Israel Medical Association Journal

Background: The 2015 American Thyroid Association (ATA2015) and the American College of Radiology Thyroid Imaging and Reporting Data System (ACR TI-RADS) are two widely used thyroid sonographic systems.

Objectives: To compare the two systems for accuracy of cancer risk prediction.

Methods: Preoperative ultrasound images from 265 patients who underwent thyroidectomy at our hospital from January 2012 to March 2019 were retrospectively categorized by the ACR TI-RADS and ATA2015 systems. Diagnostic performances were compared.

Results: Of 238 nodules assessed, 115 were malignant. Malignancy risks for the five ACR TI-RADS categories were 0%, 7.5%, 11.4%, 59.6%, and 90.0%. Malignancy risks for the five ATA2015 categories were 0%, 6.8%, 17.0%, 55.5%, and 92.1%. The proportion of total nodules biopsied was higher with the ATA2015 system than the ACR TI-RADS system: 88.7% vs. 66.3%. Proportions of malignant nodules and benign nodules biopsied were higher with ATA2015 than with ACR TI-RADS: 93.3% vs. 87.8% and 84.4% vs. 46.3%, respectively. Specificity and sensitivity rates were 53.6% and 84.3%, respectively, for ACR TI-RADS, and 15.5% and 93.3%, respectively, for ATA2015. The two systems showed similarly accurate diagnostic performance (AUC > 0.88). False negative rates for ACR TI-RADS and ATA2015 were 15.6% and 6.6%, respectively. Rates of missed aggressive cancer were similar for the two systems: 3.4% and 3.7%, respectively.

Conclusion: ACR TI-RADS was superior to ATA2015 in specificity and avoiding unnecessary biopsies. ATA2015 yielded better sensitivity and a lower false negative rate. Identification of aggressive cancers was identical in the two systems

Background: Extra peritoneal packing (EPP) is a quick and highly effective method to control pelvic hemorrhage.

Objectives: To determine whether EPP can be as safely and efficiently performed in the emergency department (ED) as in the operating room (OR).

Methods: Retrospective study of 29 patients who underwent EPP in the ED or OR in two trauma centers in Israel 2008–2018.

Results: Our study included 29 patients, 13 in the ED-EPP group and 16 in the OR-EPP group. The mean injury severity score (ISS) was 34.9 ± 11.8. Following EPP, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). A raise in the mean arterial pressure (MAP) with a median of 25 mmHg (mean 30.0 ± 27.5, P < 0.001) was documented. All patients who did not achieve hemodynamic stability after EPP had multiple sources of bleeding or fatal head injury and eventually succumbed. Patients who underwent EPP in the ED showed higher change in MAP (P = 0.0458). The overall mortality rate was 27.5% (8/29) with no difference between the OR and ED-EPP. No differences were found between ED and OR-EPP in the amount of transfused blood products, surgical site infections, and length of stay in the hospital. However, patients who underwent ED-EPP were more prone to develop deep vein thrombosis (DVT): 50% (5/10) vs. 9% (1/11) in ED and OR-EPP groups respectively (P = 0.038).

Conclusions: EPP is equally effective when performed in the ED or OR with similar surgical site infection rates but higher incidence of DVT

Background: With diagnostic imaging, such as a duplex of the carotid arteries, finding of stenosis and atherosclerotic plaque and consequent end arterectomy may be important for decreasing the danger of developing cerebrovascular accident after transient ischemic attack (TIA).

Objectives: To measure performance rates of duplex of carotid arteries within 72 hours of TIA diagnosis.

Methods: The denominator included all patients who were admitted to emergency departments because of TIA, and the numerator included those who underwent duplex within 72 hours of admission. Inclusion criteria included all patients older than 18 years who were admitted because of TIA according to the ICD9 codes.

