Israel Medical Association Journal

Background: Pregnant women with Marfan syndrome (MS) have a high risk of aortic dissection around delivery and their optimal management requires a multi-disciplinary approach, including proper cardio-obstetric care and adequate pain management during labor, which may be difficult due to the high prevalence of dural ectasia (DE) in these patients.

Objectives: To evaluate the multidisciplinary management of MS patients during labor.

Methods: Nineteen pregnant women (31 pregnancies) with MS were followed by a multi-disciplinary team (cardiologist, obstetrician, anesthesiologist) prior to delivery.

Results:^. Two patients had kyphoscoliosis; none had previous spine surgery nor complaints compatible with DE. In eight pregnancies (7 patients), aortic root diameter (ARd) before pregnancy was 40 to 46 mm. In this high-risk group, one patient underwent elective termination, two underwent an urgent cesarean section (CS) under general anesthesia, and five had elective CS; two under general anesthesia (GA), and three under spinal anesthesia. In 23 pregnancies (12 patients), ARd was < 40 mm. In this non-high-risk group three pregnancies (1 patient) were electively terminated. Of the remaining 20 deliveries (11 patients), 14 were vaginal deliveries, 9 with epidural analgesia and 5 without. Six patients had a CS; four under GA and two2 under spinal anesthesia. There were no epidural placement failures and no failed responses. There were 2 cases of aortic dissection, unrelated to the anesthetic management.

Conclusions: The optimal anesthetic strategy during labor in MS patients should be decided by a multi-disciplinary team. Anesthetic complications due to DE were not encountered during neuraxial block

Background: Fetal ventriculomegaly is one of the more common fetal anomalies detected during prenatal screening.

Objectives: To assess the rate of genetic aberrations as the cause for ventriculomegaly in these fetuses.

Methods: A historic cohort study was conducted on 164 fetuses with sonographic diagnosis of ventriculomegaly. All cases were analyzed for karyotype and 41 cases were further analyzed by chromosomal microarray (CMA). The study group was subdivided by laterality, severity, and whether the ventriculomegaly was an isolated finding or not. Subgroups were compared and the study group was compared to a control group of 209 fetuses.

Results: Karyotype aberrations were more common among fetuses with ventriculomegaly (6.6%) compared to controls (0%, P < 0.001). CMA aberrations were more common in the non-isolated ventriculomegaly cases (24.1%) compared to controls (6.2%, P = 0.031). The rate of genetic aberrations was not associated with the degree of dilatation or laterality.

Conclusions: It is equivocal whether CMA testing should be conducted on every amniotic fluid sample taken from fetuses with isolated ventriculomegaly. However, if more anomalies are detected during an anatomical survey, CMA analysis should be conducted to decrease oversights of genetic diagnoses.

Objectives: To assess the first national simulation-based communication skills training for neurosurgical residents.

Methods: Eight scenarios covering different aspects of neurosurgery were developed by our team: 1) obtaining informed consent for an elective surgery, 2) discharge of a patient following elective surgery, 3) dealing with an unsatisfied patient, 4) delivering news of intraoperative complications, 5) delivering news of a brain tumor to parents of a 5 year old boy, 6) delivering news of brain death to a family member, 7) obtaining informed consent for urgent surgery from the grandfather of a 7 year old boy with an epidural hematoma, and 8) dealing with a case of child abuse. Fifteen neurosurgery residents from all major medical centers in Israel participated in the training. The session was recorded on video and was followed by videotaped debriefing by a senior neurosurgeon and communication expert and by feedback questionnaires.

Results: All trainees participated in two scenarios and observed another two. Participants largely agreed that the actors simulating patients represented real patients and family members and that the videotaped debriefing contributed to the teaching of professional skills.

Conclusions: Simulation-based communication skill training is effective, and together with thorough debriefing is an excellent learning and practical method for imparting communication skills to neurosurgery residents. Such simulation-based training will ultimately be part of the national residency program.

Background: Pain following brain surgery is a significant problem. Infiltration of the scalp with local intradermal anesthetics was suggested for postoperative pain control but was assessed only in the first hour postoperatively.

Objectives: To evaluate wound infiltration with a single dose of metamizol (dipyrone) for postoperative pain control in patients undergoing awake craniotomy.

Methods: This open, prospective, non-randomized observational study, conducted in anesthesiology and neurosurgical departments of a teaching hospital, included 40 patients undergoing awake craniotomy for the removal of brain tumor. Intraoperative anesthesia included wound infiltration with lidocaine and bupivacaine, conscious sedation using remifentanil and propofol, and a single dose of metamizol (dipyrone) for postoperative pain control. Outcome was assessed by the Numerical Pain Scale on arrival at the postoperative care unit, and 2, 4 and 12 hours after the end of surgery.

