[PHYSIOTHERAPY TREATMENT DURING CORONA TIMES - SUMMARY AND GUIDELINES].

INTRODUCTION: The World Health Organization declared that the corona virus disease (COVID 19) is a global pandemic and public health emergency, following the outbreak in Wuhan, China, in December 2019. Fever, dry cough and fatigue were the main manifestations, but the primary concern is cases that deteriorated to severe pneumonia and acute respiratory distress syndrome (ARDS). The outbreak of COVID- 19 in Israel, in March 2020 caused major changes in the routine work in hospitals. Hasharon hospital, a small community hospital in Petah Tikvah was converted to corona patients' admissions only. In accordance with this new reality, the physiotherapy service prepared itself to provide treatments tailored to the clinical needs of the Covid 19 patients and the quarantine conditions of these patients' hospitalization. During a period of 2 months, we built a unique protocol adjusted to isolated patients and staff, including telemedicine and hands-on treatment. This article summarizes our experience of physiotherapy treatment in the acute and rehabilitation period.

Development and validation of a knowledge-driven risk calculator for critical illness in COVID-19 patients.

Facing the novel coronavirus disease (COVID-19) pandemic, evidence to inform decision-making at all care levels is essential. Based on the results of a study by Petrilli et al., we have developed a calculator using patient data at admission to predict critical illness (intensive care, mechanical ventilation, hospice care, or death). We report a retrospective validation of the calculator on 145 consecutive patients admitted with COVID-19 to a single hospital in Israel. Despite considerable differences between the original and validation study populations, of 18 patients with critical illness, 17 were correctly identified (sensitivity: 94.4%, 95% CI, 72.7%-99.9%; specificity: 81.9%, 95% CI, 74.1%-88.2%). Of 127 patients with non-critical illness, 104 were correctly identified. Our results indicate that published knowledge can be reliably applied to assess patient risk, potentially reducing the cognitive burden on physicians, and helping policymakers better prepare for future needs.

Morphological changes in peri-prostatic sympathetic ganglion cells in aging males.

A significant part of morbidity in elderly male patients involves the pelvic organs and their autonomic neural regulation. The aim of the current study was to report the histopathological changes in the peri-prostatic ganglia in elderly males. The sympathetic ganglia from 36 prostatectomy specimens, 26 due to carcinoma of the prostate and 10 prostates from total cystectomies for transitional cell carcinoma, were examined. The age range was 54-88 years. A total of 5,075 ganglion cells were counted in all the specimens. Pathological changes were identified in 1,696 neuron cells as follows: Neuronophagia in 746 neuron cells, neuron cell vacuolization (330 cells), satellite cells vacuolization (423 cells), cell pyknosis (148 cells) and nageotte nodules (49 cells). A number of these changes increased with age. All the changes were more marked in the peri-prostatic ganglion cells of patients with prostatic adenocarcinoma compared with those with benign prostate hyperplasia, which may be due to local environmental changes associated with the presence of malignancy.

Sex differences in the epidemiology, seasonal variation, and trends in the management of patients with acute appendicitis.

BACKGROUND: Acute appendicitis is the most common indication for acute surgical abdominal intervention. In this study, we analyzed the gender correlation with demographic, epidemiologic, diurnal, and seasonal trends in relation to the incidence and management of patients with acute appendicitis in our medical center. METHODS: Data of patients, 18 years of age or older who underwent emergency appendectomies at the Rabin Medical Center during the last 13 years, were collected. The data collected included demographic parameters, hospitalization, procedures, and use of preoperative imaging. RESULTS: Data were available for 3,736 patients. Males had more appendicitis attacks than females (p < 0.0001), whereas females had more normal appendixes than males (p < 0.0001). The overall rate of normal appendixes was 19.6 %, with a decline in the past 10 years from a yearly average of 23.5 % between 1998 and 2002 to 15 % between 2003 and 2007 (p < 0.0001) with a reverse correlation with the preoperative use of abdominal CT. A distinct seasonal pattern was observed; more appendectomies for acute appendicitis occurred during the summer months (p < 0.0001). Ten percent of patients had a complicated course with a mortality rate of 0.33 %; most of them were elderly, male/female ratio 0.4. CONCLUSIONS: We found distinct gender, epidemiological, seasonal, and diurnal trends influencing the incidence of acute appendicitis. The incidence rate of false-positive surgery has been gradually declining, probably due to the increased use of preoperative abdominal CT and ultrasound. Acute appendicitis was more common in males and during the summer months.

Expression of epithelial cell adhesion molecule in gallbladder carcinoma and its correlation with clinicopathologic variables.

