Israel Medical Association Journal

Background: Pancreatic injuries during nephrectomy are rare, despite the relatively close anatomic relation between the kidneys and the pancreas. The data regarding the incidence and outcome of pancreatic injuries are scarce.

Objectives: To assess the frequency and the clinical significance of pancreatic injuries during nephrectomy.

Methods: A retrospective analysis was conducted of all patients who underwent nephrectomy over a period of 30 years (1987–2016) in a large tertiary medical center. Demographic, clinical, and surgical data were collected and analyzed.

Results: A total of 1674 patients underwent nephrectomy during the study period. Of those, 553 (33%) and 294 patients (17.5%) underwent left nephrectomy and radical left nephrectomy, respectively. Among those, four patients (0.2% of the total group, 0.7% of the left nephrectomy group, and 1.36% of the radical left nephrectomy) experienced iatrogenic injuries to the pancreas. None of the injuries were recognized intraoperatively. All patients were treated with drains in an attempt to control the pancreatic leak and one patient required additional surgical interventions. Average length of stay was 65 days (range 15–190 days). Mean follow-up was 23.3 months (range 7.7–115 months).

Conclusions: Pancreatic injuries during nephrectomy are rare and carry a significant risk for postoperative morbidity.

Background: Pregestational diabetes mellitus (PGDM) carries a significantly elevated risk of adverse maternal and fetal outcomes. There is evidence that certain interventions reduce the risk for adverse outcomes. Studies have shown that a multi-disciplinary approach improves pregnancy outcomes in women with PGDM.

Objectives: To determine pregnancy outcomes in women with PGDM using a multi-disciplinary approach.

Methods: We retrospectively reviewed consecutive women with pregestational type 1 and type 2 diabetes who were monitored at a high-risk pregnancy clinic at the Sheba Medical Center. Clinical data were obtained from the medical records. All data related to maternal glucose control and insulin pump function were prospectively recorded on Medtronic CareLink® pro software (Medtronic MiniMed, Northridge, CA).

Results: This study comprised 121 neonates from 116 pregnancies of 94 women. In 83% of the pregnancies continuous glucose monitoring (CGM) sensors were applied during a part or all of the pregnancy. Pregnancy outcomes among women who were followed by a multi-disciplinary team before and during pregnancy, and during labor and puerperium resulted in better glucose control (hemoglobin A1c 6.4% vs. 7.8%), lower risk for pregnancy induced hypertension/preeclampsia (7.7% vs. 15.6%), lower birth weight (3212 g vs. 3684 g), and lower rate of large size for gestational age and macrosomia (23.1% vs. 54.2% and 3.3% vs. 28.4%, respectively), compared to data from European cohorts.

Conclusions: The multi-disciplinary approach for treating women with PGDM practiced in the high-risk pregnancy clinic at the Sheba Medical Center resulted in lower rates of macrosomia, LGA, and pregnancy induced hypertension compared to rates reported in the literature.

Background: Admission to an intensive care unit (ICU) is an objective marker of severe maternal morbidity (SMM).

Objectives: To determine the prevalence of obstetric ICU admissions in one medical center in Israel and to characterize this population.

Methods: In this retrospective study the files of women coded for pregnancy, birth, or the perinatal period and admission to the ICU were pulled for data extraction (2005–2013).

Results: During the study period, 111 women were admitted to the ICU among 120,279 women who delivered babies (0.09%). Their average age was 30 ± 6 years, most were multigravida, a few had undergone fertility treatments, and only 27% had complicated previous pregnancies. Most pregnancies (71.2%) were uneventful prior to admission. ICU admissions were divided equally between direct (usually hemorrhage) and indirect (usually cardiac disease) obstetric causes.

Conclusions: The indications for obstetrics ICU admission correlated with the proximate causes of maternal arrest observed worldwide. While obstetric hemorrhage is often unpredictable, deterioration of heart disease is foreseeable. Attention should be directed specifically toward improving the diagnosis and treatment of maternal heart disease during pregnancy in Israel.

We describe the features of nocebo, and its impact in studies of transition from the originator to the respective biosimilar in inflammatory rheumatic diseases. Investigations in healthy volunteers as well as in the neurology and anesthesiology fields demonstrated the involved cerebral areas and the neurotransmitter pathways responsible for the nocebo response. Whether these findings are applicable to patients with inflammatory rheumatic diseases remains to be demonstrated. Nocebo may account for part of the after-switching biosimilar failures. However, in the absence of validated classification or diagnostic criteria, specific neurochemical and neuroimaging studies, the lack of data on serum tumor necrosis factor and drug levels, and the disease improvement after the switching back to the originator biologic observed in some patients, the nocebo diagnosis remains the role of the individual clinician. Investigations on nocebo pathophysiology and diagnosis are required to address its impact in after-transition biosimilar studies in rheumatology.

