Israel Medical Association Journal

Background: Although exercise has been shown to improve mood and well-being, the precise mechanism remains unknown. Neurosteroids are important neuroactive molecules with demonstrated involvement in several neurophysiological and disease processes. Previous research has noted neurosteroid changes in dehydroepiandrosterone (DHEA) levels following exercise.



Objectives: To determine whether changes in DHEA levels are associated with mood improvement after exercise and whether there are any differences in the effects on younger and older individuals. 



Methods: Individuals ≤ 50 years of age or > 65 years of age were recruited for study participation. Before and after 30 minutes of a standardized cycling regimen, each patient provided a blood sample and completed a questionnaire on mood and well-being. 



Results: Findings confirmed a significant increase in DHEA levels post-exercise. A decrease in negative factors (fatigue, tension, depression, anger) and an increase in positive mood factors were noted. No difference in change of measures was noted between younger and older subjects. A positive correlation was noted between mood change and DHEA blood-level changes in older subjects. Among older males, DHEA appeared to be associated with mood change after exercise. 



Conclusions: While preliminary, findings indicate a possible association between mood improvement following exercise and DHEA blood level changes. Understanding the biological mechanisms of exercise-induced mood changes is critical to utilizing exercise as a treatment for mood disorders.

Background: One-stage direct-to-implant post-mastectomy breast reconstruction has been gaining popularity over the traditional two-stage/tissue-expander approach.

Objectives: To evaluate the outcome of the two post-mastectomy breast reconstruction procedures in terms of patient satisfaction.

Methods: Clinical data were collected by file review for patients who underwent mastectomy with immediate breast reconstruction at two tertiary medical centers in 2010–2013. Patients were asked to complete the BREAST-Q instrument, sent to them by post with a self-addressed, stamped, return envelope. Scores were compared by type of reconstruction performed.

Results: Of the 92 patients who received the questionnaire, 59 responded: 39 had one-stage breast reconstruction and 20 underwent two-stage reconstruction. The two-stage reconstruction group was significantly older, had more background diseases, and were followed for a longer period. The one-stage reconstruction group had a higher proportion of BRCA mutation carriers. There was no significant between-group difference in postoperative complications. Mean BREAST-Q scores were similar in the two groups for all dimensions except satisfaction with information, which was higher in the patients after one-stage reconstruction. Women with more background diseases had better sexual well-being, and married women had better psychological well-being. Breast satisfaction was lower among patients treated with radiation and higher among patients with bilateral reconstruction; the latter subgroup also had higher physical well-being. Complications did not affect satisfaction.

Conclusions: Patients were equally satisfied with the outcome of one- and two-stage breast reconstruction. The choice of technique should be made on a case-by-case basis. Cost analyses are needed to construct a decision-making algorithm.

Background: Accurate diagnosis of community acquired pneumonia (CAP) is crucial to its proper management and to combating antibiotic resistance. Levels of C-reactive protein (CRP) have been shown to distinguish pneumonia from other pathological conditions and can be used to control the severity of infection during admission.

Objective: To investigate an association between consecutive measurements of CRP and the severity of CAP in hospitalized patients.

Methods: A total of 500 patients with CAP were admitted to the hospital. Traditional markers of inflammation including CRP, leukocyte count, body temperature, were measured on the first, second, and fifth days of hospitalization. Correlations between these measures and the length of the hospital stay were calculated.

Results: Mean levels of CRP, body temperature, and leukocyte count were significantly lower on the second day after hospital admission and even lower on the fifth day. A positive correlation of medium strength was found between the level of CRP on the second day of hospitalization and the length of hospital stay (P < 0.001, r_s = 0.447), and a negative correlation was noted between the decrease in CRP level from the first to second day and the length of hospital stay.

Conclusions: CRP levels correlated with body temperature and leukocyte count, traditional markers of inflammation. A greater decrease in CRP level between the first and second day of hospitalization was associated with shorter hospital stay and rapid improvement. These findings support the use of CRP as a marker for the severity and complication of CAP.

Background: The most common complication after tonsillectomy is bleeding. We investigated whether performing the procedure during the summer or the winter affects the bleeding rate.

Objectives: To investigate whether there is an association between meteorological conditions and the occurrence of post-tonsillectomy hemorrhage (PTH) in the southern Israel Negev region.

Methods: All patients who underwent tonsillectomy from 2001–2013 at the Soroka Medical Center were included. We collected patient demographic data and indications for surgery. Meteorological data were obtained from a weather station operated by the Israel Ministry of Environmental Protection.

