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עמוד בית
Mon, 15.04.24

Search results


April 2018
March 2018
Narin N. Carmel-Neiderman MD, Idan Goren MD, Yishay Wasserstrum MD, Tal Frenkel Rutenberg MD, Irina Barbarova MD, Avigal Rapoport MD, Dor Lotan MD, Erez Ramaty MD, Naama Peltz-Sinvani MD, Adi Brom MD, Michael Kogan MD, Yulia Panina MD, Maya Rosman MD, Carmel Friedrich MD, Irina Gringauz MD, Amir Dagan MD, Iris Kliers MD, Tomer Ziv-Baran PhD and Gad Segal MD

Background: Accurate pulse oximetry reading at hospital admission is of utmost importance, mainly for patients presenting with hypoxemia. Nevertheless, there is no accepted or evidence-based protocol for such structured measuring.

Objectives: To devise and assess a structured protocol intended to increase the accuracy of pulse oximetry measurement at hospital admission.

Methods: The authors performed a prospective comparison of protocol-based pulse-oximetry measurement with non-protocol based readings in consecutive patients at hospital admission. They also calculated the relative percentage of improvement for each patient (before and after protocol implementation) as a fraction of the change in peripheral capillary oxygen saturation (SpO2) from 100%.

Results: A total of 460 patients were recruited during a 6 month period. Implementation of a structured measurement protocol significantly changed saturation values. The SpO2 values of 24.7% of all study participants increased after protocol implementation (ranging from 1% to 21% increase in SpO2 values). Among hypoxemic patients (initial SpO2 < 90%), protocol implementation had a greater impact on final SpO2 measurements, increasing their median SpO2 readings by 4% (3–8% interquartile range; P < 0.05). Among this study population, 50% of the cohort improved by 17% of their overall potential and 25% improved by 50% of their overall improvement potential. As for patients presenting with hypoxemia, the median improvement was 31% of their overall SpO2 potential.

Conclusions: Structured, protocol based pulse-oximetry may improve measurement accuracy and reliability. The authors suggest that implementation of such protocols may improve the management of hypoxemic patients.

January 2018
Rana Afifi MD, Benjamin Person MD and Riad Haddad MD

Background: Lymph node (LN) retrieval and assessment is essential for accurate staging and treatment planning in colorectal cancer (CRC). According to U.S. National Cancer Institute recommendations, the minimal number of LNs needed for accurately staging of node-negative CRC is 12. Awareness and implementation of the guidelines has been shown to improve after assigning an opinion leader who has a special interest in CRC.

Objectives: To evaluate the impact of dialogue between surgeons and pathologists in LN evaluation.

Methods: Consecutively treated CRC patients at the Department of Surgery B at Rambam Medical Center from January 1, 2000 through July 30, 2005 were identified from hospital discharge files. Demographic, surgical, and pathological data were extracted. Patients were divided into two groups. Group I patients underwent surgery before the initiation of a structured surgical oncology service (January 1, 2000 to October 30, 2004). Group II patients underwent surgery after the initiation of the service (November 1, 2004 to July 30, 2005).

Results: The study comprised 212 patients (Group I: n=170; Group II: n=42). The median number of LNs examined was 9 in Group I and 14 in Group II (P = 0.003). Only 35% of patients in Group I received adequate LN evaluation compared to 79% in Group II (P = 0.0001). Patients with left-sided or rectal cancer were less likely to receive adequate LN evaluation than patients with right-sided cancers.

Conclusions: A durable improvement in LN evaluation was realized through a multi-pronged change initiative aimed at both surgeons and pathologists.

November 2017
Tima Davidson MD, Amit Druyan MD, Elinor Goshen MD and Merav Lidar MD

Background: Facial rejuvenation using different dermal and sub-dermal injectable compounds is a popular cosmetic procedure which may pose a diagnostic dilemma to the radiologist.

Objectives: To describe the appearance of cosmetic facial fillers on PET-CT.

Methods: All PET-CT exams performed between January 2015 and May 2017 in which findings suggestive of prior facial filler procedures was evident and where anamnestic confirmation with the patient was possible were reviewed.

Results: We describe five females who had undergone facial filler procedures leading to calcifications around the mouth and nasolabial triangle.

Conclusions: Familiarity with the appearance of such cosmetic procedures on PET-CT is of paramount importance in order to avoid misinterpretation of the findings leading to unnecessary apprehension and work-up.

Maria Antonietta D’Agostino MD PhD

Over the last 15 years ultrasound has gained importance for the clinical management of patients with inflammatory rheumatic diseases, especially rheumatoid arthritis. This review summarizes the recent developments and achievements in the use of ultrasound in RA, as well as the unmet needs.

