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עמוד בית Wed, 26.06.19

August 2005

A. Strulov
 Until the end of the 1980s almost no intensive intervention plan was applied to narrow the vast gap (over 100%) in infant mortality between Jews and Arabs in the Western Galilee region of Israel. A special committee appointed by the Ministry of Health instituted measures to reduce the gap, including monitoring mortality rates by establishing an online and real-time computerized information system to analyze the information without delay. Based on the epidemiologic findings, an intervention program was implemented, using health education to reduce mortality due to seasonal infections – gastroenteritis in summer and upper respiratory and hyperthermia in winter. Within 1 year these infections had abated, resulting in significantly reduced mortality. The next step was the development of an ultrasound preventive campaign using sophisticated sonography to screen pregnant women in risk groups for lethal congenital defects and convincing them to discontinue the pregnancy. These two measures reduced infant mortality dramatically. The campaign has been widened to the entire northern district and is presently addressing, as a primary prevention, the traditionally difficult problem of consanguineous marriages – the major cause of congenital defects in the Arab population.

Original Articles
I. Klaz, Y. Wohl, N. Nathansohn, N. Yerushalmi, S. Sharvit, I. Kochba and S. Brenner
 Background: The Israel Defense Forces implemented a pilot teledermatology service in primary clinics.

Objectives: To assess user satisfaction and clinical short-term effectiveness of a computerized store and forward teledermatology service in urban and rural units.

Methods: A multi-center, prospective, uncontrolled, cohort pilot trial was conducted for a period of 6 months. Primary care physicians referred patients to a board-certified dermatologist using text email accompanied by digital photographs. Diagnosis, therapy and management were sent back to the referring PCP[1]. Patients were asked to evaluate the level of the CSAFTD[2] service, effect of the service on accessibility to dermatologists, respect for privacy, availability of drugs, health improvement and overall satisfaction. PCPs assessed the quality of the teledermatology consultations they received, the contribution to their knowledge, and their overall satisfaction.

Results: Tele-diagnosis alone was possible for 95% (n=413) of 435 CSAFTD referrals; 22% (n=95) of referrals also required face-to-face consultation. Satisfaction with CSAFTD was high among patients in both rural and urban clinics, with significantly higher scores in rural units. Rural patients rated the level of service, accessibility and overall satisfaction higher than did urban patients. PCPs were satisfied with the quality of the service and its contribution to their knowledge. Rural physicians rated level of service and overall satisfaction higher than the urban physicians. Tele-referrals were completed more efficiently than referral for face-to-face appointments.

Conclusions: CSAFTD provided efficient, high quality medical service to rural and urban military clinics in the IDF[3].


[1] PCP = primary care physician

[2] CSAFTD = computerized store and forward teledermatology

[3] IDF = Israel Defense Force

D. Leibovici, A. Cooper, A. Lindner, R. Ostrowsky, J. Kleinmann, S. Velikanov, H. Cipele, E. Goren and Y.I. Siegel
 Background: Stents offer a simple and effective drainage method for the upper urinary tract. However, ureteral stents are associated with frequent side effects, including irritative voiding symptoms and hematuria.

Objectives: To determine the side effects associated with ureteral stents and their impact on sexual function and quality of life.

Methods: Symptom questionnaires were administered to 135 consecutive patients with unilateral ureteral stents. The questionnaire addressed irritative voiding symptoms, flank pain, hematuria, fever, loss of labor days, anxiety, sleep impairment, decreased libido, erectile dysfunction, dyspareunia, painful ejaculation, and a subjective overall impact on quality of life. The items were graded from 1 (minimal or no symptoms) to 5 (maximal symptoms). The patients were seen and questionnaires filled at 2 weekly intervals following stent insertion until stent extraction. Following removal of the stent, stent patency, impaction and migration rates were determined. Admissions to hospital and ancillary procedures to retreive stents were noted.