Background: Autoimmune hepatitis (AIH) may be associated with other autoimmune diseases. Autoantibodies are common in AIH suggesting their potential role in the pathogenesis of the disease. Among these autoantibodies, thyroid autoantibodies have been reported in patients with chronic hepatitis, with greater prevalence in patients with chronic hepatitis C infection.

Objectives: To assess the prevalence of thyroid dysfunction among patients with AIH.

Methods: In this case-control, retrospective study, we examined patients diagnosed with AIH according to both the original and revised international AIH group scoring systems. Patients with other hepatic pathologies were excluded AIH was evaluated as an independent risk factor for thyroid disease by a logistic regression model. Univariate and multivariate regression analyses were conducted using hypothyroidism and hyperthyroidism as the dependent variables.

Results: Our cohort comprised 163 patients diagnosed with AIH and 1104 healthy age- and gender-matched controls. Hypothyroidism was more prevalent among those with AIH compared to controls (17.7% vs. 5%, respectively, 95% confidence interval [95%CI] 1.68–2.48, P <  0.001). Hyperthyroidism was more prevalent in AIH patients compared to controls (odds ratio 3.2% and 1.2%, respectively, 95%CI 1.68–2.47, P <  0.001). Using a multivariate logistic analysis, we found an independent association between AIH and hypothyroidism but not with hyperthyroidism.

Conclusions: Thyroid dysfunction is more prevalent in patients with AIH. Whether thyroid dysfunction is the cause or a risk factor for AIH, or vice versa, is still unclear. Screening for thyroid dysfunction is warranted after AIH is diagnosed.

Background: Internal thoracic impedance (ITI) measurement is a sensitive method for detecting preclinical pulmonary edema and pleural effusion.

Objectives: To investigate the efficacy of this non-invasive method for detecting early pleural effusion among geriatric patients and to monitor increased ITI during its resolution.

Methods: This prospective, controlled study was conducted between July 2012 and August 2015. The study comprised 70 patients aged 65 to 94 years; and 39 of the patients had pleural effusion. ITI was measured continuously with a RS-207 monitor. The predictive value of ITI monitoring was determined based on a total of eight measurements taken at 12-hour intervals over 84 hours.

Results: As a result of medical treatment, the median ITI of the study group increased from 31 (interquartile range [IQR] 28–33 ohms) to 41 ohms (IQR 38–41 ohms; P < 0.001) compared to non-significant changes in the control group. Average respiratory rate (per minute) in the study group decreased from 29 (IQR 28–34) to 19 (IQR 18–20).

Conclusions: ITI monitoring is efficient for diagnosis and for ongoing clinical evaluation of the treatment of elderly patients with pleural effusion. Timely treatment may prevent serious complications of effusions avoiding extended hospitalization.

Background: During Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) the surgeon operates exclusively through a single vaginal entry point, leaving no external scarring.

Objectives: To evaluate the learning curve of vNOTES hysterectomy by experienced gynecologists based on surgical times and short-term outcomes.

Methods: A retrospective study was conducted of the first 25 vNOTES hysterectomy surgeries performed from July to December 2018 at Rambam Health Care Campus by a single surgeon. The primary outcome was hysterectomy time. Secondary outcomes included intra-operative bleeding, length of hospitalization, postoperative pain, and need for analgesia. Socio-demographic and clinical data were retrieved from patient electronic medical charts.

Results: Median age was 64.5 years (range 40–79). Median hysterectomy time was 38 minutes (range 30–49) from the first cut until completion. Comparisons between median hysterectomy time in the first 10 hysterectomies and in the 15 subsequent procedures demonstrated a significant decrease in median total time: 45 minutes (range 41–49) vs. 32 minutes (range 30–38), respectively (P = 0.024). The median estimated intraoperative blood loss decreased from 100 ml (range 70–200) in the first 10 hysterectomies to 40 ml (range 20–100) in the subsequent procedures (P = 0.011)

Conclusions: vNOTES hysterectomy is feasible by an experienced gynecologist, with an exponential improvement in surgical performance in a short period as expressed by the improvement in hysterectomy time, low complication rates, negligible blood loss, minimal post-surgical pain, fast recovery, and short hospitalization. vNOTES allows easier and safer access to adnexal removal compared to conventional vaginal surgery.

