Israel Medical Association Journal

Pancreatic cancer is not a common malignancy in Israel, but it is the third most common cause of cancer mortality, attributable to a lack of screening tests, inaccessibility of the pancreas, and late cancer stage at diagnosis. We reviewed the epidemiology, known risk factors and screening methods available in Israel and describe the Israeli national consortium that was established to identify persons at risk and decide on screening methods to detect and treat their early-stage pancreatic cancer. In collaboration with the Israel National Cancer Registry, we evaluated the incidence and trends of the disease in the Jewish and non-Jewish populations. The consortium reviewed known lifestyle risk habits and genetic causes, screening methodologies used and available in Israel. Overall, there are about 600 new patients per year, with the highest incidence occurring in Jewish men of European birth (age-standardized rate 8.11/10⁵ for 2003–06). The 5 year survival is about 5%. The consortium concluded that screening will be based on endoscopic ultrasonography. Pancreatic cancer patients and families at risk will be enrolled, demographic and lifestyle data collected and a cancer pedigree generated. Risk factors will be identified and genetic tests performed as required. This concerted national program to identify persons at risk, recommend which environmental risk factors to avoid and treat, and perform endoscopic ultrasound and genetic screening where appropriate, might reduce their incidence of invasive pancreatic cancer and/or improve its prognosis

Background: Intravenous tissue plasminogen activator has been approved treatment for acute (≤ 3 hours) ischemic stroke in Israel since late 2004. The Israeli experience with IV tPA[1] is still limited. Several factors may influence the response to IV thrombolysis, including time-to-treatment parameters and tandem internal carotid artery/middle cerebral artery stenosis/occlusion.

Objectives: To compare our experience with IV tPA treatment of patients with acute ischemic stroke to the findings of the SITS-MOST (Safe Implementation of Thrombolysis in Stroke-MOnitoring STudy, international data) and of the Sheba Medical Center (national data) and to compare the early outcome among patients with ischemic stroke in the MCA[2] with and without severe ICA[3] stenosis.

Methods: We obtained demographic data, timing details, stroke severity, hemorrhagic complications, mortality, and early outcome from the records of IV tPA-treated acute ischemic stroke patients.

Results: Fifty-eight patients (median age 69 years, 26 females) with acute ischemic stroke were treated by IV tPA at the Tel Aviv Sourasky Medical Center in 2006–2007. Median time between stroke onset and IV tPA administration was 148 minutes for the Sourasky center, 150 minutes for the Sheba center, and 140 minutes for SITS-MOST. The Sourasky mortality rate was 10.5%. Of the 31 patients who suffered MCA stroke, 8 had severe ipsilateral ICA stenosis. These 8 had significantly lower neurological improvement than the 23 without ipsilateral ICA stenosis (1/8 versus 15/23, P <0.001).

Conclusions: Our data demonstrate fairly similar parameters of IV tPA treatment compared to other centers and suggest that patients with severe ICA stenosis might be less likely to benefit from IV tPA.

Background: The incidence of stroke varies among ethnically and culturally diverse groups.

Objectives: To examine the ethnic-geographic patterns of stroke incidence in men and women with coronary heart disease in Israel, focusing on the extent to which this variability can be explained by known differences in risk factors for stroke.

Methods: Patients with documented coronary heart disease were followed for 6–8 years for incident cerebrovascular events. Baseline medical evaluation included assessment of vascular risk factors and measures of blood lipids. Among 15,052 patients, a total of 1110 were identified with any incident ischemic cerebrovascular event by ICD-9 codes, of whom 613 had confirmed ischemic stroke or transient ischemic attack.

Results: A major excess of ischemic cerebrovascular events among Israeli Arab women as compared to males, and an inverse finding among Israeli born Jews, were noted. The high risk in the Arab population in Israel reflected an unfavorable risk profile, since predicted rates by multivariate analysis and observed rates were 69 and 68 per 1000, respectively. High ischemic cerebrovascular event rates were identified among patients born in the Balkan countries and North Africa (89 and 90 per 1000) but unfavorable risk factor levels of these individuals did not explain them. Most trends appeared similar in male and female patients. A comparison of observed and accepted-according-to-risk-profile rates of ischemic cerebrovascular events yielded significant differences (P = 0.04), consistent with an additional role of geographic/ethnic origin, resulting from factors that remain unrecognized,or with variables unassessed in this study.

