THA) was recently recalled from the market due to high failure rates. This modality was used frequently by surgeons at our medical center.

Objectives: To assess the clinical and radiographic outcomes in patients following the surgery and determine the revision rate in our cohort.

Methods: Between 2007 and 2010 139 hips were operated on and evaluated in our clinic. All patients underwent a clinical interview, function and pain evaluation, as well as physical examination and radiographic evaluation. When necessary, patients were sent for further tests, such as measuring cobalt-chromium levels and magnetic resonance hip imaging. Results: With an average follow-up of 42 months the revision rate was 2% (3/139). Patients reported alleviation of pain (from 8.8 to 1.7 on the Visual Analog Scale, P < 0.001), good functional outcomes on the Harris Hip Score, and improved quality of life. Overall satisfaction was 7.86 on the reversed VAS[1]. For patients who required further tests, clinical and radiographic outcomes were significantly poorer than for the rest of the cohort. Average blood ion levels were high above the normal (cobalt 31.39 ppb, chromium 13.32 ppb), and the rate of inflammatory collection compatible with pseudotumors on MRI was 57%.

Discussion: While our study favors the use of the ASR implant both clinically and radiographically, some patients with abnormal ion levels and inflammatory collections on MRI might require revision in the future. 





[1] VAS = Visual Analogue Scale



 
June 2013
I. Fuchs, M. Abu-Shakra and E. Sikuler
 Information on reactivation of chronic viral hepatitis infection in patients who are candidates for tumor necrosis factor alpha inhibitors (TNFi) is in a constant state of flux. We retrieved the most updated guidelines (in English) of prominent rheumatological and gastroenterological professional societies for the management of chronic hepatitis B (HBV) and hepatitis C virus (HCV) infection in the context of treatment with TNFi. Subsequently, the major areas of uncertainty and absence of consensus in the guidelines were located and a secondary search for additional studies addressing those areas was performed. Based on our search we formulated a personal interpretation applicable to health care settings with virological laboratories capable of performing viral load measurements, and health systems that can support use of potent nucleoside/tide analogues in well-defined patient populations.

 

April 2013
S. Golan, S. Maslovitz, M.J. Kupferminc and A. Kesler
 Background: The effects of consecutive pregnancies on the course of idiopathic intracranial hypertension (IIH) are unclear in view of the scarce published data.

Objectives: To evaluate the course and management of visual and pregnancy outcomes of consecutive pregnancies with IIH.

Methods: The medical records of women with IIH in consecutive pregnancies were reviewed for neuro-ophthalmological findings, management, and visual and pregnancy outcomes.

Results: The study group comprised eight women with at least two consecutive pregnancies (mean age 27.3 ± 5.3 years). The mean duration of IIH prior to the first pregnancy was 3.4 ± 3.16 years. One woman with IIH pre-pregnancy symptoms and three women with clinical features of IIH during the second trimester of pregnancy (gestational week 21.7 ± 4.04) were treated with acetazolamide (250 mg every 8 hours). Symptoms resolved, resulting in uncomplicated first deliveries for all four. The first deliveries of four other women were by cesarean section due to obstetric indications. Only one woman developed symptoms and signs of IIH during her second pregnancy and was thus treated with acetazolamide. Two women who completed three pregnancies had no IIH symptoms during their pregnancies. The course and outcome of those pregnancies were normal.

Conclusions: IIH apparently does not worsen or even become symptomatic in consecutive pregnancies. The appropriate management of IIH in pregnant women is similar to management for non-pregnant women; neither the course nor the obstetric outcome of first and consecutive pregnancies is influenced by the presence of IIH.

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