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עמוד בית Wed, 26.06.19

September 1999


Original Articles
 Background: Anti-neutrophil cytoplasm antibodies in necrotizing vasculitides need to be distinguished from ANCAs1  in other inflammatory conditions to avoid clinical misinterpretation.

Objectives: To help clinicians and laboratory scientists recognize and utilize vasculitis-related ANCAs as an aid in diagnostic workup and patient follow-up, and be aware that ANCAs with different characteristics are commonly found in other chronic inflammatory conditions that persistently engage neutrophils in the inflammatory process.

Methods: Indirect immunofluorescence and enzyme immunoassay methods were used to detect ANCAs with both known and unknown neutrophil autoantigenic targets.

Results: Primary necrotizing small vessel vasculitides such as Wegener’s granulomatosis, Churg-Strauss syndrome, microscopic polyangiitis, and renal-limited rapidly progressive necrotizing glomerulonephritis target either the serine protease proteinase 3 or myeloperoxidase  in azurophilic granules. In ulcerative colitis and rheumatoid arthritis, we found multiple ANCA targets contained in azurophilic and specific granules, the cytosol and the nucleus, whereas PR32 and MPO3 were not, or only weakly, recognized.

Conclusions: ANCAs typically found in active SVV4 are demonstrable both by indirect immunofluorescence and antigen-specific enzyme immunoassay, and strong reactivity to either PR3 or MPO is characteristic. Strong ANCA with MPO reactivity is also found in some patients with drug-induced syndromes (lupus, vasculitis). Intermediate to strong perinuclear ANCAs are found in a substantial proportion of patients with UC5 (40–60%) and RA6 (30–70%), but in these conditions the ANCAs have many antigen targets that are only weakly recognized.

 

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1 ANCA = anti-neutrophil cytoplasm antibody

2 PR3 = protease proteinase 3

3 MPO = myeloperoxidase

4 SVV = small vessel vasculitides

5 UC = ulcerative colitis

6 RA = rheumatoid arthritis

 

Roberto Spiegelmann, MD, Jana Gofman, MSc, Dror Alezra, MSc and Raphael Pfeffer, MD
 Background: Radiosurgery is a therapeutic technique characterized by the delivery of a single high dose of ionizing radiation from an external source to a precisely defined intracranial target. The application of radiosurgery to the treatment of acoustic neurinomas has increased substantially in the last decade. Most of the published experience pertains to the use of the gamma knife.

Objectives: To report the experience at the first Israeli Linear Accelerator Radiosurgery Unit in the management of 44 patients with acoustic neurinomas.

Methods: We analyzed the clinical records and imaging studies of all patients undergoing radiosurgery for acoustic neurinomas between 1993 and 1997, and quanitified the changes in tumor volume, hearing status, and facial and trigeminal nerve function. The contribution of radiation dose and original tumor volume upon those variables was also studied.

Results: At a mean follow-up of 32 months (range 12–60), 98% of the tumors were controlled (75% had shrunk; 23% had stable volume). The actuarial hearing preservation rate was 71%. New transient facial neuropathy developed in 24% of the patients, persisting in mild degrees in 8%. Neuropathy correlated primarily with tumor volume. Tumors with volumes 4 ml were at high risk when marginal radiation doses were 1,400 cGy. Dose reduction to a maximum of 1,400 cGy produced no neuropathies in the last 20 patients, still preserving tumor control rates.

Conclusions: Radiosurgery is an effective and cost-efficient therapeutic modality for newly diagnosed acoustic neurinomas in the elderly or medically infirm population, and for all residual or recurrent tumors after conventional surgery.

Ron Ben-Abraham, MD, Michael Stein, MD, Gideon Paret, MD, Avishy Goldberg, MD, Joshua Shemer, MD and Yoram Kluger, MD.
 Background: In the military environment it is the medics who usually provide the initial care of mass casualties in the field.

Objectives: To determine the number of incidents of trauma encountered by medics in the Israel Defense Forces during peacetime, and to ascertain the role of these medics in providing primary trauma care to the victims.

Methods: A retrospective questionnaire, reviewing the activities of medics in treating injured trauma victims, was distributed to medics who were in service for at least 2 years after their professional training.