October 2017
Sarit Appel MD, Jeffry Goldstein MD, Marina Perelman MD, Tatiana Rabin MD, Damien Urban MBBS MD, Amir Onn MD, Tiberiu R. Shulimzon MD, Ilana Weiss MA, Sivan Lieberman MD, Edith M. Marom MD, Nir Golan MD, David Simansky MD, Alon Ben-Nun MD PhD, Yaacov Richard Lawrence MBBS MRCP, Jair Bar MD PhD and Zvi Symon MD PhD

Background: Neoadjuvant chemo-radiation therapy (CRT) dosages in locally advanced non-small cell lung cancer (NSCLC) were traditionally limited to 45 Gray (Gy).

Objectives: To retrospectively analyze outcomes of patients treated with 60 Gy CRT followed by surgery.

Methods: A retrospective chart review identified patients selected for CRT to 60 Gy followed by surgery between August 2012 and April 2016. Selection for surgery was based on the extent of disease, cardiopulmonary function, and response to treatment. Pathological response after neoadjuvant CRT was scored using the modified tumor regression grading. Local control (LC), disease free survival (DFS), and overall survival (OS) were estimated by the Kaplan–Meier method.

Results: Our cohort included 52 patients: 75% (39/52) were stage IIIA. A radiation dose of 60 Gy (range 50–62Gy) was delivered in 82.7%. Surgeries performed included: lobectomy, chest-wall resection, and pneumonectomy in 67.3%, 13.4%, and 19.2%, respectively. At median follow-up of 22.4 months, the 3 year OS was 74% (95% confidence interval [CI] 52–87%), LC was 84% (95%CI 65–93), and DFS 35% (95%CI 14–59). Grade 4–5 postoperative complications were observed in 17.3% of cases and included chest wall necrosis (5.7%), bronco-pleural fistula (7.7%), and death (3.8%). A major pathologic regression with < 10% residual tumor occurred in 68.7% of patients (36/52) and showed a trend to improved OS (P = 0.1). Pneumonectomy cases had statistically worse OS (P = 0.01).

Conclusions: Major pathologic regression was observed 68.7% with 60 Gy neoadjuvant CRT with a trend to improved survival. Pneumonectomy correlated with worse survival.

June 2017
Sergio Susmallian MD, David Goitein MD, Royi Barnea PhD and Asnat Raziel MD

Background: Leakage from the staple line is the most serious complication encountered after sleeve gastrectomy, occurring in 2.4% of surgeries. The use of inappropriately sized staplers, because of variability in stomach wall thickness, is a major cause of leakage.

Objectives: To measure stomach wall thickness across different stomach zones to identify variables correlating with thickness.

Methods: The study comprised 100 patients (52 females). Stomach wall thickness was measured immediately after surgery using a digital caliper at the antrum, body, and fundus. Results were correlated with body mass index (BMI), age, gender, and pre-surgical diagnosis of diabetes, hypertension, hyperlipidemia and fatty liver.

Results: Stomach thickness was found to be 5.1 ± 0.6 mm at the antrum, 4.1 ± 0.6 mm at the body, and 2. 6 ± 0.5 mm at the fundus. No correlation was found between stomach wall thickness and BMI, gender, or co-morbidities. 

Conclusions: Stomach wall thickness increases gradually from the fundus toward the antrum. Application of the correct staple height during sleeve gastrectomy is important and may, theoretically, prevent leaks. Staplers should be chosen according to the thickness of the tissue.

 

Ronen Goldkorn MD, Alexey Naimushin MD, Roy Beigel MD, Ekaterina Naimushin, Michael Narodetski MD and Shlomi Matetzky MD

Background: While patients presenting to emergency departments (ER) with chest pain are increasingly managed in chest pain units (CPU) that utilize accelerated diagnostic protocols for risk stratification, such as single-photon emission computed tomography (SPECT) myocardial perfusion imaging (MPI), data are lacking regarding the prognostic implications of mildly abnormal scans in this population.

Objectives: To evaluate the prognostic implications of mildly abnormal SPECT MPI results in patients with acute chest pain.

Methods: Of the 3753 chest pain patients admitted to the CPU at the Leviev Heart Center, Sheba Medical Center 1593 were further evaluated by SPECT MPI. Scans were scored by extent and severity of stress-induced perfusion defects, with 1221 patients classified as normal, 82 with myocardial infarction without ischemia, 236 with mild ischemia, and 54 with more than mild ischemia. Mild ischemia patients were further classified to those who did and did not undergo coronary angiography within 7 days.