Gallbladder carcinoma is rare and fatal, and conventional therapies have been disappointing. Epithelial cell adhesion molecule (EpCAM) serves as a prognostic marker in various carcinomas and is a target of antibody-based therapies. Our purpose was to examine the expression of EpCAM in gallbladder carcinomas in relation to tumor grade, disease stage, and patient survival. Gallbladder carcinoma tissue specimens from 25 patients attending our center between 1991 and 2004 were immunohistochemically stained for EpCAM. The intensity and extent of staining were analyzed, and the specimens were classified accordingly: (1) weak, weak or no EpCAM expression in less than 10% of the selected area; (2) moderate, moderate expression in 10% to 49% of the selected area; or (3) strong, heavy staining in 50% or more of the selected area. The correlation between EpCAM expression and clinicopathologic variables was analyzed statistically.EpCAM overexpression predicted decreased survival (P = .005), but EpCAM expression did not correlate with tumor grade (P = .28) or disease stage (P = .10). EpCAM expression in gallbladder tumors may serve as a prognostic factor for poor survival. Its detection may help clinicians select patients likely to benefit from novel molecular therapies.

[Bilateral deep vein thrombosis as presenting symptom of malignancy].

In 1865 Trousseau first described the association between venous thrombosis and malignancy. We now know that unprovoked deep vein thrombosis of the legs precedes the diagnosis of malignancy in more than 7% of the cases. In bilateral deep vein thrombosis the risk of occult malignancy exceeds 40%. We describe a patient with bilateral deep vein thrombosis as presenting symptom of pancreatic cancer.

[Probiotics as prophylactic agents against antibiotic-associated diarrhea in hospitalized patients].

BACKGROUND: Antibiotic associated diarrhea is a major cause of morbidity in hospitalized elderly patients. Probiotics may shorten the duration and reduce the recurrence incidence of this problem. The researchers assessed the protective effects of probiotics in hospitalized patients. PATIENTS AND METHODS: Hospitalized patients aged 18 or older, who were scheduled for antibiotic treatment, were randomly assigned to receive either probiotics or placebo in a double-blind placebo controlled study, within 24 hours from the beginning of antibiotic treatment and for three weeks later. Baseline fecal Clostridium difficile toxin levels (A and B) were obtained within 24 hours of treatment. The patients were monitored for diarrhea, antibiotic treatment and duration of stay. The probiotics were also analyzed for sensitivity to antibiotic treatment in vitro. RESULTS: Forty-two patients completed the study; 21 patients were treated with probiotics and 21 with placebo. Diarrhea occurred in 4 patients (9%): one in the placebo group and three in the probiotic group, p=NS. Clostridium toxin samples were negative in 17 (68%) samples and 8 (23%) were positive (+2 to +4). Diarrhea occurred only in patients treated with wide-spectrum antibiotics, (p = 0.04, Chi2). In-vitro culture of the probiotic capsules yielded gram-positive cocci and bacilli, which were susceptible to many of the antibiotics used by the patients in this study. CONCLUSIONS: There was no significant protecting effect of prophylactic probiotics for antibiotic associated diarrhea in hospitalized patients under antibiotic treatment, mainly because of the susceptibility of the probiotic bacteria to the treatment.

[FUO (fever of unknown origin) as a presenting sign of West Nile fever].

West Nile fever is an infection affecting thousands of people each year, and is responsible for a wide spectrum of clinical manifestations from a mild febrile illness to lethal encephalitis. The prevalence of this infection and its associated morbidity has risen dramatically in recent years. We present a patient with non-specific complaints and prolonged fever for 7 weeks. He underwent thorough investigation, which almost ended with abdominal laparoscopy until the final diagnosis of West Nile Fever was established.

Vulvar hematoma after cunnilingus in a teenager with essential thrombocythemia: a case report.

BACKGROUND: Nonobstetric injuries of the female genital tract constitute up to 0.8% of all gynecologic admissions. Approximately 40% of such admissions are due to coital injuries. Vulvar injuries following cunnilingus have been reported only rarely. CASE: A 17-year-old with known essential thrombocytopenia was being treated with low-dose aspirin and presented with a 4-cm vulvar hematoma that occurred during cunnilingus. The hematoma was evacuated uneventfully, with no signs of further bleeding and no patient complaints. As the patient, a minor under Israeli law, wished to conceal the circumstances from her parents, we told them that she had suffered vulvar trauma from the background disease. CONCLUSION: This case demonstrates an unexpected complication of a necessary treatment for a major disease and the sometimes dual obligation of physicians to their patients and their families.

[An allergic reaction to an over the counter drug frequently used: possible pitfalls in everyday medicine].

