[Show abstract][Hide abstract] ABSTRACT: Background:
Variation in arterial pressure and plethysmographic waveforms has been shown to be predictors of cardiac output response to fluid challenge. The objective of this study was to evaluate the ability of arterial and plethysmographic waveform variables to predict hypotension during blood loss.
Patients undergoing autologous haemodilution were studied. After anaesthesia induction, blood was withdrawn in steps of 2% of estimated circulating blood volume (ECBV). Arterial and plethysmographic waveforms were recorded and analysed offline at each step of blood withdrawal.
Thirty-four (29%) out of 118 studied patients tolerated 20% ECBV withdrawal without hypotension. Patients who tolerated 20% ECBV withdrawal were younger than those who did not [mean (sd): 53.8 (11.1) vs 62.7 (10.7); P<0.0001]. Patients with hypertension developed hypotension earlier than healthier patients did. There were no differences at the baseline in arterial and plethysmographic waveform variables between those who did and those who did not tolerate 20% of ECBV withdrawal. All values of variables increased significantly from the baseline after the withdrawal of 4% of ECBV (P<0.005). There were no changes in heart rate (HR), 73 (12) at the baseline and 76 (13) after 20% of ECBV withdrawal (P=0.4).
Arterial and plethysmographic waveform variables were augmented with increasing blood loss in all patients. Older patients, patients who received anti-hypertensive drugs, or both developed hypotension earlier than others. Baseline values were weak predictors of hypotension during stepwise blood withdrawal. No clinically significant increase in HR was observed, regardless of tolerance of arterial pressure to blood withdrawal.
Preview · Article · Aug 2012 · BJA British Journal of Anaesthesia
[Show abstract][Hide abstract] ABSTRACT: Background. Colonoscopy for screening the population at an average risk of colorectal cancer (CRC) is recommended by many leading gastrointestinal associations.
Objectives. The objective was to assess the quality, complications and acceptance rate of colonoscopy by patients.
Methods. We prospectively gathered data from colonoscopies which were performed between October 2003 and September 2006. Patients were asked to return a follow-up form seven days after the procedure. Those who failed to do so were contacted by phone.
Results. 6584 patients were included (50.4% males). The average age of subjects was 57.73 (SD 15.22). CRC screening was the main indication in 12.8%. Cecal intubation was achieved in 92% of patients and bowel preparation was good to excellent in 76.2%. The immediate outcome after colonoscopy was good in 99.4%. Perforations occurred in 3 cases—1 in every 2200 colonoscopies. Significant bleeding occurred in 3 cases (treated conservatively). 94.2% of patients agreed to undergo repeat colonoscopy in the future if indicated.
Conclusions. The good quality of examinations, coupled with the low risk for complications and the good acceptance by the patients, encourages us to recommend colonoscopy as a primary screening test for CRC in Israel.
Full-text · Article · Jun 2012 · Diagnostic and Therapeutic Endoscopy
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to characterize the normal ultrasonographic growth of the fetal superior sinus sagittalis (SSS) throughout gestation.
In a prospective cross-sectional study, measurements of the fetal sinus sagittalis were obtained in patients undergoing elective fetal anatomical surveys or fetal growth scan at between 16.6 and 34.7 weeks of gestation. Special attention was given to the SSS of the fetal brain. On the coronal plane, the SSS may be easily identified immediately below the frontal bone, and anterior to the fetal head parenchyma.
206 fetuses were scanned. A regression line of the SSS was created throughout gestation and a first-degree correlation was found between gestational age (GA) and the SSS height (r = 0.418; p < 0.0001; SSS = -0.015 + 0.0178 × GA). Normal values were established for different gestational weeks.
We provide ultrasonographic dimensions of the fetal SSS across pregnancy. This data potentially allows for prenatal diagnosis of abnormal appearance of the SSS.
No preview · Article · Dec 2011 · Fetal Diagnosis and Therapy
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to characterize the normal ultrasonographic growth of the corpus callosum (CC) in normal and in growth-restricted fetuses throughout gestation.
This was a prospective cross-sectional study. Consecutive routine biometric measurements and fetal organ scans were obtained in patients undergoing elective fetal anatomical surveys or evaluation of the fetal growth between 16 to 33 weeks. Special attention was given to the CC of the fetal brain. In addition, we evaluated the growth of the CC in growth-restricted fetuses throughout pregnancy.
