[WOLFSON MEDICAL CENTER - PAST, PRESENT AND FUTURE].

INTRODUCTION: The Wolfson Medical Center was established forty years ago, in 1980, with the aim of providing residents of the surrounding cities with medical services of international standards. It has about 700 hospital beds. The population served by the Wolfson Medical Center numbers about one million residents, from the cities of Bat Yam, Holon, Rishon Lezion and Tel Aviv-Yafo. This population is very diverse, and includes patients of a wide age range, residents of all religions and cultures, religious and secular, people of socioeconomic and educational status from a broad spectrum, foreign workers, refugees and residents of countries from all over the world. This diversity reflects the unique challenges facing Wolfson Medical Center. As part of the activities of "Save a Child's Heart" over 5,000 children with congenital heart defects from 65 countries around the world have been operated on in Wolfson in the last 25 years. As part of the joint work with "Save a Child's Heart", the new Children's Hospital will be opened in the coming months. In this issue, we will present works that reflect the diversity of clinical and research work at the medical center.

Structured, Protocol-Based Pulse-Oximetry Measurement Improves the Evaluation of Hypoxemic Patients at Hospital Admission.

BACKGROUND: Accurate pulse oximetry reading at hospital admission is of utmost importance, mainly for patients presenting with hypoxemia. Nevertheless, there is no accepted or evidence-based protocol for such structured measuring. OBJECTIVES: To devise and assess a structured protocol intended to increase the accuracy of pulse oximetry measurement at hospital admission. METHODS: The authors performed a prospective comparison of protocol-based pulse-oximetry measurement with non-protocol based readings in consecutive patients at hospital admission. They also calculated the relative percentage of improvement for each patient (before and after protocol implementation) as a fraction of the change in peripheral capillary oxygen saturation (SpO2) from 100%. RESULTS: A total of 460 patients were recruited during a 6 month period. Implementation of a structured measurement protocol significantly changed saturation values. The SpO2 values of 24.7% of all study participants increased after protocol implementation (ranging from 1% to 21% increase in SpO2 values). Among hypoxemic patients (initial SpO2 < 90%), protocol implementation had a greater impact on final SpO2 measurements, increasing their median SpO2 readings by 4% (3-8% interquartile range; P < 0.05). Among this study population, 50% of the cohort improved by 17% of their overall potential and 25% improved by 50% of their overall improvement potential. As for patients presenting with hypoxemia, the median improvement was 31% of their overall SpO2 potential. CONCLUSIONS: Structured, protocol based pulse-oximetry may improve measurement accuracy and reliability. The authors suggest that implementation of such protocols may improve the management of hypoxemic patients.

Disability Progression in Multiple Sclerosis Is Affected by the Emergence of Comorbid Arterial Hypertension.

BACKGROUND AND PURPOSE: We assessed the prevalence and potential association of hypertension with multiple sclerosis (MS)-related disability progression. METHODS: This was a retrospective study of 2,813 patients who were followed for 20 years. We modeled the associations of several risk factors with the pattern of disability progression. The primary end point was the rate of disability progression. RESULTS: In total, 2,396 patients were available for analysis, of which 1,074 (44.8%) scored 4 (EDSS4) on the Expanded Disability Status Scale (EDSS), 717 (29.9%) scored 6 (EDSS6), and 261 (10.9%) scored 8 (EDSS8). The mean times to reach scores of 4, 6, and 8 were 123.5, 163.1, and 218.9 months, respectively. Hypertension was present in 207 (8.6%) patients during follow-up. Hypertension was associated with a higher probability of reaching each EDSS score compared to non-hypertensive patients: 62% vs. 43% for EDSS4 (p<0.01), 51% vs. 28% for EDSS6 (p<0.01), and 17% vs. 10% for EDSS8 (p<0.01). Nevertheless, hypertensive MS patients experienced longer intervals to reach each EDSS score: longer by 51.6, 38.9, and 62.7 months to EDSS4, EDSS6, and EDSS8, respectively (p<0.01) when compared to non-hypertensive MS patients reaching the same EDSS scores. CONCLUSIONS: Disability progression is more prevalent amongst hypertensive MS patients. However, they experience longer time intervals between the stages of disability progression.

