Israel Medical Association Journal

Background: The estimated incidence of esophageal atresia (EA) with or without tracheo-esophageal fistula (TEF) is 1:3500 live births. During childhood these patients have various co-morbidities, but the overall quality of life among adults is similar to that of the general population.

Objectives: To evaluate short- and long-term co-morbidities and quality of life among infants born with EA ± TEF at a large single medical center.

Methods: Medical records of 65 children born over a 21 year period were reviewed for short- and long-term medical data. Telephone interviews were conducted with 46 of their parents regarding medical problems and quality of life after home discharge.

Results: The main long-term co-morbidities during the first 2 years of life, 4–6 years of age, and during adolescence (12–16 years) included gastro-esophageal reflux disease (GERD) in 56.5%, 35.8%, and 18.7%, respectively; stridor in 84.8%, 45.2%, and 12.5%, respectively; hyper-reactive airway disease (HRAD) in 43.5%, 35.5%, and 36.5%, respectively; recurrent pneumonia in 43.5%, 32.3%, and 18.8%, respectively; and overall recurrent hospitalizations in 87%, 41.9%, and 25%, respectively. The quality of life was reportedly affected among 100%, 75%, and 33.3% respectively.

Conclusions: Long-term follow-up of patients with EA ± TEF indicates a high burden of co-morbidities during the first 6 years of life, with a gradual decrease in symptoms thereafter. Nevertheless, HRAD continued to impact the daily life of about one-third of the older adolescents, and GERD one-fifth. A long-term multidisciplinary follow-up should be conducted to prevent late onset complications that may affect the quality of life.

Background: Children and adolescents are commonly referred to an orthopedic surgeon to assess knee malalignment.

Objectives: To assess the prevalence of genu varum and valgum among adolescents, and to identify correlates of these conditions.

Methods: A medical database of 47,588 candidates for military service presenting to the northern recruitment center during an 11 year period was analyzed to identify clinical knee alignment. Based on the standing skin surface intercondylar distance (ICD) or intermalleolar distance (IMD), the prevalence rates of genu varum (ICD ≥ 3 cm) and genu valgum (IMD ≥ 4 cm) were calculated. The association of gender, body mass index (BMI), and place of residence to knee alignment was studied.

Results: The rates of genu varum and valgum were 11.4% (5427) and 5.6% (2639), respectively. Genu varum was significantly more prevalent among males than females (16.2% vs. 4.4%, P < 0.001). It was also more prevalent among underweight subjects and less prevalent among overweight and obese subjects (P < 0.001). Genu valgum was significantly more prevalent among females than males (9.4% vs. 2.9%) and in overweight and obese subjects compared to those with normal BMI, while less prevalent in underweight subjects (P < 0.001). Multivariate analysis revealed that genu varum was independently positively associated with male gender, underweight, and living in a rural area. Genu valgum was independently positively associated with female gender, overweight, and obesity.

Conclusions: This study establishes a modern benchmark for the cutoff and prevalence of genu varum and valgum as well as associations with gender and BMI.

Background: Since the introduction of the electrocardiogram (ECG) in 1902, the fundamentals of ECG data acquisition, display, and interpretation in the clinical arena have not changed much.

Objectives: To present a new method to enhance and improve acquisition, analysis, and display of the standard ECG.

Methods: We performed ECG enhancement by superimposition and summation of multiple standard ECG cycles of each lead, by temporal alignment to peak R wave and voltage alignment to an improved baseline, at the T-P segment.

Results: We enhanced ECG recordings of 504 patients who underwent coronary angiograms for routine indications. Several new ECG features were noted on the enhanced recordings. Examination of a subgroup of 152 patients with a normal rest 12-lead ECG led to the discovery of a new observation, which may help to distinguish between patients with and without coronary artery disease (CAD): namely, a spontaneous cycle-to-cycle voltage spread (VS) at the S-T interval, normalized to VS at the T-P interval. The mean normalized VS was significantly greater in those with CAD (n=61, 40%) than without (n=91, 60%), 5.61 ± 3.79 vs. 4.01 ± 2.1 (P < 0.05).

Conclusions: Our novel method of multiple ECG-cycle superimposition enhances the ECG display and improves detection of subtle electrical abnormalities, thus facilitating the standard rest ECG diagnostic power. We describe, for the first time, voltage spread at the S-T interval, an observed phenomenon that can help detect CAD among individuals with normal rest 12-lead ECG.

Background: The authors describe a multifaceted cross-infection control program that was implemented to contain an epidemic of multidrug-resistant microorganisms (MRO) (carbapenem resistant Pseudomonas aeruginosa and Acinetobacter baumannii; extended spectrum β-lactamase producing Klebsiella pneumoniae, Escherichia coli, Enterobacter Cloacae, and Proteus mirabilis; and ‎methicillin-resistant Staphylococcus aureus and Candida species). 

Objectives: To assess the effect of a control program on the incidence of cross-infection with MRO.

Methods: Clinical criteria triaged patients into a high-risk wing (HRW) or a low-risk wing (LRW). Strict infection control measures were enforced; violations led to group discussions (not recorded). Frequent cultures were obtained, and use of antibiotics was limited. Each quarter, the incidence of MRO isolation was reported to all staff members. 

Results: Over a 6 year period, 1028 of 3113 patients were placed in the HRW. The incidence of MRO isolation within 48 hours of admission was 8.7% (HRW) vs. 1.91% (LRW) (P < 0.001). Acquired MRO infection density was 30.4 (HRW) vs. 15.6 (LRW) (P < 0.009). After the second year, the incidence of group discussions dropped from once or twice a month to once or twice a year.

