Ronen Durst, MD, Deborah Rund, MD, Daniel Schurr, MD, Osnat Eliav, MSc, Dina Ben-Yehuda, MD, Shoshi Shpizen, BSc, Liat Ben-Avi, BSc, Tova Schaap, MSc, Inna Pelz, BSc and Eran Leitersdorf, MD
Background: Low density lipoprotein apheresis is used as a complementary method for treating hypercholesterolemic patients who cannot reach target LDL-cholesterol levels on conventional dietary and drug treatment. The DALI system (direct absorption of lipoproteins) is the only extracorporeal LDL-removing system compatible with whole blood.
Objective: To describe our one year experience using the DALI system.
Methods: LDL apheresis was used in 13 patients due to inability to reach target LDL-C levels on conventional treatment. They included seven patients with familial hypercholesterolemia, three who had adverse reactions to statins, and three patients with ischemic heart disease who did not reach LDL-C target level on medical treatment.
Results: The average triglyceride, total cholesterol, high density lipoprotein-C and LDL-C levels before and after treatment in all patients were: 170 ± 113 vs. 124 ± 91, 269 ± 74 vs. 132 ± 48, 42 ± 8 vs. 37 ± 7.9, and 196 ± 77 vs. 80 ± 52 mg/dl, respectively. Comparing the results of a subgroup of seven patients who had previously been treated with plasma exchange, it is noteworthy that while the reduction in triglyceride, total cholesterol and LDL-C are comparable, the effect on HDL-C concentration was less apparent: from an average of 39.7 ± 8.7 and 23 ± 5.7 mg/dl before and after plasma exchange to an average of 43.9 ± 8.1 and 38.4 ± 7 mg/dl before and after LDL apheresis, respectively. Five patients developed treatment-related adverse events: three experienced allergic reactions manifested as shortness of breath, urticaria and facial flushing; one patient developed rhabdomyolysis, an adverse reaction that was not reported previously as a result of LDL apheresis; and one patient had myopathy with back pain. All untoward effects occurred during the first few treatment sessions.
Conclusions: LDL apheresis using the DALI system is highly efficacious for the treatment of hypercholesterolemia. It is associated with a significant number of side effects occurring during the first treatment sessions. In patients not experiencing adverse effects in the early treatment period, it is well tolerated, and can provide remarkable clinical benefit even after short-term therapy.
Michael Lurie, MD, Ines Misselevitch, MD and Milo Fradis, MD
Background: Fine-needle aspiration is a widely accepted method in the preoperative evaluation of head and neck tumors. However, its effectiveness in the interpretation of salivary gland disorders is controversial.
Objectives: To evaluate the effectiveness of FNA as a preoperative diagnostic tool of parotid lesions.
Methods: Reports of 52 FNA from various parotid gland lesions were compared with the final pathologic diagnoses.
Results: We noted 31 true-positive, 5 true-negative and 16 false-negative results. There were no false-positive FNA reports. The calculated sensitivity, specificity and accuracy of FNA diagnosis in this study were 66%, 100%, and 69.2% respectively.
Conclusions: The high rate (30.8%) of false-negative FNA results was partly explained by sampling errors, therefore specificity of the procedure could be improved by the precise selection of a representative aspiration site.
Yaron Niv, MD and Shlomo Birkenfield, MD
Background: Guidelines are important for keeping family physicians informed of the constant developments in many fields of medicine.
Objectives: To compare the knowledge of gastroenterologists and family physicians regarding the diagnosis and treatment of gastroesophageal reflux disease in order to determine the need for expert guidelines.
Methods: A 25 item questionnaire on the definition, diagnosis and treatment of GERD was presented to 35 gastroenterologists and 35 family physicians. Each item was rated on a four point scale from 1 = highly recommended to 4 = not recommended. A voting system was used for each group on separate occasions. The proportions of correct answers according to the level of recommendation were compared between the groups.
Results: The groups' responses agreed on only 4 of the 25 items; differences between the remaining 21 were all statistically significant. For 14 items, 70% of the gastroenterologists chose the grade 1 recommendation, whereas more than 70% of the family physicians chose mostly grade 2.
