Israel Medical Association Journal

Background: Defibrillation threshold (DFT) testing at the time of implantable cardioverter defibrillator (ICD) insertion is performed routinely. Recently this practice is being reconsidered due to doubts about its ability to improve ICD efficacy and evidence that survival may not be affected by the test.

Objectives: To compare the outcome of ICD recipients who underwent DFT testing and those in whom no testing was performed.

Methods: A total of 213 eligible patients were implanted with an ICD between 2004 and 2009. DFT testing was performed in 80. We compared total mortality, appropriate and inappropriate ICD shocks, and anti-tachycardia pacing (ATP) events between DFT and non-DFT patients during a follow-up of 2 years.

Results: On comparing the DFT and non-DFT groups, we found a 2 year mortality rate of 7.5% versus 8.3%, respectively (P = 0.8). Furthermore, 20.7% of patients in the DFT group and 12.4% in the non-DFT group had at least one episode of ICD shock (P = 0.15). With regard to ICD treatment (ICD shocks or ATP events), 57.7% in the DFT group and 64.2% in the non-DFT group received appropriate treatments (P = 0.78).

Conclusions: No significant differences in the incidence of 2 year mortality or percentage of ICD treatment emerged between the DFT and non-DFT groups.
 

Background: The presence of stones in the common bile duct (CBD) may cause complications such as obstructing jaundice or ascending cholangitis, and the stones should be removed.

0bjectives: To report our results with percutaneous elimination of CBD stones from the gallbladder through the papilla.

Methods: During a 4 year period, six patients (five men and one woman, mean age 71.5 years) who had CBD stones and an existing gallbladder drain underwent percutaneous stone push into the duodenum after balloon dilatation of the papilla, with a diameter equal to that of the largest stone. Access into the CBD was from the gallbladder, using an already existing percutaneous gallbladder drain (cholecystostomy tube).

Results: Each patient had one to three CBD stones measuring 7–14 mm. Successful CBD stone elimination into the duodenum was achieved in five of the six patients. The single failure occurred in a patient with choledochal diverticulum, who was operated successfully. There were no major or minor complications during or after the procedures.

Conclusions: Trans-cholecystic CBD stone elimination is a safe and feasible percutaneous technique that utilizes existing tracts, thus obviating the need to create new percutaneous access. This procedure can replace endoscopic or surgical CBD exploration.
 

Background: Studies suggest that global semen quality is declining, but the debate remains open owing to geographic variation.

Objectives: To evaluate temporal trends of sperm parameters – namely concentration, motility and total motile sperm count – in sperm donated during the period 1995–2009.

Methods: In a retrospective longitudinal cohort study we analyzed the sperm count and motility of 2182 semen samples provided on a weekly basis by 58 young, healthy, fertile, university-educated, paid donors.

Results: Despite the lowering of criteria for sperm parameters satisfactory for donation that were implemented in 2004, 38% of applicants for sperm donation are now rejected based on semen quality as compared to a third of applicants 10–15 years ago (P < 0.001). If the old strict criteria were in place 88% of candidates would be rejected today (P < 0.0001). Over the study period, the average sperm parameters dropped from a concentration of 106 ± 25 million spermatozoa/ml with 79% ± 4.3% motility to 68 ± 14 million/ml with 66% ± 4.5% motile sperm (P < 0.0001, P < 0.0001, respectively). The total motile sperm count per ejaculate also decreased, from 66.4 ± 18.2 million to 48.7 ± 12 million (P < 0.005). When the previous criteria were implemented for the analysis of the latest group of sperm donors, only 18% of donors had an acceptable sperm quality, with an average concentration of 87 ± 12 million spermatozoa/ml, 73% ± 2.6% motile sperm and total motile sperm count of 53.1 ± 3.8 million per ejaculate – still significantly lower than 15 years ago (P = 0.01, P = 0.003, P = 0.058 respectively).

Conclusions: The rapid deterioration of sperm quality among fertile semen donors is alarming and may lead to cessation of sperm donation programs.

Background: Skin-prick tests (SPT), food-specific immunoglobulin E level (sIgE) and clinical history have limited value individually in predicting the severity of outcome of the oral food challenge (OFC). 

Objectives: To develop a score that accounts for SPT, sIgE and clinical history to predict the risk of severe reaction to the OFC. 

Methods: A 5 year retrospective chart review was performed on 983 children who underwent OFC to egg, milk and peanut. 

Results: Using multilogistic regression, four major indicators were found to be independently associated with failed OFC: sIgE (odds ratio = 1.04, P < 0.0001) , wheal size of the SPT (OR = 1.23, P < 0.0001), a history of any prior reaction to the food (OR = 1.13, P < 0.01), and a history of a prior non-cutaneous reaction (OR = 1.99, P < 0.01)  and three were independently associated with anaphylaxis: wheal size (OR = 1.16, P < 0.001), a history of a prior non-cutaneous reaction (OR = 4.24, P < 0.01), and age (OR = 1.07, P < 0.03). A Food Challenge Score (0–4) was developed which accounted for SPT wheal, sIgE, a history of a prior non-cutaneous reaction, and age. A score of 0–1 had a negative predictive value for multisystem reaction to the OFC: 95% for milk, 91% for egg and 93% for peanut. A score of 3–4 had a positive predictive value for anaphylaxis:  62% for milk, 92% for egg and 86% for peanut.

Conclusions: Severe reaction to milk, egg and peanut OFC can be predicted using a simple score that takes into account clinical data that are commonly available prior to the challenges.

