Israel Medical Association Journal

Background: The very long-term prognostic significance of ventricular late potentials (VLP) in patients post ST-elevation myocardial infarction (STEMI) is unclear.

Objective: To evaluate the long-term predictive value of VLP for mortality post-STEMI.

Methods: We conducted serial signal-averaged electrocardiography (SAECG) measurements in 63 patients on the 1st, 2nd and 3rd day pre-discharge, and 30 days after STEMI in patients admitted in 2001. We followed the patients for 10 years and correlated the presence of VLP with all-cause and cardiovascular mortality.

Results: The mean age was 59.9 ± 12.3 years. Thrombolysis was performed in 41 patients (65%). Percutaneous coronary intervention was performed pre-discharge in 40 patients (63%) and coronary artery bypass grafting in 7 (11%). Five consecutive measurements to define the presence of VLP were obtained in 52 patients (21 with VLP and 31 without). We found a higher prevalence of VLP in males compared to females (QRS segment > 114 msec, 51% vs. 12%, P = 0.02, duration of the low amplitude signal < 40 mV) in the terminal portion of the averaged QRS complex > 38 msec, 47% vs. 25%, P = 0.05). Over 10 years of follow-up, 14 (22%) patients died, 10 (70%) due to cardiovascular non-arrhythmic complications, 6 with VLP compared to only 3 without (28.6% vs. 9.7%, P = 0.125, hazard ratio = 2.96, confidence intervals = 0.74–11.84) (are these numbers meant to total 10?).

Conclusions: Over 10 years of follow-up, the presence of VLP in early post-STEMI is not predictive of arrhythmic or non-arrhythmic cardiovascular mortality.

Background: Accurate assessment of liver fibrosis is crucial for the management of patients with hepatitis C virus (HCV) infection.

Objectives: To evaluate the performance of liver segment-to-spleen volume ratio in predicting the severity of liver fibrosis.

Methods: Sixty-four consecutive HCV patients were enrolled in this retrospective study. All patients underwent contrast-enhanced computed tomography (CT) and were divided into three groups based on their hepatic fibrosis stage evaluated by shear-wave elastography (SWE): non-advanced (F0–F1, n=29), advanced (F2, n=19) and severe fibrosis (F3–F4, n=16). Using semi-automated liver segmentation software, we calculated the following liver segments and spleen volumes for each participant: total liver volume (TLV), caudate lobe (CV), left lateral segment (LLV), left medial segment (LMV), right lobe (RV) and spleen (SV), a well as their ratios: CV/SV, RV/SV, LLV/SV, LMV/SV and TLV/SV.

Results: RV/SV was found to discriminate between patients with non-advanced and advanced fibrosis (P = 0.001), whereas SV, CV, RV, TLV/SV, LMV/SV and RV/SV discriminated between patients with advanced and severe fibrosis (P < 0.05). RV/SV ≤ 3.6 and RV ≤ 2.9 were identified as the best cutoff values to differentiate non-advanced from advanced fibrosis and advanced from severe fibrosis with sensitivities of 72.2% and 92.7%, specificities of 72.7% and 77.8%, and with an area under the receiver operating characteristic (ROC) curve of 0.797 and 0.847, respectively (P ≤ 0.002).

Conclusions: RV/SV may be used for the assessment and monitoring of liver fibrosis in HCV patients prior to the administration of antiviral therapy, considering SWE as the reference method.

Background: Pre-exposure prophylaxis (PrEP) for populations at high risk for human immunodeficiency virus (HIV) is still not available in Israel.

Objectives: To analyze post-exposure prophylaxis (PEP) treatment adherence rates among adult men in Tel Aviv, Israel, who have sex with men (MSM), and to obtain data on the demographics of PEP users, exposure types, timeline of exposure and PEP administration, incidence of side effects, number of treatments per individual, and satisfaction with selected elements of treatment provision.

Methods: The authors conducted an observational cohort study of adult MSM who requested PEP treatment in the Tel Aviv Sourasky Medical Center. Information from patients receiving treatment between January 2013 and June 2014 was obtained through telephone interviews by means of a 30-item questionnaire.