Conclusions: We identified an ethnic diversity in stroke risk among Israeli born in different parts of the world beyond what could be expected on the basis of differences in known risk factors. These findings call for detailed research aimed at identifying additional differences in the risk profile of patients with atherothrombotic disease exposed to an increased risk of stroke.
 

Background: Identification of pathogens and their susceptibility to antimicrobials is mandatory for successful empiric antibiotic treatment.

Objectives: To compare the clinical characteristics of patients with bacteremia, as well as the bacterial distribution and antimicrobial susceptibility in community, hospital and long-term care facilities during two periods (2001–2002 and 2005–2006).

Methods: The study was conducted at the HaEmek Medical Center, a community 500-bed teaching hospital in northern Israel serving a population of ~500,000 inhabitants. All episodes of bacteremia (n=1546) during two 2 year periods (2001–2 and 2005–6) were prospectively recorded, evaluated and compared (755 in 2001–2 and 791 in 2005–6).

Results: In both periods the urinary tract was the main port of entry in community and long-term care facility bacteremia, while the urinary tract – primary and catheter-related – were similar in frequency as sources of hospital bacteremia. Escherichia coli was the most frequent pathogen isolate. No significant changes in the frequency of methicillin-resistant Staphylococcus aureus and extended-spectrum beta-lactamase-producing bacteria were seen between the two 2 year periods (2001–2 and 2005–6). The susceptibility of non-ESBL[1]-producing E. coli decreased for some antibiotics while non-ESBL-producing Klebsiella pneumoniae susceptibility profile improved in the same period. A non-statistically significant trend of increased resistance in gram-negative isolates to quinolones, piperacillin and piperacillin-tazobactam was observed, but most isolates still remained highly susceptible to carbapenems. There was a small increase in mortality rate in hospital bacteremia during the second period.

Conclusions: Continuous surveillance is imperative for monitoring the local epidemiology and for developing local treatment guidelines.

Background: Familial dysautonomia is a genetic disease that affects the sensory and autonomic nervous systems with varying severity. The deep breath test is one of several measures used to assess the severity of autonomic diseases, but its value in familial dysautonomia has not yet been investigated.

Objectives: To determine the diagnostic value of the DBT[1] in patients with familial dysautonomia.

Methods: Eight patients with familial dysautonomia and eight healthy volunteers were examined by electrocardiography for 1 minute at rest and during forced deep breathing. The following values were recorded: maximum expiratory and minimum inspiratory heart rate and the difference between them (ΔE/I), standard deviation of the heart rate values, interbeat intervals, and E/I[2] ratio. Spectral power analysis of heart rate variability was also performed.

Results: The patients with familial dysautonomia showed a lesser change in heart rate in response to the change in breathing pattern than the controls. Mean values in the study group were significantly higher for minimal inspiratory heart rate and significantly lower for ΔE/I, heart rate standard deviation and E/I ratio, indicating a non-flexible heart response and abnormal parasympathetic function. These findings were supported by power spectral analysis.

Conclusions: Patients with familial dysautonomia have a significantly disturbed response to physiological stimuli. The DBT may serve as a reliable means to quantify autonomic dysfunction in this patient population.

Background: Double balloon enteroscopy is a new technique that enables deep intubation of the endoscope into the small bowel lumen. Through a channel in the endoscope, invasive procedures such as biopsy, polypectomy and hemostasis can be performed, avoiding the need for surgery.

Objectives: To prospectively analyze our results of the first 124 DBEs[1] performed since February 2007.

Methods: The study group comprised all patients who underwent DBE at the Sheba Medical Center between February 2007 and February 2009. Recorded were the patients' demographic data, comorbidities, indications for the examination, results of previous non-invasive small bowel imaging (computed tomography enterography, capsule endoscopy, etc), investigation time, and results of the procedure including findings, endoscopic interventions, complications and pathological report.

Results: A total of 124 procedures were performed in 109 patients. Of the 124 examinations, 57 (46%) were normal and 67 (54%) showed pathology. The main pathologies detected on DBE were polyps (14%), vascular lesions (17.6%) and inflammation (12%). Endoscopic biopsies and therapeutic interventions were required in 58 examinations (46%). A new diagnosis was established in 15% of patients, diagnosis was confirmed in 29% and excluded or corrected in 12%. One complication was observed: a post-polypectomy syndrome that was treated conservatively.

