Israel Medical Association Journal

Background: Population screening for the BRCA mutations in Ashkenazi Jewish women was recently implemented in Israel and is expected to lead to a 10-fold increase in the diagnosis of asymptomatic carriers. Performing the screening follow-up within multidisciplinary dedicated clinics for carriers is recommended for early detection and risk reduction.

Objectives: To determine the availability, capacity, and practices of dedicated screening clinic for BRCA carriers in Israel.

Methods: A telephone-based survey of all public hospitals in Israel was conducted October 2020 to August 2021 to determine whether they had a dedicated clinic. Dedicated clinics were defined as multidisciplinary screening clinics offering at least breast and gynecological screening and risk reducing services on site. The clinic director or nurse navigator answered a questionnaire about screening practices followed by a semi-structured interview.

Results: Of the ten dedicated BRCA clinics found in Israel, nine participated. Approximately 4500 BRCA carriers are currently being followed. No specialized clinics are available in the southern district or in the northernmost half of the northern district of Israel, leading to a disparity between periphery and center. Screening recommendations, although asserted as adhering to international guidelines, vary among clinics including age at initiating of clinical exam, use of adjunct imaging modalities, and follow-up during lactation and after risk reducing surgery.

Conclusions: There is a suboptimal distribution of dedicated clinics for BRCA carriers in Israel. Nationally centralized attempt to create guidelines that will unify screening practices is warranted, especially considering the expected increase in demand.

Background: Patients with systemic sclerosis (SSc) are at increased risk for autoimmune thyroid diseases, but information regarding thyroid nodules and cancer in SSc is scarce.

Objectives: To evaluate the thyroid gland in patients with SSc at a single Israeli center.

Methods: Thyroid workup was conducted in consecutive SSc patients: thyroid-stimulating hormone (TSH), free thyroxine (fT4), anti-thyroid peroxidase, and anti-thyroglobulin antibodies, as well as thyroid ultrasound and fine needle aspiration (FNA) when appropriate.

Results: Fifty patients, mean age 51.3 ± 13.5 years (44 women) were evaluated. Ten were previously diagnosed with thyroid disease. Median TSH level was 2.0 (normal range 0.23–4 mIU/l) and median fT4 level was 1.0 (normal range 0.8–2.0 ng/dL). Among the 40 thyroid disorder-naive patients, 3 had subclinical hypothyroidism and 5 had positive anti-thyroid antibodies; 22 (44%) had 1–6 thyroid nodules, which were ≥ 1 cm in 12 (24%). Accordingly, six patients underwent FNA, and five were diagnosed as colloid nodules and one as papillary carcinoma.

Conclusions: New cases of clinically significant autoimmune thyroid disease were not detected in our cohort of patients with SSc. Nevertheless, almost half had thyroid nodules. The clinical significance of these findings and their relation to thyroid cancer remains to be determined.

Background: There is an increasing use of anti-protein convertase subtilisin/kexin type 9 (PCSK9) monoclonal antibodies (mAbs); however, real-world data is lacking.

Objectives: To define the demographic and clinical characteristics of patients treated with anti-PCSK9 mAbs. To evaluate efficacy, tolerability, and differences between the approved agents.

Methods: A retrospective cohort study was conducted of patients treated at the lipid clinic at Rabin Medical Center (Beilinson Campus), Israel, from January 2016 to December 2019. Data from electronic records were evaluated for demographic and clinical characteristics, indication for use, response of lowering low-density lipoprotein cholesterol (LDL-C)/non-high-density lipoprotein cholesterol (non-HDL-C) levels and reaching target levels, side effects, tolerability, differences between the agents, and doses.

Results: The study cohort included 115 patients. Two-thirds (n=75) were at high cardiovascular risk, the rest at very high risk (n=40). The major indication for treatment was statin intolerance (n=97, 84%). Most patients (n=102, 88%) were treated by anti-PCSK9 mAbs agents only. LDL-C and non-HDL-C levels were decreased by 47% and 39%, respectively (156 + 49 to 81 + 39 and 192 + 53 to 116 + 42 mg/dl), within 6 months and remained stable. Two-thirds (n=76) of the patients reached their lipid target levels. No clinically significant differences were observed between the agents in efficacy or tolerability.

