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Schwartz N.,Haifa University | Schwartz N.,Clinical Research Unit | Nachum Z.,Emek Medical Center | Nachum Z.,Technion - Israel Institute of Technology | Green M.S.,Haifa University
American Journal of Obstetrics and Gynecology | Year: 2015

Reports on the gestational diabetes mellitus (GDM) recurrence rate have been highly variable. Our objectives were to examine the possible causes of GDM recurrence rate variability and to obtain pooled estimates in subgroups. We have carried out a systematic review and metaanalysis based on the Metaanalysis Of Observational Studies in Epidemiology statement. We identified papers published from 1973 to September 2014. We identified papers using Medline (PubMed and Ovid), ClinicalTrials.gov and Google Scholar databases, and published references. We included only English-language, population-based studies that reported specified GDM criteria and GDM recurrence rate. A total of 18 eligible studies with 19,053 participants were identified. We used the Cochrane's Q test of heterogeneity to choose the model for estimating the pooled GDM recurrence rate. Metaregression was also used to explore the possible causes of variability between studies. The pooled GDM recurrence rate was 48% (95% confidence interval, 41-54%). A significant association between ethnicity and GDM recurrence rate was found (P =.02). Non-Hispanic whites had lower recurrence rate compared with other ethnicities (39% and 56%, respectively). Primiparous women had a lower recurrence rate compared with multiparous women (40% and 73%, respectively; P <.0001) No evidence for association between family history of diabetes and GDM recurrence was found. The overall GDM recurrence rate is high. Non-Hispanic whites and primiparous women have substantially lower GDM recurrence rates, which contributes to the variability between studies. Because no association between family history of diabetes and GDM recurrence was found, the large differences between ethnic groups may have also resulted from nongenetic factors. Thus, intervention programs could reduce the GDM recurrence rates. © 2015 Elsevier Inc. All rights reserved.


Habib G.S.,University of Sfax | Habib G.S.,Nazareth Hospital | Saliba W.,Emek Medical Center | Nashashibi M.,Carmel Medical Center
Clinical Rheumatology | Year: 2010

Intra-articular corticosteroid injection (IACI) is a very popular procedure. In this review, we wanted to review all that had been published about local effects of IACIs. English literature search was made through PubMed using the terms intra-articular and local effect. Effects on subjective, functional, structural, cellular, humoral, molecular, and imaging aspects were included. Also, all local adverse effects were documented. The main beneficial effect of IACI is pain relief. The duration of this effect is variable and depends on underlying disease, type of disease, amount of structural damage, type of IACI, dose of IACI, presence of joint effusion, level of inflammatory mediators, emptiness of joint effusion, availability of imaging, and others. At large, inflammatory problems had higher rate of favorable response in terms of pain and function. IACI at the knee joint in juvenile idiopathic arthritis patients resulted in remission for >6 months in >80% of the patients with a mean duration of ∼1.2 years, while in the osteoarthritic knee there was a pain relief for 3 weeks only and in rheumatoid arthritis (RA) knee for 8 weeks. There was no joint space loss at the knee joint following multiple IACI in osteoarthritis and also no increase in cartilage or bone erosions in RA following a single IACI. IACI guide imaging is important in achieving better results in particular joints. Joint infection rate is very low. Other adverse effects included intra-articular and periarticular calcifications, cutaneous atrophy, cutaneous depigmentation, avascular necrosis, rapid destruction of the femoral head, acute synovitis, Charcot's arthropathy, tendinopathy, Nicolau's syndrome, and joint dislocation. IACI is associated with a wide range of local effects. Subjective and functional favorable response is prominent mainly in juvenile idiopathic arthritis patients. Adverse effects are either rare or insignificant. © 2010 Clinical Rheumatology.


