Israel Medical Association Journal

Echinococcus infections of the liver and lungs are well-known, but cardiac echinococcus is rare, requiring further understanding. A 19-year-old male presented with chest pain, shortness of breath and palpitations. Changes in an electrocardiogram, increased troponin, and a computed tomography (CT) scan revealed a cardiac cyst at the left ventricle’s posterior lateral wall. Medical management included albendazole and praziquantel for 2 weeks followed by surgical cyst removal.

Clinical presentation of cardiac involvement of echinococcus granulosis is variable, requiring high clinical suspicion. Cardiac CT scan and echocardiography provided sufficient information for the diagnosis. The treatment included surgical removal of the cyst and albendazole administration.

Hydatid cyst is a rare zoonotic disease caused by the parasite Echinococcus granulosus [1]. The incidence in endemic areas is about 1–200 cases per 100,000 in population [2].

The liver (60–70% of cases) and lungs (20–30%) are the most common locations of hydatid cysts, with rare cardiac involvement of only 0.05% to 2% of all cases [3], with the left ventricle most frequently involved (60%) [2,4].

Background: Presentation of intoxicated patients to hospitals is frequent, varied, and increasing. Medical toxicology expertise could lead to important changes in diagnosis and treatment, especially in patients presenting with altered mental status.

Objectives: To describe and analyze clinical scenarios during a 1-year period after the establishment of a medical toxicology consultation service (MTCS).

Methods: Cases of 10 patients with altered mental status at presentation were evaluated. Medical toxicology consultation suggested major and significant changes in diagnosis and management.

Results: Of 973 toxicology consultations performed during the study period, bedside consultation was provided for 413 (42%) patients. Of these 413, 88 (21%) presented with some level of altered mental status. We described 10 patients in whom medical toxicology consultation brought about major and significant changes in diagnosis and management.

Conclusions: Benefits may be derived from medical toxicology consultations, especially in patients with altered mental status. Medical toxicology specialists are well positioned to provide high value and expedited patient care.

Background: Among the most frequent complications following transcatheter aortic valve replacement (TAVR) is hemostasis imbalance that presents either as thromboembolic or bleeding. Deviations in platelet count (PC) and mean platelet volume (MPV) are markers of hemostasis imbalance.

Objectives: To determine the predictive value of pre- and post-procedural PC and MPV fL 1-year all-cause mortality in patients who underwent TAVR.

Methods: In this population-based study, we included 236 TAVR patients treated at the Tzafon Medical Center between 1 June 2015 and 31 August 2018. Routine blood samples for serum PC levels and MPV fL were taken just before the TAVR and 24-hour post-TAVR. We used backward regression models to evaluate the predictive value of PC and MPV in all-cause mortality in TAVR patients.

Results: In this study cohort, MPV levels 24-hour post-TAVR that were greater than the cohort median of 9 fL (interquartile range 8.5–9.8) were the strongest predictor of 1-year mortality (hazard ratio 1.343, 95% confidence interval 1.059–1.703, P-value 0.015). A statistically significant relationship was seen in the unadjusted regression model as well as after the adjustment for clinical variables.

Conclusions: Serum MPV levels fL 24-hour post-procedure were found to be meaningful markers in predicting 1-year all-cause mortality in patients after TAVR.

Background: The evaluation of syncope in emergency departments (EDs) and during hospitalization can be ineffective. The European Society of Cardiology (ESC) guidelines were established to perform the evaluation based on risk stratification.

Objectives: To investigate whether the initial screening of syncope adheres to the recent ESC guidelines.

Methods: Patients with syncope who were evaluated in our ED were included in the study and retrospectively classified based on whether they were treated according to ESC guidelines. Patients were divided into two groups according to the ESC guideline risk profile: high risk or low risk.