Results: Mild ischemia patients who underwent coronary angiography were more likely to be male (92% vs. 81%, P = 0.01) and to have left anterior descending ischemia (67% vs. 42%, P = 0.004). After 50 months, these patients returned less often to the ER with chest pain (53% vs. 87%, P < 0.001) and had a lower combined endpoint of acute coronary syndrome and death (8% vs. 16%, P < 0.001).

Conclusions: Compared to patients with chronic stable angina, patients presenting with acute chest pain exhibiting mildly abnormal SPECT MPI findings should perhaps undergo a more aggressive diagnostic and therapeutic approach.

March 2017
Noémi Gyarmati MD, Ágota Kulisch MD PhD, András Németh MD, Annamária Bergmann MD, József Horváth MD, Zsuzsanna Mándó MD, Ágnes Matán MD, Erika Szakál MD, Tímea Sasné Péter, Dóra Szántó and Tamás Bender MD PhD DSc
November 2016
Yael Leitner MD, Alexis Mitelpunkt MD, Idit Posner MD and Noa Vardi MD

Background: Six medical disciplines are responsible for assessment, diagnosis and treatment of people with attention deficiency hyperactivity disorder (ADHD) in Israel: family doctors, pediatricians, adult and child neurologists, adult and child psychiatrists.  

Objectives: To investigate differences in ADHD diagnostic practices between three different pediatric subspecialties in the clinical setting in order to establish a common ground for a future unified approach.

Methods: An anonymous web-based questionnaire was administered to child psychiatrists, pediatric neurologists and general pediatricians who are actively involved in ADHD diagnosis (n=104).

Results: Neurologists and pediatricians rarely use the mental status examination, while psychiatrists rarely perform a neurological or physical examination (P < 0.0001). A general clinical impression of learning abilities and/or neurodevelopmental skills was implemented more often by pediatric neurologists (P < 0.04).

Conclusions: The significant differences found between the three medical specialties with regard to the clinical evaluation of ADHD could be attributed, at least in part, to the ambiguity of available guidelines concerning the clinical examination, and to the adherence of each specialty to its own "skills." Larger surveys in other countries should be considered and an effort made to create a common, "inter-disciplinary" ground on this important part of ADHD evaluation, differential diagnosis, and research.

 

September 2016
Efstathia K. Kapsogeorgou PhD and Athanasios G. Tzioufas MD

Autoimmune diseases constitute a diverse group of disorders characterized by cellular and humoral responses against self. The humoral autoimmune responses are directed against various cellular and extracellular components. These responses are highly specific for each autoimmune disease and result in the production of autoantibodies that characterize certain disease entities, representing a valuable tool for the diagnosis of autoimmune diseases. Furthermore, certain autoantibodies are helpful in the prognosis of disease development, progression and severity, as well as in the classification of patients with distinct disease subtypes. Today, the value of autoantibodies in the follow-up of patients is limited, but preliminary data suggest that they may be useful in predicting response to treatment. 

February 2016
Moshe Herskovitz MD and Yitzhak Schiller MD PhD

Background: Resective epilepsy surgery is an accepted treatment option for patients with drug-resistant epilepsy (DRE). Presurgical evaluation consists of a phase 1 non-invasive evaluation and a phase 2 invasive evaluation, when necessary.

Objectives: To assess the results of phase 1 evaluation in patients with focal DRE.

Methods: This observational retrospective study was performed in all consecutive DRE patients admitted to our clinic from January 2001 to July 2010, and who underwent a presurgical evaluation which included at least magnetic resonance imaging (MRI) scan and long-term video EEG monitoring (LTVEM).

Results: A total of 253 consecutive patients with a diagnosis of DRE (according to the ILAE recommendations) who underwent presurgical evaluation were extracted from our clinic and department registry. In 45 of these patients either imaging or ictal video EEG data were missing; the final analysis therefore involved 208 patients. The combined result of the LTVEM and the MRI scan were as follows: 102 patients (49% of the cohort) had a lesion on the MRI scan, in 77 patients (37% of the cohort) the LTVEM results were localizing and congruent with the MRI findings, and in 25 patients (12% of the cohort) the LTVEM results were either non-localizing or incongruent with the MRI findings. In 106 patients (51% of the cohort) the MRI scan was normal or had a non-specific lesion. The LTVEM was localizing in 66 of these patients (31.7% of the cohort) and non-localizing in 40 (19.2% of the cohort).

