Israel Medical Association Journal

Background: Exposure to air pollution in the form of particulate matter smaller than 10 µm in diameter (PM10) has been associated with increased morbidity and mortality. However, since air pollution is correlated with confounding factors that might otherwise affect health, identifying the causal link has proven challenging. 

Objectives: To identify the effect of PM10 on hospital admissions due to respiratory illnesses. 

Methods: We used the Instrumental Variable (IV) methodology to control for confounding factors affecting hospital admissions. Exploiting the timing of sandstorms as an instrumental variable allows for a better estimate of the relationship between PM10 and hospital admissions. Data on PM concentrations and hospital admissions rates were compiled for Israel’s two largest cities, Jerusalem and Tel Aviv, for 2007–2009. We compared our IV estimates to those derived from a Poisson regression, which is commonly used in the existing literature. 

Results: Sandstorms led to an increase of 307 µg/m3 of PM10 concentrations. A 10 µg/m3 increase in PM10 is associated with a 0.8% increase in hospital admissions due to respiratory conditions, using Poisson regression. The same finding was noted using the IV methodology. 

Conclusions: The association between PM10 and hospital admission reflects a primarily causal relationship. Instrumental variable methodology could be applied to analysis of the effect of air pollution on hospital admissions. 

 

Background: Extracorporeal membrane oxygenation (ECMO) may serve as a bridge to regain cardiac function in refractory resuscitation. However, its use has so far been limited owing to low availability, especially in emergency departments. 

Objectives: To describe two children with acute myocarditis successfully treated with ECMO in the emergency department of a tertiary pediatric medical center. 

Description: The children presented with vomiting, followed by rapid deterioration to cardiogenic shock that failed to respond to conservative treatment. Given the urgency of their condition and its presumably reversible (viral) etiology, treatment with ECMO was initiated in the department’s resuscitation room. 

Results: Outcome was excellent, and cardiac function remained normal throughout 6 and 10 months follow-up. 

Conclusions: Extracorporeal life support has enormous potential in the emergency department and warrants further assessment.  

Background: Left cardiac sympathetic denervation (LCSD) was reported to be effective in patients with intractable ryanodine receptor mutation-associated catecholaminergic polymorphic ventricular tachycardia (CPVT). 

Objectives: To report our experience with LCSD in calsequestrin (CASQ2) mutation-associated CPVT. 

Methods: LCSD was performed in three patients with CASQ2 mutation-associated CPVT with symptoms and exercise-induced ventricular arrhythmia despite high dose beta-blocker. 

Results: None of them experienced symptoms or exercise-induced ventricular arrhythmia after LCSD. However, all had recurrence of symptoms and/or exercise-induced ventricular arrhythmia after 6 months (6–18 months).

Conclusions: LCSD conferred short-term suppression but less than optimal long-term suppression of exercise-induced ventricular arrhythmia among CASQ2-associated CPVT patients.

 

Background: Gastric bezoars in children are infrequent. Most are trichobezoars. Surgical intervention is sometimes necessary.

Objectives: To describe the clinical findings and radiological workup, as well as treatment and outcome of patients with complicated gastric bezoars who underwent surgery in our institution.

Methods: We conducted a retrospective review of all cases of surgery for gastric bezoars performed in our institution between 2000 and 2010. Data collected included gender and age of the patients, composition and extent of the bezoar, presenting signs and symptoms, imaging studies used, performance of endoscopy, and surgical approach. Outcome was measured by the presence of postoperative complications.

Results: We identified seven patients with gastric bezoars who underwent surgery. All were females aged 4–19 years. Six had trichobezoars and one had a mass composed of latex gloves. Presenting symptoms included abdominal pain, vomiting, weight loss, and halitosis. All patients had a palpable epigastric mass. A large variety of imaging modalities was used. Endoscopic removal was attempted in three patients but failed, and the laparoscopic approach was attempted in one patient and failed. All patients eventually underwent laparotomy with gastrotomy and recovered without complications. 

Conclusions: The presence of gastric bezoars should be suspected in any child with unexplained abdominal pain, vomiting, weight loss, or halitosis, or with a palpable abdominal mass, especially in girls. A variety of imaging modalities can aid in diagnosis. Endoscopic removal might be attempted, although failure of this approach is frequent and must prompt surgical intervention, preferably laparotomy and gastrotomy, which has an excellent outcome.