Results: Measuring this indicator started in 2015 with 5504 patients and a 58% success rate. The figures for the years 2016, 2017, and 2018 were 5309, 5447, and 5278 patients with success rates of 73%, 79%, and 83%, respectively. Six of 26 hospitals (23.0%) reached the target of 80% in 2018. From 2015 to 2018 a total of 21,538 patients were admitted to emergency departments in Israel and diagnosed with TIA. Of these, 15,722 (72.9%) underwent duplex within 72 hours. The mortality rate within 30 days from diagnosis was 0.81% in patients who performed duplex within 72 hours of diagnosis and 2.37% in patients who did not, odds ratio 2.676, 95% confidence interval 2.051–3.492, P < 0.0001. These results indicate a statistically significant decrease of 65.82%.

Conclusions: A significant decrease in mortality was noted in patients with a new diagnosis of TIA who underwent duplex within 72 hours of diagnosis

Background: Real-world information regarding the use of direct oral anticoagulants therapy and the outcome in patients with renal dysfunction is limited.

Objectives: To evaluate the clinical characteristics and outcomes of patients with atrial fibrillation (AF) and severe renal dysfunction who are treated with apixaban.

Methods: A sub-analysis was conducted within a multicenter prospective cohort study. The study included consecutive eligible apixaban- or warfarin-treated patients with non-valvular AF and renal impairment (estimated glomerular filtration rate [eGFR] modification of diet in renal disease [MDRD] < 60 ml/min/BSA) were registered. All patients were prospectively followed for clinical events and over a mean period of 1 year. Our sub-analysis included the patients with 15 < eGFR MDRD < 30 ml/min/BSA. The primary outcomes at 1 year were recorded. They included mortality, stroke or systemic embolism, major bleeding, and myocardial infarction as well as their composite occurrence.

Results: The sub-analysis included 155 warfarin-treated patients and 97 apixaban-treated ones. All had 15 < eGFR MDRD < 30 ml/min/BSA. When comparing outcomes for propensity matched groups (n=76 per group) of patients treated by reduced dose apixaban or warfarin, the rates of the 1-year composite endpoint as well as mortality alone were higher among the warfarin group (30 [39.5%] vs. 14 [18.4%], P = 0.007 and 28 [36.8%] vs.12 [15.8%], P = 0.006), respectively. There was no significant difference in the rates of stroke, systemic embolism, or major bleeding.

Conclusions: Apixaban might be a reasonable alternative to warfarin in patients with severe renal impairment.

Background: Heart failure with preserved ejection fraction (HFpEF) is a common clinical entity, with a mechanism that appears to involve endothelial dysfunction of the cardiac microcirculation. Endothelial progenitor cells (EPC) are bone marrow derived cells that are able to differentiate into functional endothelial cells and participate in endothelial surface repair.

Objectives: To compare the level and function of EPCs in patients with HFpEF compared with heart failure with reduced ejection fraction (HFrEF) and control subjects.

Methods: We enrolled 21 patients with HFpEF (LVEF ≥ 50%, age 74.5 ± 9.9 years, 43% men, 48% diabetes), 20 patients with HFrEF (LVEF < 40%, age 70 ± 11.5 years, 90% men, 60% diabetes), and 11 control subjects with cardiovascular risk factors (age 53.3 ± 6.1years, 90% men, 64% diabetes). Circulating EPC levels were evaluated by expression of vascular endothelial growth factor receptor-2 (VEGFR-2), CD34, and CD133 by flow-cytometry. EPCs colony forming units (CFUs) were quantified after 7 days in culture.

Results: The proportion of cells that co-expressed VEGFR-2 and CD34 or VEGFR-2 and CD133 was similar among the HFpEF and HFrEF groups, and significantly lower than in the control group. The number of EPC-CFUs was also similar among the two heart failure groups and significantly lower than the control group.

Conclusions: Patients with HFpEF, like HFrEF, have significant reduction in EPC level and function.

Background: The coronavirus disease-2019 (COVID-19) outbreak had an effect on healthcare.