Two hundred and fifty two normal fetuses were scanned between 16 and 36 weeks of gestation. A regression line of the CC was established through gestation and a second-degree correlation was found between gestational age and CC outer margin. Twenty four growth-restricted fetuses were also evaluated in which the growth of the CC was significantly below both the 25(th) and 50(th) percentiles in 77.3% and 95.5%, respectively, for the same gestational age.
We provide nomograms for the ultrasonographic dimensions of the fetal CC that allows for prenatal diagnosis of abnormal dimensions of CC. The significance of abnormal CC growth in growth-restricted fetuses should be further evaluated.
No preview · Article · Sep 2011 · Prenatal Diagnosis
[Show abstract][Hide abstract] ABSTRACT: The findings of interim fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET/CT) predict progression-free survival of patients with Hodgkin's lymphoma. Historically, the assessment was based on a static all-or-none scoring system. However, the clinical significance of any positivity in interim FDG-PET/CT has not been defined.
Ninety-six patients with Hodgkin's lymphoma who underwent interim FDG-PET/CT were evaluated using dynamic and visual scores, employing mediastinal or liver blood pool uptake as a comparator. FDG-PET/CT was prospectively defined as positive if any abnormal F(18)FDG uptake was present. In a retrospective analysis dynamic score 0 indicated resolution of all disease sites; score 1 defined a single residual focus; score 2 denoted a reduction in the number of foci; score 3 defined a reduction in intensity with no reduction in number; and score 4 indicated no change in the number and intensity of foci or appearance of new foci.
The dynamic visual score review reduced the number of positive interim studies from 24 to 6 if a score of 2 or less was considered negative, with significantly better specificity (96%) as compared to static visual scores (78%-86%). The 5-year progression-free survival and overall survival rates in patients who had a negative dynamic score were 92% and 97%, respectively; the corresponding figures for patients with positive results were 50% and 67%.
A dynamic visual score may be a better indicator for tailoring therapy than static visual scoring.
[Show abstract][Hide abstract] ABSTRACT: Respiratory-induced arterial and plethysmographic (pulse oximetry) waveform changes were shown to be good predictors of cardiac output response to increased preload. The aim of this study was to evaluate the reliability of arterial and plethysmographic waveform variables in patients with mild hypovolemia.
Patients undergoing autologous hemodilution were studied. After anesthesia induction, hemodilution was performed by withdrawing blood in steps of 2% of estimated circulating blood volume (ECBV), up to 20%. The patients who did not develop hypotension (systolic blood pressure < 80 mmHg) were studied. Arterial and plethysmographic waveforms were recorded and analyzed off-line at baseline and after each withdrawal of blood. Variations in arterial systolic and pulse pressure were analyzed using standard methods. Plethysmographic waveform variation and delta pulse oximetry plethysmography were determined by using pulse oximetry recordings.
There were 33 study participants. Systolic blood pressure decreased by 11%, and heart rate increased from 73 to 76 beats/min after a 20% reduction of ECBV. Systolic pressure and pulse pressure variations increased (P < 0.005) after a 4% reduction of ECBV. The values of arterial pressure and pulse oximetry waveform variables almost doubled in value after a 20% reduction of ECBV. Systolic pressure variation was the most reliable variable during hypovolemia. Plethysmographic waveform variation increased significantly after a 6% reduction of ECBV and delta pulse oximetry plethysmography after an 8% reduction of ECBV.
Arterial and pulse oximetry respiratory-induced changes in waveform variables are reliable indicators of mild hypovolemia in anesthetized patients. The pulse oximetry plethysmographic waveforms accurately reflect arterial waveforms during more progressive hypovolemia.
[Show abstract][Hide abstract] ABSTRACT: To determine sonographic dimensions of the fetal facial profile in normal pregnancy.
This was a prospective, cross-sectional study of 397 normal healthy fetuses at 14-33 weeks of gestation. After exclusion of the small numbers of patients at the upper GAs, 379 patients between 14.0 and 26.9 weeks of gestation were included in the analyses. The sagittal plane of the fetal facial profile was evaluated using transvaginal and transabdominal ultrasound. Distances from the tip of the nose to the mouth (the line between the lips), from the mouth to the gnathion (lower chin), from the upper philtrum to the mouth, and from the mouth to the upper concavity of the chin were measured and are presented according to gestational age (GA).