Results: The study included 114 patients (age 50.6 ± 21.9 years, 43% females); 74 (64.9%) had neurally mediated syncope, 11 (9.65%) had cardiac syncope, and 29 (25.45%) had an unknown cause. The low-risk group included 70 patients (61.4%), and the high-risk group included 44 (38.6%). Only 48 patients (42.1%) were evaluated according to the ESC guidelines. In fact, 22 (36.7%) of 60 hospitalizations and 41 (53.2%) of 77 head computed tomography (CT) scans were not mandatory according to guidelines. The rate of unnecessary CT scans (67.3% vs. 28.6%, respectively, P = 0.001) and unnecessary hospitalization (66.7% vs. 6.7%, respectively, P < 0.02) were higher among low-risk patients than high-risk patients. Overall, a higher percentage of high-risk patients were treated according to guidelines compared to low-risk patients (68.2% vs. 25.7% respectively, P < 0.0001).

Conclusions: Most syncope patients, particularly those with a low-risk profile, were not evaluated in accordance with the ESC guidelines.

Background: Acute coronary syndrome (ACS) represents a spectrum of ischemic myocardial disease including unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI). Various prognostic scores were developed for patients presenting with NSTEMI-ACS. Among these scores, the GRACE risk score offers the best discriminative performance for prediction of in-hospital and 6-month mortality. However, the GRACE score is limited and cannot be used in several ethnic populations. Moreover, it is not predictive of clinical outcomes other than mortality.

Objective: To assess the prognostic value of traditional cardiovascular risk factors and laboratory biomarkers in predicting 6-month major adverse cardiac and cerebrovascular events (MACCE), including hospitalization, recurrent percutaneous coronary intervention (PCI), stroke, and cardiovascular mortality in patients with NSTEMI treated with PCI.

Methods: This retrospective study included consecutive patients admitted with an initial diagnosis of NSTEMI to the cardiac intensive care unit (CICU) at the Tzafon Medical Center, Israel, between April 2015 and August 2018 and treated by PCI within 48 hours of admission.

Results: A total of 223 consecutive patients with NSTEMI treated by PCI were included in the study. Logarithm_ebrain natriuretic peptide (LogₑBNP), prior MI, and Hb levels were found to be significant predictors of any first MACCE. Only logₑBNP was found to be an independent predictor of a first MACCE event by multivariate logistic regression analysis.

Conclusions: LogₑBNP is an independent predictor of worse prognosis in patients with NSTEMI. Routine evaluation of BNP levels should be considered in patients admitted with NSTEMI.

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: Cardiac rehabilitation (CR) is underutilized globally despite evidence of clinical benefit. Major obstacles for wider adoption include distance from the rehabilitation center, travel time, and interference with daily routine. Tele-cardiac rehabilitation (tele-CR) can potentially address some of these limitations, enabling patients to exercise in their home environment or community.

Objectives: To evaluate the clinical and physiological outcomes as well as adherence to tele-CR in patients with low cardiovascular risk and to assess exercise capacity, determined by an exercise stress test, using a treadmill before and following the 6-month intervention.

Methods: A total of 22 patients with established coronary artery disease participated in a 6-month tele-CR program. Datos Health (Ramat Gan, Israel), a digital health application and care-team dashboard, was used for remote monitoring, communication, and management of the patients.

Results: Following the 6-month tele-CR intervention, there was significant improvement in exercise capacity, assessed by estimated metabolic equivalents with an increase from 10.6 ± 0.5 to 12.3 ± 0.5 (P = 0.002). High-density lipoproteins levels significantly improved, whereas low-density lipoproteins, triglyceride, glycosylated hemoglobin, and systolic and diastolic blood pressure levels were not significantly changed. Exercise adherence was consistent among patients, with more than 63% of patients participating in a moderate intensity exercise program for 150 minutes per week.

Conclusions: Patients who participated in tele-CR adhered to the exercise program and attained clinically significant functional improvement. Tele-CR is a viable option for populations that cannot, or elect not to, participate in center-based CR programs.

Background: Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAA) is associated with decreased perioperative morbidity and mortality.

Objectives: To report the outcomes of EVAR among patients older than 80 years of age.

Methods: In this retrospective study, we reviewed patients older than 80 years of age who underwent elective EVAR at our institution between 2007 and 2017. The demographics, perioperative morbidity and mortality, and long-term results are reported.

