Stereotactic body radiation therapy for stage I non-small cell lung cancer: a small academic hospital experience.

PURPOSE/OBJECTIVE(S): Stereotactic body radiation therapy (SBRT) has been shown to have increased local control and overall survival relative to conventional external beam radiation therapy in patients with medically inoperable stage I non-small cell lung cancer (NSCLC). Excellent rates of local control have been demonstrated both in clinical trials and in single-center studies at large academic institutions. However, there is limited data on the experiences of small academic hospitals with SBRT for stage I NSCLC. The purpose of this study is to report the local control and overall survival rates in patients treated with SBRT for stage I NSCLC at Winthrop-University Hospital (WUH), a small academic hospital. MATERIALS/METHODS: This is a retrospective review of 78 stage I central and peripheral NSCLC tumors treated between December 2006 and July 2012 with SBRT at WUH. Treatment was given utilizing fiducials and a respiratory tracking system. If the fiducials were not trackable, a spine tracking system was used for tumor localization. CT-based planning was performed using the ray trace algorithm. Treatment was delivered over consecutive days to a median dose of 4800 cGy delivered in four fractions. The Kaplan-Meier method was used to calculate local control and overall survival. RESULTS: The median age was 78.5 years. Fifty-four percent of the patient population was female. Sixty seven percent of the tumors were stage IA, and 33% of the tumors were stage IB. Fifty-three percent of the tumors were adenocarcinomas and 29% were squamous cell carcinomas, with the remainder being of unknown histology or NSCLC, not otherwise specified The 2-year local control rate was 87%, and the 2-year overall survival was 68%. CONCLUSION: Our findings support that local control and overall survival at a small academic hospital are comparable to that of larger academic institutions' published experiences with SBRT for stage I NSCLC.

The prevalence of uveitis in juvenile rheumatoid arthritis.

BACKGROUND: Because asymptomatic uveitis has been an important cause of visual loss in children with juvenile rheumatoid arthritis, periodic ophthalmologic screenings of such patients have been recommended. Recently, some authors have found a decreased prevalence of uveitis in children with juvenile rheumatoid arthritis. METHODS: We studied a total of 76 patients (63 girls and 13 boys, aged 1 to 16 years), referred to 3 pediatric ophthalmology practices between March 1976 and October 1999. Follow-up examinations were performed at intervals of 3 to 6 months according to current guidelines, during the following 6 months to 23 years (mean, 55 months). RESULTS: Uveitis developed in 10 children (13%). Of these 10 children, 2 were symptomatic (blurred vision, discomfort) and 7 were diagnosed with uveitis at the initial visit. Only 1 patient had asymptomatic uveitis after initial negative findings on screening examination. Final visual acuity for all the compliant children in the uveitis group was better than 20/30. DISCUSSION: The prevalence of uveitis in our study is similar to rates found by other recent authors. This decrease may reflect a tendency for systemic medications to prevent the development of ocular inflammation. We believe that screening guidelines should be reevaluated, especially for asymptomatic children with negative findings on initial examinations.

Referrals of patients by family physicians to consultants: a survey of the Israeli Family Practice Research Network.

OBJECTIVE: We aimed to analyse factors influencing referral of patients by primary care physicians to specialist consultants at the beginning of the era of direct access to specialists in Israel. METHODS: We carried out a study of referrals by family physicians to specialists over a continuous period of 3 months. Twenty-four certified family physicians filled in a questionnaire detailing referrals during the study period. All patients were referred for consultation to a specialist at regional speciality clinics or hospital out-patient departments. RESULTS: Ten physicians met the study conditions. In 1140 of 10896 (10.5%) visits, patients were referred to specialist consultants. The percentage of referral ranged from 7.4 to 15.9%. The difference between the physicians with the lowest and highest rates of referral was statistically significant (P < 0.0001). The variance in referral rates was not explained by significant differences in physician or practice variables. The types of specialists to whom the most referrals were made were orthopaedic surgeons, ophthalmologists, dermatologists, ear, nose and throat, general surgeons and plastic surgeons. There was a significant correlation between the type of specialist and the age of the patient. Older patients were referred more frequently to urologists, cardiologists and ophthalmologists, while younger patients were referred more frequently to ear, nose and throat specialists and gynaecologists (P < 0.01). CONCLUSIONS: The results of this study can be used as an aid for decision makers in the health services for determining policy. Direct access to some specialties might be appropriate, but not to all. Adoption of a policy based on these findings could lead to reduced health care costs by reducing the burden on hospital emergency rooms. It might also increase patient satisfaction in that the patients will have greater freedom of choice. On the other hand, more appropriate training of family physicians and more extensive self- and peer-quality assurance will increase the primary physician's knowledge and ability to diagnose and treat a broad range of problems and improve the level of care.

Juvenile rheumatoid arthritis: cervical spine involvement and MRI in early diagnosis.