Conclusions: DBE is a safe procedure and has a high diagnostic and therapeutic yield. Most of the examinations were performed under conscious sedation, and only a minority of patients required deeper sedation. 

Background: Injury to patent grafts or cardiac chambers may occur during reoperation after coronary artery bypass grafting. Preoperative spatial localization of bypass grafts with computed tomography may improve the safety of these procedures.

Objectives: To characterize patients who undergo CT before repeat operations after previous coronary artery bypass grafting, and evaluate its benefit in terms of surgical outcome.

Methods: We compared 28 patients who underwent cardiac gated CT angiography before reoperation (CT group) to 45 re-do patients who were not evaluated with CT (no‑CT group).

Results: The two groups were similar in most preoperative and operative characteristics. The CT group, however, included more patients with patent saphenous vein grafts and fewer with emergency operations, acute myocardial infarction and need for intraaortic balloon pump support. During mid-sternotomy, there was no injury to grafts in the CT group, while there were two patent grafts and three right ventricular injuries in the no-CT group. There was no significant difference in perioperative mortality (3.6% vs. 8.9%). The overall complication rate in the CT group was 21.4% compared to 42.2% in the no‑CT group (P = 0.07). The only independent predictors of postoperative complications were diabetes mellitus, preoperative stroke and preoperative acute MI[1].

Conclusions: The patency and proximity of patent grafts to the sternum are well demonstrated by multidetector CT and may provide the surgeon with an important roadmap to avoid potential graft injury. A statistical trend towards reduced complications rate was demonstrated among patients who underwent CT angiography before their repeat cardiac operation. Larger series are required to demonstrate a statistically validated complication-free survival benefit of preoperative CT before repeat cardiac surgery.

Background: Information regarding long-term survival after stroke in many countries is scarce.

Objectives: To both assess 5 year survival after stroke in the Israeli population and determine its independent prognostic factors.

Methods: We followed 616 people with acute stroke who were admitted consecutively to seven large general hospitals in Israel. The data were collected on admission to the hospital, at discharge, at 3, 6 and 12 months thereafter, and 5 years after the stroke.

Results: The 5 year cumulative probability of survival was 49.2% (95% CI 45.0–53.7%). In the multivariate Cox analysis, lower age and functioning independently before the event were associated with a lower risk of death, while other demographic characteristics and cardiovascular risk factors were not found to be associated with mortality.

Conclusions: Five year survival after stroke in Israel, though high, is similar to other western countries. There is a need to ensure early, active and sustained implementation of strategies for preventing stroke events.

Background: Chronic heart failure is associated with excessive hospitalizations and poor prognosis.

Objectives: To summarize the 5 year experience of a single-center CHF[1] day care service, detect the cardiovascular and non-cardiovascular events, and evaluate the safety of the treatments provided.

Methods: We retrospectively studied all patients admitted to the CHF day care service of the Sheba Medical Center between September 2000 and September 2005.

Results: Advanced (New York Heart Association class III-IV) CHF patients (n=190), mean age 65 ± 12 years and left ventricular ejection fraction 25 ± 11%, were treated for 6 hourly biweekly visits; 77% had ischemic and 23% had non-ischemic cardiomyopathy. Treatment included: intravenous diuretic combinations (91%), intermittent low dose (≤ 5 mg/kg/min) dobutamine (87%), low dose (≤ 3 mg/kg/min) dopamine (38%), intravenous iron preparation and/or blood (47%), and intravenous nitropruside (36%). Follow-up of at least 1 year from initiation of therapy was completed in 158 of 190 patients (83%). Forty-six (29.3%) died: 23% due to CHF exacerbation, 5.7% from infection, 4.4% from sudden cardiac death, 3.8% from malignancy, 2.5% from malignant arrhythmias, 1.9% from renal failure, 1.3% from stroke, and 0.6% from myocardial infarction. There were only 0.68 rehospitalizations/patient/year; the most frequent cause being CHF exacerbation (16.5%).

Conclusions: Our study demonstrates the safety and potential benefits of a supportive day care service for advanced CHF patients. Multidrug intravenous treatment, accompanied by monitoring of electrolytes, hemoglobin and cardiac rhythm, along with education and psychological support, appear to reduce morbidity in advanced CHF patients and may have contributed to the lower than expected mortality/hospitalization rate.