Mor Aharoni MD, Yiftach Barash MD, Yaniv Zager MD, Roi Anteby MD, Saed Khalilieh MD, Imri Amiel MD, Eyal Klang MD, Yuri Goldes MD, Mordechai Gutman MD FACS, Nir Horesh MD, and Danny Rosin MD FACS
Background: The coronavirus disease-2019 (COVID-19) outbreak had an effect on healthcare.
Objectives: To evaluate the presentation and management of patients with acute appendicitis.
Methods: A retrospective study was conducted of all patients presenting with acute appendicitis to the emergency department of a large tertiary center during March and April 2020. Clinical features, diagnostic workup, and management were compared.
Results: Seventy-four patients presented with acute appendicitis during the pandemic compared to 60 patients during the same time the year before. There were no significant differences in patient demographics: age (P = 0.65), gender (P = 0.73), smoking status (P = 0.48). During COVID-19 patients were more likely to complain of right lower quadrant pain (100% vs. 78.3%, P < 0.01). Rates of surgical treatment was similar (83.8% vs. 81.7%, P = 1); mean operative time was longer during COVID-19 (63 ± 23 vs. 52 ± 26 minutes, P = 0.03). There were no significant differences in intra-operative findings including the presence of appendiceal perforation (16.3% vs. 14.5%, P = 0.8), abscess (6.1% vs. 9.7%, P = 0.73), or involvement of cecum or terminal ileum (14.28% vs. 19.63%, P = 1). Postoperative treatment with antibiotics was more prevalent during COVID-19 (37.1% vs. 18%, P = 0.04). Length of stay (1.82 ± 2.04 vs. 2.74 ± 4.68, P = 0.2) and readmission rates (6% vs. 11.3%, P =0.51) were similar.
Conclusion: The COVID-19 pandemic did not significantly affect the presentation, clinical course, management, and outcomes of patients presenting with acute appendicitis.
Yechiel Michael Barilan
This focus article is a theoretical reflection on the ethics of allocating respirators to patients in circumstances of shortage, especially during the coronavirus disease-2019 (COVID-19) outbreak in Israel. In this article, respirators are placeholders for similar life-saving modalities in short supply, such as extracorporeal membrane oxygenation machines and intensive care unit beds.
In the article, I propose a system of triage for circumstances of scarcity of respirators. The system separates the hopeless from the curable, granting every treatable person a real chance of cure. The scarcity situation eliminates excesses of medicine, and then allocates respirators by a single scale, combining an evidence-based scoring system with risk-proportionate lottery.
The triage proposed embodies continuity and consistency with the healthcare practices in ordinary times. Yet, I suggest two regulatory modifications: one in relation to expediting review of novel and makeshift solutions and the second in relation to mandatory retrospective research on all relevant medical data and standard (as opposed to experimental) interventions that are influenced by the triage
Sorin Daniel Iordache MD, Albert Gorski MD, Marwa Nahas MSc (OT) MHA, Lior Feintuch MD, Nimrod Rahamimov MD, and Tal Frenkel Rutenberg MD
Background: The collapse of the Syrian healthcare system during the civil war led numerous citizens to cross the Syrian–Israeli border to seek medical care.
Objectives: To describe the epidemiology of peripheral nerve injuries (PNIs) sustained in war, their management, and short-term outcomes.
Methods: A retrospective case series study was conducted on 45 consecutive patients aged 25.7 ± 9.3 years. These patients were referred to the hand surgery unit of the department of orthopedic surgery and traumatology at Galilee Medical Center between December 2014 and June 2018. Median time between injury and presentation was 60 days. Injury pattern, additional injuries, surgical findings and management, complications, and length of hospital stay were extracted from medical records.
Results: Most injuries were blast (55.6%) followed by gunshot injuries (37.8%). There were 9 brachial plexus injuries, 9 sciatic nerve injuries, and 38 PNIs distal to the plexus: specifically 20 ulnar, 11 median, and 7 radial nerve injuries. In the latter group, neurotmesis or axonotmesis was found in 29 nerves. Coaptation was possible in 21 nerves necessitating cable grafting in 19. A tendon transfer was performed for 13 peripheral nerves, occasionally supplementing the nerve repair. The patients returned to their country after discharge, average follow-up was 53.6 ± 49.6 days.
Conclusions: For nerve injuries sustained in war, early surgical treatment and providing adequate soft tissue conditions is recommended. Tendon transfers are useful to regain early function.
Naama Bursztyn MD, Tomer Arad MD, Tamar Fink RN, Jonathan Cohen MD, and Michael Stein MD
Background: Consent rates for organ donation remain one of the most important factors determining the number of organs available for transplantation. Trauma casualties constitute a substantial part of the deceased organ donor pool and have unique characteristics that distinguish them from the general donor population. However, this group has not been extensively studied.
Objectives: To identify donor factors associated with positive familial consent for solid organ donation among trauma casualties.
Methods: This retrospective study included all trauma casualties who were admitted to the Rabin Medical Center, Beilinson hospital, during the period from January 2008 to December 2017, who were potential organ donors. Data collected included demographic features, the nature of the injury, surgical interventions, and which organs were donated. Data was collected from the Rabin Medical Center Trauma Registry.
Results: During the study period 24,504 trauma patients were admitted and 556 died over their hospital course. Of these 76 were potential donors, of whom 32 became actual donors and donated their organs. Two factors showed a statistically significant correlation to donation, namely female gender (P = 0.018) and Jewish religion of the deceased (P = 0.032).