Conclusions: The gap in knowledge on gastroesophageal reflux disease between gastroenterologists and family physicians is significant and may have a profound impact on diagnosis and treatment. Clear and accurate guidelines may improve patient evaluation in the community.
Yunis Abou-Rbiah, MD and Shimon Weitzman, MD MPH
Background: Previous studies have shown a low prevalence of diabetes and other cardiovascular risk factors among Bedouins living in the Negev Desert. New evidence suggests that diabetes is becoming highly prevalent.
Objectives: To estimate the prevalence of diabetes in the town of Rahat, describe the cardiovascular risk factor profile and therapeutic modalities for diabetes and related conditions in this population, and compare these findings with those in the Jewish population.
Methods: A complete record review of all known diabetic individuals aged 35 and older registered at the Rahat Clinic (Clalit Health Services) was carried out by a trained nurse and a research assistant. Information on demographic, anthropometric and clinical characteristics was abstracted. Data on prescribed hypoglycemic agents and other medications were also obtained.
Results: Of the 316 known diabetic patients in the clinic, complete data were available for 271 (85.8 %). The prevalence of known diabetes was 7.3% in males and 9.9% in females. Females had a significantly higher body mass index than males (30.9 vs. 29, P < 0.002), but lower levels of HBA1c and microalbuminuria. Oral hypoglycemic medications were taken by 69% of women and 76% of men, and insulin by 19% of women and 15% of men.
Conclusions: Compared with data on Jewish diabetic patients in the Negev and Israel, the overall prevalence of diabetes in the population of Rahat is higher, but their cardiovascular risk profile is better, except for obesity. These findings support the hypothesis that diabetes and obesity have become major public health problems among Bedouins.
George S. Habib, MD and Walid R. Saliba, MD
Background: The prevalence of clinical manifestations and laboratory parameters in systemic lupus erythematosus differ among various ethnic groups. Few studies have reported on SLE in Arabs.
Objectives: To summarize the demographic, clinical and laboratory features of Arab SLE patients and to compare them with other series from different Arab countries.
Methods: We reviewed the charts of all Arab SLE patients who had been seen at the Carmel Medical Center in Haifa, the Nazareth Hospital and the Holy Family Hospital in Nazareth, and a professional clinic (a referral outpatient clinic of the largest health maintenance organization in Israel) in Acre – all cities in northern Israel. Only patients with symptoms of more than one year were included. Demographic, clinical and laboratory parameters were documented and compared with those of four series from different Arab countries.
Results: The study group comprised 34 patients. The majority of the patients was Moslem; there were a few Druze and one Christian. There was no statistical difference between our patients and any of the other Arab series in terms of arthritis, neuropsychiatric manifestations and VDRL. The presence of serositis and mucocutaneous manifestations was significantly lower in our series compared to some of the other series. However, there was significantly less renal involvement in our patients compared to each of the other series.
Conclusions: The prevalence of most clinical and laboratory parameters in Israeli Arab SLE patients is comparable to that of other series of SLE patients from different Arab countries. The prevalence of renal involvement in Israeli Arab SLE patients seems to be lower than in SLE patients from different Arab countries.
Dov Gavish, MD, Eyal Leibovitz, MD, Itzhak Elly, MD, Marina Shargorodsky, MD and Reuven Zimlichman, MD
Background: The implementation of treatment guidelines is lacking worldwide.
Objectives: To examine whether follow-up in a specialized lipid clinic improves the achievement rate of the treatment guidelines, as formulated by the National Cholesterol Education Program and the Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure.
Methods: The study group included patients who were referred to the lipid clinic because of hyperlipidemia. At each of five visits over a 12 month period, lipid levels, liver and creatine kinase levels, body mass index, and adherence to diet and medications were measured, and achievement of the NCEP target level was assessed.
