Israel Medical Association Journal

Background: Defibrillation threshold (DFT) testing at the time of implantable cardioverter defibrillator (ICD) insertion is performed routinely. Recently this practice is being reconsidered due to doubts about its ability to improve ICD efficacy and evidence that survival may not be affected by the test.

Objectives: To compare the outcome of ICD recipients who underwent DFT testing and those in whom no testing was performed.

Methods: A total of 213 eligible patients were implanted with an ICD between 2004 and 2009. DFT testing was performed in 80. We compared total mortality, appropriate and inappropriate ICD shocks, and anti-tachycardia pacing (ATP) events between DFT and non-DFT patients during a follow-up of 2 years.

Results: On comparing the DFT and non-DFT groups, we found a 2 year mortality rate of 7.5% versus 8.3%, respectively (P = 0.8). Furthermore, 20.7% of patients in the DFT group and 12.4% in the non-DFT group had at least one episode of ICD shock (P = 0.15). With regard to ICD treatment (ICD shocks or ATP events), 57.7% in the DFT group and 64.2% in the non-DFT group received appropriate treatments (P = 0.78).

Conclusions: No significant differences in the incidence of 2 year mortality or percentage of ICD treatment emerged between the DFT and non-DFT groups.
 

Background: While many are familiar with postpartum depression, the phenomenon of postpartum post-traumatic stress disorder (PTSD) is less well known and investigated. Objectives: To assess the prevalence of postpartum PTSD in a cohort of women in Israel, and to examine factors affecting its development.

Methods: Eighty-nine women completed several ratings immediately after delivery and one month later. The factors examined related to the pregnancy, childbirth expectations, and delivery. Rating scales comprised evaluations of attachment, personality, PTSD, and demographic variables.

Results: The prevalence of post-partum PTSD was 3.4% (complete PTSD), 7.9% nearly complete PTSD, and 25.9% significant partial disorder. Women who developed PTSD symptoms had a higher prevalence of "traumatic" previous childbirth, with subsequent depression and anxiety. They also reported more medical complications and “mental crises” during pregnancy as well as anticipating more childbirth pain and fear. Instrumental or cesarean deliveries were not associated with PTSD. Most of the women who developed PTSD symptoms delivered vaginally but received fewer analgesics with stronger reported pain. Women with PTSD reported more discomfort with the undressed state, stronger feelings of danger, and higher rates of not wanting more children.

Conclusions: The study results indicate a) the importance of inquiring about previous pregnancy and birthing experiences, b) the need to identify at-risk populations, and c) increased awareness of the disorder. The importance of addressing anticipatory concerns of pain prior to delivery and of respecting the woman’s dignity and minimizing the undressed state during childbirth should not be underestimated. A short questionnaire following childbirth may enable rapid identification of symptoms relevant to PTSD.
 

Background: The presence of stones in the common bile duct (CBD) may cause complications such as obstructing jaundice or ascending cholangitis, and the stones should be removed.

0bjectives: To report our results with percutaneous elimination of CBD stones from the gallbladder through the papilla.

Methods: During a 4 year period, six patients (five men and one woman, mean age 71.5 years) who had CBD stones and an existing gallbladder drain underwent percutaneous stone push into the duodenum after balloon dilatation of the papilla, with a diameter equal to that of the largest stone. Access into the CBD was from the gallbladder, using an already existing percutaneous gallbladder drain (cholecystostomy tube).

Results: Each patient had one to three CBD stones measuring 7–14 mm. Successful CBD stone elimination into the duodenum was achieved in five of the six patients. The single failure occurred in a patient with choledochal diverticulum, who was operated successfully. There were no major or minor complications during or after the procedures.

Conclusions: Trans-cholecystic CBD stone elimination is a safe and feasible percutaneous technique that utilizes existing tracts, thus obviating the need to create new percutaneous access. This procedure can replace endoscopic or surgical CBD exploration.
 