Conclusions: Although some of the patients with focal DRE can be safely treated with resective surgery based solely on the findings of phase 1 evaluation, a substantial percent of patients do need to undergo a phase 2 evaluation before a final surgical decision is made.

 

November 2015
Abdel-Rauf Zeina MD, Mika Shapira-Rootman MD PhD, Ahmad Mahamid MD, Jalal Ashkar MD, Saif Abu-Mouch MD and Alicia Nachtigal MD

Background: Plain abdominal radiographs are still performed as a first imaging examination to evaluate abdominal pain in the emergency department (ED), despite uncertainty regarding their utility.

Objectives: To describe the frequency and outcomes of the use of plain abdominal radiographs in the diagnosis of patients presenting with acute non-traumatic abdominal pain in the ED of a medical center. 

Methods: We retrospectively reviewed the records of patients presenting to the ED with acute abdominal pain during a 6 month period. Further imaging (computed tomography, ultrasonography), when performed, was compared with the abdominal radiography. 

Results: Of 573 consecutive patients, 300 (52%) underwent abdominal radiography. Findings were normal in 88% (n=264), non-specific in 7.3% (n=22), and abnormal in 4.7% (n=14). For those with normal results, no further imaging was ordered for 43% (114/264). Of the 57% (150/264) who had follow-up imaging, 65% (98/150) showed abnormal findings. In 9 (3%) of the 300 patients, abdominal radiography identified bowel perforations and obstructions, and treatment was provided without the need for further radiologic examination.

Conclusions: The use of plain abdominal radiography is still common despite the high rate of false positive results. Efforts are needed to decrease the indiscriminate use of radiography in patients presenting with abdominal symptoms.

 

October 2015
Ophir Lavon MD and Yedidia Bentur MD

Background: Exposure to silica gel, a common desiccant, is considered common and non-toxic although data are limited.

Objectives: To evaluate the characteristics of silica gel ingestion, and to attempt to estimate the associated health care costs.

Methods: We conducted a one year retrospective review of charts of a national poison information center to characterize ingestions of silica gel and estimate its direct cost to health care services. Cost evaluation was based on emergency department and community clinic tariffs (NIS 807/US$ 213 and NIS 253/US$ 67, respectively).

Results: A total of 546 cases were recorded, 2.1% of the annual calls to the poison information center. Most ingestions occurred in children younger than 6 years old (91.4%, 65.2% < 2 years). Median monthly exposure was 42; the peak (74) occurred in April, before the Passover holiday. Sixty calls (11%) came from health care facilities and the rest were reported by the public; 2.7% were symptomatic, mainly mild self-limited mouth and throat discomfort. The direct annual treatment cost of patients who referred themselves to health care facilities without consulting first with the Poison Center (n=60) was NIS 24,598/US$ 6507 (emergency department and community clinic visit fees). 

Conclusions: Silica gel ingestion is relatively common, occurring mainly in young children; it is rarely symptomatic but is a source of unnecessary referrals to health care facilities. The potential annual saving by preventing unnecessary referrals due to poison information center advice was estimated at NIS 375,678/US$ 99,383. The availability of poison information center services may prevent unnecessary referrals to health care facilities and thus save costs. 

 

September 2015
Ahikam Olmer MD, Binyamin Greenberg MD and Rael D. Strous MD

Background: In criminal law, psychiatrists are consulted regarding the "insanity defense" and the defendant's competency to stand trial. Court-ordered hospital admissions for such evaluations are on the increase, creating a major burden on the health system.

Objectives: To assess, in a hospital setting, whether hospitalization of the defendant is necessary for conducting a psychiatric evaluation.

Methods: A 6 month prospective observational study exploring the phenomenon was conducted at the Beer Yaakov Mental Health Center. The psychiatrist was asked both at the initiation and again at the end of the assessment process whether the subject was competent to stand trial and responsible for his/her actions and if hospitalization was necessary in order to conduct the evaluation. 

Results: During the study period there were 112 admissions with a court request for a psychiatric evaluation. In 73 of the cases (65.2%) the evaluating psychiatrist believed there was no need for hospitalization. This assessment did not change by the end of the hospitalization in all cases. Employment and alcohol use were the only factors associated with a lower need for hospitalization (OR 0.24, 95%CI 0.07–0.77, and 0.34, 95%CI 0.13–0.90, respectively).

Conclusions: In the majority of cases, based on the evaluating psychiatrist's responses, the evaluation could have been conducted without need for hospitalization. The findings indicate that an outpatient unit designated to write court-requested psychiatric evaluations could significantly reduce the rates of hospital admissions for this purpose.

 

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