Mohamad Arow MD, Yonatan Shneor Patt MD, Zehavit Kirshenboim MD, Roy Mashiach MD, Howard Amital MD MHA
In this case report, we elucidated the complex etiology of new-onset ascites through the unusual presentation of a 32-year-old female with abdominal swelling, oliguria, and acute renal failure. This patient's ascites was attributed to urinary bladder rupture, a rare but critical consideration in differential diagnoses. Highlighting the significance of this case, bladder rupture without recent trauma history, especially post-gynecological surgery, poses a diagnostic challenge due to its rarity and potential for severe morbidity and mortality if not promptly recognized and managed. Our patient's journey, from initial symptoms to the eventual discovery of bladder rupture, underscores the necessity of considering this diagnosis in similar clinical scenarios. The case uniquely demonstrates pseudo-renal failure, a phenomenon resulting from reversed dialysis across the peritoneal membrane, which further complicated the diagnostic process.
Moshe Salai MD, Yoram Sandhaus MD, Eitan Lunenfeld MD, Naomi Levine-Rahimi MD, Shai Ashkenazi MD, Avinoam Tzabari MD, Ahuva Golik MD, Zachi Grossman MD, Talma Kushnir PHD
War is a chaotic situation for most of the public sectors in the countries involved. These sectors also include the medical systems, especially medical education, of which medical communication is often neglected or forgotten due to objective and subjective causes on either side of the involved countries. By planning lessons on various aspects of medicine for countries at war and close mentoring and utilization of modern communications technologies, these difficulties can be minimized without jeopardizing the quality of medical studies nor medical communication. In this perspective article, we describe the objective and subjective measures taken by our team to achieve these goals during the Iron Swords war in our region.
Naama Srebnik MD, Jennia Michaeli MD, Rosa Ruchlemer MD, Rivka Farkash MPH, Keren Rotshenker-Olshinka MD, Sorina Grisaru-Granovsk MD PhD
Background: Fetal weight estimation at term is a challenging clinical task.
Objectives: To evaluate the association between peripheral white blood cell (WBC) count of the laboring women and neonatal birth weight (BW) for term uncomplicated pregnancies.
Methods: We conducted a single-center, retrospective cohort study (2006–2021) of women admitted in the first stage of labor or planned cesarean delivery. Complete blood counts were collected at admission. BW groups were categorized by weight (grams): < 2500 (group A), 2500–3499 (group B), 3500–4000 (group C), and > 4000 (group D). Two study periods were used to evaluate the association between WBC count and neonatal BW.
Results: There were a total of 98,632 deliveries. The dataset analyses showed a lower WBC count that was significantly and linearly associated with a higher BW; P for trend < 0.001 for women in labor. The most significant association was noted for the > 4000-gram newborns; adjusted odds ratio 0.97, 95% confidence interval 0.96–0.98; P < 0.001; adjusted for hemoglobin level, gestational age, and fetal sex. The 2018–2021 dataset analyses revealed WBC as an independent predictor of macrosomia with a significant incremental predictive value (P < 0.0001). The negative predictive value of the WBC count for macrosomia was significantly high, 93.85% for a threshold of WBC < 10.25 × 103/µl.
Conclusions: WBC count should be considered to support the in-labor fetal weight estimation, especially valuable for the macrosomic fetus.
Raneen Abu Shqara MD, Maya Frank Wolf MD, Jawad Karram MD, Inshirah Sgayer MD, Ala Aiob MD, Lior Lowenstein MD, Susana Mustafa Mikhae MD
Background: Pelvic organ prolapse in pregnancy is rare. Consequent complications include cervical infection, spontaneous abortion, and premature birth. Conservative management by means of a pessary have been described as improving maternal symptomatology and minimizing gestational risk. The delivery mode is controversial.
Objective: To describe the clinical courses of patients diagnosed with pelvic organ prolapse during pregnancy, and to present our multidisciplinary approach.
Methods: In this retrospective case series, we summarized the obstetrical outcomes of women diagnosed with pelvic organ prolapse during pregnancy in a single university-affiliated hospital.
Results: We identified eight women with advanced uterine prolapse at a mean age of 30.3 years. Seven were diagnosed with advanced uterine prolapse (Pelvic Organ Prolapse Quantification [POPQ] stage ≥ 3). All were treated by pessary placement, which was tolerable and provided symptomatic relief. The pessary type was chosen according to the prolapse stage. In women with cervical prolapse POPQ stage > 2 and cervical edema, a support pessary was less beneficial. However, the prolapse was well-controlled with a space-filling Gellhorn pessary. Low complication rates were associated with vaginal deliveries. The few complications that were reported included minor cervical laceration, postpartum hemorrhage, and retained placenta.