Background: Microvolt T-wave alternans (MTWA) measures subtle beat-to-beat fluctuations in the T-wave amplitude. It was found to be associated with cardiac electrical instability in patients with ischemic and dilated cardiomyopathy.

Objectives: To investigate the reproducibility of the MTWA test results in patients with ischemic heart disease.

Methods: The study group comprised patients with ischemic heart disease who participated in a rehabilitation program at the Assaf Harofeh Medical Center. MTWA was measured during a bicycle exercise test at the first encounter and repeated after one week.

Results: Of the 40 study patients with coronary artery disease, 4 had an indeterminate result and were excluded from the data analysis; 5 had a positive MTWA in the first and second study (14%), 27 had a negative MTWA in the first and second study (75%), and 4 had a negative MTWA in the first study and a positive MTWA in the second study (11%). Overall, there was a correlation between the results of the first and the second study in 89% of the patients (kappa = 0.652, P = 0.0001).

Conclusions: MTWA measurements are reproducible in the short term in patients with coronary artery disease.

Background: Delayed diagnosis of choroidal neovascularization (CNV) in age-related macular degeneration (AMD) adversely affects visual outcome.

Objectives: To identify factors associated with early detection of CNV in the clinic setting.

Methods: Demographic and clinical data and lesion characteristics were retrospectively collected from 76 consecutive AMD patients who had a history of CNV in one eye and presented with CNV in the second eye. These data were evaluated for association with visual acuity (VA) at the time of presentation.

Results: Better VA was associated with a history of CNV in the fellow eye (P < 0.0001), adherence to follow-up every 4 months (P = 0.015), younger age (P = 0.03), smaller lesion (P < 0.0001), and non-subfoveal location (P = 0.048). VA of the fellow eye did not correlate with VA at presentation with CNV.

Conclusions: These data suggest that patients’ experience of CNV, regardless of VA, facilitates early diagnosis in the fellow eye. Adherence to follow-up in the routine clinic setting also facilitates early detection of CNV.

Background: Establishing the etiology of a large pericardial effusion is of crucial importance since it is likely the result of a serious underlying disease. However, there is a paucity of literature on the diagnostic management of patients with large hemorrhagic effusions.

Objectives: To analyze the management of patients with large hemorrhagic pericardial effusion.

Methods: We reviewed seven cases of large hemorrhagic pericardial effusions hospitalized in Soroka University Medical Center in 2010.

Results: All seven patients underwent a comprehensive evaluation followed by pericardiocentesis. Six of the seven cases demonstrated echocardiographic signs of tamponade. Large amounts of hemorrhagic pericardial effusion (> 600 ml) were aspirated from each patient. A pericardial window was performed in two of the seven patients. The causes for the hemorrhagic effusions were malignancy, streptococcal infection, familial Mediterranean fever exacerbation, and idiopathic. Four patients completely recovered. The condition of one patient improved after initiation of chemotherapy for lung cancer, and two patients with progressive malignancies passed away shortly after discharge. Two cases of massive pulmonary embolism were diagnosed which resolved spontaneously without anticoagulation therapy after the effusion was treated.

Conclusions: All cases of pericardial effusion resolved after rapid diagnosis and initiation of specific treatment. Pulmonary embolism in situ may be a complication of large pericardial effusions that does not require anticoagulation treatment after the effusion resolves.
 

Background: Studies suggest that global semen quality is declining, but the debate remains open owing to geographic variation.

Objectives: To evaluate temporal trends of sperm parameters – namely concentration, motility and total motile sperm count – in sperm donated during the period 1995–2009.

Methods: In a retrospective longitudinal cohort study we analyzed the sperm count and motility of 2182 semen samples provided on a weekly basis by 58 young, healthy, fertile, university-educated, paid donors.