Conclusions: These measures contained epidemics. Clinical criteria successfully triaged HRW from LRW patients and reduced cross-infection between the medical center wings. The quarterly reports of culture data were associated with improved staff compliance. MRO epidemic control with limited resources is feasible. 

 

Background: Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus. 

Objectives: To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized. 

Methods: Current evidence on perimortal cesarean section shows that immediate section during resuscitation provides restoration of the integrity of the mother’s vascular compartment and increases her probability of survival. We analyzed Jewish scriptures from the Talmud and verdicts of the oral law and revealed that the Jewish ethical approach toward late gestational resuscitation was discouraged since it may jeopardize the mother. 

Results: We discuss the pertinent Jewish principles and their application in light of emerging scientific literature on this topic. An example case that led to an early perimortem cesarean delivery and brought about a gratifying, albeit only partially satisfying outcome, is presented, albeit with only a partially satisfying outcome. The arguments that were raised are relevant to such cases and suggest that previous judgments should be reconsidered.  

Conclusions: The Jewish perspective can guide medical personnel to modify and adapt the concrete rules to diverse clinical scenarios in light of current medical knowledge. With scientific data showing that both mother and fetus can prosper from immediate surgical extrication of the baby during resuscitation of the advanced pregnant woman, these morals should dictate training and practice in urgent perimortal cesarean sections whenever feasible. 

 

Background: Pulmonary arterial hypertension (PAH) is a significant consequence of congenital heart disease (CHD). Its presence and severity is associated with increased morbidity and mortality. 

Objectives: To evaluate the clinical and demographic characteristics of adults with congenital heart diseases (ADCHD) and PAH at a single center. 

Methods: A prospective registry of all patients with PAH was conducted between 2009 and 2015. 

Results: Thirty-two patients were identified. The mean age at the last visit was 44 years (range 19–77 years). The prevalence of PAH among all ADCHD patients was 6% (95% confidence interval 4.3%–8.4%). A much higher prevalence (53%) was found in patients with Down syndrome. Most patients with PAH had moderate or severe disease. Fifteen patients (47%) were treated with pulmonary vasodilators and 6 (19%) with combination therapy. The average World Health Organization functional class was 2.6. Morbidity included cerebral vascular accident or transient ischemic attack in 22% (mostly in patients with right-to-left shunt) and arrhythmia in 37% of the patients. During a median follow-up of 3.5 years, 5 patients (15.6%) died. Of 13 women with no mental retardation, 11 were or had been married and all had children (between 1 and 13, mean 3.3). 

Conclusions: Patients with congenital heart disease and PAH have significant morbidity and mortality. PAH is more prevalent in patients with Down syndrome. While pulmonary pressure during the reproductive years was not always known, 27% of women with PAH at the time of the study were multiparous.

 

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: Deliberate self-harm (DSH) increases the danger of future suicide death and the risk increases with age. Self-harm in older adults is often associated with greater suicidal intent and lethality. 

Objectives: To investigate clinical and psychosocial variables of older patients (age ≥ 65 years) assessed due to DSH, compared with younger adults.

Methods: Patients admitted to the Emergency Department following DSH during an 8 year period were included.

Results: Of 1149 participants, 187 (16.6%) were older adults (age ≥ 65) and 962 (83.4%) were younger adults (< 65). The older adults reported DSH closer to mid-day (P < 0.01) and suffered more frequently from adjustment disorder and depression. Personality disorders and schizophrenia were less commonly diagnosed (P < 0.001). Prescription medication (sedatives and hypnotics) were a more frequent means (88% vs. 71%) of DSH among older patients. Younger patients with DSH used over-the-counter medications (21.9% vs. 6.4%) three times more than did the older patients (P < 0.01). Past DSH was significantly more frequent in younger adults. Following DSH the older patients were frequently admitted for further general hospitalization (P < 0.001). 

Conclusions: Older adults with DSH are a unique group with different clinical characteristics. There is a need for targeted prevention strategies and education of caregivers regarding DSH in older adults.

 

Background: Radiotherapy to the prostate bed is used to eradicate residual microscopic disease following radical prostatectomy for prostate cancer. Recommendations are based on historical series. 

Objectives: To determine outcomes and toxicity of contemporary salvage radiation therapy (SRT) to the prostate bed. 

Methods: We reviewed a prospective ethics committee-approved database of 229 patients referred for SRT. Median pre-radiation prostate-specific antigen (PSA) was 0.5 ng/ml and median follow-up was 50.4 months (range 13.7–128). Treatment was planned and delivered using modern three-dimensional radiation techniques. Mean bioequivalent dose was 71 Gy (range 64–83 Gy). Progression was defined as two consecutive increases in PSA level > 0.2 ng/ml, metastases on follow-up imaging, commencement of anti-androgen treatment for any reason, or death from prostate cancer. Kaplan-Meier survival estimates and multivariate analysis was performed using STATA. 

Results: Five year progression-free survival was 68% (95%CI 59.8–74.8%), and stratified by PSA was 87%, 70% and 47% for PSA < 0.3, 0.3–0.7, and > 0.7 ng/ml (P < 0.001). Metastasis-free survival was 92.5%, prostate cancer-specific survival 96.4%, and overall survival 94.9%. Low pre-radiation PSA value was the most important predictor of progression-free survival (HR 2.76, P < 0.001). Daily image guidance was associated with reduced risk of gastrointestinal and genitourinary toxicity (P < 0.005). 

Conclusions: Contemporary SRT is associated with favorable outcomes. Early initiation of SRT at PSA < 0.3 ng/ml improves progression-free survival. Daily image guidance with online correction is associated with a decreased incidence of late toxicity.