Avraham Rivkind

P53 expression in patients with cirrhosis with and without hepatocellular carcinoma

Background. Mutated p53 acts as a dominant oncogene, whereas the wild type (wt) p53 gene product suppresses cell growth. Abnormalities in the p53 gene are reported in more than 50% of malignant tumors. Recently, an allelic loss of chromosome 17p, where the p53 gene is located, was found to be more frequent in hepatocellular carcinoma (HCC) cell lines and human tumors. In addition, in half of the cases of HCC from endemic areas for hepatitis B virus and aflatoxin, a hot spot point mutation at codon 249 was detected, as previously reported. Missense mutations in p53, mdm‐2 complex formation, and other unknown mechanisms may lead to stabilization of the gene product, thus rendering it detectable by immunohistochemistry.

Cognitive knowledge decline after Advanced Trauma Life Support Courses

OBJECTIVEnTo assess the cognitive knowledge decline among graduates of the Advanced Trauma Life Support (ATLS) program in Israel, to compare the rate of decline between surgeons and nonsurgeons, and to recommend appropriate timing for refresher courses.nnnMETHODSnA prospective study based on multiple-choice question test results of 220 ATLS course graduates was conducted 3 to 60 months after course completion. These results were then compared with the examination results immediately after the course. A statistical model based on survival analysis was used to evaluate the decline pattern and extent and to compare the study groups.nnnRESULTSnA significant decline of cognitive knowledge over time among ATLS graduates was demonstrated. This decline was significantly greater in the nonsurgical group. A critical point of 20% cognitive knowledge loss among 50% of the examined physicians was observed around the 180th week after completion of the course.nnnCONCLUSIONnPhysicians taking the ATLS course lose a significant part of their acquired cognitive knowledge after 3.5 years. Surgeons retain their cognitive knowledge for longer periods of time. Based on the study results, the optimal timing for a refresher course is between 3 and 4 years after the initial ATLS course.

Emergency Preparedness and Response in Israel During the Gulf War

We examined the effect of the emergency response on medical and public health problems during the 1991 Gulf War in Israel. On the first day of the conflict, the number of deaths from suffocation, asphyxiation, aspiration, myocardial infarction, cardiac arrest, and cerebrovascular accident increased abruptly, as did the number of sudden deaths associated with the use of tight-fitting masks with filters in sealed rooms. Much of the excess risk for death from cardiorespiratory complications during the first alert may have been a consequence of its duration (140 minutes). Mass evacuation and concrete buildings are believed to have kept the death toll from trauma down, and mask use may have protected against facial and upper-airway injuries. Falls and hip fractures, airway irritation from exposure to bleach, carbon monoxide intoxication from open kerosene heaters in sealed rooms, and self-injection with atropine syringes were also noted. A measles epidemic and increased death rates from automobile crashes were other preventable causes of death. Protection against biological warfare was limited to surveillance of trends for pneumonia and gastroenteritis. Emergency planners failed to anticipate the need for better mask fit, hands-on training in the use of masks, and special guidelines for older persons to prevent deaths from suffocation and other cardiovascular-respiratory problems in the first minutes of use. If masks are to be distributed as a protection against chemical warfare, a simpler model including the use of shrouds for whole-body skin protection might help avoid cardiorespiratory complications. Public health problems not adequately dealt with in the predisaster period are apt to emerge with greater severity during a crisis.

The accumulated experience of the Israeli advanced trauma life support program

BACKGROUNDnBetween January 1990 and May 1995 one faculty in Israel taught Advanced Trauma Life Support (ATLS) courses to 3,700 physicians. Two types of courses were given to three subpopulations. We studied the influence of demographic variables on students achievements in the course and compared students achievements as a function of their course type.nnnSTUDY DESIGNnThis study was conducted as a concurrent longitudinal study.nnnRESULTSnAchievements of 3,700 students were analyzed. The precourse grade, type of course, and their interaction were found to have a significant effect on the postcourse grades. Physicians practicing surgical subspecialties, in general, did better, as did students educated in English-speaking countries. Students who took part in the Combat Trauma Life Support (CTLS) course, which included the entire ATLS course and additional lectures and exercises, also ended with better scores.nnnCONCLUSIONSnPhysicians country of origin and clinical subspecialty have a significant effect on the cognitive achievement in the ATLS course provided in Israel. An expanded ATLS course (CTLS), to include additional military trauma topics as well as additional skill station training, can improve the results of the postcourse grades.

Complications from supervised mask use in post-operative surgical patients during the Gulf War.