There was a significant linear correlation between GA and the distance from the tip of the nose to the mouth (r = 0.943; P < 0.00001; y = -37.98 + 7.54 x GA), from the mouth to the gnathion (r = 0.946; P < 0.00001; y = -46.34 + 7.95 x GA), from the upper level of the philtrum to the mouth (r = 0.71; P < 0.00001; y = 0.22 + 3.33 x GA) and from the mouth to the upper concavity of the chin (r = 0.665; P < 0.00001; y = 1.65 + 2.95 x GA). The ratio between the distance from the tip of the nose to the mouth and that from the mouth to the gnathion was also almost constant throughout gestation, as was the ratio between the distance from the upper philtrum to the mouth and that from the mouth to the upper concavity of the chin.
We provide normative data of the fetal facial profile across GA. Our data offer a potential tool for the prenatal diagnosis of abnormal fetal facial profile.
Preview · Article · Feb 2010 · Ultrasound in Obstetrics and Gynecology
[Show abstract][Hide abstract] ABSTRACT: Haematologica 2010 [Epub ahead of print] doi:10.3324/haematol.2009.016105 Publisher's Disclaimer. E-publishing ahead of print is increasingly important for the rapid dissemination of science. Haematologica is, therefore, E-publishing PDF files of an early version of manuscripts that have completed a regular peer review and have been accepted for publication. E-publishing of this PDF file has been approved by the authors. After having E-published Ahead of Print, manuscripts will then undergo technical and English editing, typesetting, proof correction and be presented for the authors' final approval; the final version of the manuscript will then appe-ar in print on a regular issue of the journal. All legal disclaimers that apply to the journal also pertain to this production process. Haematologica (pISSN: 0390-6078, eISSN: 1592-8721, NLM ID: 0417435, www.haemato-logica.org) publishes peer-reviewed papers across all areas of experimental and clinical hematology. The journal is owned by the Ferrata Storti Foundation, a non-profit organiza-tion, and serves the scientific community with strict adherence to the principles of open access publishing (www.doaj.org). In addition, the journal makes every paper published immediately available in PubMed Central (PMC), the US National Institutes of Health (NIH) free digital archive of biomedical and life sciences journal literature.
[Show abstract][Hide abstract] ABSTRACT: Background In many countries there is a gap between the clinical evidence for cardiovascular disease (CVD) prevention and implementation in clinical practice. Inadequate control of cardiovascular risk factors and underutilization of aspirin, statins, angiotensin converting enzyme inhibitors and β-blockers are well-established examples. The optimal approach to implementation of CVD prevention in clinical practice is still under debate. The screening and monitoring (SaM) approach is based on cyclic monitoring and individual treatment of patients with cardiovascular risk factors in the primary care setting. After achieving improvements in risk factor levels and in the use of preventive medications in a pilot study, it was decided to test the efficacy of this approach in a larger population at risk.Methods Five primary care clinics adopted the SaM approach. A total of 1622 patients with established CVD, diabetes mellitus or hypertension were assessed by their family physicians for cardiovascular risk factors and use of medications for cardiovascular risk reduction. Interventions were made according to accepted clinical guidelines. Cardiovascular risk factor levels and the use of medications for CVD prevention were retrospectively analyzed.Results The results demonstrated significant reductions in blood pressure, hemoglobin A1c and low-density lipoprotein-cholesterol levels, as well as significant increases in the use of medications for CVD prevention.Conclusion A systematic approach to CVD reduction, with an emphasis on multiple risk factor assessment and use of preventive medications in patients at cardiovascular risk, yielded significant improvements in measures of the quality of preventive care.
No preview · Article · Dec 2009 · Primary Health Care Research & Development
[Show abstract][Hide abstract] ABSTRACT: This retrospective study assessed the contribution of exercise stress testing (EST) in the evaluation of patients with low risk for coronary heart disease who presented to the emergency department (ED) with chest pain.
The study included 175 patients who presented to the ED with chest pain and underwent EST between January 1, 2005, and November 30, 2006.
After the EST, 113 patients were discharged, and 62 were admitted. Exercise stress testing's positive predictive value for coronary artery disease among admitted patients was 35.7%, and sensitivity was 95.2%. Exercise stress testing's negative predictive value among discharged patients was 99.1%. None of the 113 discharged patients returned to the ED for cardiac reasons during the 30-day follow-up period.
