Background: Adequate lymphadenectomy is an important factor affecting survival in gastric cancer patients. Retrieval and examination of at least 15 lymph nodes is recommended in order to properly stage gastric malignancies. The objectives of this study were to evaluate the proportion of patients undergoing inadequate lymphadenectomies and possible risk factors for inadequate surgery.
Methods: This was a retrospective study that included patients, 18 years and older, who underwent gastrectomies with oncologic intent in the Hillel Yaffe Medical Center. We analyzed the association of demographic, clinical, and pathological variables with adequate number of lymph nodes.
Results: The retrieval of less than 15 lymph nodes was reported in 51% (53/104) patients undergoing gastrectomies with oncologic intent. The extent of surgery was the only variable associated with inadequate lymphadenectomy on univariate analysis: subtotal/proximal versus total gastrectomy (P=0.047). Differ¬ences observed for previous surgery (P=0.193), T stage (P=0.053), N stage (P=0.051), and lymphovascular invasion (P=0.14) did not reach significance. Subtotal/proximal gastrectomy resulted in inadequate resec¬tion of lymph nodes in 56% of the patients, while this occurred in only 30% of the patients undergoing total gastrectomy (relative risk 1.865; 95% CI 0.93, 3.741). Logistic regression confirmed that only subtotal/prox¬imal versus total gastrectomy was associated with inadequate number of lymph nodes resected (P=0.043).
Discussion and Conclusion: In this study we analyzed the association of patient, tumor, and surgery-related factors on adequate lymphadenectomy in patients undergoing gastrectomies for possible gastric cancer. Larger extent of the surgery (total, rather than subtotal/proximal gastrectomy) was revealed to be the only indicator positively associated with adequate lymphadenectomy.
The personal reflections of Peter Hotez regarding the triple threats of illness, antiscience, and anti-Semitism indicate a shocking state of affairs, reveal¬ing the dark and sinister element of antivaccine activism which must be surmounted. This letter addresses basic lessons on vaccination from India in a nutshell.
Background: The dental needs of cerebral palsy children are an area of study much in need of attention. The neglect of this aspect should be rectified, and simpler diagnostic methodologies should be established and used to serve this purpose.
Aim: This study aimed to determine oral health status and salivary biomarkers (salivary flow rate, pH, buffering capacity) among children with cerebral palsy (CP), to compare their data with that of their healthy siblings, and to evaluate the relationship between salivary biomarkers and dental caries.
Methods: A total of 30 CP children (study group) and 30 normal healthy siblings (controls) were selected between the ages of 5 and 12 years. Salivary biomarkers were assessed, and oral health status was examined.
Statistical Analysis: Chi-square test was used for comparison of oral health status. “Unpaired t test was used to compare caries indexes (decay/filled teeth–primary dentition [dft] and decay/missing/filled teeth–permanent dentition [DMFT]) and salivary biomarkers between the groups. Pearson correlation was used to find the correlation between salivary biomarkers and caries.
Results: The dft scores were significantly higher in the study group (P<0.05). The pH values and salivary flow rates were significantly lower in the study group (P<0.05 and P<0.001, respectively). There was a significant correlation between DMFT scores and salivary flow rate in the study group (P<0.05).
Conclusion: Low pH and low salivary flow rate might be risk factors for dental caries in CP populations; moreover, the significant correlation between DMFT score and salivary flow rate suggests that salivary flow rate could be used as a screening tool for assessing at-risk subjects in such populations.
Developments in technology have led to a rapid progress in robotic endocrine surgery applications. With the advent of minimally invasive techniques in thyroid surgery, robot-assisted transaxillary thyroid surgery (RATS) has emerged as one of the most promising approaches. Its main advantages are improved cosmetic outcome, avoiding cervical incisions, thereby increasing patient satisfaction, and improved visualization, arms articulations, and precision, resulting in fewer surgical complications. The main disadvantages are potential new injuries to the brachial plexus, esophagus, and trachea, longer operative time, and increased cost compared to conventional thyroidectomy. In skilled hands, RATS is a safe alternative to conservative thyroidectomy and should be presented to patients with aesthetic concerns. As with any new emerging technique, careful patient selection is crucial, and further evidence must be sought to confirm its indications over time.
The mystery behind the behavior of infamous personalities leaves many open questions, particularly when related to the practice of medicine. This paper takes a brief look at two Jewish physicians who played memorable roles in the life of Adolf Hitler.