Results: Despite the lowering of criteria for sperm parameters satisfactory for donation that were implemented in 2004, 38% of applicants for sperm donation are now rejected based on semen quality as compared to a third of applicants 10–15 years ago (P < 0.001). If the old strict criteria were in place 88% of candidates would be rejected today (P < 0.0001). Over the study period, the average sperm parameters dropped from a concentration of 106 ± 25 million spermatozoa/ml with 79% ± 4.3% motility to 68 ± 14 million/ml with 66% ± 4.5% motile sperm (P < 0.0001, P < 0.0001, respectively). The total motile sperm count per ejaculate also decreased, from 66.4 ± 18.2 million to 48.7 ± 12 million (P < 0.005). When the previous criteria were implemented for the analysis of the latest group of sperm donors, only 18% of donors had an acceptable sperm quality, with an average concentration of 87 ± 12 million spermatozoa/ml, 73% ± 2.6% motile sperm and total motile sperm count of 53.1 ± 3.8 million per ejaculate – still significantly lower than 15 years ago (P = 0.01, P = 0.003, P = 0.058 respectively).

Conclusions: The rapid deterioration of sperm quality among fertile semen donors is alarming and may lead to cessation of sperm donation programs.

Background: Clefts of the lip and palate are the most common significant congenital birth anomaly of orofacial region. The condition may vary from a minor easily correctable cleft to a significant functional and cosmetic incapacitation. This is the first epidemiological study of orofacial clefts in the Negev region in Israel.

Objectives: To establish the frequency of cleft lip and palate in the population of the Negev, characterize the demographic features of affected individuals and find possible risk factors, compare the risk in two major population groups: Bedouin and Jewish in a well-defined geographic area, and determine whether there is a change over time in the birth of babies with facial clefts.

Methods: We conducted a retrospective survey of the Soroka Medical Center archives. The sample population comprised all 131,218 babies born at Soroka during the 11 year period 1 January 1996 to 31 December 2006. Statistical tests used Pearson's chi-square test, Student’s t-test and Spearman's correlation coefficient test according to the type of parameter tested.

Results: During the study period 140 babies were born with orofacial cleft. The overall incidence of cleft lip and palate was 1.067/1000. The incidence of facial clefts was 1.54/1000 among Bedouins and 0.48/1000 among Jews (P < 0.001). Cleft palate was significantly more frequent in female than male babies (P = 0.002). Over the study years we found a significant decrease in the incidence of facial clefts in the Bedouin population, with Spearman's correlation coefficient rank -0.9 (P < 0.01).

Conclusions: A significant decrease occurred in the incidence of facial clefts among Bedouin. This change may be attributed to prenatal care in the Bedouin Negev population as part of social and health-related behavior changes. The reduction in rates of congenital malformations, however, does not mean a reduction in the number of cases in a growing population. Also, with a modern western lifestyle, the expectancy and demand for reconstructive facial surgery and comprehensive care for these children are on the rise.

Background: Corneal haze is a significant complication of photorefractive keratectomy (PRK) and laser-assisted sub-epithelial keratectomy (LASEK).

Objectives: To evaluate the effect of ascorbic acid supplementation in addition to perioperative topical mitomycin-C for the prevention of haze after LASEK.

Methods: We performed a retrospective, non-randomized case series study of two groups of 48 consecutive patients (96 myopic eyes) who had LASEK surgery. The treatment group was given ascorbic acid (vitamin C) orally 500 mg twice daily from 1 week before to 2 weeks after surgery. The control group was not offered any additional treatment. Ascorbate supplementation was the only difference in the postoperative treatment protocol between the treatment and control groups. Haze was assessed on a scale from 0 to 4 at the 1 year visit.

Results: Overall, 33.3% and 37.5% of the patients in the treatment and control groups respectively developed corneal haze. The trend of increased haze severity in the control group did not reach statistical significance.

Conclusions: Our results showed that systemic ascorbate supplementation does not have an additional effect on the prevention of haze after LASEK compared to the effect of topical mitomycin-C alone.