 

Background: The practice of administering intravenous contrast to children varies by institution depending on their routine. 

Objectives: To assess the necessity of routine contrast administration in brain magnetic resonance imaging (MRI) of pediatric outpatients referred for chronic headache workups. 

Methods: We conducted a retrospective review of consecutive pediatric brain MRI examinations performed during January and February 2014 in 30 pediatric outpatients referred for evaluation of chronic headache. Independent review was performed by two board-certified neuroradiologists. The raters reviewed each MRI first as a non-contrast examination (without seeing the post-contrast images) and then with post-contrast images. 

Results: No abnormalities were found in six patients. One patient had an indeterminate finding of a tubular cerebellar lesion requiring follow-up. In the remaining patients (n=23), the findings were subclinical and included: mucosal thickening in the paranasal sinuses in 9 patients, cystic changes of the pineal gland in 8 (size 2–9 mm), small developmental venous anomalies in 6, non-specific FLAIR hyperintensities in 4, opacification of the mastoids in 2, and telangiectasia in 1 patient. The subclinical cases that were missed on pre-contrast images were: one small developmental venous anomaly, one telangiectasia and one small pineal cyst, none of which hold clinical significance. All kappa inter-rater and intra-rater agreement scores resulted in values above 0.75, excellent agreement according to Fleiss guidelines.

Conclusions: There seems to be little reason to medically justify large-scale use of routine IV contrast administration to evaluate a brain MRI of pediatric patients referred for chronic headache. 

 

Background: Systemic sclerosis (SSc) is a chronic disease with prominent vasculopathy, inflammation, production of autoantibodies, and tissue fibrosis. Periodontitis is a chronic inflammatory oral condition manifesting as microbial infection, inflammation and destruction of the alveolar bone. In both conditions tumor necrosis factor-alpha (TNFα) and other pro-inflammatory cytokines play an important role in pathogenesis. 

Objectives: To assess the periodontal status in SSc patients and compare these parameters to TNFα level in gingival crevicular fluid (GCF) of SSc patients and healthy controls.

Methods: Twenty SSc patients and 20 controls underwent periodontal examination, including probing depth (PD), plaque index (PI), gingival index (GI), bleeding on probing (BOP), and measurement of TNFα levels in collected GCF. 

Results: SSc patients had a greater PD (3.74 ± 0.32 mm vs. 3.35 ± 0.31 mm, P > 0.003), GI (1.53 ± 0.34 vs. 1.12 ± 0.54, P > 0.049), and non-significantly higher BOP than controls. TNFα levels in GCF were higher in SSc patients (1.63 ± 0.36 vs. 1.15 ± 0.34 pg/ml, P = 0.001). Periodontitis parameters correlated with several SSc variables; PI in particular was higher in patients with longer disease duration, sclerodactyly, more severe skin involvement, and SSc activity score.

Conclusions: Patients with SSc have higher indices of periodontal inflammation and higher TNFα level in GCF than did healthy individuals. These changes probably reflect the complexity of factors that influence oral health in SSc. Common pathologic pathways may be responsible for the association between SSc and periodontitis, which requires further study.

 

Background: The association between antiphospholipid antibodies (aPL) and multiple sclerosis (MS) has been suggested previously, but prior studies provided contradicting findings. 

Objectives: To characterize the expression profile of eight classic and non-classic aPL in patients diagnosed with MS.

Methods: Using the BioPlex™ 2200 immunoassay, we measured the levels of serum immunoglobulin (Ig)M and IgG isotypes of three classic aPL and five non-classic aPL in 98 subjects with MS and 237 healthy controls. 

Results: Three non-classic aPL were significantly more prevalent among MS patients in comparison to the control group. These antibodies included IgM and IgG against phosphatidylserine-β2GPI (PS-B2), IgG prothrombin complex (PT-PT) and IgM prothrombin (PT). The positive results according to Bonferroni correction are PS-B2 IgG and PT-PT IgG. The remaining aPL profiles did not differ significantly between the two groups.

Conclusions: An association between certain non-classic aPL and MS has been established. The specific role of these autoantibodies in the pathogenesis of the condition remains uncertain.  