Results: Of 4438 patients who underwent tonsillectomy, with or without adenoidectomy, 432 (9.73%) experienced hemorrhage. Patients who suffered from PTH were significantly older: median age 9.61 years vs.4.7 years, P < 0.0001. When comparing patients without PTH to those who bled within 0–3 days after surgery, there was a higher risk for bleeding during the warmer seasons: relative risk (RR) 1.38, 95% confidence interval ([95%CI] 1.07–1.77), RR 1.45 (95%CI 1.17–1.80), and 1.62 (95%CI 1.27–2.06) comparing the winter to spring, summer, and fall, respectively. A statistically significant positive association was also found with the average temperature on the day of surgery. Bleeding more than 3 days after surgery was less likely in summer: RR 0.82, 95%CI 0.69–0.97. We found no association with temperature on the day of surgery and PTH after postoperative day 3.

Conclusions: Seasonality, and to an extent temperature, seem to play only a minor role in PTH.

Background: Wandering spleen is a rare entity that may pose a surgical emergency following torsion of the splenic vessels, mainly because of a delayed diagnosis. Complications after surgery for wandering spleen may necessitate emergency treatment.

Objectives: To describe the clinical course and treatment for children who underwent emergency surgeries for wandering spleen at a tertiary pediatric medical center over a 21 year period and to indicate the pitfalls in diagnosis and treatment as reflected by our experience and in the literature.

Methods: The database of a tertiary pediatric medical center was searched retrospectively for all children who underwent emergency treatment for wandering spleen between 1996 and 2017. Data were collected from the medical files. The relevant literature was reviewed.

Results: Of ten patients who underwent surgery for wandering spleen during the study period, five underwent seven emergency surgeries. One patient underwent surgery immediately at initial presentation. In the other four, surgical treatment was delayed either due to misdiagnosis or for repeated imaging studies to confirm the diagnosis. Emergency laparotomy revealed an ischemic spleen in all patients; splenectomy was performed in two and the spleen was preserved in three. Four of the seven emergency operations were performed as the primary surgery and three were performed to treat complications.

Conclusions: Wandering spleen should ideally be treated on an elective or semi-elective basis. Surgical delays could be partially minimized by a high index of suspicion at diagnosis and by eliminating unnecessary and time-consuming repeated imaging studies.

Background: About half of all patients with heart failure are diagnosed with heart failure preserved ejection fraction (HFpEF). Until now, studies have failed to show that medical treatment improves the prognosis of patients with HFpEF.

Objectives: To evaluate changes in exercise capacity of patients with HFpEF compared to those with heart failure with reduced ejection fraction (HFrEF) following an exercise training program.

Methods: Patient data was retrieved from a multi-center registry of patients with heart failure who participated in a cardiac rehabilitation program. Patients underwent exercise testing and an echocardiogram prior to entering the program and were retested6  months later.

Results: Of 216 heart failure patients enrolled in the program, 170 were diagnosed with HFrEF and 46 (21%) with HFpEF. Patients with HFpEF had lower baseline exercise capacity compared to those with HFrEF. Participating in a 6 month exercise program resulted in significant and similar improvement in exercise performance of both HFpEF and HFrEF patients: an absolute metabolic equivalent (MET) change (1.45 METs in HFrEF patients vs. 1.1 in the HFpEF group, P = 0.3).

Conclusions: An exercise training program resulted in similar improvement of exercise capacity in both HFpEF and HFrEF patients. An individualized, yet similarly structured, cardiac rehabilitation program may serve both heart failure groups, providing safety and efficacy.

Background: Type 2 diabetes mellitus is a multifactorial disease in which genetic susceptibility and environmental factors induce pancreatic β-cell dysfunction and insulin resistance. Additional factors such as hyperglycemia and hyperlipidemia have roles in β-cell dysfunction and disease progression. The phenomenon of lipid-induced pancreatic β-dysfunction, designated as lipotoxicity, has been observed in several in vitro and in vivo experiments; however, there is still no solid evidence for the occurrence of this event in humans. The toxic effect of high lipid levels on β-cell function consists of impaired insulin gene expression, apoptosis, and reduced glucose-stimulated insulin secretion.

Objectives: To demonstrate the importance of treating hypertriglyceridemia in reducing glucose intolerance and the need for insulin therapy in hospitalized diabetic patients.

Methods: We evaluated five clinical case reports and conducted a detailed literature review via the PubMed search engine.

Results: Reduction in elevated blood triglyceride and glucose levels in hospitalized diabetic patients resulted in a rapid decline in glucose levels and in the need for insulin therapy.

Conclusions: A decrease in high triglyceride levels in “lipotoxic” diabetic patients may improve insulin intolerance and glucose homeostasis and reduce the need for insulin therapy.

Background: The treatment of advanced dementia patients is very complex and presents a difficult dilemma for physicians, and especially for the patient's family. In many cases, when the advanced dementia patient has no decisional capacity, the family needs to decide about force-feeding and resuscitation for their relative.

Objectives: To examine public opinion regarding force-feeding and resuscitation of patients with advanced dementia.

Methods: Data from 1002 people who accompanied a patient to a hospital emergency department in Israel were collected and analyzed.