Conclusions: Treatment of pelvic organ prolapse during pregnancy must be individualized and requires a multidisciplinary approach of urogynecologists, obstetricians, dietitians, pelvic floor physiotherapists, and social workers. Conservative management, consisting of insertion of a vaginal pessary when prolapse symptoms appeared, provided adequate support for the pelvic floor, improved symptomatology, and minimized pregnancy complications. Vaginal delivery was feasible for most of the women.
Andrei Braester MD, Artyom Bilyk MD, Celia Suriu MD, Luiza Akria MD, Najib Dally MD, Masad Barhoum MD
Background: Preeclampsia is a unique vascular disease during pregnancy that generally appears after 20 of weeks gestation or until 6 weeks after delivery. Left undiagnosed, preeclampsia can lead rapidly to death of both mother and fetus.
Objectives: To verify the efficacy of peripheral blood inflammatory markers (BIMs)in diagnosing preeclampsia and compare them with results from other studies.
Methods: Our retrospective case-control study comprised two patient groups. Pregnant women with preeclampsia and pregnant women without preeclampsia were compared for BIMs: neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), and mean platelet volume (MPV). The primary endpoint of our research was to assess the predictive power of BIMs for preeclampsia diagnosis.
Results: The sample size was calculated based on expected differences of BIMs between the control and study groups. Comparison of quantitative variables was conducted with independent sample t-test or alternatively by Wilcoxon rank sum test. The MPV values were slightly higher in the preeclampsia group, but not statistically significant. NLR and PLR did differentiate between study and control groups.
Conclusions: The diagnostic accuracy of BIMs is unsatisfactory for preeclampsia diagnosis. Discrepancies concerning these values need to be clarified. Further large prospective studies are necessary to validate the potential factor accuracy in preeclampsia diagnosis.
Gassan Moady MD, Michal De Picciotto, Naila Aslan MA, Shaul Atar MD
Background: Heart failure (HF) is an emerging pandemic associated with increased mortality, recurrent hospitalizations, and reduced quality of life. Guideline-directed medical therapy has been shown to improve outcomes, particularly in patients with HF with reduced ejection fraction (HFrEF). The main goal of HF clinics is optimizing medical therapy.
Objectives: To assess the impact of our HF clinic on medical therapy and clinical outcomes.
Methods: We obtained demographic, echocardiographic, and clinical data of patients listed in our HF clinic during a 4-year period. Medical therapy was evaluated based on patient reports and documented data. Recurrent admissions for HF were documented.
Results: A total of 317 patients (74.1% male, median age 66 years, IQR 55–74) were listed in the clinic with a total of 1140 visits. Of these patients, 62.5% had HFrEF, 20.5% presented with mildly reduced ejection fraction, and 17% showed preserved ejection fraction at the time of the first visit. The use of sodium glucose co-transporter 2 inhibitors and mineralocorticoid receptor antagonists was optimized in 92% and 91% of the patients, respectively. In the subgroup of patients with HFrEF, the use of angiotensin-receptor antagonist/neprilysin inhibitor increased from 22.6% to 87.9% (P < 0.001) and SGLT2 inhibitor use increased from 49.2% to 92% (P < 0.001). During the follow-up period (2.2 years, IQR 1.1–3.1), 203 patients (64%) were readmitted to the hospital for HF at least once. The rate of readmissions decreased over time.
Conclusions: An HF clinic plays an important role in optimizing medical therapy and reducing readmissions.
Ilan Rozenberg MD, Sydney Benchetrit MD, Tali Zitman-Gal PhD, Moanis Ajaj MD, Maysam Shehab MD, Naomi Nacasch MD, Keren Cohen-Hagai MD
Background: Hemodialysis requires reliable, recurrent access to the circulatory system. Central venous tunneled dialysis catheters (TDC) are frequently used for patients receiving hemodialysis as a bridge to permanent vascular access or as a final option. TDC are prone to complications such as infection and dysfunction.
Objective: To assess the prevalence and predictors of TDC dysfunction in a cohort of chronic hemodialysis patients.
Methods: This single-center, retrospective study was based on data from an electronic database of chronic hemodialysis patients during 5 years of follow-up.
