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עמוד בית Fri, 23.08.19

June 2013


Original Articles
A. Hilmi, Y. Pasternak, M. Friger, N. Loewenthal, A. Haim and E. Hershkovitz
 Background: The existent glycemic control of type 1 diabetes mellitus (T1DM) patients in daily practice might not reach the goals determined in guidelines. Ethnic diversity was also shown to influence glycemic control.

Objectives: To evaluate glycemic control, prevalence of diabetic ketoacidosis (DKA) at presentation, diabetic complications rate, and associated autoimmune diseases in a pediatric T1DM patient population in the Negev area.

Methods: Clinical and demographic details of 168 T1DM patients were evaluated, including HbA1C levels, long-term complications, related autoimmune diseases, and insulin pump usage. The data were analyzed and the Jewish and Bedouin patient groups compared.

Results: Only 13.1% of the patients had reached the HbA1C levels recommended by the current guidelines at the first and second year follow-up visits, and 9.5% and 7.1% at the third and fourth year visits, respectively. A significant difference in HbA1c levels between Jewish and Bedouin patients was found (P = 0.045 at the first year follow-up, P ≤ 0.01 thereafter). Significant difference was found between the Jewish and the Bedouin groups regarding presentation with DKA, 33% and 56% of the patients respectively (P = 0.01).

Conclusions: Existent glycemic control in daily practice is far from the guideline goals. Bedouin ethnicity was associated with less favorable diabetes control, emphasizing the need for better awareness of T1DM and its treatment options in this population. More resources should be directed to address T1DM in the general population, especially among the Bedouin.

 

G.S. Breuer, R. Nesher, K. Reinus and G. Nesher
 Background: In most cases of giant cell arteritis (GCA) the diagnosis is confirmed by temporal artery biopsy. Aside from the diagnostic purpose, histological parameters may serve as prognostic markers.

Objectives: To review positive temporal artery biopsiese of GCA in an attempt to correlate various histological parameters with clinical features, disease complications and outcome.

Methods: Positive biopsies from 65 GCA patients were randomly selected for review by a single pathologist. In each biopsy the following parameters were scored: intensity and location of the inflammatory infiltrate, presence of giant cells and other cell types, fragmentation and calcification of the internal elastic lamina, intimal thickening, and presence of luminal thrombus. Clinical data were obtained from the patients’ charts. Intensity of the initial systemic inflammatory reaction (ISIR) at the time of diagnosis was scored by the presence of five parameters: fever, anemia, thrombocytosis, leukocytosis, and sedimentation rate > 100 mm/hr.

Results: In cases with bilateral positive biopsy (n=27), there was good correlation between the two sides regarding intensity of inflammation (r = 0.65, P < 0.001), location of the infiltrate (r = 0.7, P < 0.001), degree of intimal thickening (r = 0.54, P < 0.001), and presence of giant cells (r = 0.83, P < 0.001). The rate of corticosteroid discontinuation tended to be quicker in patients with inflammatory infiltrates confined mainly to the adventitia, but other histological parameters did not affect this rate.

Conclusions: Inflammatory infiltrates confined to the adventitia were associated with more neuro-ophthalmic ischemic manifestations, weak/moderate ISIR at the time of diagnosis, and faster rate of corticosteroid discontinuation. No association was found between other temporal artery biopsy histological parameters and clinical features of GCA patients.

 

A. Yakirevitch, G. Nakache, N. Lipschitz, E.E. Alon, M. Wolf and Y.P. Talmi
 Background: Tracheostomy is a frequent, and at times semiurgent, surgical procedure. It is performed in close proximity to the thyroid gland, and in many cases requires division of its isthmus putting a patient in danger of significant bleeding.

Objectives: To examine prospectively the feasibility of vessel sealing in tracheostomy.

Methods: A vessel-sealing device was used in 24 consecutive patients undergoing tracheostomy. There were no exclusion criteria for enrolling the patients. No other hemostatic technique was used for dividing the isthmus.

Results: There were no bleeding events throughout the postoperative period. The operating time savingwas 5–10 minutes.