Objectives: To evaluate the presentation and management of patients with acute appendicitis.

Methods: A retrospective study was conducted of all patients presenting with acute appendicitis to the emergency department of a large tertiary center during March and April 2020. Clinical features, diagnostic workup, and management were compared.

Results: Seventy-four patients presented with acute appendicitis during the pandemic compared to 60 patients during the same time the year before. There were no significant differences in patient demographics: age (P = 0.65), gender (P = 0.73), smoking status (P = 0.48). During COVID-19 patients were more likely to complain of right lower quadrant pain (100% vs. 78.3%, P < 0.01). Rates of surgical treatment was similar (83.8% vs. 81.7%, P = 1); mean operative time was longer during COVID-19 (63 ± 23 vs. 52 ± 26 minutes, P = 0.03). There were no significant differences in intra-operative findings including the presence of appendiceal perforation (16.3% vs. 14.5%, P = 0.8), abscess (6.1% vs. 9.7%, P = 0.73), or involvement of cecum or terminal ileum (14.28% vs. 19.63%, P = 1). Postoperative treatment with antibiotics was more prevalent during COVID-19 (37.1% vs. 18%, P = 0.04). Length of stay (1.82 ± 2.04 vs. 2.74 ± 4.68, P = 0.2) and readmission rates (6% vs. 11.3%, P =0.51) were similar.

Conclusion: The COVID-19 pandemic did not significantly affect the presentation, clinical course, management, and outcomes of patients presenting with acute appendicitis.

Background: Evaluation of children's anthropometrics poses challenges due to age-related changes. The main focus is on height and weight. However, since weight is height-dependent, body mass index (BMI) is the best surrogate measurement of adiposity. Israel has not developed national growth tables; therefore, researchers and clinicians utilize either World Health Organization (WHO) or U.S. Centers for Disease Control and Prevention (CDC) tables as benchmarks.

Objectives: To evaluate the anthropometrics of Israeli children benchmarked by CDC and WHO tables.

Methods: A retrospective review was conducted of the 1987–2003 birth cohort (age 4–18 years) from Clalit Health Services databases. Anthropometrics were retrieved twice: at study entry and one year later. We evaluated them as separate cohorts. Gender-specific age-matched median height and BMI were compared with CDC and WHO height and BMI tables.

Results: The study consisted of 15,650, mean age at study entry 9.5 years (range 4–18). Gender-specific median heights of the Israeli children were similar to CDC and WHO values at younger ages, but were slightly shorter than the age-matched CDC and WHO toward the age of final height in both cohorts. However, gender-specific median BMI was considerably and statistically significant higher compared to CDC and WHO values consistently along the entire age range in both cohorts.

Conclusions: Israeli children were slightly shorter toward the age of final height, compared to WHO and CDC. However, BMI in Israeli children was significantly higher compared to the CDC and WHO consistently along the age range, which raises an alarm regarding obesity patterns

Background: Pancreatic trauma is uncommon in pediatric patients and presents diagnostic and therapeutic challenges. While non-operative management (NOM) of minor pancreatic injuries is well accepted, the management of major pancreatic injuries remains controversial.

Objectives: To evaluate management strategies for major blunt pancreatic injury in children.

Methods: Data were retrospectively collected for all children treated for grade III or higher pancreatic injury due to blunt abdominal trauma from 1992 to 2015 at two medical centers. Data included demographics, mechanism of injury, laboratory and imaging studies, management strategy, clinical course, operative findings, and outcome.

Results: The cohort included seven boys and four girls aged 4–15 years old (median 9). Six patients had associated abdominal (mainly liver, n=3) injuries. The main mechanism of injury was bicycle (handlebar) trauma (n=6). Five patients had grade III injury and six had grade IV. The highest mean amylase level was recorded at 48 hours after injury (1418 U/L). Management strategies included conservative (n=5) and operative treatment (n=6): distal (n=3) and central (n=1) pancreatectomy, drainage only (n=2) based on the computed tomography findings and patient hemodynamic stability. Pseudocyst developed in all NOM patients (n=5) and two OM cases, and one patient developed a pancreatic fistula. There were no differences in average length of hospital stay.