Background: Adjuvant/neoadjuvant chemotherapy in breast cancer patients may be associated with amenorrhea and a marked reduction in ovarian reserve.

Objectives: To assess the use of letrozole with follicle-stimulating hormone (FSH) in gonadotropin-releasing hormone (GnRH) analogue protocols, based on reported attempts to avoid the estradiol (E2) increase during controlled ovarian hyperstimulation for embryo cryopreservation in breast cancer patients using a combination of low dose FSH and aromatase inhibitor (letrozole) in a GnRH-antagonist protocol.

Methods: Twenty-four breast cancer patients were treated with recombinant FSH (150–450 U/day) and letrozole (5 mg/day) in a long GnRH-agonist (n=7) or GnRH-antagonist (n=17) protocol. After oocyte retrieval, insemination and/or intracytoplasmic sperm injection was performed. The embryos were frozen.

Results: The average interval from surgery to oocyte retrieval was 40 days. Average duration of treatment was 9.6 days and mean peak E2 level 1342 ± 1091 pmol/L, yielding 16.0 ± 16.3 oocytes (range 0–82). Mean fertilization rate was 69.5 ± 20.4% and mean number of embryos cryopreserved 10.3 ± 9.3. More oocytes were retrieved with the long GnRH protocol, but the difference was not statistically significant (24.8 ± 24.6 vs. 12.0 ± 8.8 pmol/L, P = 0.07).

Conclusions: As previously reported, ovarian stimulation with letrozole and FSH, in both the long GnRH-agonist and GnRH-antagonist protocols, is apparently effective in breast cancer patients and spares them exposure to high E2 levels.
 

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: Patients with heart failure (HF) have a poor prognosis. Heart failure centers with specialized nurse-supervised management programs have been proposed to improve prognosis.

Objectives: To evaluate the clinical outcome of patients with HF treated at a multidisciplinary HF center of Clalit Health Services in Jerusalem in collaboration with Hadassah University Hospital.

Methods: We evaluated clinical outcome including hospitalizations and death in all HF patients followed at the HF center for 1 year.

Results: Altogether, 324 patients were included and followed at the HF center; 58% were males with a mean age of 76 ± 11 years, and 58% were in New York Heart Association (NYHA) functional class 3-4. The overall 1 year survival rate was 91% and the 1 year hospitalization rate 29%. Comparing patients in the HF center to the whole cohort of patients with a diagnosis of HF (N=6618) in Clalit Health Services in Jerusalem demonstrated a similar 1 year survival rate: 91% vs. 89% respectively but with a significantly reduced hospitalization rate: 29% vs. 42% respectively (P < 0.01). Cox regression analysis demonstrated that treatment in the HF center was a significant predictor of reduced hospitalization after adjustment for other predictors (hazard ratio 0.65, 95% confidence interval 0.53–0.80, P < 0.0001). A subset of patients that was evaluated (N=78) showed significantly increased compliance. NYHA class improved in these patients from a mean of 3.1 ± 0.1 to 2.6 ± 0.1 after treatment (P < 0.0001).

Conclusions: Supervision by dedicated specialized nurses in a HF center increased compliance, improved functional capacity in HF patients, and reduced hospitalization rate. HF centers should be considered part of the standard treatment of patients with symptomatic HF.
 

Background: Epidemiological studies have found that intrauterine growth retardation (IUGR) is closely related to hypertension and is associated with a reduced number of nephrons that may be a predisposing factor for the development of hypertension.

Objectives: To determine whether blood pressure levels of children with a history of IUGR are higher than those of children without IUGR.

Methods: Diastolic, systolic and mean arterial blood pressure levels were measured in 64 children aged 8–12 years old with a history of IUGR (mean birth weight 1780 ± 422 g) and compared with 64 age and gender-matched controls who had a normal birth weight (mean 3134 ±  594 g).

Results: Contrary to previous reports, systolic blood pressure values were significantly lower in the IUGR group compared to the controls (91.6 ±11.3 vs. 96.6 ±13.9, P = 0.027). There was no difference in diastolic blood pressure values. In the IUGR group, systolic blood pressure correlated significantly with current weight (P < 0.01) and body mass index (P < 0.05), and diastolic blood pressure with weight gain between age 2 and 4 years (P < 0.05). None of the blood pressure values correlated with birth weight.

Conclusions: Children born with IUGR have lower systolic blood pressure levels than matched controls at age 8–12 years. These data indicate that postnatal weight gain in this group has a greater impact on systolic blood pressure than birth weight.
 

Background: There is a growing shortage of anesthesiologists practicing in Israel. This shortage is in contrast with the United States where anesthesiology has become a very desired specialty.

Objectives: To discover what factors attract Israeli students to choose a residency and how students view the option of choosing anesthesiology.

Methods: We sent questionnaires to students in the Israeli and American programs at Tel Aviv University’s Sackler Faculty of Medicine asking about factors that influenced their choice of residency and the advantages and disadvantages of a residency in anesthesiology. Although the students were studying at the same medical school and hospitals, students in the Israeli program were planning to enroll in Israeli residency programs while students in the American program planned to apply for residency in the United States.

Results: A significantly larger proportion of American students (12.9%) were interested in an anesthesiology residency when compared with the Israeli students (0%) (P = 0.034). American students considered salary and working conditions to be advantages of the anesthesiology residency while Israeli students considered Israeli working conditions and salaries to be a disadvantage.

Conclusions: Whereas there is considerable interest among American students at Sackler Medical School in an anesthesia residency, there is little interest among Israeli students.