Results: Of the 128 responding medics, 87 (68%) had actively participated in the treatment of trauma victims under various circumstances. The average number of trauma events was 1.2 events over a period of 2 years per combat medic, and 0.7 for medics stationed in rear units. Their activities included insertion of numerous intravenous fluid lines (57% of medics), assistance in intubations (37%), tube thoracostomies (23%), insertions of central catheters (14%) or orogastric tubes (28%), and manual ventilations (41%).

Conclusion: Since it is difficult to increase the level of practical experience in dealing with trauma within the military framework, new techniques should be applied to improve the trauma training.

Gideon Nesher, MD, Hanan Gur, MD, Michael Ehrenfeld, MD, Alan Rubinow, MD and Moshe Sonnenblick, MD.
 Objectives: To evaluate whether the increasing incidence of temporal arteritis in Israel is associated with a changing clinical presentation.

Methods: The demographic data and clinical manifestations of 144 TA1 patients in this large multicenter study were recorded and compared with data obtained in a previous study.

Results: The patient population was older, with 24% ≥80 years compared to 6% in the previous study.  There was an increase in the number of nonspecific presenting symptoms, and less patients presented with the “classical” manifestations of headache (81% vs. 71%), fever (83% vs. 40%), jaw claudication (21% vs. 13%), and visual symptoms (47% vs. 24%). The median time from presentation to diagnosis was significantly reduced, from 5 to 1.5 months.

Conclusions: There were substantial changes in the clinical presentation of TA patients in Israel during 1980–95 compared to patients diagnosed prior to 1978. It is suggested that these changes may be attributed not only to the influence of aging of the population, but are due largely to increasing physician awareness to the spectrum of manifestations of TA, which leads to earlier diagnosis.

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1TA = temporal arteritis

Moshe Salai, MD, Moshe Pritsch, MD, Yehuda Amit, MD, Amnon Israeli, MD and Aharon Chechick, MD.
 Background: Bone banking and the clinical use of banked tissue are the most common forms of allopreservation and transplantation in modern medicine.

Objectives: This article reviews 25 years (1973–98) of experience in bone banking in Israel.

Methods: A nationwide survey on the clinical application of the banked musculoskeletal tissues during 1996 was conducted by means of a written questionnaire sent to all orthopedic departments in Israel.

Results:  The response rate to the questionnaire was 84%. A total of 257 cases were allocated bone allografts: the majority comprised 225 spongy bones, 26 were massive bone allografts and 6 were soft tissue allografts.

Conclusion:  Improvement of quality control and quality assurance of the banked tissues, together with development of skills in the use of osteoinductive and osteoconductive materials, cast the future of musculoskeletal tissue banking.

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 * A Tribute to Professor Henry Horoszowski

Editorials
Reviews
Derek Le-Roith, MD, Michael Karas, MD, Shoshana Yakar, MD, Bao-He Qu, MD, Yiping Wu, MD, and Vicky A. Blakesley, MD.
Pnina Langevitz, MD, Avi Livneh, MD, Shai Padeh, MD, Nurit Zaks, MD, Yael Shinar, MD, Deborah Zemer, MD, Elon Pras, MD, and Mordechai Pras, MD.
Sandra Reynoso-Paz, MD, Ross L. Coppel, MD, Aftab A. Ansari MD, and M.Eric Gershwin, MD
Case Communications
Ben Zion Garty, MD, Itzhak Levy, MD, and Zvi Laron, MD.
Hertzel Salman, MD, Pearl I. Herskovitz, MD, Simcha Brandis, MD, Michael Bergman, MD, Dror Dicker, MD, and Izhar Zahavi, MD.
Avishai Ziser, MD, Ludmila Guralnik, MD, Robert Markovits, MD, Yousif Matanis, MD, and Genia Mahamid, MD.
Michael Gdalevich, MD, Daniel Mimouni, MD, Isaac Ashkenazi, MD, and Joshua Shemer ,MD.
Dan Regev, MD, Yoram Wolf, MD, and Daniel Hauben, MD.
Ittai Shavit, MD, Naim Shehadeh, MD, Osnat Zmora, MD, Israela Avidor, MD, and Amos Etzioni, MD.
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