This is a report of three patients in a surgical ward of a hospital who developed complications seemingly related to the use of full-face-fitting masks associated with the first Scud Missile attack on Israel during the Gulf War. Patient 1 developed atrial fibrillation with an uncontrolled ventricular rate; Patient 2 redeveloped a gastrointestinal hemorrhage; and Patient 3 developed a severe anxiety attack. Each of the three was severely ill prior to the event. Special attention should be given to severely ill patients during such events.

Glasgow Coma Scale Score in Survivors of Explosion With Possible Traumatic Brain Injury in Need of Neurosurgical Intervention

ImportancenHead injury following explosions is common. Rapid identification of patients with severe traumatic brain injury (TBI) in need of neurosurgical intervention is complicated in a situation where multiple casualties are admitted following an explosion.nnnObjectivenTo evaluate whether Glasgow Coma Scale (GCS) score or the Simplified Motor Score at presentation would identify patients with severe TBI in need of neurosurgical intervention.nnnDesign, Setting, and ParticipantsnAnalysis of clinical data recorded in the Israel National Trauma Registry of 1081 patients treated following terrorist bombings in the civilian setting between 1998 and 2005. Primary analysis of the data was conducted in 2009, and analysis was completed in 2015.nnnMain Outcomes and MeasuresnProportion of patients with TBI in need of neurosurgical intervention per GCS score or Simplified Motor Score.nnnResultsnOf 1081 patients (median age, 29 years [range, 0-90 years]; 38.9% women), 198 (18.3%) were diagnosed as having TBI (48 mild and 150 severe). Severe TBI was diagnosed in 48 of 877 patients (5%) with a GCS score of 15 and in 99 of 171 patients (58%) with GCS scores of 3 to 14 (Pu2009<u2009.001). In 65 patients with abnormal GCS (38%), no head injury was recorded. Nine of 877 patients (1%) with a GCS score of 15 were in need of a neurosurgical operation, and fewer than 51 of the 171 patients (30%) with GCS scores of 3 to 14 had a neurosurgical operation (Pu2009<u2009.001). No difference was found between the proportion of patients in need of neurosurgery with GCS scores of 3 to 8 and those with GCS scores of 9 to 14 (30% vs 27%; Pu2009=u2009.83). When the Simplified Motor Score and GCS were compared with respect to their ability to identify patients in need of neurosurgical interventions, no difference was found between the 2 scores.nnnConclusions and RelevancenFollowing an explosion in the civilian setting, 65 patients (38%) with GCS scores of 3 to 14 did not experience severe TBI. The proportion of patients with severe TBI and severe TBI in need of a neurosurgical intervention were similar in patients presenting with GCS scores of 3 to 8 and GCS scores of 9 to 14. In this study, GCS and Simplified Motor Score did not help identify patients with severe TBI in need of a neurosurgical intervention.

Trauma care and case fatality during a period of frequent, violent terror attacks and thereafter.

BackgroundFrom September 1999 through January 2004 during the second Intifada (al-Aqsa), there were frequent terror attacks in Jerusalem. We assessed the effects on case fatality of introducing a specialized, intensified approach to trauma care at the Hebrew University-Hadassah Hospital Shock Trauma Unit (HHSTU) and other level I Israeli trauma units. This approach included close senior supervision of prehospital triage, transport, and all surgical procedures and longer hospital stays despite high patient-staff ratios and low hospital budgets. Care for lower income patients also was subsidized.MethodsWe tracked case fatality rates (CFRs) initially during a period of terror attacks (1999–2003) in 8,127 patients (190 deaths) at HHSTU in subgroups categorized by age, injury circumstances, and injury severity scores (ISSs). Our comparisons were four other Israeli level I trauma centers (nxa0=xa02,000 patients), and 51 level I U.S. trauma centers (nxa0=xa0265,902 patients; 15,237 deaths). Detailed HHSTU follow-up continued to 2010.ResultsFive-year HHSTU CFR (2.62xa0%) was less than half that in 51 U.S. centers (5.73xa0%). CFR progressively decreased; in contrast to a rising trend in the US for all age groups, injury types, and ISS groupings, including gunshot wounds (GSW). Patients with ISSxa0>xa025 accounted for 170 (89xa0%) of the 190 deaths in HHSTU. Forty-one lives were saved notionally based on U.S. CFRs within this group. However, far more lives were saved from reductions in low CFRs in large numbers of patients with ISSxa0<xa025. CFRs in HHSTU and other Israeli trauma units decreased more through the decade to 1.9xa0% up to 2010.ConclusionsSustained reductions in trauma unit CFRs followed introduction of a specialized, intensified approach to trauma care.