Conclusions: In a real-world setting, anti-PCSK9 mAbs are used primarily as a single agent in high-risk and very high-risk cardiovascular populations with statin intolerance. They are well tolerated and effective in reduction of LDL-C levels. Further studies are needed to clarify comparisons between agents and doses.

Background: The hepatobiliary system is a sterile micro-environment. Bacterial infection in this system is most commonly associated with anaerobes as well as gram-positive and gram-negative bacteria. Biliary infections with Staphylococcus aureus are poorly characterized.

Objectives: To depict the clinical characteristics and outcome of patients with S. aureus infection of the hepatobiliary system.

Methods: Medical records of patients with bile cultures positive for S. aureus from January 2006 to November 2020 were extracted from the computerized database of a hospital in Israel.

Results: We analyzed the results of 28 cases that were found in the database. The mean age of study patients was 62.2 ± 19 years. Hypertension, dyslipidemia, chronic kidney disease, diabetes, and benign prostatic hypertrophy were the most common co-morbidities (57.1%, 32.1%, 25%, 25%, and 25%, respectively). Fourteen of the methicillin-resistant S. aureus (MRSA) bile cultures (82.3%) were a result of primary S. aureus biliary infections (no other source for S. aureus infection) and the remainder were of a secondary infection. Eight of the MRSA cultures (47.1%) were from hospital acquired infections. Increased hospital mortality in patients with S. aureus hepatobiliary infection was associated with hypertension (P = 0.04), bedridden status (P = 0.01), and nursing home residence (P = 0.003).

Conclusions: Hepatobiliary infection with S. aureus can manifest in a variety of ways. S. aureus should be especially considered in patients who are bedridden, present with hypertension, or live in nursing homes because of their association with in-hospital mortality resulting from this entity.

Background: Primary central nervous system lymphoma (PCNSL) is a rare aggressive non-Hodgkin's lymphoma. There are limited data on the management of PCNSL outside of clinical trials.

Objectives: To report experience with three main high-dose methotrexate (HDMTX)-based protocols for PCNSL treatment at one medical center.

Methods: We conducted a retrospective review of the medical records of patients diagnosed with PCNSL who were treated at Soroka Medical Center between 2007 and 2019.

Results: The study included 36 patients, median age 64.9 years; 33 patients received a HDMTX backbone induction therapy, 21 (58.3%) received consolidation treatment in addition. In the entire cohort, 25 patients (75.7%) achieved complete remission (CR, CRu-unconfirmed), with mean progression-free survival (PFS) 32 ± 6.9 months and median overall survival (OS) 59.6 ± 12.4 months. More aggressive regiment such as combination of rituximab, HDMTX, cytarabine and thiotepa had better responses 5 (100%) CR, but also a higher incidence of side effects such as neutropenic fever 5 (100%). In subgroup analysis by age (younger vs. older than 60 years), the PFS was 24.2 vs. 9.3 months, and OS was 64.1 vs. 19.4 months, respectively.

Conclusions: A difference in CR and PFS favored a more aggressive protocol, but the toxicity of the multiagent combinations was significantly higher. The prognosis in younger was better than in older patients, with higher rates of CR, PFS, and OS, although not statistically significant. Overall treatment outcomes are encouraging; however, there is a real need for an adaptive approach for older patients and balancing among the effectiveness and side effects.

Background: The growing popularity of trampoline jumping in the past years has led to an increase in trampoline-related injuries. The risk is particularly high in large trampoline parks, which are attended by many individuals of various sizes and ages.

Objective: To describe a tertiary pediatric center experience in Israel.

Methods: The database of a tertiary pediatric medical center was retrospectively reviewed for all trampoline-associated admissions to the emergency department in 2015–2018. Data were collected on patient demographics and injury characteristics with an emphasis on type and venue.