Results: A total of 1,133 patients (mean age 61.3 years, 60% males) were studied. Additional risk factors for atherosclerosis included hypertension (41%), type II diabetes mellitus (21%), smoking (17%), and a positive family history of coronary artery disease (32%). All patients had evidence of atherosclerotic vascular disease (coronary, cerebrovascular or peripheral vascular diseases). The low density lipoprotein target of <100 mg was present in only 22% of patients before enrollment, with improvement of up to 57% after the follow-up period. During follow-up, blood pressure control was improved (from 38% at the time of referral to 88% after 12 months, P < 0.001), as was glycemic control in diabetic patients (HgA1C improved from 8.2% to 7.1% after 12 months, P < 0.001). Improved risk factor control was due to increased compliance to medication treatment (from 66% at enrollment to more than 90% after 12 months), as well as careful attention to risk factor management that translated into a change in the treatment profile during the follow-up. There was an increase in the use of the following medications: aspirin from 68% to 96%, statins from 42% to 88%, beta blockers from 20% to 40%, and angiotensin-converting enzyme inhibitors from 28% to 42%; while calcium channel blocker use decreased from 40% to 30% in patients during follow-up.
Conclusion: Follow-up of patients in a specialized clinic enhances the achievement of LDL-cholesterol treatment goals as well as other risk factor treatment goals, due to increased patient compliance and increased use of medications.
Yaacov Ori, MD, Haim Neuman, MD, Avry Chagnac, MD, Annette Siegal, MD, Ana Tobar, MD, Maxim Itkin, MD, Uzi Gafter, MD, PhD and Asher Korzets, MB, BS
Background: The use of an automated biopsy system for renal biopsy has recently gained popularity, but its safety in single functioning kidneys is unclear.
Objective: To report our experience with the automated system for closed renal biopsy during a 5 year period.
Methods: Eighty-five patients underwent percutaneous native renal biopsy with the automated biopsy gun (16G needle) under real-time ultrasound. They were chronologically divided into two groups: 41 patients (group A), using an older ultrasound machine; and 44 patients (group B), using a newer ultrasound machine. Nine patients biopsied with a manual 14G Tru-cut needle served as the control (group C).
Results: The number of "attempted" passes at the kidney was 4.0 ± 0.1 in group B, 4.7 ± 0.3 in group A (P < 0.05 vs. group B), and 5.8 ± 0.5 in group C (P < 0.01 vs. group B). The number of successful passes did not differ (3.3 ± 0.1, 3.3 ± 0.1, 3.1 ± 0.2). The ratio of "attempted/successful" was 1.28 ± 0.07 in group B, 1.95 ± 0.38 in A, and 1.90 ± 0.21 in C (P < 0.01 vs. B). The number of glomeruli obtained was similar in the three groups. Adequate tissue was obtained in 95%, 98%, and 100%, respectively. Hemoglobin decreased by 4.3 ± 1.1% in group B, 6.9 ± 1.3% in group A, and 11.3 ± 1.8% in group C (P < 0.05 vs. B). Perinephric/subcapsular hematoma occurred in 5 patients (11.4%) in group A (2 taking aspirin), in 2 patients (4.9%) in group B, and in none in group C. The necessity for blood transfusion post-biopsy was similar in all groups. Four of five patients with single functioning kidneys (one in group A and four in group B) had uneventful biopsies, and adequate tissue was obtained in three.
Conclusions: The use of the automated biopsy gun is effective, safe and has a low rate of major complications. It may be used safely in single functioning kidneys.
Aliza Amiel, PhD, Orit Reish, MD, Elena Gaber, PhD, Ronit Masterman, MD, Tally Tohami, MSc and Moshe D. Fejgin, MD
Background: While most allelic pairs of DNA replicate synchronously during the S phase of the cell cycle, some genes normally replicate asynchronously, i.e., genes on the X chromosome and imprinted genes. The replication control mechanism is unknown but was shown to be impaired in malignancies and chromosomal trisomies where replication pattern becomes asynchronous.
Objectives: To determine the level of asynchronization in replication timing of cells from patients with microdeleted genomes.
Methods: We applied monocolor fluorescent in situ hybridization with different probes on leukocytes from microdeleted genomes.
Results: All samples derived from the microdeleted genomes showed significantly higher levels of an asynchronized pattern compared to normal individuals.
Conclusions: Even a “small” genetic imbalance (microdeletion) can interfere with gene replication and cell cycle progression, as previously shown in full trisomies.