Results: Of 336 individuals requesting PEP treatment, 255 (75.9%) were adult MSM, and 100 (39.2%) satisfactorily completed the interview. The average age of the study cohort was 32.4 years (standard deviation of 7.5). Ninety-one (91%) reported completing a full 28-day course of treatment, 84% reported side effects, and 20% underwent multiple courses. Satisfaction was high for interactions with the HIV specialists. Patient experience with PEP treatment in the emergency room setting, and follow-up were inadequate deficient.

Conclusions: PEP adherence rates in Tel Aviv were significantly higher than previously reported. PEP should be administered in designated community settings. PrEP as a general treatment policy might suit the MSM population in Tel Aviv.

Background: Bowel ultrasound has several possible uses in inflammatory bowel disease (IBD), including the initial evaluation of suspected IBD, monitoring of therapeutic response, detection of relapse, and diagnosis of complications as well as of extra-intestinal manifestations. However, its use has been limited mainly to countries where it is performed by the attending physician. 

Objectives: To investigate the feasibility and sensitivity of bedside bowel ultrasound performed by a gastroenterologist for assessing disease activity and complications in IBD.

Methods: We performed a feasibility study to compare the results of bowel ultrasound examination with those of another cross-sectional imaging modality (computed tomographic enterography or magnetic resonance enterography) in Crohn's disease, or with colonoscopy in ulcerative colitis.

Results: Between May 2015 and March 2016, 178 bowel ultrasound examinations were performed in 178 patients with suspected or established diagnosis of IBD. In 79 cases the results of another cross-sectional imaging or endoscopic examination performed within 3 months prior to the ultrasound exam were available. The sensitivity for detection of intestinal bowel thickening (a surrogate of inflammation) was 90%, and for detection of Crohn's disease complications, namely bowel stenosis and inflammatory mass, was 94% and 75%, respectively.

Conclusions: Bowel ultrasound is a useful and feasible bedside imaging tool for the detection of inflammation and complications in IBD patients. Bedside bowel ultrasound can be a valuable non-invasive tool to assess disease activity and complications in IBD patients when performed by the attending physician.

 

Background: The optimal approach to the evaluation of asymptomatic bacteruria in stroke patients is uncertain. 

Objectives: To compare elderly patients after an acute stroke with and without asymptomatic bacteriuria for the development of symptomatic urinary tract infections (UTI).

Methods: We prospectively monitored patients over 65 years of age admitted to our rehabilitation hospital after an acute stroke, with and without asymptomatic bacteriuria, for the development of symptomatic UTIs. The prevalence of bacteriuria was determined by urine cultures obtained 2 and 4 weeks after admission. Patients with and without persistent bacteriuria were compared to identify variables associated with bacteriuria.

Results: Fifty-five patients were included in the study. The prevalence of asymptomatic bacteriuria at baseline was 20%. Of all 55 stroke patients, 13 (23.6%) developed a symptomatic UTI during the 30 day follow-up. Patients with stroke and asymptomatic bacteriuria at baseline had an increased risk of developing a symptomatic UTI (54.5% with asymptomatic bacteriuria vs. 15.9% without, P = 0.011). To exclude the effects of several confounders, we performed multivariate Cox regression analysis, which showed that bacteruria remained a significant covariate for symptomatic UTI (hazard ratio 2.86, 95% confidence interval 0.71–10.46, P = 0.051). When subjects who experienced symptomatic urinary infection were included, the prevalence of bacteriuria in the study cohort declined to about 45.5% by 30 days. 

Conclusion: Elderly patients with stroke and asymptomatic bacteriuria have an increased risk of developing a symptomatic UTI compared to those without asymptomatic bacteriuria during a 30 day post-stroke follow-up.

 

Background: Burn scar reconstruction is extremely challenging, even for the most proficient reconstructive surgeon. Within the arsenal of tools at the plastic surgeon’s disposal, tissue expansion provides an efficient modality for reconstruction despite the reported complication rates. 

Objectives: To critically review our experience with tissue expansion for burn scar reconstruction, comparing particularly the adult and pediatric populations.