Vomiting and Hyponatremia Are Risk Factors for Worse Clinical Outcomes Among Patients Hospitalized Due to Nonsurgical Abdominal Pain: A Retrospective Cohort Study.

After initial evaluation in the Emergency Department (ED), many patients complaining of abdominal pain are classified as suffering from nonsurgical abdominal pain (NSAP). Clinical characteristics and risk factors for worse prognosis were not published elsewhere.Characterizing the clinical profile of patients hospitalized due to NSAP and identifying predictor variables for worse clinical outcomes.We made a retrospective cohort analysis of patients hospitalized due to NSAP compared to matched control patients (for age, gender, and Charlson comorbidity index) hospitalized due to other, nonsurgical reasons in a ratio of 1 to 10. We further performed in-group analysis of patients admitted due to NSAP in order to appreciate variables (clinical and laboratory parameters) potentially associated with worse clinical outcomes.Overall 23,584 patients were included, of which 2144 were admitted due to NSAP and 21,440 were matched controls. Patients admitted due to NSAP had overall better clinical outcomes: they had lower rates of in-hospital and 30-days mortality (2.8% vs 5.5% and 7.9% vs 10.4% respectively, P < 0.001 for both comparisons). They also had a significantly shorter length of hospital stay (3.9 vs 6.2 days, P < 0.001). Rates of re-hospitalization within 30-days were not significantly different between study groups. Among patients hospitalized due to NSAP, we found that vomiting or hyponatremia at presentation or during hospital stay were associated with worse clinical outcomes.Compared to patients hospitalized due to other, nonsurgical reasons, the overall prognosis of patients admitted due to NSAP is favorable. The combination of NSAP with vomiting and hyponatremia is associated with worse clinical outcomes.

Low Norton Scale Score Predicts Worse Outcomes for Parkinson's Disease Patients Hospitalized Due to Infection.

Background:Parkinson's disease (PD) patients are prone to infections leading to hospitalization. We used the Norton Scale score (NSS) as a prognostic tool for these patients. Method: Retrospective analysis of consecutive PD patients, all had NSS appreciation upon admission. Analyses were made to establish the association between NSS upon admission, short-term, and long-term clinical outcomes. Results: Five hundred twenty-eight PD patients' records were reviewed, of which 81 were eligible for analysis. Patients who died during hospitalization had a significantly lower NSS (10.0 vs. 13.1, p = .026). Among surviving patients, those who were discharged to more intensive care facilities relative to their original place of arrival also had a significantly lower NSS (10.38 vs. 13.63, p = .0002). Lower NSS was found to increase the risk for 1-year mortality (odds ratio = 1.3; 95% confidence interval = [1.09, 1.56], p = .003). Conclusion: Lower NSS upon admission of PD patients, suffering from infection is associated with worse clinical outcomes.

Neurocysticercosis in travelers: a nation-wide study in Israel.

BACKGROUND: Cysticercosis, a human infestation by Taenia solium is endemic in many resource-limited countries. In developed countries it is mostly encountered among immigrant populations. Only few cases are reported in travelers. This report summarizes a nation-wide study of neurocysticercosis (NCC) diagnosed among Israeli travelers to endemic countries, with an estimation of disease incidence among the traveler population. METHODS: We performed a retrospective, nation-wide survey of travel-related NCC in Israel between the years 1994 and 2009. RESULTS: Nine cases of NCC were diagnosed in Israeli travelers during the study years. Most patients had traveled to South and/or Southeast Asia. The most common symptom at diagnosis was a seizure. The average interval between return from the suspected travel and symptom onset was 3.2 ± 1.8 years. Two patients suffered from multiple lesions, whereas the rest had a single lesion. Antihelminthic treatment was given to most patients with resolution of symptoms. Median duration of antiepileptic treatment was 16 ± 41 months after albendazole was given. Antiepileptic treatment was discontinued without any complications. The estimated attack rate of clinical disease was 1 : 275,000 per travel episode to an endemic region. CONCLUSIONS: NCC in travelers is a rare phenomenon commonly presenting as seizure disorder manifesting months to years post-travel. Antihelminthic therapy followed by 12 to 24 months of antiepileptic therapy resulted in complete resolution of symptoms in our patients.