Results: We noted the following results: the more religious the orientation of the respondents, the more likely they were to agree to forcefully feed and resuscitate advanced dementia patients and advanced dementia patients older than 80 years; those accompanying younger patients were more likely to think that the medical staff should resuscitate advanced dementia patients and advanced dementia patients older than 80 years compared to those accompanying elderly patients; younger people were more likely than older people to agree to force-feed and resuscitate patients.

Conclusions: This paper attempts to provide decision-makers and medical staff with some knowledge about public opinion regarding a sensitive and complex issue. This awareness may guide physicians in making critical medical decisions about those with dementia.

Background: Williams syndrome (WS) is a neurogenetic syndrome characterized by a variety of medical conditions and cognitive deficits along with distinct psychiatric and behavioral characteristics. To the best of our knowledge, no studies to date have comprehensively reported the prevalence of medical, cognitive deficits, and psychiatric disorders in one cohort of people with WS in one study.

Objectives: To detail the prevalence of the various clinical features of WS in a large nationwide Israeli cohort. To examine potential risk factors for attention deficit hyperactivity disorder (ADHD) in WS.

Methods: We investigated the effects of cardiovascular anomalies, intellectual quotient (IQ), and phonophobia (fear of sounds) on the likelihood of ADHD. The study included 80 participants with WS (mean age 7.76 years). Relevant medical information from medical records was obtained retrospectively. In addition, IQ testing and psychiatric assessments using structured tools were conducted. The association between ADHD and cardiovascular anomalies, IQ, and phonophobia was analyzed using a logistic regression.

Results: Supravalvular aortic stenosis and supravalvular pulmonary stenosis are the prevalent cardiovascular anomaly in WS. Phonophobia and ADHD are the most prevalent psychiatric diagnoses in people with WS. Phonophobia was significantly associated with the risk for ADHD in WS participants.

Conclusions: Our findings regarding the type and prevalence of medical, cognitive, and psychiatric characteristics in WS correspond to results in previous publications. We also showed a potential link between phonophobia and ADHD that merits further research.

Background: Vitamin D deficiency and insufficiency have been reported in fibromyalgia. However, to the best of our knowledge, only one study has evaluated the role of 25-hydroxyvitamin D [25(OH)D] supplementation on fibromyalgia symptoms.

Objectives: To analyze the effects of 3 months of 25(OH)D supplementation on symptoms of fibromyalgia.

Methods: This study included 11 female patient. Demographic and clinical data, tender points, visual analog scale results, and pre- and post-serum levels of 25(OH)D supplementation were analyzed. The levels of 25(OH)D were measured by a radioimmunologic test.

Results: Patients with fibromyalgia diagnosis and 25(OH)D values ≤ 30 ng/ml were recruited to receive 50,000 IU of oral vitamin D once every week for 3 months. The disease was diagnosed based on the American College of Rheumatology criteria. The median age of all patients was 48.5 (28–67) years and 63.4% were Caucasian. Disease duration varied from 1–10 years. The 25(OH)D levels increased significantly after 3 months, 18.4 (15.5–25.8) ng/ml vs. 33.8 (28–58) ng/ml, P = 0.01. Interestingly, an improvement of visual analog scale scores was observed at 3 months, 90 (0–100) vs. 30 (0–80), P = 0.002. Eight patients (72.2%) responded that they experienced a very significant improvement in symptoms. In addition, a trend for reduction of the number of tender points was observed after 3 months, 17 (11–18) vs. 10 (0–18), P = 0.07.

Conclusions: The 25(OH)D levels and disease symptoms in patients with fibromyalgia and vitamin D deficiency/insufficiency seem to improve with vitamin D supplementation.

Background: Increasing antibiotic resistance in the community results in greater use of empiric broad spectrum antibiotics for patients at hospital admission. As a measure of antibiotic stewardship it is important to identify a patient population that can receive narrow spectrum antibiotics.

Objectives: To evaluate resistance patterns of Escherichia coli bloodstream infection (BSI) from strictly community-acquired infection and the impact of recent antibiotic use on this resistance.

Methods: This single center, historical cohort study of adult patients with E. coli BSI was conducted from January 2007 to December 2011. Patients had no exposure to any healthcare facility and no chronic catheters or chronic ulcers. Data on antibiotic use during the previous 90 days was collected and relation to resistance patterns was assessed.

Results: Of the total number of patients, 267 BSI cases met the entry criteria; 153 patients (57%) had bacteria sensitive to all antibiotics. Among 189 patients with no antibiotic exposure, 61% of isolates (116) were pan-sensitive. Resistance to any antibiotic appeared in 114 patients and 12 were extended-spectrum beta-lactamase (ESBL) producers. Quinolone use was the main driver of resistance to any antibiotic and to ESBL resistance patterns. In a multivariate analysis, older age (odds ratio 1.1) and quinolone use (odds ratio 7) were independently correlated to ESBL.

Conclusions: At admission, stratification by patient characteristics and recent antibiotic use can help personalize primary empirical therapy.