Conclusions: Use of the vessel sealer was found to be straightforward, efficacious, rapid and safe. 

O. Sarig, A. Hass and A. Oron
 Background: Various methods of core suture and suture material are used successfully in acute flexor tendon repair.

Objectives: To assess the current practice in acute flexor tendon repair among Israeli hand surgeons.

Methods: A five-question survey was conducted among certified hand surgeons in Israel regarding their preferred materials and method for performing acute flexor tendon repair.

Results: Forty-eight hand surgeons participated in the survey. The most widely used core suture in zone 2 (58.3%), as well as in zones 3 and 4 (62.5%), was the modified Kessler type. The most widely used suture material was nylon. All surgeons incorporated epitendinous sutures to augment their core sutures. 

Conclusions: The modified Kessler core suture technique is the most widely used technique among Israeli hand surgeons for repairing acute flexor tendon lacerations in zones 2, 3 and 4. This finding agrees with worldwide data and with emerging data attesting to the lower risk of adhesion formation and postoperative tendon ruptures with this method. The core suture technique initially popularized by the late Prof. Isidor Kessler, who headed our department during the years 1973–92, remains the most practiced acute flexor tendon repair technique among hand surgeons in Israel. 

G. Barkai, A. Barzilai, E. Mendelson, M. Tepperberg-Oikawa, D. Ari-Even Roth and J. Kuint
 Background: Congenital cytomegalovirus (C-CMV) infection affects 0.4–2% of newborn infants in Israel, most of whom are asymptomatic. Of these, 10–20% will subsequently develop hearing impairment and might have benefitted from early detection by neonatal screening.

Objectives: To retrospectively analyze the results of a screening program for C-CMV performed at the Sheba Medical Center, Tel Hashomer, during a 1 year period, using real-time polymerase chain reaction (rt-PCR) from umbilical cord blood.

Methods: CMV DNA was detected by rt-PCR performed on infants’ cord blood. C-CMV was confirmed by urine culture (Shell-vial). All confirmed cases were further investigated for C-CMV manifestations by head ultrasound, complete blood count, liver enzyme measurement, ophthalmology examination and hearing investigation.

Results: During the period 1 June 2009 to 31 May 2010, 11,022 infants were born at the Sheba Medical Center, of whom 8105 (74%) were screened. Twenty-three (0.28%) were positive for CMV and 22 of them (96%) were confirmed by urine culture. Two additional infants, who had not been screened, were detected after clinical suspicion. All 24 infants were further investigated, and 3 (12.5%) had central nervous system involvement (including hearing impairment) and were offered intravenous ganciclovir for 6 weeks. Eighteen (82%) infants would not otherwise have been diagnosed.

Conclusions: The relatively low incidence of C-CMV detected in our screening program probably reflects the low sensitivity of cord blood screening. Nevertheless, this screening program reliably detected a non-negligible number of infants who could benefit from early detection. Other screening methods using saliva should be investigated further.

 

O. Ben-Ishay, E. Brauner, Z. Peled, A. Othman, B. Person and Y. Kluger
 Background: Colon cancer is common, affecting mostly older people. Since age is a risk factor, young patients might not be awarded the same attention as older ones regarding symptoms that could imply the presence of colon cancer.

Objectives: To investigate whether young patients, i.e., under age 50, complain of symptoms for longer than older patients until the diagnosis of colon cancer is established.

Methods: In this retrospective cohort study, patients were divided into two groups: < 50 years old (group 1) and ≥ 50 (group 2). All had undergone surgery for left or right colon cancer during the 1 year period January 2000 through December 2009 at one medical center. Rectal and sigmoid cancers were excluded. Data collected included age, gender, quantity and quality of complaints, duration of complaints, in-hospital versus community diagnosis, pathological staging, the side of colon involved, and overall mortality. The main aim was the quality and duration of complaints. Secondary outcomes were the pathological stage at presentation and the mortality rate.