Results: During the study period, 444 patients underwent elective EVAR for AAAs. Among them 128 patients (29%) were > 80 years of age. Mean age was 84 ± 3.4 (range 80–96) years, and 110 patients (86%) were male. The EVAR was technically successful in 127 patients (99%) and there were intraoperative mortalities. Within 30 days of the surgery, nine patients (7%) died. Major and minor adverse events occurred in 26 (20%) and 59 (46%) patients, respectively. Factors associated with increased risk of perioperative morbidity and mortality included chronic kidney disease, peripheral artery disease, and the existence of three or more co-morbidities.

Conclusions: EVAR in the elderly can be performed with a high rate of success; however, it is associated with a substantial rate of morbidity and mortality, particularly when patients present with multiple co-morbidities. When performing EVAR in this population group, the risk of rupture must be considered opposed to the life expectancy of these patients and the risk of perioperative morbidity and mortality.

Background: Medical clowns are increasingly used for diminishing pain and anxiety during painful procedures being performed on children in the hospital setting. Cortisol levels rise as a response to emotional distress. 

Objectives: To investigate whether medical clown-assisted interventions to reduce child's distress during venipuncture have an effect on cortisol levels. 

Methods: During a 1 year period, children requiring blood work or intravenous access in the pediatric emergency department were prospectively randomized to either the presence or absence of a medical clown during the procedure. The child's distress was evaluated using the Faces Pain Scale - revised (FPS-R) for the 4–7 year age group and the visual analog scales (VAS) for those aged 8–15 years. Serum cortisol levels were measured in blood samples obtained by venipuncture. 

Results: Fifty-three children aged 2–15 years were randomly assigned to the study group (with medical clown, n=29) or to the control group (without medical clown, n=24). Combined pain scores of the study group and control group were 2.2 and 7.5 respectively (P < 0.001). No difference in mean cortisol levels was found between the study group and the control group at all ages (16.4 µg/dl vs. 18.3 µg/dl, P = 0.65).

Conclusions: In this pilot study, medical clowns reduced the distress from venipuncture in children. No effect on cortisol levels was observed. 

Abstract

Background: Iatrogenic ureteral injury may be seen following abdominopelvic surgeries. While ureteral injuries identified during surgery should be immediately and surgically repaired, those that are postoperatively diagnosed may be treated non-surgically by draining the ipsilateral kidney. Data regarding the outcome of this approach are still missing.

Objectives: To evaluate the success rates of non-surgical management of ureteral injuries diagnosed following abdominopelvic surgeries.

Methods: We retrospectively reviewed the files of all patients treated for iatrogenic ureteral injuries diagnosed following abdominopelvic surgeries. Patients' ipsilateral kidney was percutaneously drained following diagnosis of injury by either nephrostomy tube (NT)/nephro-ureteral stent (NUS) or double-J stent (DJS) inserted retrogradely. The tube was left in place until a pyelogram confirmed healing or a conservative approach was abandoned due to failure.

Results: Twenty-nine patients were identified as having ureteral injury following abdominopelvic surgery. Median time from injury to renal drainage was 9 days, interquartile range (IQR) 4–17 days. Seven cases (24%) had surgical repair. Among the other 22 patients, in 2 oncology patients the conservative approach was maintained although renal drainage failed to resolve the injury. In the remaining 20, median drainage length was 60 days (IQR 43.5–85). Calculated overall success rates following renal drainage was 69% (18/29), and with NS approached 78.5%.

Conclusions: Ureteral injuries diagnosed following abdominopelvic surgeries can be treated conservatively. Ipsilateral renal drainage should be the first line of treatment before surgical repair, and NUS may be the preferred drainage to obtain spontaneous ureteral healing. 

Objectives: To describe a single-center experience with fenestrated and branched endografts for the treatment of complex aortic aneurysms.

Methods: We reviewed all cases of complex aortic aneurysms treated with branched or fenestrated devices in our center. Data collected included device specifics, perioperative morbidity and mortality, re-intervention rates and mid-term results.

Results: Between 2007 and 2012 nine patients were treated with branched and fenestrated stent grafts. Mean age was 73 years. Mean aneurysm size was 63 mm. Perioperative mortality was 22% (2/9). During the follow-up, re-interventions were required in 3 patients (33%). Of 34 visceral artery branches 33 remained patent, resulting in a patency rate of 97%. Sac expansion was seen in a single patient due to a large endoleak. No late aneurysm- related deaths occurred.