Background: Asthma is a common respiratory disease, which is linked to air pollution. However, little is known about the effect of specific air pollution sources on asthma occurrence.

Objective: To assess individual asthma risk in three urban areas in Israel characterized by different primary sources of air pollution: predominantly traffic-related air pollution (Tel Aviv) or predominantly industrial air pollution (Haifa bay area and Hadera). 

Methods: The medical records of 13,875, 16- 19-year-old males, who lived in the affected urban areas prior to their army recruitment and who underwent standard pre-military health examinations during 2012–2014, were examined. Nonparametric tests were applied to compare asthma prevalence, and binary logistic regressions were used to assess the asthma risk attributed to the residential locations of the subjects, controlling for confounders, such as socio-demographic status, body mass index, cognitive abilities, and education.

Results: The asthma rate among young males residing in Tel Aviv was 8.76%, compared to 6.96% in the Haifa bay area and 6.09% in Hadera. However, no statistically significant differences in asthma risk among the three urban areas was found in controlled logistic regressions (P > 0.20). This finding indicates that exposure to both industrial- and traffic-related air pollution is associated with asthma prevalence.

Conclusions: Both industrial- and traffic-related air pollution have a negative effect on asthma risk in young males. Studies evaluating the association between asthma risk and specific air pollutants (e.g., sulfur dioxide, particulate matter, and nitrogen dioxide) are needed to ascertain the effects of individual air pollutants on asthma occurrence. 

 

Background: Untreated dental caries or even dental manipulations, such as a tooth extraction, might cause direct spread of an odontogenic infection and consequently the development of life-threatening conditions such as deep neck infections (DNI). The most common source of DNI is of odontogenic origin (38.8–49%). Abscess formation or cellulitis can lead to life-threatening complications, despite new diagnostic imaging technology and widespread availability of antibiotics. 

Objectives: To demonstrate the dangers of DNI, which can create life-threatening situations.

Methods: Five cases of DNI of odontogenic origin, which were referred to the oral and maxillofacial surgery unit, are presented. 

Results: Clinical manifestations included trismus, dysphagia, dysphonia, dyspnea, and infection symptoms. In all cases, computed tomography confirmed diagnosis and extent of abscess. Complications included mediastinitis, respiratory distress, osteomyelitis of the jaws, and in rare cases the mandibular condyle. Treatment included securing the airway, immediate surgical drainage, removal of the infection source, and antibiotic therapy. All patients were discharged in stable and improved condition.

Conclusions: DNI treatment on an emergency basis requires proper diagnosis and effective management. To confirm diagnosis and prevent serious complications, it is essential for physicians to recognize the spaces of the head and neck that are likely to be affected by DNI. 

 

Background: Anastomotic leakage (AL) is a major complication following colorectal surgery, with many risk factors established to date. The incidence of AL varies in the medical literature and is dependent on research inclusion criteria and diagnostic criteria.

Objectives: To determine the incidence of and the potential risk factors for AL following colorectal surgery at a single academic medical center.

Methods: We retrospectively reviewed all operative reports of colorectal procedures that included bowel resection and primary bowel anastomosis performed at Sheba Medical Center during 2012. AL was defined according to the 1991 United Kingdom Surgical Infection Study Group criteria. Data were assessed for leak incidence within 30 days. In addition, 17 possible risk factors for leakage were analyzed. A literature review was conducted.

Results: This cohort study comprised 260 patients, and included 261 procedures performed during the study period. The overall leak rate was 8.4%. In a univariate analysis, male sex (odds ratio [OR] 3.37, 95% confidence interval [95%CI] 1.21–9.43), pulmonary disease (OR 3.99, 95%CI 1.49–10.73), current or past smoking (OR 2.93, 95%CI 1.21–7.10), and American Society of Anesthesiologist score ≥ 3 (OR 3.08, 95%CI 1.16–8.13) were associated with an increased risk for anastomotic leakage. In a multivariate analysis, male gender (OR 3.62, 95%CI 1.27–10.33) and pulmonary disease (OR 4.37, 95%CI 1.58–12.10) were associated with a greater risk.

Conclusions: The incidence of AL in the present study is similar to that found in comparable series. Respiratory co-morbidity and male sex were found to be the most significant risk factors.