 

Background: In the last decade the number of robotic devices and the medical procedures utilizing them increased significantly around the world.

Objective: To evaluate the implementation of robotic surgeries in Israel in various surgical disciplines.

Methods: We conducted a retrospective study accessing information about the annual purchases of robots, the number of physicians trained for their use, and the number of robotic surgeries performed each year, according to indications of surgery and the disciplines of the operating medical staff. The data were taken from the database of Intuitive Surgical Inc.

Results: Six robots were purchased by six medical centers in Israel during the years 2008–2013. There are currently 150 physicians trained to use the robot in one of the simulators of Intuitive Surgical Inc. Of them, 104 are listed as active robotic surgeons. Most of these physicians are urologists, gynecologists, or general surgeons. The number of robotic surgeries increased each year in all fields in which it was implemented. In 2013, 975 robotic surgeries were performed in Israel. Of them, 52% were performed by urologists; 80% of which were radical prostatectomy. 

Conclusions: The use of robotic surgery increased considerably in Israel over recent years, in urology, gynecology, general surgery, and otolaryngology. Despite the lack of conclusive evidence of the advantages of robotic surgery over the laparoscopic approach, the market power and the desire to be at the technological forefront drive many medical centers to purchase the robot and to train physicians in its use.

 

Background: In recent years several reports have been published describing dogs’ ability to detect, by scent, patients with cancer. This ability is based on the sniffing of volatile organic elements that are secreted by malignant cells, react to them. 

Objectives: To evaluate the ability of trained dogs to detect (i) breast cancer cell cultures (MCF7) compared to the control pseudo-normal keratinocyte cell line (HaCaT), and then (ii) melanoma (BG) and (iii) type 2 epithelial lung carcinoma (A549) malignant cell cultures to which they were not previously exposed in the course of their training.

Methods: Cell cultures were prepared in a standard manner. Two Belgian Shepherd dogs were trained and then tested in a single-blind test (for dogs and trainers) on their ability to detect the "target specimen," a MCF7 breast cancer cell culture. Following this, the ability of the dogs to detect cancer cell cultures that they were not previously exposed to (i.e., A549, BG) was tested. In each test round, four specimens placed in identical blocks were arranged in a line with one meter between them: one target specimen (MCF7, A549, BG), two control specimens (HaCaT), and a sample containing cell culture medium only.

Results: The two dogs picked out all the target specimens of MCF7 breast cancer cell cultures that they were trained to detect (10/10) as well as all the target specimens that they were not previously exposed to [A549 (5/5) and BG (5/5)], but did not pick out the control specimens or the cell culture medium. Thus, the sensitivity, specificity, and positive and negative predictive values for both dogs were 100%.

Conclusions: The results of this study support the assumption that cancer cells have a unique odor pattern, and that this odor pattern is common to different types of cancer.

 

Background: Several studies have identified associations between low vitamin D concentrations and risk of upper respiratory infections (URI). T lymphocytes have a major anti-viral role, are affected by vitamin D metabolism, and may mediate the link between vitamin D and URIs. Competitive swimmers have a relatively high rate of URIs, alongside a high prevalence of low vitamin D concentration. 

Objectives: To examine the associations linking T cell receptor excision circles (TREC, markers of thymus activity), circulating 25(OH)D concentrations and the effect of vitamin D supplementation, and URI symptoms in young competitive swimmers.

Methods: We tested 82 adolescent swimmers for serum 25(OH)D and TREC concentrations and found that 55 had vitamin D insufficiency. Randomized supplementation of either vitamin D3 or placebo was given for 12 winter weeks. URI symptoms were recorded weekly. The associations between TREC copy numbers, vitamin D and URI burden were examined.

Results: TREC concentrations decreased with the participants’ age (r = -0.346, P = 0.003), with no significant between-gender difference. TREC concentrations did not materially differ among subjects with normal, insufficient or deficient vitamin D status, and were not affected by vitamin D supplementation. No significant correlations were found between TREC levels or their changes during the study period, and mean URI severity or duration. 

Conclusions: Thymus activity, represented by higher TREC levels, was not related to vitamin D concentrations or status, and was not affected by vitamin D supplementation in adolescent swimmers. TREC concentrations were not associated with URI severity or duration in this population.