Harefuah最新文献

Introduction: Establishing a new team for endoscopic endonasal skull base surgeries (EES) requires a period of adjustment. Our team was established 4 years ago and consists of surgeons with previous experience. Our objective was to examine the learning curve associated with the establishment of such a team.

Methods: All patients who underwent EES between January 2017 and October 2020 were reviewed. The first 40 patients were defined as the 'early group' and the last 40 as the 'late group'. Data was retrieved from electronic medical records and surgical videos. Study groups were compared in terms of the level of surgical complexity, (II to V according to EES complexity level scale; level I cases were excluded), surgical outcome and complication rate.

Results: 'Early group' cases and 'late group' cases were operated on in 25 and 11 months, respectively. Complexity level II surgeries, which mainly included pituitary adenomas, were the most common in both groups (77.5% and 60%, respectively); of these, functional adenomas and reoperations were more common in the 'late group'. The rate of advanced complexity surgeries (III - V) was higher in the 'late group' (40% vs. 22.5%); level V surgeries were performed only in the 'late group'. No significant differences were observed in terms of surgical outcomes or complications; postoperative cerebrospinal fluid (CSF) leaks were less common in the 'late group' (2.5% vs. 7.5%).

Conclusions: Our findings indicate that the establishment of a new EES team, even if it includes experienced skull base surgeons, is associated with a learning curve, which requires about 40 cases.

Introduction: The 5-aminolevulinic acid (5-ALA) fluorescence-guided resection is an essential part of the current state-of-the-art treatment of primary malignant brain tumors. Metabolized by tumor cells, creating Protoporphyrin-IX, which is fluorescent under UV light emitted from the microscope, 5-ALA facilitates visual distinction between the tumor and the normal brain tissue surrounding it, coloring it pink. This real-time diagnostic feature was shown to lead to more complete removal of the tumor and confers a survival benefit. Nevertheless, despite the high sensitivity and specificity that was described using this method, there are other pathological processes in which 5-ALA is being metabolized that fluoresce similarly to a malignant glial tumor.

Introduction: Brain metastases (BM) are a leading cause of morbidity and mortality in patients with systemic cancer. In the last two decades, an enormous improvement in controlling extra-cranial disease has been achieved, positively affecting the overall survival of patients. However, this has led to an increased number of patients who live long enough to develop BM. In addition, technological improvements in neurosurgery and radiotherapy caused both surgical resection and stereotactic radiosurgery (SRS) to become an integral part of the armamentarium when treating a patient with 1-4 BM. These increased therapeutic possibilities and combination of therapeutic options such as surgical resection, SRS, whole brain radiation therapy (WBRT) and lately targeted molecular therapy, have led to an enormous amount of, yet sometimes confusing, published data.

Introduction: Teachers employed in educational centers inside hospitals, encounter thousands of hospitalized children every year. Although many pedagogical tools are at hand, in order to establish a designated unique pedagogical profession, their practice is in need of an organizing principle compatible with hospital goals. In this article we assert that hospital teachers can and should become an inherent and meaningful factor in promoting children's health and supporting healing processes. We will examine and elaborate on the potential basis for synergizing goals by exploring the meaning of structures of health and illness existing in the bio-medical model and those in integrative models. Through three examples from the hospital teacher's work, we will try to demonstrate how a combination of points of view can constitute both an organizing principle in pedagogical practice and a profit in holistic medical care for hospitalized children.

Introduction: In recent years, we witnessed significant changes in the way we diagnose prostate cancer and the options for management of low risk localized prostate cancer. This review discusses today's approach to men with elevated PSA. The use of biomarkers and or prostate MRI is strongly recommended prior to the decision on a biopsy. Following a suspicious finding in MRI the best approach is MRI-guided biopsy. Traditionally, biopsies are performed transrectally but the emerging transperineal biopsy has considerable advantage. With a new diagnosis of low risk prostate cancer, each man should have a lengthy discussion with his urologist and in many cases the preferred way is to proceed with active surveillance and avoid radical treatment.