Livermore D.M.,University of East Anglia | Livermore D.M.,Public Health England | Andrews J.M.,City Hospital | Hawkey P.M.,University of Birmingham | And 5 more authors.
Journal of Antimicrobial Chemotherapy | Year: 2012

Recent EUCAST advice asserts that, with low breakpoints, susceptibility results for cephalosporins and carbapenems can be reported 'as found', even for strains with extended-spectrum β-lactamases (ESBLs) and carbapenemases. The CLSI has similar advice, but with higher ceftazidime and cefepime breakpoints than those of EUCAST. Pharmacodynamic and animal data are used to support these views, along with some analysis of clinical case series. We contend that such advice is misguided on three counts. First, whilst there are cases on record where cephalosporins and carbapenems have proved effective against infections due to low-MIC ESBL producers and low-MIC carbapenemase producers, respectively, there are similar numbers of cases where such therapy has failed. Second, routine susceptibility testing is less precise than in research analyses, meaning that ESBL and carbapenemase producers with 'real' MICs of 1-8 mg/L will oscillate between susceptibility categories according to who tests them and how. Third, although EUCAST continues to advocate ESBL and carbapenemase detection for epidemiological purposes, the likely consequence of not seeking these enzymes for treatment purposes is that some laboratories will not seek them at all, leading to a loss of critical infection control information. In short, it is prudent to continue to seek ESBLs and carbapenemases directly and, where they are found, generally to avoid substrate drugs as therapy. © The Author 2012. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.


Rottem M.,Emek Medical Center | Rottem M.,Technion - Israel Institute of Technology
Journal of Asthma | Year: 2012

Objective. Approved by the FDA in 2003, omalizumab is the first recombinant humanized monoclonal anti-immunoglobulin E antibody developed for the treatment of allergic asthma. Due to the heterogeneity of asthma symptoms, investigation of the efficacy of omalizumab in patients outside controlled trials is particularly important. The purpose of the current study was to evaluate the efficacy of omalizumab as an add-on treatment for allergic asthma in a real-life setting in Israel. Methods. This was a retrospective study based on patient records and computerized database for drug dispensing, emergency room visits, and hospital admissions. Results. The sample comprised 33 individuals (18 men, 15 women; mean age 50.0 ± 12.2, range 2579) who were treated with omalizumab for severe allergic asthma for a duration of at least 16 weeks. After the initiation of omalizumab therapy, the number of patients who used oral or injected corticosteroids decreased (p < .003, .03, respectively), as did the median dosage of oral corticosteroids (p < .02). Visits to the emergency room decreased from an incidence of 0.526 visits per person-year to an incidence of 0.246 per person-year (p < .05). No adverse reactions to omalizumab were observed. Conclusion. Omalizumab as an add-on therapy reduced the use of corticosteroids and improved the control of asthma, as evidenced by reduced asthma-related emergency room visits. This study supports both controlled and uncontrolled studies that have demonstrated the efficacy and safety of omalizumab, and particularly those that demonstrated effectiveness among severe asthma patients. "Real-life" studies are important to identify patients who will most benefit from omalizumab therapy. © 2012 Informa Healthcare USA, Inc.


Rottem M.,Emek Medical Center
Harefuah | Year: 2010

Allergic rhinitis causes major illness and disability worldwide, but it is still underdiagnosed and undertreated. Allergic rhinitis is a risk factor for both the development and for exacerbations of asthma. Up to 30% of patients with rhinitis suffer from asthma, and the majority of patients with asthma suffer from rhinitis. Measurements of allergic status can help to identify risk factors that cause asthma. Hence, the Allergic Rhinitis and its Impact on Asthma (ARIA) initiative recommends that the presence of asthma must be considered in all patients with rhinitis, and that in planning treatment, both should be considered together in terms of efficacy and safety. Treatment of rhinitis may improve asthma symptoms. Due to new studies and diagnostic techniques the ARIA guidelines, initially formed in 1999, were recently updated. They are intended for specialists, general physicians and health care providers in order to increase the knowledge on allergic rhinitis and its impact on asthma and to provide evidence-based revision on the diagnostic methods, treatments and a stepwise approach to management. There is a need for a collaborative effort of all specialists and primary physicians involved in the treatment of rhinitis and asthma for the proper implementation of the guidelines.