A chest pain unit or a parallel facility for evaluating patients with chest pain and with low risk for active coronary disease is necessary for detecting low-risk patients who eventually need cardiac intervention.
No preview · Article · Oct 2009 · The American journal of emergency medicine
[Show abstract][Hide abstract] ABSTRACT: Term-born children conceived by in vitro fertilisation (IVF) are reportedly taller than naturally conceived (NC) children. High levels of growth promoting hormones and epigenetic imprinting have been suggested as pathogenetic mechanisms.
Tall stature in prematurely born IVF-conceived (IVF-C) children suggests pre- or early implantation imprinting rather than a postnatal effect.
We studied 334 very low birthweight (VLBW: birth weight <1500 g) children born prematurely during 1995-1999 and obtained their anthropometric measures at 6-10 years of age. Perinatal and neonatal data were obtained from the Israeli VLBW database. We compared IVF-C, ovulating agents conceived (OA-C) and naturally conceived (NC) groups of children with respect to their and their parents' anthropometry and their perinatal/neonatal variables.
Childhood height standard deviation scores (SDSs) were greatest in IVF-C (-0.12 (SD 1.25); p<0.022) and insignificantly greater in OA-C (-0.37 (SD 1.02)) as compared to NC (-0.58 (SD 1.36)) children. The IVF-C and NC groups were significantly different regarding 17 parental and perinatal variables; however, multiple regression analysis including these variables showed that, as compared with NC, IVF-C children had significantly older mothers at birth with earlier follow-up during pregnancy and more multi-fetal pregnancies.
IVF-C and to a lesser extent OA-C prematurely born children are taller than otherwise NC children. After ruling out postnatal and parental causes, we speculate that pre- or early implantation factors might have contributed to the taller stature of IVF-C children.
No preview · Article · Sep 2009 · Archives of Disease in Childhood - Fetal and Neonatal Edition
[Show abstract][Hide abstract] ABSTRACT: Deepening sedation is often needed in patients with intracranial hypertension. All widely used sedative and anesthetic agents (opioids, benzodiazepines, propofol, and barbiturates) decrease blood pressure and may therefore decrease cerebral perfusion pressure (CPP). Ketamine is a potent, safe, rapid-onset anesthetic agent that does not decrease blood pressure. However, ketamine's use in patients with traumatic brain injury and intracranial hypertension is precluded because it is widely stated that it increases intracranial pressure (ICP). Based on anecdotal clinical experience, the authors hypothesized that ketamine does not increase-but may rather decrease-ICP.
The authors conducted a prospective, controlled, clinical trial of data obtained in a pediatric intensive care unit of a regional trauma center. All patients were sedated and mechanically ventilated prior to inclusion in the study. Children with sustained, elevated ICP (> 18 mm Hg) resistant to first-tier therapies received a single ketamine dose (1-1.5 mg/kg) either to prevent further ICP increase during a potentially distressing intervention (Group 1) or as an additional measure to lower ICP (Group 2). Hemodynamic, ICP, and CPP values were recorded before ketamine administration, and repeated-measures analysis of variance was used to compare these values with those recorded every minute for 10 minutes following ketamine administration.
The results of 82 ketamine administrations in 30 patients were analyzed. Overall, following ketamine administration, ICP decreased by 30% (from 25.8 +/- 8.4 to 18.0 +/- 8.5 mm Hg) (p < 0.001) and CPP increased from 54.4 +/- 11.7 to 58.3 +/- 13.4 mm Hg (p < 0.005). In Group 1, ICP decreased significantly following ketamine administration and increased by > 2 mm Hg during the distressing intervention in only 1 of 17 events. In Group 2, when ketamine was administered to lower persistent intracranial hypertension, ICP decreased by 33% (from 26.0 +/- 9.1 to 17.5 +/- 9.1 mm Hg) (p < 0.0001) following ketamine administration.
In ventilation-treated patients with intracranial hypertension, ketamine effectively decreased ICP and prevented untoward ICP elevations during potentially distressing interventions, without lowering blood pressure and CPP. These results refute the notion that ketamine increases ICP. Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations.