Results: The findings presented refer to questionnaire items scoring 3 or more. Dysuria, urinary frequency and urgency were reported by 40%, 50% and 55% of the patients, respectively. Flank pain, gross hematuria or fever was reported by 32%, 42% and 15% respectively. Among working patients, 45% lost at least 2 labor days during the first 14 days, and 32% were still absent from work by day 30. A total of 435 labor days were lost in the first month. Anxiety and sleep disturbance were reported by 24% and 20% respectively, and 45% of patients reported impairment in their quality of life. Decreased libido was reported by 45%, and sexual dysfunction by 42% of men and 86% of women. Stent removal necessitated ureteroscpoy in 14 patients (10.5%), due to upward migration in 11 (8.2%) and incrustration and impaction in 3. Spontaneous stent expulsion occurred in one patient. Forty-six (34%) stents were obstructed at the time of removal. Obstructed stents were associated with a longer mean dwell time as compared to the whole population, 75 versus 62 days respectively (P = 0.04).

Conclusions: Ureteral stents are associated with frequent side effects and significantly impact on patient quality of life. Our findings should be considered when deciding on ureteral stent insertion and dwell time.

E. Konen, I. Greenberg and J. Rozenman
 Background: Chest radiography is still the most frequently performed radiologic imaging study. Digital radiography is gradually replacing the conventional systems.

Objectives: To compare the subjective visibility of normal anatomic landmarks in the chest on storage phosphor-based digital radiographs versus conventional screen-film radiographs.

Methods: Digital phosphor-based and screen-film posteroanterior chest radiographs were obtained during 1 year in 140 asymptomatic patients without any known pulmonary disease (119 men, 21 women; mean age 52.1 years, range 23–86). Both sets of films were independently compared by two experienced radiologists in different sessions. The visibility of each of the following anatomic landmarks was graded from 1 to 3: pulmonary fissures, carina, bronchi to left upper lobe, right upper lobe and left lower lobe, bronchus intermedius, anterior and posterior junctional lines, and vessels behind the heart and diaphragm. Additionally, subjective general quality impression of each radiograph was graded similarly. Statistical analyses were performed using the chi-square test. A P value less than 0.05 was considered significant.

Results: Visibility with the digital images was statistically significantly higher for the carina, left lower lobe bronchus, bronchus intermedius, and vessels behind the heart and diaphragm. Subjective general quality impression of digital radiographs was also higher (P < 0.001). No significant visibility differences were found for pulmonary fissures or junctional lines.

Conclusion: Subjective visibility of anatomic structures behind the heart and diaphragm and at the hilae is significantly improved with phosphor-based digital radiography compared with conventional screen-film radiography. This suggests that pathologic processes such as pulmonary nodules, masses or consolidations projected over those structures may be more easily and reliably depicted on digital than conventional chest X-rays.

R. Fedakar, N. Turkmen, D. Durak, and U.N. Gundogmus
 Background: Despite many published retrospective analyses on cardiac injuries in treated patients, there is a striking scarcity of population-based studies that include autopsies.

Objectives: To provide data on fatal traumatic heart wounds in autopsied cases.

Methods: We reviewed 2,487 medico-legal autopsy records of the morgue department of the Bursa branch of the Turkish Council of Forensic Medicine for the period 1997–2001.

Results: Of these cases, 160 (6.4%) had cardiac injury; 13.8% were females and 86.2% males, and the mean age was 35.9 years old (range 4–65). The most common cause of heart wounds was penetrating trauma (87.5%), namely sharp injuries (48.1%) and firearm injuries (39.4%). The two most common causes of blunt heart wounds were traffic accidents (5.6%) and falls from a height (5%). Rupture was present in 96.9% of the cases, and isolated left ventricle and isolated right ventricle were ruptured in 31.3% and 23.8%, respectively. In penetrating injury the risk of ventricle rupture was higher than of atrium rupture. Alcohol was detected in 16.3% of cases. Only 3.5% of the penetrating cardiac injury cases and 5% of the blunt cardiac injury cases were admitted to hospital.

Conclusions: Given that only a very low percentage of the patients who sustain cardiac injury reach hospital alive, population-based studies, especially autopsy results, should be conducted to define the characteristics of cardiac injuries.

D. Schwartz
 Background: Many emergency departments use coagulation studies in the evaluation of patients with suspected acute coronary syndromes.