Results: On arrival at the postoperative care unit, patients reported NPS[1] scores of 1.2 ± 1.1 in a scale of 0–10 (mean ± SD) (median = 1, range 0–4). The scores were 0.8 ± 0.9, 0.9 ± 0.9, and 1 ± 0.9 at 2 hours, 4 hours, and 12 hours after the end of surgery, respectively. Based on patients' complaints and NPS lower then 3, 27 patients did not require any supplementary analgesia during the first 12 postoperative hours, 11 patients required a single dose of oral metamizol or intramuscular diclofenac, one patient was given 2 mg of intravenous morphine, and one patient required two separate doses of metamizol.

Conclusions: Although the clinical setup prevents the use of placebo local analgesia as a control group, the results suggest the possible role of local intradermal infiltration of the scalp combined with a single dose of metamizol to control postoperative pain in patients undergoing craniotomy.

Objectives: To validate and evaluate the reliability and realism of incorporating simulation-based OSCE into the Israeli Board Examination in Anesthesia.

Methods: Validation was performed before the exam regarding Content Validity using the modified Delphi technique by members of the Task Force of the Israeli Board Examination Committee in Anesthesiology.

Results: The examination has been administered six times in the past 3 years to a total of 145 examinees. The pass rate ranged from 62% (trauma) to 91% (regional anesthesia). The mean inter-rater correlations for the total score (all items), for the Critical checklist items score, and for the Global (General) rating were 0.89, 0.86 and 0.76, respectively. The inter-correlations between the five OSCE stations scores were significant (P < 0.01) only between Trauma & Ventilation for the Total score (r = 0.32, n=63), and between Resuscitation & Regional and OR-crisis for the Global score (r = 0.42 and 0.27, n=64 and 104, respectively). The correlation between the OSCE examination score and the success rate at each of the eight different clinical domains of the oral board examination did not reach statistical significance. Most participants (70–90%) found the difficulty level of the examination stations reasonable to very easy. All major errors, which were identified in the initial two exam periods, disappeared later in the next two exam periods.

Conclusions: The exam has gradually progressed from being an optional part of the oral board examination to a prerequisite component of this test. Other anesthesiology programs or medical professions can adopt the model described here.

With chemical warfare becoming an imminent threat, medical systems need to be prepared to treat the resultant mass casualties. Medical preparedness should not be limited to the triage and logistics of mass casualties and first-line treatment, but should include knowledge and training covering the whole medical spectrum. In view of the unique characteristics of chemical warfare casualties the use of simulation-assisted medical training is highly appropriate. Our objective was to explore the potential of simulator-based teaching to train medical teams in the treatment of chemical warfare casualties. The training concept integrates several types of skill-training simulators, including high tech and low tech simulators as well as standardized simulated patients in a specialized simulated setting. The combined use of multi-simulation modalities makes this maverick program an excellent solution for the challenge of multidisciplinary training in the face of the looming chemical warfare threat.

Background: The Bloom syndrome gene, BLM, was mapped to 15q26.1 and its product was found to encode a RecQ DNA helicase. The Fanconi anemia complementation group C gene was mapped to chromosome 9q22.3, but its product function is not sufficiently clear. Both are recessive disorders associated with an elevated predisposition to cancer due to genomic instability. A single predominant mutation of each disorder was reported in Ashkenazi Jews: 2281delATCTGAinsTAGATTC for Bloom syndrome (BLM-ASH) and IVS4+4A®T for Fanconi anemia complementation group C.

Objectives: To provide additional verification of the mutation rate of BLM and FACC[1] in unselected Ashkenazi and non-Ashkenazi populations analyzed at the Sheba Medical Center, and to trace the origin of each mutation.

Methods: We used polymerase chain reaction to identify mutations of the relevant genomic fragments, restriction analysis and gel electrophoresis. We then applied the Pronto^TM kit to verify the results in 244 samples and there was an excellent match.

Results: A heterozygote frequency of 1:111 for BLM-ASH and 1:92 for FACC was detected in more than 4,000 participants, none of whom reported a family history of the disorders. The Pronto^TM kit confirmed all heterozygotes. Neither of the mutations was detected in 950 anonymous non-Ashkenazi Jews. The distribution pattern of parental origin differed significantly between the two carrier groups, as well as between each one and the general population.

Conclusions: These findings as well as the absence of the mutations in non-Ashkenazi Jews suggest that: a) the mutations originated in the Israelite population that was exiled from Palestine by the Roman Empire in 70 AD and settled in Europe (Ashkenazi), in contrast to those who remained; and b) the difference in origin distribution of the BS[2] and FACC mutations can be explained by either a secondary migration of a subgroup with a subsequent genetic drift, or a separate geographic region of introduction for each mutation.

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[1] FACC = Fanconi anemia complementation group C