Intelligent Design (ID) burst onto the scene in 1996, with the publication of Darwin’s Black Box by Mi-chael Behe. Since then, there has been a plethora of articles written about ID, both pro and con. How-ever, most of the articles critical of ID deal with peripheral issues, such as whether ID is just another form of creationism or whether ID qualifies as science or whether ID should be taught in public schools. It is our view that the central issue is whether the basic claim of ID is correct. Our goal is fourfold: (I) to show that most of the proposed refutations of ID are unconvincing and/or incorrect, (II) to describe the single fundamental error of ID, (III) to discuss the historic tradition surrounding the ID controversy, showing that ID is an example of a “god-of-the-gaps” argument, and (IV) to place the ID controversy in the larger context of proposed proofs for the existence of God, with the emphasis on Jewish tradition.
In this brief review, written from the perspective of a physician-leader who has fostered the development of comprehensive quality improvement efforts at two academic medical centers, I review the need for improvement, some conceptual barriers that must be overcome, the goals of a comprehensive quality improvement (QI) effort, some of the results we have obtained, and some observations on how to develop a culture of continuous improvement in an academic medical center. The mandate for quality improvement is clear; current healthcare is wasteful and error-prone, leading to excessive morbidity and mortality and unsustainably high costs. Successful quality improvement requires the abandonment of two paradigms: the craft model of medical practice and the notion that many forms of harm to patients are not preventable. I will describe how dramatic improvement has been achieved in reducing, by up to 10-fold, rates of central line infections, ventilator-associated pneumonias, peritonitis in peritoneal dialysis patients, and mortality due to cardiac arrest in hospital. I will describe as well how these methods can improve access to out-patient clinics dramatically and enhance the reliability and safety of hand-offs between covering physicians. To develop and maintain systematic quality improvement in all phases of medical care we must articulate a culture in which: everyone working at the medical center makes improvements every day; front-line staff, who know best how the work is done, are empowered to improve the processes of care; and multidisciplinary teams create the protocols that reduce variation that is due to physician preference, leaving only the variation required by the individual needs of patients. I will review as well the crucial elements of education of trainees and faculty members needed to guide and sustain a culture of quality. Finally, I will add some observations on how oversight boards and medical center leaders can help create systematic quality improvement in their medical centers.
Although Maimonides stated that perfection in the medical art, both in theoretical and in practical expertise, is very difficult to achieve, he did not accept Galen's opinion, i.e. that perfection is beyond human capability.
Any person seeking intellectual perfection should, according to Maimonides' view, be fully trained in logic, in the natural sciences, and in theology.
A physician is moreover requested to study and memorize basic medical literature; he must consider each patient as a sick individual, without neglecting the patient's psychological disposition; and he should aim at inspiring confidence and trust, not only to his patient, but also to the latter's environment.
Even when feeling competent and trustworthy, the physician should not be conceited; here Maimonides insists on offering his personal experience, in a quite impressive way.
This approach of Maimonides to the practice of medicine should be considered, even today, as a valuable incentive for patient-oriented medical education, as already expressed in the late eleventh century.
Celiac disease (CD) is an autoimmune disorder occurring in genetically susceptible subjects. The incidence of CD is around 1%, and it is much more common in first-degree relatives of CD patients, 10%–18%. However, the pattern of the genetic inheritance is still obscure. Environmental factors are undoubtedly affecting the disease’s clinical presentation, time at presentation, and maybe effect on the characteristics of the disease. The clinical presentation of CD has shifted during the previous decades from the classical presentation in which the toddler suffers from diarrhea, constipation, vomiting, failure to thrive, abdominal distension, etc., to the child with a monosymptomatic presentation, such as anemia, as well as an enlarged list of extra-intestinal disorders. The diagnosis of CD is being established by symptoms consistent with CD and positive serology. The ultimate diagnosis should be made upon histological evaluation of the small bowel mucosa. The treatment of CD is a lifelong, strict gluten-free diet (GFD). Compliance with a GFD is quite difficult. Therefore, new strategies for prevention and treatment modalities other than GFD are greatly needed. Recently several promising therapeutic modalities have been developed; these include resuming traditional baking techniques. Another methodology is using probiotic-driven prolylendopeptidase. Another pathway to tackle the therapeutic option in CD is by down-regulation of the activity of zonulin—the active pump enabling gluten to enter the enterocytes. We are facing an era where other modalities beyond a GFD might allow CD patients to be able to tolerate occasionally a small amount of gluten in their diet.
Background—Bedside rounds have long been a time-honored component of medical education. Recently, there have been various recommendations that residency training programs further incorporate bedside teaching into clinical curricula.
Objectives—To compare these current attitudes regarding bedside education with the position of traditional Jewish law and ethics.
Methods—Relevant medical journal articles and traditional Jewish sources were reviewed.
Results—Halakha (the corpus of traditional Jewish law and ethics) gives greater focus to a patient-centered rather than student-centered bedside education experience.
Conclusion—Residency training programs should give greater consideration to the importance of a patient-centered bedside education experience.