Objectives: To determine the prevalence of abnormal coagulation studies in ED[1] patients evaluated for suspected ACS[2], and to investigate whether abnormal international normalized ratio/partial thromboplastin time testing resulted in changes in patient management and whether abnormal results could be predicted by history and physical examination.

Methods: In this retrospective observational study, hospital and ED records were obtained for all patients with a diagnosis of ACS seen in the ED during a 3 month period. ED records were reviewed to identify all patients in whom the cardiac laboratory panel was performed. Other data included demographics, diagnosis and disposition, historical risk factors for abnormalities of coagulation, ED and inpatient management, INR[3]/PTT[4], platelet count and cardiac enzymes. Descriptive statistical analyses were performed.

Results: Complete data were available for 223 of the 227 patients (98.7%). Of these, 175 (78.5%) patients were admitted. The mean age was 64.2 years. Thirteen patients (5.8%) were diagnosed with acute myocardial infarction. Of the 223 patients, 29 (13%) and 23 (10%) had INR and PTT results respectively beyond the reference range. Seventy percent of patients with abnormal coagulation test results had risk factors for coagulation disorders. The abnormal results of the remaining patients included only a mild elevation and therefore no change in management was initiated.

Conclusions: Abnormal coagulation test results in patients presenting with suspected ACS are rare, they can usually be predicted by history, and they rarely affect management. Routine coagulation studies are not indicated in these patients.


[1] ED = emergency department

[2] ACS = acute coronary syndromes

[3] INR = international normalized ratio

[4] PTT = partial thromboplastin time

E. Tamir, M. Heim and I. Siev-Ner
 Background: Neuropathic plantar ulceration of the foot is treated by de-loading the ulcer. The total contact cast is considered to be the gold standard, but it is a labor-intensive procedure and frequent cast changes are needed.

Objectives: To describe an alternative de-loading method using a fiberglass removable walking cast.

Methods: This prospective uncontrolled study comprised 24 diabetic and non-diabetic patients with a single planter neuropathic ulcer. Exclusion criteria included the presence of osteomyelitis or cellulites, peripheral vascular disease, severe foot or leg edema, more than one ulcer on the treated foot, ulcers on the other foot, visual problems, gait instability, and personality or psychiatric problems. All patients were treated with the removable fiberglass de-loading cast. At each weekly follow-up visit the cast was removed. Data were collected using a clinical report form.

Results: The ulcer healed completely in 21 of the 24 patients treated (87.5%). The mean time for healing was 6.8 weeks (range 3–20 weeks, SD = 4.2). New ulcers developed in six patients (25% of the group).

Conclusions: The effectiveness and safety of the method is comparable to that of the total contact cast, but is less labor intensive because the cast is manufactured only once and serves for the whole length of treatment. Improving the technique is expected to lower the complication rate.

K. Peleg, Y. Kluger, A. Giveon, Israel Trauma Group, and L. Aharonson-Daniel

Background: The proportion of motorcyclists injured in road accidents in Israel is larger than their proportion among road users.

Objectives: To identify factors contributing to the risk of injury for motorcyclists as compared to drivers of other motor vehicles.

Methods: We retrieved and analyzed National Trauma Registry data on drivers, aged 16 and above, who were involved in traffic accidents and hospitalized between 1 January 1997 and 30 June 2003.

Results: The study group comprised 10,967 patients: 3,055 (28%) were motorcyclists and 7,912 (72%) were drivers of other motor vehicles. A multiple logistic regression revealed that Tel Aviv, the busiest metropolitan city in Israel, is a risk for motorcycle injury as compared to other regions; males have an increased risk compared to females; and age is a protecting factor since the risk of injury as a motorcyclist decreases as age increases. Nevertheless, the population of injured motorcyclists in Tel Aviv was significantly older (mean age 32.5 years vs. 28.6 elsewhere; t-test P < 0.0001). Twenty percent (n=156) of the injured motorcyclists in Tel Aviv were injured while working, compared to 9.5% (n=217) in other regions (chi-square P < 0.0001). Motorcycle injuries in Tel Aviv were of lower severity (7.7% vs. 16.4% according to the Injury Severity Scale 16+, c2 P < 0.0001), and had lower inpatient death rates (1.2% vs. 2.5%, c2 P = 0.001).