Results: Of the 23,248 admissions for orthopedic trauma during the period, 244 children were admitted for 246 trampoline-related injuries. Injuries involved the lower limb in 130 children (53%), upper limb in 87 (36%), spine in 20 (8%), and other sites in 9 (3%). Almost half of the injuries (113/246, 46%) were fractures, 27% required either closed or open reduction in the operating room. Large trampoline centers were responsible for half of the cases.

Conclusions: Trampoline injuries accounted for 1.05% of all emergency department admissions at a tertiary pediatric hospital in 2015–2018. Nearly half of the trampoline-related injuries were fractures. Large trampoline centers pose a potential risk for more serious injuries. We raise awareness of the risks of trampoline jumping, considering increasing popularity of trampoline parks, and encourage the authorities to implement safety regulations.

Background: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert.

Objectives: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress.

Methods: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial.

Results: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress.

Conclusions: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

Background: Changes accommodating requirements of religious authorities in Israel resulted in the Brain and Respiratory Death Determination Law (BRDDL), which came into effect in 2009. These included considering patient wishes regarding the brain respiratory death determination (BRDD), mandatory performance of apnea and ancillary testing, establishment of an accreditation committee, and accreditation required for physicians performing BRDD.

Objectives: To assess the impact of the legislation from 2010–2019.

Methods: Data collected included the number of formal BRDDs and accredited physicians. Obstacles to declaring brain death and interventions applied were identified.

Results: Obstacles included lack of trained physicians to perform BRDD and interpret ancillary test results, inability to perform apnea or ancillary testing, and non-approach to next-of-kin objecting to BRDD. Interventions included physician training courses, additional ancillary test options, and legal interpretation of patient wishes for non-determination of BRD. As a result, the number of non-determinations related to next-of-kin objecting decreased (26 in 2010 to 5 in 2019), inability to perform apnea or ancillary testing decreased (33 in 2010 to 2 in 2019), and number of physicians receiving accreditation increased (210 in 2010 to 456 in 2019). Last, the consent rate for organ donation increased from 49% to 60% in 2019.

Conclusions: The initial decrease in BRDDs has reversed, thus enabling more approaches for organ donation. The increased consent rate may reflect in part the support of the rabbinate and confidence of the general public that BRDD is performed and monitored according to strict criteria.

Background: Environmental, social, and governance (ESG) is a form of international private business self-regulation that aims to contribute to society from a philanthropic, activist, or charitable nature by engaging in or supporting volunteering or ethically oriented practices. The major benefit of ESG is having the organization’s workers recruited for the goal of making the world a better place. There is a growing understanding regarding the extent of the environmental impacts of health services. Therefore, the interest in measuring and reporting the sustainability of health system performance is becoming crucial. As population aging and growth in healthcare demand are two of the main challenges of the current and mainly future health services, performance, and quality measurement as well as sustainability metrices are relevant more than ever.

Objectives: To review the ESG activities at Assuta Medical Centers (AMC) that helped the organization earn the Maala Index Platinum + grade in 2021.

Methods: We reviewed the ESG elements that were implemented at AMC.

Results: AMC entered an ESG process in November 2019 and earned Platinum and Platinum+ grades from the Maala Index in 2020 and 2021, respectively. AMC won the Workforce Diversity prize for having many employees over 60 years of age. AMC activities are detailed as a case study for other health organizations in Israel and worldwide.

Conclusions: A big leading health organization can spearhead sustainable development goals model in Israel and worldwide.

Background: Traditionally, the task of health promotion and early detection screening has been the purview of health maintenance organizations through the family physician. For some years, it has become popular for private health organizations to offer a concentrated day of comprehensive medical testing, which is promoted as a perk by many organizations to their employees. What do these programs offer? Are the tests that are offered evidence based?

Objectives: To describe a concentrated day of comprehensive medical testing program in view of current evidence base medicine (EBM) recommendations.

Methods: We reviewed official internet sites of the most popular concentrated days of comprehensive medical testing and compared the tests offered to the recommendation of several Israeli and international guidelines.

Results: Many tests performed at director screening days do not follow EBM recommendations. Tests like mammography, colonoscopy, bone density, and prostate-specific antigen tests are often offered outside of the recommended age and risk groups and without pretest consultation.