Preview · Article · Aug 2009 · Journal of Neurosurgery Pediatrics
[Show abstract][Hide abstract] ABSTRACT: Earlier studies indicate that high circulating levels of insulin-like growth factor-1 (IGF-1) may be associated with premenopausal breast cancer. We studied variations in the IGF-1 gene and the growth hormone (GH1) gene in relation to risk of breast cancer in 667 Ashkenazi Jewish women (321 cases, 346 controls) from a population-based case-control study in Northern Israel, and a clinical series of 331 founder BRCA mutation carriers (161 affected, 170 unaffected). All participants were tested for six polymorphisms in the IGF-1 gene and one GH1 polymorphism. Logistic regression models were used to estimate odds ratios for haplotype-specific and genotype-specific age-adjusted risks. Two common IGF-1 haplotypes (ATTCAC, GAGTGT) were found, when compared with the most prevalent haplotype ATTCGC (32.5%), to be associated with a decreased risk of breast cancer in premenopausal noncarrier women only. Age-adjusted odds ratios were 0.5 (95% confidence interval: 0.28-0.92) for ATTCAC and 0.46 (95% confidence interval: 0.24-0.89) for GAGTGT. The GH1 polymorphism did not influence the risk of breast cancer in our study population. The IGF-1 gene seems to be associated with breast cancer risk in premenopausal Ashkenazi Jewish women who are not carriers of mutations in BRCA1/2 genes.
No preview · Article · Jul 2009 · European journal of cancer prevention: the official journal of the European Cancer Prevention Organisation (ECP)
[Show abstract][Hide abstract] ABSTRACT: Uncorrected refractive error is the leading cause of visual impairment in children. In 2002 a screening project was launched in Israel to provide data on the effectiveness of the illiterate E-chart in identifying Jewish and Arab schoolchildren in need of a comprehensive eye examination.
To present the aims, design and initial results of the visual screening project and the prevalence of vision abnormality in the study population.
A cross-sectional population-based study was conducted during 2002-2003 among first- and eighth-graders in 70 schools in northern Israel. The nurse's test included use of the illiterate E-chart to measure visual acuity. The medical examination included vision history, clinical eye examination, VA and retinoscopy. The ophthalmologist's evaluation as to whether a child needed a referral for, diagnostic procedures, treatment and/or follow-up was recorded and compared with explicit referral criteria formulated after data collection.
Of 1975 schoolchildren, 31% had abnormal VA, defined as VA worse than 6/6 in at least one eye, and a quarter had VA equal or worse than 6/12 in both eyes. The prevalence of vision abnormality among the children was 22.4% when based on the evaluation of the field ophthalmologist and 26.1% when based on two sets of explicit severity scores and referral criteria.
Vision abnormality is a significant health problem among northern Israeli schoolchildren. This project is unique in scope and importance, providing evidence to assist policy making with regard to vision screening for schoolchildren (including data on test reliability and validity) and optimal VA cutoff level, and confirming the need for clinical guidelines regarding referral criteria.
No preview · Article · Apr 2009 · The Israel Medical Association journal: IMAJ
[Show abstract][Hide abstract] ABSTRACT: Estimate the reliability of the E-chart as used with Israeli school children.
Cross-sectional, population-based study conducted among 751 Israeli students of the Northern District, aged 6- and 7-year-olds and 13- and 14-years-old in 30 schools in 2003.
Each student was screened separately by two public health nurses using the illiterate E-chart. Collected data included the students' vision and demographic characteristics, the nurses' professional background, and whether they referred students for medical testing. The reliabilities of vision testing and of the recommendations were determined using total, positive, and negative percentages of agreement and Kappa coefficients.
Total percentage of agreement on vision (combined findings for both eyes) was 78.2% (Kappa 0.47, 95%CI 0.41-0.53). Logistic regression models to predict agreement on vision abnormality showed a higher percentage of agreement among females and 13- and 14-year-old students than among males and 6- and 7-year old students. Total agreement of 85.8% was found in referral recommendations (Kappa 0.58, 95%CI 0.51-0.65). Significant relationships were noted with student age, ethnicity, subdistrict of residence, nurse seniority, and agreement on vision findings.
Improvement in school vision-screening reliability is needed, especially among 6- and 7-year-old students. To this end, the determinants of fair reliability should be investigated and training programs planned. Reasons for differences in the reliability of nurses' recommendations detected among subdistricts must be further studied, together with careful supervision, to ensure better performance and adherence to PHS guidelines. Implications for nurses and nursing should be considered.
Demographic characteristics were found to predict reliability, which can guide nurses in selecting students who need more careful attention or closer supervision during vision testing.
No preview · Article · Feb 2009 · Journal of Nursing Scholarship