Results: A total of 625 TDC were inserted in 361 patients, of which 234 (37.4%) were replaced due to dysfunction. The main insertion site was the right internal jugular vein. Diabetes mellitus was an important predictor of TDC dysfunction and was significantly correlated with TDC extraction. Chronic anticoagulation and antiplatelet treatment did not affect the rate of TDC dysfunction or replacement.
Conclusions: TDC use for chronic dialysis patients is increasing and dysfunction is a major problem. In our study, we highlighted the high prevalence of TDC dysfunction and the need for further research to improve hemodialysis access as well as TDC patency and function.
Yair Binyamin MD, Amit Frenkel MD, Alexander Geftler MD, Israel Melamed MD, Salim Alobra MD, Alexander Zlotnik MD, Gali Pariente MD
The use of smaller-diameter, pencil-point spinal needles has increased to reduce post-dural puncture headaches in obstetric patients. However, this therapy has also led to more needle deformation and breakage. While risk factors and prevention are described, there is limited literature on management when breakage occurs.
The utilization of neuraxial techniques for labor analgesia and cesarean delivery has experienced a consistent increase in recent years [1]. Spinal anesthesia has emerged as the preferred technique for cesarean deliveries due to its advantages, including a reduction in morbidity and mortality, decreased complications related to airway management, reduced bleeding, improved bonding with the baby, and better outcomes for newborns [2]. While the adoption of smaller diameter, non-cutting bevel spinal needles has successfully reduced the incidence of post-dural puncture headaches in obstetric patients, it has also given rise to complications such as spinal needle deformation and breakage [3,4]. The current understanding of the incidence of neuraxial needle breakage remains limited, with estimated incidences reported between approximately 1 in 5,000 to 1 in 11,000 spinal anesthesia procedures performed [4]. Although numerous case reports have documented broken needles during attempted neuraxial anesthesia, the existing literature predominantly focuses on associated risk factors and preventive measures for this complication [3]. However, there is a lack of literature regarding the subsequent management once this adverse event has transpired. In this report, we present a case involving a broken spinal needle during an attempt to perform spinal anesthesia for an urgent cesarean delivery. By sharing this case, we shed light on the management strategies and considerations following such an event.
Ohad Gabay MD, Alexander Zhuravlov MD, Yakov Perlov MD, Chun Ho Szeto MD MPH, Yoav Bichovsky MD, Dana Braiman MD, Leonid Koyfman MD, Asaf Honig MD, Mohamed Eldada MD, Evgeni Brotfain MD
Reversible cerebral vasoconstriction syndrome (RCVS) comprises a group of conditions characterized by reversible vasoconstrictions of cerebral arteries. Clinical manifestations include sudden-onset severe headaches with or without additional neurologic signs and symptoms [1].
The incidence of RCVS is 2.7 cases per million adults. It predominantly affects women, and about 9% of all RCVS cases occur during the postpartum period [2,3]. Other possible precipitating factors, such as subarachnoid hemorrhage, ischemic stroke, intracranial hemorrhage, and exposure to vasoactive drugs, have also been reported in association with RCVS [2]. The exact pathophysiology of RCVS is not well understood, although hormonal influences have been suggested as possible contributing factors.
Alkalosis-induced cerebral vasoconstriction is described but not well understood. Hyperventilation is commonly used in neurologic patients to decrease intracranial pressure and cerebral blood flow. Hyperventilation causes cerebral vasoconstriction directly by hypocapnia and may indirectly affect through alkalosis.
We present a case of RCVS in a postpartum patient admitted to the intensive care unit (ICU) with severe metabolic alkalosis necessitating hemodialysis.
Sharon Slomovich MD, Visala Natarajan MBA, Gal Rubinstein MD, Pavel Gozenput MD, Benhoor Shamian MD
Hepatitis E Virus (HEV), a single-stranded RNA virus, is the leading cause of viral-induced acute liver failure globally. It is estimated to infect 20 million people annually, resulting in 3.3 million symptomatic cases and 44,000 deaths, worldwide [1]. Transmission is fecal-oral through contaminated food and water, zoonotic spread, or blood transfusions, and usually results in a self-limiting disease. While prevalent in resource-limited countries, cases are sporadic in the developed world [1]. Established risk factors for severe HEV infection include pregnancy, immunocompromised state, and underlying liver disease, while reports of malignancy as a predisposing factor are not well documented [1]. Here we present a case of a patient who, without established risk factors, developed a severe HEV infection leading to multiorgan failure and death.