Conclusions: Tel Aviv is a risk for motorcycle injury compared to other regions, males have an increased risk compared to females, and age is a protecting factor. The proportion of motorcyclists in Tel Aviv injured while working is double that in other regions 

S. Berger-Achituv, T. Shohat and B-Z. Garty
 Background: The rate of breast-feeding in Israel has increased over the last two decades but is still lower than rates in other developed countries that have taken an active role in promoting breast-feeding.

Objective: To determine breast-feeding patterns and the association between sociodemographic characteristics and breast-feeding in the Tel Aviv district.

Methods: The mothers of infants aged 2, 4, 6 and 12 months, attending 59 well-baby clinics in the Tel Aviv district, were interviewed by telephone. Singleton infants who weighed less than 2,000 g and multiple-gestation infants were excluded from the study. The questions covered background data, sociodemographic characteristics of the family, and breast-feeding practices. Stepwise logistic regression was used to analyze the association between breast-feeding and various sociodemographic characteristics.

Results: Altogether, 78.5% of the mothers (1,307/1,665) initiated breast-feeding. The rate of breast-feeding at 2, 4, 6 and 12 months was 55.8, 36.8, 29.9 and 11.8%, respectively. Only 35.8% of the infants at 2 months and 11.2% at 6 months were exclusively breast-fed. The mean duration of breast-feeding was 5.2 ± 0.2 months. Grand multiparas (≥5 children) had a significantly higher rate of breast-feeding than women with one to four children (P < 0.001). More likely to breast-feed for 2 weeks or longer were women married to Yeshiva students (odds ratio = 5.3), women with ≥13 years education (OR[1] = 2.1), and women on maternity leave (OR = 1.6). The predictors for breast-feeding for 6 months or longer were similar.

Conclusions: Although the rate of breast-feeding initiation in central Israel was 78.5%, only 29.9% of the mothers continue to breast-feed for 6 months. Already at a young age, an appreciable number of breast-fed infants receive infant formula. Breast-feeding promotion should focus on less educated women, homemakers, and families with one to four children.


[1] OR = odds ratio

Y. Niv
 Colorectal cancers develop as a consequence of genomic instability. Microsatellite instability is involved in the genesis of about 15% of sporadic colorectal cancers and in most hereditary non-polyposis cancers. High frequency MSI[1] has been associated with a favorable prognosis, however it is not clear whether this is because MSI-H[2] tumors are inherently less aggressive or because they are more sensitive to chemotherapy. Chemotherapy with a combination of 5-fluorouracil and leukovorin or levamizole has been the standard of care for high risk stage II and stage III CRC[3]; it is also used in stage IV CRC. Several in vitro studies have shown that colon cancer cell lines displaying MSI-H are less responsive to fluorouracil than microsatellite-stable cell lines. Human studies, all of them retrospective, yielded conflicting results. The selection of patients with CRC for 5-FU[4] treatment has been based so far on the stage of tumor rather than the biology of the tumor. Although surgical staging is highly predictive of survival, there are indications that the form of genomic instability within a patient’s colorectal tumor has clinical implications, with and without 5-FU treatment. This review suggests that patients with MSI-H colorectal tumors may not benefit from 5-FU-based chemotherapy and can avoid its potential side effects (nausea, diarrhea, stomatitis, dermatitis, alopecia, and neurologic symptoms) that occur in half the treated patients. If confirmed by future prospective randomized controlled studies, these findings would indicate that microsatellite-instability testing should be conducted routinely and the results used to direct rational adjuvant chemotherapy in colon cancer.


[1] MSI = microsatellite instability

[2] MSI-H - high frequency MSI

[3] CRC = colorectal cancer

[4] 5-FU = 5-fluorouracil

Case Communications
I. Galperin and J.M. van Dijk
A. Balbir-Gurman, D. Markovits, A.M. Nahir, A. Rozin and Y. Braun-Moscovici
R. Elazary, A. Maly, A. Khalaileh, C. Rubinstein, K. Olstain-Pops, G. Almogy, A.I. Rivkind and Y. Mintz
G.Y. Stein, Z. Fradin, Y. Ori, P. Singer, Y. Korobko and A. Zeidman
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