This is a case study of a 76-year-old female patient, who was admitted to our ward with complaints of diarrhea, abdominal pain and weight loss of five kilograms over the past month. This case contains three topics of interest. Firstly, the problem with frequent use of commercial drug names making it difficult for patients and treating physicians to identify those drugs for what they are, and thus enabling possible side-effects. Secondly, a topic worthy of attention is the existence of many over the counter drugs, some of which, like salicylates, have many possible side-effects, which compel reliance on patients to intelligently use available over the counter drugs. As this case demonstrates, such reliance does not always prove to be appropriate. The third issue to be addressed is that pepto-bismuth subsalycilate contains a salycilate moiety. Manufacture's instructions call for abstinence from this drug with known allergy to aspirin. However, given the different capabilities of salycilates, and the relative safety attributed to this drug, the salycilate moiety in peptobismuth subsalycilate does not always receive sufficient attention by both patients and physicians.

Trends in admissions to internal medicine wards in a community hospital in Israel.

BACKGROUND: Epidemiological studies are useful both for investigating possible etiologic factors and for determining the extent of health provisions required. In an attempt to improve the quality of care, we have analyzed the trends of admissions to the four internal medicine wards in a community hospital in Israel. METHODS: Data was collected on admission to all of the internal medicine wards of Hasharon Hospital, Rabin Medical Center, Petach-Tikva, Israel, from 1999 to 2004, including discharge diagnosis, duration of stay, and mortality. The data source was the "Bina" data warehouse system of Clalit Health Services. RESULTS: The yearly admission rate was 10,482+/-386. Ninety-six percent of the admissions were of Jews and 3% were of Arabs. Most of the patients were older than 75 years (43.1%); 23.6% were between 65 and 74 years of age. The readmission rate was 7.4% within 1 week and 16.3% within 1 month. The three most common discharge diagnoses, not including pre-existing illnesses, were: coronary artery disease-related (21.9%), heart failure (5.4%), and pneumonia (5.6%). The average duration of stay was 4.6+/-0.1 days. Patients admitted for newly diagnosed malignancy, pneumonia, or CVA had a longer duration of stay (7.1, 6.8, and 6.5 days, respectively). There was a steady decline in mortality from 4.5% in 1999 to 4.2% in 2004. CONCLUSION: In the 5-year period studied, there was a changing trend in mortality rate, hospital duration rate, and patient age.

PET-CT imaging of combined brachial and lumbosacral neurolymphomatosis.

Neurolymphomatosis is a rare manifestation of progressive non-Hodgkin's lymphoma. A 44-yr-old man with diffuse large B-cell lymphoma presented with unilateral progressive peripheral sensorimotor neuropathy after the 7th cycle of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone) therapy. No pathology in the nervous system was evident by computerized tomography (CT), magnetic resonance imaging (MRI) of the head, spinal axis and plexuses and by repeated analysis of cerebrospinal fluid. However, the hybrid modality of positron emission tomography (PET) of fluorinated deoxyglucose (FDG) combined with CT scan (PET-CT) showed unilateral involvement of both the brachial and lumbosacral nervous plexuses. A complete recovery of neurological manifestations and normalization of PET-CT followed intensive chemotherapy with autologous stem cell transplantation. The diagnosis and localization of neurolymphomatosis may be supported by PET-CT imaging.

Fulminant intravascular lymphoma presenting as fever of unknown origin.

Intravascular large cell lymphoma (IVLL) is a rare neoplasm characterized by the proliferation of malignant lymphoid cells within the lumens of small to medium-sized blood vessels. The central nervous system, skin, and endocrine systems are most commonly involved. IVLL may disseminate to the heart, pancreas, liver, spleen, kidneys, and adrenal glands. We report a 52-year-old patient who was admitted for fever of unknown origin for 3 weeks, jaundice and abnormal liver function tests. Fever, high levels of bilirubin, severe anemia, thrombocytopenia, and a very fulminant course characterized the clinical picture. Although bone marrow involvement is quite rare, the diagnosis of IVLL in this patient was done by bone marrow biopsy. The patient was treated with CHOP protocol and received the first course but the aggressive disease led to the patient's death.

Treatment of resistant thrombotic thrombocytopenic purpura with rituximab and cyclophosphamide.

Thrombotic thrombocytopenic purpura (TTP) is an uncommon acquired disease in adults, especially young women, characterized by fever, neurologic manifestations, microangiopathic hemolytic anemia, thrombocytopenia, and renal dysfunction. Treatment with plasmapheresis has increased the survival rate from 10% to greater than 90%. Still, a subset of patients with resistant TTP fail to respond to plasmapheresis or remain dependent on this procedure. We report such a patient who was successfully treated with rituximab and cyclophosphamide. She has now been disease free for more than 6 months. This novel treatment modality for TTP has been described for only a few patients. A well-controlled clinical trial is warranted to determine the role and place of this therapeutic approach in the management of TTP.

Clinical and ethnic characteristics of stroke in an Israeli population: a study in a community hospital population.