Introduction: The autologous serum drops treatment is an advanced, effective and safe treatment for severe dry eye and recurrent epithelial erosions. It contains growth factors, proteins, and vitamins, similar to the tear layer. In a recent review by the American Academy of Ophthalmology, many studies included showed a significant effect of serum drops in treating dry eye and recurrent epithelial erosions. Notwithstanding the above, to date, no randomized controlled clinical trials have investigated the effectiveness of autologous serum drops. Moreover, serum drops concoction has strict regulations, and in Israel, it is available in a small handful of hospitals, which causes limited accessibility to this valuable treatment. Precautions must be taken when using serum drops to avoid bottle contamination and infections during storage.

Introduction: Competence-based medical education (CBME) re-shaped medical education in North America and in Europe and is making its first steps in Israel in recent years. This article reviews the literature regarding the Mini-Clinical Evaluation Exercise (mini-CEX), a tool for the evaluation of clinical competencies in CBME. The mini-CEX has been adopted by the American Board of Internal Medicine (ABIM) and the European Federation of Internal Medicine (EFIM) and is cited in leading documents of these organizations on medical education. The mini-CEX allows direct observation on a clinical encounter of a learner (medical student or resident) and a patient by a skilled clinician (observer). The mini-CEX provides the basis for the provision of feedback to the learner by the observer following the observation.

Introduction: The radial tunnel syndrome (RTS) is an entrapment of the radial nerve in the forearm. It is characterized by pain focused on the trapping area in the proximal forearm as well as pain radiated down the forearm. The syndrome is more common in men and in our estimation, there is a circumstantial connection to the continuous use of the computer keyboard. Radial tunnel syndrome is a consequence of nerve entrapment in the tunnel, which is formed from a covering consisting of the supinator muscle and the distal margins of this muscle. There is a clear association between radial tunnel syndrome and the occurrence of tennis elbow. The sensitivity in nearby locations along with the lack of familiarity of some of the clinicians with RTS lead to misdiagnosis and therefore, even to mistreatment in some cases. The physical examination is the most important means of making the correct diagnosis. The treatment of radial tunnel syndrome is divided into the conservative one in which emphasis is placed on physiotherapy and mobilizations of the nerve and the surgical one during which decompression of the radial canal is performed and in fact release of pressure at the exact anatomical location.

Introduction: Chronic lymphocytic leukemia (CLL) is the most common leukemia in the Western world. Liver function tests (LFT) revealing impairment are described in 5% of CLL patients. Although these effects are described in the literature, their occurrence at the diagnosis of CLL and correlation with prognostic data have rarely been evaluated. We aimed to evaluate the prevalence of impairment of different LFT at CLL diagnosis and its correlation with prognosis.

Methods: This is a descriptive observational retrospective study. Diagnostic and prognostic data from CLL patients followed at Bnai Zion Medical Center were collected from charts for the period January 1st, 2000 until October 6, 2020. A t-test for continuous variables, Chi-2 and Fisher-exact tests for discrete variables, and log-rank test for survival analysis, were performed to evaluate prognostic correlations of impaired as compared with normal LFT. The significance level was defined as p value < 0.05.

Results: Overall, 153 patients with CLL diagnosed from 2000 until 2020 were included. The median age was 66 (42-89) years, and 62 were women (40.5%). Before CLL treatment initiation, mildly elevated cholestatic enzymes were encountered among 12% patients, while hepatocellular enzymes were elevated in only 2%. After excluding patients with hemolysis, hyperbilirubinemia was found among 5% of the patients. Cholestatic impairment was associated with negative prognostic data, especially increased alkaline phosphatase levels which was associated with a shorter overall survival (p=0.001).

Conclusions: Impairment of cholestatic enzymes and hyperbilirubinemia is not rare before CLL treatment. Despite its mild impairment, it seems to be associated with worse prognosis.