Results: The study group comprised 236 patients: 31 (13.1%) were < 50 years old and 205 (86.9%) were ≥ 50 years. No significant difference was found in the quantity and quality of complaints between the two groups. Patients in group 1 (< 50 years) complained for a longer period, 5.3 vs. 2.4 months (P = 0.002). More younger patients were diagnosed with stage IV disease (38.7% vs. 21.5%, P = 0.035) and fewer had stage I disease (3.2% vs. 15.6%, P = 0.06); the mortality rates were similar (41.9% vs. 39%). Applying a stepwise logistic regression model, the duration of complaints was found to be an independent predictor of mortality (P = 0.03, OR 1.6, 95% CI 1–3.6), independently of age (P = 0.003) and stage (P < 0.001).

Conclusions: Younger patients are more often diagnosed with colon cancer later, at a more advanced stage. Alertness to patients’ complaints, together with evaluation regardless of age but according to symptoms and clinical presentation are crucial. Large-scale population-based studies are needed to confirm this trend. 

E.D. Amster, S.S. Fertig, U. Baharal, S. Linn, M.S. Green, Z. Lencovsky and R.S. Carel
 Background: From 2 to 5 December 2010, Israel experienced the most severe forest fire in its history, resulting in the deaths of 44 rescue workers. Little research exists on the health risks to emergency responders during forest fires, and there is no published research to date on occupational health among firefighters in Israel.

Objectives: To describe the exposures experienced by emergency responders to smoke, fire retardants and stress; the utilization of protective equipment; and the frequency of corresponding symptoms during and following the Carmel Forest fire.

Methods: A cohort of 204 firefighters and 68 police who took part in rescue and fire-abating activities during the Carmel Forest fire were recruited from a representative sample of participating stations throughout the country and interviewed regarding their activities during the fire and their coinciding symptoms. Unpaired two-sample t-test compared mean exposures and symptom frequency for firefighters and police. Chi-square estimates of OR and 95% CI are provided for odds of reporting symptoms, incurring injury or being hospitalized for various risk factors.

Results: Of the study participants, 87% reported having at least one symptom during rescue work at the Carmel Forest fire, with eye irritation (77%) and fatigue (71%) being the most common. Occupational stress was extremely high during the fire; the average length of time working without rest was 18.4 hours among firefighters.

Conclusions: Firefighters and police were exposed to smoke and occupational stress for prolonged periods during the fire. Further research is needed on the residual health effects from exposure to forest fires among emergency responders, and to identify areas for improvement in health preparedness.  

Reviews
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.

 

O. Keret
 Synthetic biology is a relatively new field of biological research and development that focuses on the engineering of genetic molecular machines with a specific predefined function. Plainly put, the newly engineered organism functions as a machine. It can process information, manufacture, heal and even diagnose. We just have to engineer it to do so. The famous quote "Biology is the nanotechnology that works" is currently being put to the test on a worldwide scale. The application of these machines is theoretically boundless. In laboratories worldwide synthetic biology technologies are being rationally designed to assist in diagnosis or disrupt disease mechanisms. In the not too distant future they are expected to reach the clinical setting. This new field should be distinguished from classic genetic engineering. The latter researches naturally found DNA segments via cloning. It is weakly associated with engineering. Synthetic biology focuses on the engineering of molecular biological machines for the benefit of mankind. This is done via synthetic (computer printed) DNA sequences, man-designed or altered in silico. In this article I will briefly introduce synthetic biology, elaborate on the Biobrick Foundation as an independent fast-growing synthetic biology-sharing movement, and report on selected developing applications for medicine.

הבהרה משפטית: כל נושא המופיע באתר זה נועד להשכלה בלבד ואין לראות בו ייעוץ רפואי או משפטי. אין הר"י אחראית לתוכן המתפרסם באתר זה ולכל נזק שעלול להיגרם. כל הזכויות על המידע באתר שייכות להסתדרות הרפואית בישראל. מדיניות פרטיות
ז'בוטינסקי 35 רמת גן, בניין התאומים 2 קומות 10-11, ת.ד. 3566, מיקוד 5213604. טלפון: 03-6100444, פקס: 03-5753303