Conclusions: NOM of high-grade blunt pancreatic injury in children may pose a higher risk of pseudocyst formation than OM, with a similar hospitalization time. However, pseudocyst is a relatively benign complication with a high rate of spontaneous resolution with no need for surgical intervention.

Background: Low folate levels are associated with megaloblastic anemia, neural tube defects, and an increased risk of cancer. Data are scarce regarding the sex aspect of this deficiency.

Objectives: To assess sex differences in folate levels in a large cohort of patients and to investigate the effect of low folate levels on homocysteine concentrations.

Methods: Data were collected from medical records of patients examined at a screening center in Israel between 2000 and 2014. Cross sectional analysis was conducted on 9214 males and 4336 females.

Results: The average age was 48.4 ± 9.5 years for males and 47.6 ± 9.4 years for females. Average folate levels were 19.2 ± 8.6 and 22.4 ±10.3 nmol/L in males and females, respectively (P < 0.001). The prevalence of folate levels below 12.2 nmol/L was 19.5% in males compared to 11.6% in females (P < 0.001). In patients with low folate levels and normal B12 levels, homocysteine levels above 15 μmol/L were found in 32.4% of males and 11.4% of females (P < 0.001). Males had a significantly higher odds ratio (OR) of having folate levels below 12.2 nmol/L: OR 1.84 (95% confidence interval [95%CI] 1.66–2.05) in a non-adjusted model, and OR 2.02 (95%CI 1.82–2.27) adjusted for age, smoking status, body mass index, kidney function, albumin, and triglycerides levels.

Conclusions: Folate levels are lower in males compared to females, which may contribute to the higher homocysteine levels found in males and thus to their increased risk of developing atherosclerosis and coronary artery disease.

Background: Transanal minimally invasive surgery (TAMIS) is a single port access platform used for full thickness local excision of rectal lesions. It is an appealing alternative to a radical resection of rectum that often can cause a significant bowel dysfunction described as low anterior resection syndrome (LARS). LARS is evaluated using a validated score. Functional outcomes of patients undergoing TAMIS has not yet been evaluated using the LARS score.

Objectives: To evaluate long-term bowel function in patients who underwent TAMIS.

Methods: In this case series, all patients who underwent TAMIS in a single tertiary institute between 2011 and 2017 were retrospectively reviewed. We evaluated bowel function using the LARS score questionnaire through telephone interviews.

Results: The study consisted of 23 patients, average age of 67 ± 6.98 year; 72% were male. The median follow-up from the time of surgery was 5 years. Six patients (26.08%) had malignant type lesions. The average height of the lesion from the anal verge was 7.4 cm. The average size of the specimen was 4 cm. The total LARS score revealed that 17 patients (73.91%) had no definitive LAR syndrome following the surgery. Four patients (17.39%) fit the description of minor LARS and only two (8.69%) presented with major LARS.

Conclusions: TAMIS provides relatively good long-term functional outcomes in terms of bowel function. Further randomized studies with larger cohorts are still needed to better evaluate the outcomes.

Background: Recent data regarding polymicrobial bacteremia (PMB) are lacking.

Objectives: To characterize risk factors as well as clinical, microbiological, and prognostic patterns of patients with PMB in a modern hospital setting.

Methods: A single center retrospective study including all patients diagnosed with PMB during 2013 was conducted. PMB was defined as two or more organisms cultured from the blood of the same patient within 72 hours. Patients with monomicrobial infections served as controls.