Magnetic resonance imaging (MRI) of the cervical spine was performed on 20 patients (mean age 10 years) with a preliminary diagnosis of juvenile rheumatoid arthritis (JRA). In all patients conventional x-rays of the cervical spine were obtained, and the relationship between clinical status and MRI findings were evaluated. Two patients with clinical manifestations, including neck pain and diminished range of motion, exhibited significant pathologic features on radiogram and MRI, the latter providing more detailed information. Among 18 patients who had no complaints about their cervical spines, 3 patients (65%) had either soft tissue involvement, pannus formation or erosions on the surface of atlantoaxial joints; only four patients (20%) had erosions on plain x-ray views. Since the early diagnostic ability of MRI in JRA allows early therapeutic intervention, every patient with a probable diagnosis of JRA would benefit from MRI.

The in vivo effect of endothelins on retinal circulation in nondiabetic and diabetic rats.

PURPOSE: The endothelins are potent vasoactive peptides. This study was performed to characterize the in vivo effects of the endothelin peptides on the retinal circulation in nondiabetic and diabetic rats. METHODS: The video fluorescein angiography methodology was used to quantitate retinal hemodynamic responses to endothelin-1 (ET-1) and endothelin-3 (ET-3) in rats. A total of 99 rats were used for these experiments. Video fluorescein angiography recordings were performed before and at different times after intravitreal injection of different concentrations of ET-1 and ET-3 in nondiabetic and diabetic rats. Vascular diameters and retinal circulation times were determined using computer-assisted image analysis of the recorded angiograms. RESULTS: The maximal response to ET-1 was observed at 15 minutes after intravitreal injection and was maintained for as long as 30 minutes after injection. Subsequent data measured at 15 minutes after intravitreal injection showed significant prolongation of retinal circulation times and retinal artery constriction. For example, at a concentration of 10(-7) M, the retinal circulation time increased by 270% +/- 121% of the baseline value. In contrast, 10(-7) M ET-3 injection showed a 52% +/- 29.5% increase in circulation time compared to baseline. In diabetic animals, 10(-7) M ET-1 injection showed a blunted response (only 26% +/- 8% of baseline) compared to the same ET-1 injected concentration in nondiabetic rats. CONCLUSIONS: The rat retinal circulation shows a pronounced retinal response to ET-1 intravitreal injection. The response to ET-3 is significantly less than it is to ET-1, and in diabetic animals there was also a significant blunting of the retinal response to ET-1. The blunted response to ET-3 is consistent with the lower affinity of retinal vessel ET-1 receptors to ET-3. The blunted ET-1 response in diabetic rats is consistent with previously reported results, demonstrating resistance to ET-1 action in retinal pericytes exposed to high glucose.

Assessment of clinical impact and predisposing factors for neonatal thrombocytopenia.

Thrombocytopenia is a common hemostatic abnormality in the newborn infant. The early diagnosis of thrombocytopenia and the underlying primary pathology process play an important role in reducing the risk of severe complications and mortality. We performed a 2-year prospective study of 643 neonates admitted to our neonatology unit to determine the frequency, predisposing factors, and clinical impact of thrombocytopenia. Thrombocytopenia developed in 18.2% of the preterm neonates and 0.8% of the term neonates. Prematurity, sepsis, hypoxia, intrauterine growth retardation, and disseminated intravascular coagulation were identified as predisposing factors for thrombocytopenia. The incidence of complications and mortality were higher in thrombocytopenic infants. Especially the prognosis was worse in cases who had mucosal hemorrhage, without a relation with the degree of thrombocytopenia. The thrombocytopenia occurred by day 2 in 43% of the infants, and resolved by day 8 in 61%. The platelet count nadir occurred by day 2. Since thrombocytopenic infants are at greater risk for bleeding, and the thrombocytopenia itself may have contributed to the high mortality, predisposing factors such as prematurity, infections, hypoxia must be eliminated by providing better care, giving adequate hygiene of both mother and the baby during the prenatal, natal, and neonatal period.

A case of common truncus arteriosus with rare cardiac abnormalities.

Truncus arteriosus communis is a well-known, congenital, cardiac abnormality. In this report, we describe a very rare variant in which the truncus arose from the right ventricle, the atrial and ventricular septa were intact, the left ventricle was hypoplastic and the small right atrium was draining to the truncus arteriosus through a fibrose tunnel-like connection.

A case report: familial hypoalphalipoproteinemia.