Conclusions: Only a small group of in hospital trauma deaths were potential solid organ donors (13.7%) and less than half of these became actual donors. Consent rates were higher when the deceased was female or Jewish
Alexander Feldman MD, Nahum A. Freedberg MD, Dante Antonelli MD, Ehoud Rozner MD, and Yoav Turgeman MD
Background: Patients admitted to the hospital after successful resuscitation from sudden cardiac death (SCD) are treated with therapeutic hypothermia (TH) to facilitate brain preservation. The prognostic significance of J (Osborn) waves (JOW) in the 12 leads electrocardiogram in this setting has not been elucidated as yet.
Objectives: To ascertain retrospectively the prognostic significance of JOW recorded during TH in SCD survivors.
Methods: The study comprised 55 consecutive patients who underwent TH. All patients achieved a core temperature of 33°C at the time of electrocardiogram analysis. We compared 33 patients with JOW to 22 patients without JOW. The endpoints were in-hospital, long-term all-cause mortality, and irreversible anoxic brain injury (IABI).
Results: Patients with JOW compared to patients without JOW were younger (55.1 ± 11.6 vs. 64.5 ± 11.7 years, respectively, P < 0.006), with a lower incidence of hypertension (52% vs. 86%, P < 0.007), diabetes mellitus (15% vs. 50%, P < 0.005), and congestive heart failure (15% vs. 45%, P < 0.013). In-hospital and long-term mortality were significantly higher in patients without JOW (86% vs. 21%, 91% vs. 24%, respectively, P < 0.000001). Among patients without JOW who survived hospitalization, 66.7% presented with IABI versus 7.7% of the patients with JOW (P < 0.0001). In multivariate analysis, the absence of JOW was a significant predictor for poor prognosis.
Conclusions: The absence of J (Osborn) waves on electrocardiograms obtained during TH is associated with poor prognosis among SCD survivors
Vladimir Poletaev MD, Dante Antonelli MD, Galina Litskevich MD, and Yoav Turgeman MD
Background: The cold season seems to be a trigger for atrial fibrillation (AF). Some reports are controversial and demonstrate variability according to the climatic characteristics in different regions.
Objective: To analyze whether meteorological factors contribute to seasonal variation of exacerbation of AF diagnosed in patients referred to the emergency department (ED) of our hospital.
Methods: We retrospectively reviewed medical data of consecutive patients admitted to the ED with symptomatic acute onset AF from 1 January 2016 to 31 December 2018. We recorded the mean monthly outdoor temperature, barometric pressure, and relative humidity during the study period.
Results: During the study period, 1492 episodes of AF were recorded. New onset AF were 639 (42.8%) and paroxysmal atrial fibrillation (PAF) were 853 (57.2%) (P = 0.03). The number of overall admission of AF episodes was not distributed uniformly through the year. Incidence of AF episodes peaked during December and was lowest in June (P = 0.049). Of 696 episodes (46.6 %) the patients were hospitalized and for 796 (53.4%) the patients were discharged (0.01). The number of hospitalizations was not distributed uniformly through the year (P = 0.049). The highest number of hospitalizations happened in December and the lowest in May. Outdoor temperature and barometric pressure (but not relative humidity) may mediate a monthly fluctuation in AF episodes with highest number of ED visits in December and the lowest in June.
Conclusions: Meteorological conditions influence exacerbation of AF episodes and hospitalization. Outdoor temperature and barometric pressure may mediate a monthly fluctuation in AF
Lea Kahanov MD, José E. Cohen MD, Shifra Fraifeld MBA, Cezar Mizrahi MD, Ronen R. Leker MD, Samuel Moscovici MD, and Sergey Spektor MD PhD
Background: Superficial temporal artery-middle cerebral artery microvascular bypass (STA-MCA MVB) is an important strategy for the management of selected patients.
Objective: To present our 19-year experience with STA-MCA MVB.
Methods: Data for consecutive patients who underwent STA-MCA MVB from 2000–2019 due to moyamoya/moyamoya-like disease, complex intracranial aneurysms, or intractable brain ischemia due to internal carotid artery or MCA occlusive disease with repeated ischemic events were retrospectively analyzed under a waiver of informed consent. Key surgical steps and the important role of neuroendovascular interventions are presented. Surgical results and late outcomes were analyzed.
Results: The study included 32 patients (17 women [53%], 15 men [47%]), mean age 42.94 years (range 16–66). The patients underwent 37 STA-MCA MVB procedures during the study period: 22 with moyamoya/moyamoya-like disease (69%) underwent 27 surgeries (five bilateral); 7 patients with complex aneurysms (22%) and 3 patients with vascular occlusive disease (9%) underwent unilateral bypass. Five of seven aneurysms were treated with coiling or flow-diverter stent implant prior to bypass surgery; two were clipped during the bypass procedure. There were no surgical complications, no perioperative mortality, and no death from complications related to neurovascular disease at late follow-up. Transient neurological deficits following 7/37 surgeries (19%) resolved with no permanent neurologic sequelae. Transient ischemic attacks occurred only in the immediate postoperative period in four patients (11%).
Conclusions: In specific cases, STA-MCA MVB is a feasible and clinically effective procedure. It is important to preserve this technique in the surgical armamentarium