Conclusions: Branched and fenestrated stent grafts are feasible and relatively safe alternatives for the treatment of complex aortic aneurysms involving the visceral segment. Further research is needed to determine the long-term durability of this new technology. 

Objectives: To assess the results of endovascular revascularization for lower extremity ischemia in dialysis patients.

Methods: We conducted a retrospective review of all dialysis patients who underwent endovascular treatment for critical limb ischemia (CLI) in our institution between 2007 and 2011. Data collected included comorbidities, clinical presentation, anatomic distribution of vascular lesions, amputation and survival rates.

Results: We identified 50 limbs (41 patients). Indications included: gangrene in 22%, non-healing wounds in 45%, rest pain in 31%, and debilitating claudication in 4%. Mean follow-up was 12 months (1–51 months). Nineteen patients required amputations. Freedom from amputation at 5 years was 40%. Factors associated with amputation included non-healing wounds or gangrene (68% and 36% respectively) and diabetes (P < 0.05). The survival rate was 80% after 5 years.

Conclusions:  Despite improvement in endovascular techniques for lower extremity revascularization, the incidence of limb salvage among dialysis patients remains poor, resulting in a high rate of major amputations. 

Background: Some specialists and policy makers advocate progression of the mental health reform in Israel by transferring beds from psychiatric to general hospitals.

Objectives: To compare the demographic, diagnostic and psychopathological profiles of psychiatric inpatients hospitalized in psychiatric and general hospitals, as well as their patterns of drug abuse and to estimate the preparedness of general hospitals for the possible expansion of their psychiatric services.

Methods: Between 2002 and 2006 a total of 250 patients were consecutively admitted to the Jerusalem Mental Health Center-Kfar Shaul Hospital and 220 to the psychiatric department of Sheba Medical Center, a general hospital in central Israel; the patients’ ages ranged from 18 to 65. The two groups were compared for demographic features, psychiatric diagnoses and severity of psychopathology (utilizing PANSS, HAD-21, YMRS rating scales). Drug abuse was diagnosed by urine analyses and self-report.

Results: The patients in the psychiatric hospital were significantly younger, predominantly male, and more dependent on social security payments. In the general hospital, diagnoses of affective and anxiety disorders prevailed, while in the psychiatric hospital schizophrenic and other psychotic patients constituted the majority. The patients in the general hospital were decidedly more depressed; in the psychiatric hospital, notably higher rates of manic symptoms as well as positive, negative and general schizophrenic symptoms were reported. For the most abused substances (opiates, cannabis and methamphetamines) the rates in the psychiatric hospital were significantly higher.

Conclusions: The differences between the two groups of inpatients were very pronounced, and therefore, the transferring of psychiatric beds to general hospitals could not be done without serious and profound organizational, educational and financial changes in the psychiatric services of general hospitals. Since each of the two inpatient systems has particular specializations and experience with the different subgroups of patients, they could coexist for a long time.
 

Background: The American Academy of Pediatrics recently published recommendations for the red reflex assessment in the newborn period to detect and treat ocular disorders as early as possible, and to prevent lifelong visual impairment and even save lives. The test is technically simple to perform, non-invasive, requires minimal equipment and can detect a variety of ocular pathologies including cataracts and retinal abnormalities. No specific national guidelines exist on this issue.

Objectives: To document the implementation of red reflex examination in routine neonatal care and present the findings.

Methods: Our clinical experience following implementation of the red reflex test into the newborn physical examination in a single center was reviewed. In addition, an electronic mail questionnaire was sent to all neonatology departments in Israel regarding the performance of the red reflex test.

Results: During 2007–2008, five infants were identified with congenital cataracts at days 2–6 of life prior to discharge from hospital. Surgery was performed in one infant at age 2 months and all infants underwent a thorough follow-up. The incidence of congenital cataract in our center was 1:2300. Less than half the neonatology departments have endorsed the AAP[1] recommendation and perform the red reflex test routinely.

Conclusions: Abnormal red reflex test after delivery enables a rapid ophthalmologic diagnosis, intervention and close follow-up. We recommend that red reflex screening be performed as part of the newborn physical examination if abnormal, an urgent ophthalmologic referral should be made. 

[1] AAP = American Academy of Pediatrics