[Neurocysticercosis in Israel].

BACKGROUND: Neurocysticercosis is the most common cause of adult onset seizures in developing countries. In recent years, with the rise in the number of immigrants to developed countries and travelers to endemic areas, neurocysticercosis is increasingly diagnosed in non-endemic countries. AIMS OF THE STUDY: The authors describe the clinical and epidemiologic characteristics of patients diagnosed with neurocysticercosis acquired in Israel or in immigrants to Israel from endemic countries. METHODS: A retrospective national survey of patients diagnosed with neurocysticercosis during 1994-2009 was conducted. Clinical and epidemiologic data were recorded. Case definition consisted of roentgenologic, serologic and pathologic features. RESULTS: In all, 17 cases of neurocysticercosis were diagnosed in Israel during the study period. Nine (53%) cases were diagnosed in travelers to endemic areas, and six (35%) in immigrants from endemic areas. Two cases were native Israelis who had never traveled to an endemic area. Most immigrants suffered from multiple brain lesions. Two immigrants underwent brain biopsy. CONCLUSIONS: This is the first report of the clinical and epidemiologic characteristics of patients diagnosed with neurocysticercosis acquired in Israel or diagnosed in immigrants to Israel. Neurocysticercosis must be included in the differential diagnosis of seizures, headache or neurologic deficit with single or multiple brain lesions, especially in immigrants from endemic countries. Invasive procedures may be obviated by appropriate clinical diagnosis, imaging and serology.

Changes in ultrasound findings in posterior uveal melanoma after Ruthenium 106 brachytherapy.

PURPOSE: To analyze the postbrachytherapy ultrasonographic dynamics of uveal melanoma tumor height and internal reflectivity. DESIGN: Prospective, comparative, observational case series. PARTICIPANTS: One hundred forty-seven patients (147 eyes) with posterior uveal melanoma having a mean age of 61 years (range, 29-97 years) who were treated with Ruthenium 106 brachytherapy. METHODS: Patients were followed-up with ultrasonography using both A and B modes of standardized echography every 6.7 +/- 0.3 months (mean +/- standard error of the mean) for a total of 1001 ultrasound examinations. On average, each patient was examined 5.8 times (range, 3-17 times). The echographic parameters included tumor base size, height, internal reflectivity, regularity, vascularity, and extra-scleral extension. To compare the response of tumors of different sizes, each tumor was standardized to its initial size at brachytherapy. MAIN OUTCOME MEASURES: The dynamics of the tumor height and internal reflectivity. RESULTS: At the time of brachytherapy, the mean height of the tumors was 5.2 mm (range, 2.2-11.8 mm). After brachytherapy, 142 tumors (96.6%) responded by a decrease in height. The decrease in height was at an initial rate of approximately 3% per month. Most of the tumors did not regress entirely; rather, their height stabilized on a constant value (on average 61% of the initial height) after approximately 18 to 24 months. The decrease in height after brachytherapy was best fitted by the sum of a first order exponential decay and a constant (h = 61 + 35*e(-0.12t), in which t = time in months). The half-life of the decay was 5.8 months. Large tumors (>8 mm) had a faster initial decrease in height, and stabilized on a lower percentage of their initial height (50%) compared with small tumors (70%). Thus, the half-life of the height exponential decay was 5.3 months for small tumors (2-4 mm) and 3.3 months for the large tumors (>8 mm). Internal reflectivity increased from a mean of 40% before therapy to 70% after 2 years. The dynamics of the reflectivity were best fitted with the function: f = 45 + 24(1-e(-0.09t)). Larger tumors, which initially had lower internal reflectivity, presented with a slower increase in internal reflectivity (t() = 8.7 months) compared with smaller tumors (t(1/2) = 5 months). CONCLUSIONS: The postbrachytherapy ultrasonographic dynamics of uveal melanomas resemble a function composed of the sum of a constant and a first order exponent, suggesting the possible existence of two components (cell populations), one unaffected by brachytherapy and the other a radiosensitive population that reacts to brachytherapy in an exponential decay. An exponential decay can imply that the postbrachytherapy death of each tumor cell is a stochastic Markovian process that is independent of the death of other tumor cells.