Background: Stroke mainly affects the older population, although it has also been reported in younger patients. In this study, we focused on patients 65 years of age or younger with stroke. Methods: The files of three patient populations were studied: 93 patients aged 65 years or younger with stroke (group A), 93 patients older than 65 with stroke (group B), and 604 patients without stroke representing the general population of patients admitted to our service during January 2000 (group C). We reviewed the patient files and compared patient characteristics, epidemiological features, clinical picture,imaging findings, and coagulation tests. Results: Overall, 318 patients were studied. The mean age of group A was 55 years compared to 77 years in group B and 71 years in group C. In both stroke groups (A and B), the male: female ratio was 2:1, in contrast with a balanced ratio in group C. Most of the patients in group A (63%) were of Sephardic origin compared to 39% in group B (P=0.002) and 30% in group C. The clinical picture in both stroke groups (A and B) was similar. The risk factor smoking was reported by 45% in group A and by only 29% in group B (P=0.034). Hypertension, diabetes mellitus, and hyperlipidemia were evenly prevalent in both stroke groups. The coagulation system was studied in the "young" patients (group A): hyperhomocysteinemia was found in 37%, high titers of anticardiolipin antibodies in 35%, low levels of antithrombin III in 13%, protein C deficiency in 5%, and activated protein C resistance (APCR) in 4%. Overall, 49% of the patients from group A were found to have coagulation abnormalities. Conclusions: We found in our study that the younger patient with stroke tends to be a Sephardic male with the classical risk factors as well as a history of smoking and coagulopathy. These findings suggest strict medical supervision and primary prophylaxis. This work also lays the basis for a prospective, interventional trial with younger patients.

Platelet function and its clinical significance in the myelodysplastic syndromes.

The current study was aimed at investigating platelet function in MDS and its clinical significance. There were 23 patients with untreated MDS at presentation, including refractory anemia (RA), RA with ringed sideroblasts, RA and excess blasts and chronic myelomonocytic leukemia RAEBt. The mean platelet count was 167.9 x 109/L. Patients with a platelet count less than 70 x 109/l were excluded. The mean bleeding time (BT) was 2.7 min. Only four MDS patients had BT longer than the normal 1-4 min range. Platelet aggregation (PA) was studied with epinephrine (Epi), ADP, arachidonic acid (AA), ristocetin and collagen. Overall, 16 (70%) patients had PA abnormality, 65% had impaired Epi-induced PA, 57% demonstrated reduced ADP-induced PA. AA, ristocetin and collagen was decreased PA in 48, 22 and 17%, respectively. Five patients (22%) demonstrated spontaneous PA. Only seven patients (30%) were found to have normal PA with all five inducers. Six (26%) patients had spontaneous mild bleeding and all six bleeding MDS patients demonstrated at least one abnormal platelet function. The only bleeding patient with all five PA tests normal demonstrated prolonged BT. In the present study of 23 newly diagnosed MDS patients, PA abnormalities were relatively common, the BTs were usually normal, and bleedings were relatively uncommon and mild at platelet count between 70 and 397 x 109/l.

Erythropoietin has an anti-myeloma effect - a hypothesis based on a clinical observation supported by animal studies.

Recombinant human erythropoietin (rHuEpo) was introduced into clinical practice more than a decade ago, and has been found to be effective in the treatment of several types of anemia, including anemia of end-stage renal failure and cancer-related anemia. No study has suggested that Epo might have an effect on the biology of the disease, nor any survival advantage to cancer patients treated with Epo for anemia has been reported. Here we report six patients with advanced multiple myeloma (MM) with very poor prognostic features, whose expected survival was <6 months. All six patients were treated with rHuEpo for their anemia, either without any chemotherapy or very mild chemotherapy for a short time. Yet, surprisingly they lived for 45-133 months totally from MM diagnosis and 38-94 months with rHuEpo (with a good quality of life). In fact, one patient, is still alive and well, more than 8 yr after chemotherapy was discontinued because of a resistant aggressive disease. The course in these six MM patients led us to hypothesize that Epo might have an antineoplastic or antimyeloma effect. We proceeded and tested that hypothesis in mouse models of myeloma (Mittelman M et al., Proc Natl Acad Sci USA 98:5181,2001). In these models we confirmed that rHuEpo induced tumor regression in about 50% of the BALB/c mice inoculated with MOPC-315 myeloma cells. We then presented evidence that the mechanism is a new immune-mediated phenomenon, via activation of CD8+ T cells. Furthermore, evidence from the literature supports the antineoplastic effect of Epo. Epo might be used as an adjunct immune treatment in various malignant diseases, in addition to the current regimens and chemotherapeutic protocols. Future trials should determine the role of Epo in myeloma and cancer treatment, besides clarifying concerns about the presence of Epo receptors on some tumor cells.