Results: There were 135 episodes (2% of all bacteremia episodes) of true PMB among 123 patients during the study period. Recent invasive procedures (odds ratio [OR] 3.59, 95% confidence interval [95%CI] 1.41–9.12, P = 0.006) and foreign bodies (OR 1.88, 95%CI 1.06–3.33, P = 0.04) were risk factors for PMB when compared with 79 patients with monomicrobial bacteremia. Central-line-associated infections were the most common infection source among patients with PMB (n=34, 28%). Enterobacteriaceae were the most commonly implicated pathogen (n=95, 77%). Non-fermenting Gram-negative bacilli were significantly more common than previously reported (n=55, 45%). Although crude 30-day mortality was higher (48% vs. 33%) in PMB patients, adjusted mortality was comparable in the two groups.

Conclusions: PMB rate in our cohort was considerably lower than in previous reports. Central-line-associated infections were more common than classic PMB sources. Mortality remained high. Strategies for early identification and better care for these patients should be pursued.

Background: Hysterectomy is common in the management of symptomatic uterine prolapse. Vaginal wall repair is often necessary, for which vaginal mesh remains a popular option.

Objectives: To evaluate the risk of mesh erosion following mesh-augmented vaginal prolapse repair, with or without concomitant vaginal hysterectomy.

Methods: This retrospective cohort comprised 70 women who underwent vaginal mesh-augmented pelvic organ prolapse repair from 2007 to 2010. Of the participants, 36 (51.4%) had a vaginal hysterectomy concomitant to the anterior and/or posterior vaginal mesh repair (hysterectomy group) and 34 (48.6%) underwent mesh repair without vaginal hysterectomy (no hysterectomy group).

Results: There were no inter-group differences in age, parity, menopausal state, hormonal use, or presenting symptoms. Previous prolapse repair surgery was much more common in the no hysterectomy group (29.4% vs. 5.5%, P = 0.01). Eleven patients (32.3%) in the no hysterectomy group had previously undergone hysterectomy. Anterior mesh repair was performed in 77.7% and 67.6% of hysterectomy and no hysterectomy patients, respectively. Posterior mesh repair was performed in 27.7% and 44.1%, respectively. One patient in the hysterectomy group underwent immediate removal of mesh due to infection. Surgically treated mesh erosion (limited local excision) occurred in three patients (8.3%) in the hysterectomy group (3, 16, and 18 months following surgery) and in two patients (5.8%) in the no hysterectomy group at 6 months following surgery (P = 0.67).

Conclusions: Vaginal mesh-augmentation concomitant with vaginal hysterectomy for pelvic organ prolapse repair does not carry an increased risk of erosion.

Background: The number of patients undergoing shoulder arthroplasty is increasing yearly.

Objectives: To evaluate the results of a consecutive series of patients who underwent shoulder replacement for a variety of indications in a single medical center in Israel.

Methods: All shoulder arthroplasties performed in our institution between 2006 and 2015 were retrospectively reviewed. The functional outcomes and satisfaction of 180 shoulder arthroplasties were evaluated for objective and subjective parameters using the American Shoulder and Elbow Surgeons Shoulder Score (ASES), the Disabilities of the Arm, Shoulder and Hand (DASH) outcome measure, and the Short Form Health Survey (SF-12).

Results: The indications for surgery were osteoarthritis (n=35), rotator cuff arthropathy (n=32), fractures (n=99), and other reasons (n=14). The mean follow-up was 52 months. The scores improved markedly among the patients who underwent surgery later in the study period. The mean DASH score before 2012 was 48.8 and improved to 37.2 after 2013. The respective ASES also improved from 54.2 to 68.6. The use of hemiarthroplasty decreased from 85% to 33% as of 2013, while the use of total shoulder arthroplasty increased.

Conclusions: Shoulder arthroplasty represents an effective treatment modality with satisfactory functional outcomes. Our current study demonstrates a shift from hemiarthroplasty to total shoulder arthroplasty, with the number of procedures increasing yearly. Surgeon experience and the expanding volume of operations had a direct positive effect on the functional outcomes of shoulder arthroplasties.