Halachmi-Eyal O.,Emek Medical Center | Kowal L.,Royal Melbourne Hospital
Current Opinion in Ophthalmology | Year: 2013

PURPOSE OF REVIEW: We aim to give a systematic approach on how to assess the cause of a patient's abnormal head posture (AHP). RECENT FINDINGS: Over the decades, many important clinical observers and teachers have described diagnostic techniques for patients with AHP. Recently, Wong has added a new set of office-based diagnostic criteria that expand and solidify the office assessment of AHP. SUMMARY: We describe old and new, well known and poorly known office techniques for the assessment of AHP. © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins.


Salim R.,Emek Medical Center
Obstetrics and Gynecology | Year: 2015

OBJECTIVE:: To examine the effect of prophylactic balloon catheters on bleeding morbidity among women with a prenatal diagnosis of placenta accreta. METHODS:: In a randomized trial, women with a prenatal diagnosis of placenta accreta were randomized to either preoperative prophylactic balloon catheters (intervention group) or to a control group. Other than placement of the prophylactic balloon catheters in the anterior division of the internal iliac arteries, the same multidisciplinary approach was used in both groups. The primary study outcome was the number of packed red blood cell (RBC) units transfused. To detect a mean reduction of three packed RBC units with the prophylactic balloon catheters, 12 women in each group were needed. RESULTS:: Between January 2009 and March 2015, 27 women were randomized: 13 in the intervention group and 14 in the control group. Demographic and obstetric characteristics were similar between the groups. Six (46.2%) women in the intervention and seven (50.0%) in the control group underwent cesarean hysterectomy (P=.84). There were no significant differences between the intervention and control groups in the mean number of packed RBC units transfused, 5.2 (±6.2) and 4.1 (±3.8), respectively (P=.90), or in the calculated blood loss, 4,950 (±5,051) and 4,709 (±3,434) mL (P=.72). The number of women with blood loss greater than 2,500 mL, number of plasma products transfused, duration of surgery, peripartum complications, and hospitalization length did not differ significantly between the groups. Reversible adverse effects related probably to prophylactic balloon catheter insertion were noted in 2 of 13 (15.4%) women. CONCLUSION:: In women with preoperative suspicion of placenta accreta, preoperative placement of prophylactic balloon catheters did not affect the number of packed RBC units transfused. CLINICAL TRIAL REGISTRATION:: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01373255. LEVEL OF EVIDENCE:: I © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.


Zafran N.,Emek Medical Center | Salim R.,Emek Medical Center
Archives of Gynecology and Obstetrics | Year: 2012

Purpose To assess the impact of liberal compared with restrictive use of mediolateral episiotomy on the incidence of obstetric anal sphincter tear (OAST). Methods Data between the years 1999-2001 (era 1) when liberal mediolateral episiotomy was applied were compared with the years 2004-2008 (era 2) when restricted mediolateral episiotomy was implemented. Liberal mediolateral episiotomy was done for fetal or maternal indications, while restrictive mediolateral episiotomywas done when a tear was imminent. Primary outcome was the incidence of OAST. Results A total of 25,170 women who delivered vaginally were included. After adjusting for potential confounders, the incidence of OAST was found to be significantly higher in era 2 (0.4 %) compared to era 1 (0.1 %), (p = 0.02; adjusted OR 2.23; 95 % CI, 1.16-4.29). Among primiparous women, the incidence of mediolateral episiotomy was 71.8 and 27.1 % in eras 1 and 2, respectively (p<0.001), and the incidence of OAST was 0.2 and 1 % in eras 1 and 2, respectively (p = 0.009; adjusted OR 4.15; 95 % CI, 1.42-12.10). Among multiparous women, the incidence of OAST did not differ significantly (p = 0.52). Returning to the liberal policy among primiparous women only, 124 deliveries are needed to prevent one OAST. Conclusion Liberal compared to restrictive use of mediolateral episiotomy may be a sphincter-saving procedure among primiparous women. © Springer-Verlag 2012.