We studied an 8 year-old girl whose height was 129 cm (25-50th percentile), weight 30 kg (75th percentile), blood pressure 115/75 mm Hg (75th percentile) and had a calcified mass lesion in the left posterior mediastinum. In the histopathological investigation of this mass lesion, symptoms of complicated atherosclerosis, such as mural thrombus and diffused calcification, were observed. Lipid investigations were performed in this patient whose total cholesterol and triglyceride levels were in the normal ranges. HDL-cholesterol, apoprotein A-I and alpha band were low without any other lipid and lipoprotein abnormalities. During one year, in her monthly lipid analysis the mean levels of HDL-cholesterol, apoprotein A-I and alpha band were found to be 0.73 +/- 0.11 mmol/l, 90 +/- 20 mg/dl and 23 +/- 5% respectively. Studies of her family revealed low levels of HDL-cholesterol, apoprotein A-I and alpha band in her mother and sister. We describe our investigation of this rare case of familial hypoalphalipoproteinemia.

Diffuse erythrodermic cutaneous mastocytosis with bone marrow infiltration.

We report a case of diffuse erythrodermic cutaneous mastocytosis with bone marrow infiltration. An 11-month-old female patient was referred to our hospital for intermittent flushing, fever, intense itching, erythematous rash and bullous lesions. Cutaneous biopsy demonstrated diffuse cutaneous mastocytosis. The bone marrow aspirate revealed mast cell infiltration. Ketotifen treatment was very effective.

Single-dose ornidazole versus seven-day metronidazole therapy of giardiasis in Kibbutzim children in Israel.

The efficacy of single-dose ornidazole versus seven days metronidazole in the treatment of giardiasis was tested in a randomized study of 75 Kibbutzim children in Israel. All the children treated were clinically cured, and the parasites disappeared from stool examinations after the first follow-up. By the end of the study (21 days after the beginning of treatment), all the patients remained free of symptoms, but cysts of Giardia lamblia were found in the stools of three children from the ornidazole group (p = 0.24). The possibility of treating Giardia lamblia with ornidazole in a single dose, with results similar to those obtained with a seven-day course of metronidazole, makes this drug a good alternative in the treatment of Giardia lamblia in children, especially if compliance is not assured.

An outbreak of molluscum contagiosum in a kibbutz.

Molluscum contagiosum is a viral disease that presents in a primary care setting as single or multiple wart-like lesions. We have seen an outbreak of Molluscum contagiosum in a small rural community, affecting 34 individuals. The most infected were children two-to nine-years-old. The diagnosis was made on clinical grounds. Spread appeared to be as a result of direct contact and by fomites. There was no evidence, in our study, of spread via swimming pool. Cryosurgery was used to treat our patients with Molluscum contagiosum.

[Antimicrobial susceptibility of organisms infecting the urinary tract in northern Israel].

Urinary tract infections (UTI), especially in women, are very frequent and require antimicrobial treatment. The choice of drug depends on the susceptibility of the infecting organism. In many cases treatment is begun before the identity and susceptibility of the organism/s cultured are known. Knowledge of the profile of the infecting organisms and their drug susceptibility can improve the treatment of community-acquired UTI. We recorded the distribution and susceptibility of 50,699 positive UTI cultures, during the years 1986-7, in 2 community laboratories in northern Israel serving a population of about 830,000. The sensitivity of organisms to ampicillin was only 32 in the Haifa region and 42 in the Afula region and, respectively, to cotrimoxazole 51 and 76, to cephalexin 60 and 77, to nitrofurantoin 83 and 89, and to nalidixic acid 80 and 92. The differences between the regions were statistically significant. As a result of this study, we suggest that ampicillin should not be used empirically in UTI in these these 2 regions, nor cotrimoxazole in the Haifa region. All women with uncomplicated UTI should be treated with nitrofurantoin or nalidixic acid, provided they are not sensitive to these drugs and tolerate them well. The use of new drugs such as the quinolones and amoxicillin/clavulanic acid must be controlled and monitored to avoid rapid development of resistant strains.

Urinary Mycobacterium fortuitum infection.

Mycobacterium fortuitum, a common saprophyte usually found in water and soil, can also be isolated from sputum and gastric secretions of healthy carriers. Under certain conditions, significant clinical infections due to M. fortuitum do occur. Urinary tract infections are rarely caused by atypical mycobacteria. This report describes a urinary tract infection caused by M. fortuitum in a 73-year-old patient treated with corticosteroids for bronchial asthma, who was successfully treated with ofloxacin.

Unsuspected source of vitamin K in patients treated with anticoagulants: a case report.

The administration of warfarin requires careful attention. The concurrent intake of drugs can either enhance or compete with its anticoagulant effect. Less frequently encountered are the effects from vitamin K added to food, intake of foods with naturally occurring high levels of vitamin K and diets deficient in vitamin K. We report a case in which loss of anticoagulant control was caused by a dietary supplement taken during a weight reducing diet by a patient who was receiving warfarin following a pulmonary embolus. A review of the literature reveals several similar cases. Amounts of vitamin K in food supplements and in foods with large amounts of naturally occurring vitamin K are tabulated along with suggestions for surveillance of patients taking anticoagulants.