Methods: We conducted a retrospective study of the outcomes of patients who underwent burn scar reconstruction with tissue expansion at Hadassah Medical Center between January 2003 and July 2012. The data included patient age, anatomical site of expansion, number of procedures, and associated complications. The outcomes of the above-mentioned populations were also compared with those in a control group of patients undergoing reconstruction with tissue expansion for indications other than burn scars. 

Results: Sixty-seven tissue expansion procedures were carried out in 50 patients, 42 in the pediatric population (< 16 years of age) and 25 in the adult population. Complications were observed in 10 of the 42 pediatric procedures (23.8%) and in 3 of the 25 adult procedures (12%). This difference was found to be statistically significant. When the complication rate for each population was compared to its control group (tissue expansion for indications other than burn scar reconstruction, such as reconstruction for motor vehicle accident scarring, congenital nevi, or vascular malformations), no statistically significant difference was found between them (complication rates 19.8% and 12.5%, respectively). Furthermore, there was no statistically significant difference in complication rates between the different anatomical areas of expansion within both populations undergoing burn scar reconstruction. Most of the complicated cases completed successful reconstruction.

Conclusions: Tissue expansion is a useful surgical tool in post-burn scar reconstruction, both in the adult and pediatric populations and in all anatomic sites, despite consistently high complication rates, especially in the pediatric population. This complication rate is not higher than in patients undergoing tissue expansion for indications other than burn scar reconstruction. 

Background: In recent decades cataract surgery has shifted slowly from public hospitals to ambulatory surgery centers, demonstrating changes in the profile of patients presenting to public hospitals for cataract surgery. These changes may potentially affect the complexity of surgeries, their volume, resident training, and perhaps also visual outcomes and patient satisfaction. 

Objectives: To assess the changes in the medical and demographic characteristics of patients undergoing cataract surgery in a public hospital over a period of 15 years. 

Methods: We retrospectively reviewed the records of patients undergoing preoperative assessment before cataract surgery. Records for the period October 2000 to January 2001 (100 patients), October 2006 to January 2007 (100 patients), and October 2013 to January 2014 (150 patients) were assessed for demographic, systemic and ocular related parameters. 

Results: There was a significant increase in the average age of patients (70.4, 72.4, 73.9 years, P = 0.026), with a significant increase in the percentage of patients of Arab ethnicity (17%, 11%, 28.7%, P = 0.002), and concomitant systemic co-morbidities (38%, 46%, 64.7%, P < 0.0001). There was an increase in the percentage of patients with narrow palpebral fissures (0%, 2%, 8%, P = 0.003), deep-set eyes (2%, 4%, 18%, P < 0.0001), dense nuclear sclerotic cataract (38%, 34.4%, 56.9%, P = 0.001), and a significant increase in the percentage of patients taking alpha-blocking medications (0%, 8%, 10.7 %, P = 0.004).

Conclusions: Patients presenting for cataract surgery in 2013 compared to those in earlier periods are older, sicker and have more ocular conditions potentially affecting cataract surgery outcomes, patient satisfaction and residents' training. 

 

Background: More than 90% of all thyroid cancers are differentiated thyroid carcinomas (DTC) with a 10 year survival rate greater than 90%. The commonly used risk stratification systems for DTC include: European Organization for Research and Treatment of Cancer (EORTC), AGES (Age, histologic Grade, Extent of tumor, Size), AMES (Metastasis) and MACIS (Completeness of resection, local Invasion). Other systems are also utilized. Several new factors that may be involved in DTC risk stratification have emerged in recent studies, with other "traditional" factors being challenged. 

Objectives: To present recent updates in the literature on new potential prognostic factors for DTC.

Methods: We conducted a literature review and analysis of publications regarding DTC prognostic factors or risk stratification published in the last 10 years. 

Results: Several new factors with potential prognostic implications for DTC were noted, including family history, lymph node involvement parameters, positive PET-CT findings, multifocal disease, thyroglobulin level and several molecular markers including BRAF. Increasing age is associated with poorer outcome in DTC; however, recent studies suggest that the cutoff point of 45 years may be contested. Furthermore, several studies have shown contradictory results regarding male gender as a negative prognostic factor, thus questioning its prognostic significance. 

Conclusions: A number of new factors with potential prognostic implications for DTC have emerged and should be addressed. However, their role and possible inclusion in new staging systems has yet to be determined.