Conclusions: We recommend against routine general health examinations for healthy adults. The most important treatment is not screening and early detection but real prevention. We recommend turning these director screening days into real investments in future health by changing the focus from diagnosis to treatment through prevention. One-on-one conversations, explanations, and most importantly tools to encourage lifestyle changes, will really make a difference.

Dear unique individual:

Really very sorry to hear that you are living with shoulder pain. I’m writing this open letter to you to support decisions you will need to make about how best to manage your symptoms. Shoulder pain never comes at the right time, it always interferes with important work, sports, or social events, and like any pain, we want it gone the moment it starts. In this letter I present to you information that I hope may support you with decisions you will need to make about how best to find an answer for your symptoms. I would like to share with you information about shoulder pain and information about imaging investigations, injections, surgical, and nonsurgical management. I would also like to share with you important lifestyle factors that you need to be aware of, that may also help make sense of the symptoms you are experiencing. This letter focuses on the 90% of people who experience non-traumatic shoulder pain. This letter includes important questions you should ask when you see a clinician. Remember, it is you, not the health professional, who is the most important person in healthcare. No decision should be made without you being fully and truthfully informed of the anticipated benefits, timeframes, and commitments you will need to address and the possible harm of any intervention. I hope you find this letter helpful.

Background: On 18 March 2020, the Israeli Health Ministry issued lockdown orders to mitigate the spread of coronavirus disease 2019 (COVID-19).

Objectives: To assess the association of lockdown orders on telemedicine practice and the effect of social distancing on infectious diseases in a primary care community pediatric clinic as well as the rate of referrals to emergency departments (ED) and trends of hospitalization.

Methods: Investigators performed a retrospective secondary data analysis that screened for visits in a large pediatric center from 1 January to 31 May 2020. Total visits were compared from January to December 2020 during the same period in 2019. Visits were coded during the first lockdown as being via telemedicine or in-person, and whether they resulted in ED referral or hospitalization. Month-to-month comparisons were performed as well as percent change from the previous year.

Results: There was a sharp decline of in-person visits (24%) and an increase in telemedicine consultations (76%) during the first lockdown (p < 0.001). When the lockdown restrictions were eased, there was a rebound of 50% in-person visits (p < 0.05). There was a profound decrease of visits for common infectious diseases during the lockdown period. Substantial decreases were noted for overall visits, ED referrals, and hospitalizations in 2020 compared to 2019.

Conclusions: COVID-19 had a major impact on primary care clinics, resulting in fewer patient-doctor encounters, fewer overall visits, fewer ED referrals, and fewer hospitalizations

Background: Data on how the coronavirus disease 2019 (COVID-19) affected consultations in ophthalmic departments are sparse.

Objectives: To examine the epidemiology of ophthalmic consultations in a large pediatric emergency medicine department (PED) during the first nationwide COVID-19 lockdown in Israel.

Methods: The database of a tertiary pediatric medical center was retrospectively reviewed for patients aged < 18 years who attended the PED from 17 March to 30 April 2020 (first COVID-19 lockdown) and the corresponding period in 2019. Background, clinical, and disease-related data were collected from the medical charts and compared between groups.

Results: The study included 757 PED visits. There were no significant differences in demographics between the groups. The 2020 period was characterized by a decrease in PED visits (by 52%), increase in arrivals during late afternoon and evening (P = 0.013), decrease in visits of older children (age 5–10 year), and proportional increase in younger children (age 1–5 years) (P = 0.011). The most common diagnoses overall and during each period was trauma followed by conjunctivitis and eyelid inflammation. The mechanisms of trauma differed (P = 0.002), with an increase in sharp trauma and decrease in blunt trauma in 2020 (P < 0.001 for both). In 2020, 95% of traumatic events occurred in the home compared to 54% in 2019 (P < 0.001).

Conclusions: Parents need to learn appropriate preventive and treatment measures to prevent serious and long-term ophthalmic injury while minimizing their exposure to the COVID-19. PEDs and ophthalmic pediatric clinics should consider increasing use of telemedicine and the availability of more senior physicians as consultants during such times.