Zuarez-Easton S.,Emek Medical Center
Journal of Perinatology | Year: 2016

Objective:Obstetric brachial plexus palsy (OBPP) at birth, is a serious neurologic injury that may lead to a long lasting disability. We aimed to examine the occurrence and risk factors associated with disability lasting >1 year.Study Design:A retrospective cohort study conducted between 1993 and 2012 included individuals with diagnosis of OBPP at birth. Affected individual’s motor function was evaluated by a direct physical exam based on a muscle grading system of the limb, shoulder, elbow and hand. When not feasible a telephone questionnaire was used. Participants reported on activities of daily living, disability duration and any type of intervention. Stepwise logistic regression model was used to identify demographic and obstetric risk factors for disability lasting >1 year.Results:Of all 83 806 deliveries during this period, 144 OBPP cases were identified (1.7/1000). Of the 91 (63.2%) individuals located 42 (46.2%) were evaluated by a physical exam and 49 (53.8%) answered a telephone questionnaire. In 12 (13.2%) disability lasted >1 year. Significant predictors for disability lasting >1 year included birthweight >4 kg (P=0.02; odds ratio (OR) 6.17; 95% confidence interval (CI) 1.33–28.65) and younger maternal age (P=0.02; OR 0.84; 95% CI: 0.73–0.97). OBPP decreased 16% per 1 year increase in maternal age.Conclusions:OBPP is a transient injury in most cases. Birthweight over 4 kg and younger maternal age maybe associated with disability lasting >1 year.Journal of Perinatology advance online publication, 20 October 2016; doi:10.1038/jp.2016.195. © 2016 Nature America, Inc., part of Springer Nature.


Elboim-Gabyzon M.,Haifa University | Rozen N.,Emek Medical Center | Laufer Y.,Haifa University
Clinical Rehabilitation | Year: 2013

Objective: To determine whether neuromuscular electrical stimulation applied to the quadriceps femoris muscle will enhance the effectiveness of an exercise programme in patients with knee osteoarthritis. Design: A randomized trial with parallel intervention treatment groups. Setting: Outpatient physical therapy clinic. Subjects: Fifty participants (mean age (SD) 68.9 (7.7) years) with symptomatic idiopathic knee osteoarthritis and radiographic evidence (grade ≥II Kelgren's classification). Interventions: Participants were randomized into one of two groups receiving 12 biweekly treatments: An exercise-only group or an exercise combined with neuromuscular electrical stimulation group (biphasic pulses, at 75 Hz and 250 μs phase duration). Main measures: Knee pain intensity; maximal voluntary isometric contraction and voluntary activation of the quadriceps femoris muscle; measures of functional performance. Results: A significant interaction effect (P = 0.01) indicated greater improvement in pain for the electrical stimulation group. The mean (SD) change in pain intensity was from 7.5 ± 2 to 5 ± 2.2 and from 7.4 ± 1.9 to 3.3 ± 2.4 in the exercise and electrical stimulation groups, respectively. A significant treatment effect was also noted for the voluntary activation of the quadriceps femoris, which increased by 22.2% in the electrical stimulation group and by 9.6% in the exercise group (P = 0.045). Significant improvements were observed in both groups in all remaining measures, with no differences between groups. Conclusions: Electrical stimulation treatment to the quadriceps femoris enhanced the effectiveness of an exercise programme in alleviating pain and improving voluntary activation in patients with knee osteoarthritis, but did not enhance its effect on muscle strength or functional performance. © 2012 The Author(s).

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