Israel Medical Association Journal

On 7 October 2023, the Hamas terror organization launched an unprecedented terror attack on Israel. Their forces infiltrated the country from the Gaza Strip invading nearby kibbutzim (collective farm settlements) and towns. During the attack an estimated 1200 Israelis were murdered and another 255 taken hostage, including children and older people, women and men.

Background: Younger patient age and relatively good prognosis have been described as factors that may increase caregiver motivation in treating patients with septic shock in the intensive care unit (ICU).

Objectives: To examine whether clinical teams tended to achieve unnecessarily higher map arterial pressure (MAP) values in younger patients.

Methods: We conducted a population-based retrospective cohort study of patients presenting with septic shock who were treated with noradrenaline and hospitalized in a general ICU between 2006 and 2018. The patients were classified into four age groups: 18-45 (n=129), 46-60 (n=96), 61-75 (n=157), and older than 75 years (n=173). Adjusted linear mixed models and locally weighted scatterplot smoothing (LOWESS) curves were used to assess associations and potential non-linear relationships, respectively, of age group with MAP and noradrenaline dosage.

Results: The cohort included 555 patients. An inverse relation was observed between average MAP value and age. Among patients aged 18–45 years, the average MAP was 4.7 mmHg higher (95% confidence interval 3.4–5.9) than among patients aged > 75 years (P-value <0.001) after adjustment for sex, death in the intensive care unit, and Sequential Organ Failure Assessment scores.

Conclusions: Among patients with septic shock, the titration of noradrenaline by staff led to a higher average MAP for younger patients. Although the MAP target is equal for all age groups, staff may administer noradrenaline treatment according to a higher target of MAP due to attitudes toward patients of different ages, despite any evidence that such practice is beneficial.

In the acute settings of generalized myasthenia gravis (MG) treatment options include plasma exchange (PLEX), intravenous immunoglobulin (IVIG), and pyridostigmines. A thymoma is associated with the disease in up to 20% of cases [1,2].

In cases where a thymoma is detected, surgical treatment to remove the tumor is recommended in certain age groups. At present, there are no clear guidelines regarding the optimal time to perform thymectomy after diagnosis of acute crisis or from the last treatment to thymectomy. Treatment is at the clinician's discretion.

Background: Massive, non-compressible bleeding is a leading cause of preventable trauma mortality. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) is a minimally invasive procedure in which a balloon catheter is maneuvered into the aorta to temporarily occlude large vessels and enable stabilization of the exsanguinating patient.

Objectives: To present experiences in assimilating REBOA at a single level 1 trauma center in Israel, to evaluate the technical aspects of the procedure, and to describe patient characteristics and outcomes.

Methods: This retrospective cohort study comprised civilians admitted with hemorrhagic shock to our trauma department who were treated with REBOA between November 2017 and July 2021. Descriptive statistics of the patients, characteristics of the injuries and patient outcomes are presented.

Results: The study included 22 patients (median age 30.1 years, 21 male). The mean systolic blood pressure (SBP) before REBOA inflation was 59.6 ± 11.4 mmHg, and the mean SBP measured after the procedure was 115.2 ± 26.3 mmHg. In 20 patients (91%), the SBP was normalized (> 90 mmHg) shortly after inflation of the balloon, and they survived the treatment in the trauma department; 15 (75%) survived the first 30 days. 

Conclusions: REBOA is an effective method for the initial resuscitation and hemorrhage control of patients with massive, non-compressible bleeding and is relatively easy to assimilate in a hospital. The achievement of immediate normalization of SBP enables medical personnel to correct physiological parameters and obtain accurate imaging before proceeding to the operating theater. 

Serum sickness is an immune-complex-mediated hypersensitivity reaction that classically presents with fever, rash, polyarthritis, or poly arthralgias. Damage is caused by formation or deposition of antigen-antibody complexes in vessels or tissues. Deposition of immune complexes causes complement activation and/or recruitment of neutrophils by interaction of immune complexes with Fc immunoglobulin G receptors. The condition was first recognized as an entity in the early 1900s in patients who had received heterologous antisera, which was historically used to treat infectious diseases. The symptoms typically occur one to two weeks after exposure to an offending agent and resolve within several weeks of discontinuation [1].

Background: Low serum albumin is known to be associated with mortality in sepsis, as it reflects effects of nutrition, catabolism, and edema.

Objectives: To examine the association of albumin levels with in-hospital mortality in adults with sepsis, stratified by age groups.

Methods: This nationwide retrospective cohort study comprised patients admitted with sepsis to intensive care units in seven tertiary hospitals during 2003–2011. Only patients with available serum albumin levels at hospital admission and one week after were included. Patients with an intra-abdominal source of sepsis were excluded. The association between sepsis and mortality was analyzed using multivariate logistic regression models.

Results: The study included 3967 patients (58.7% male, median age 69 years). Mean serum albumin levels were 3.1 ± 0.7 g/dl at admission and 2.4 ± 0.6 g/dl one week later. In a multivariate logistic regression model, serum albumin one week after admission was inversely associated with in-hospital mortality (odds ratio [OR] 0.64, 95% confidence interval 0.55–0.73 per 1 g/dl). In an age-stratified analysis, the association was stronger with younger age (OR 0.44 for patients aged < 45 years, 0.60 for patients aged 45–65 years, and 0.67 for patients aged > 65 years). Serum albumin on admission was not associated with in-hospital mortality.

Conclusions: The decline in serum albumin one week after admission is a stronger predictor of mortality in younger patients. Older patients might have other reasons for low serum albumin, which reflect chronic co-morbidity rather than acuity of disease.

Background: Emergency surgical repair is the standard approach to the management of an incarcerated abdominal wall hernia (IAWH). In cases of very high-risk patients, manual closed reduction (MCR) of IAWH may prevent the need for emergency surgery.

Objectives: To evaluate the safety, success rate, and complications of MCR in the management of IAWH conducted in an emergency department.

Methods: The data of all patients who underwent MCR between 2012 and 2018 were retrospectively collected. Patient demographics, presenting symptoms, clinical parameters, and management during the hospitalization were retrieved from the medical charts.

Results: Overall, 548 patients underwent MCR during the study period. The success rate was 25.4% (139 patients). One patient had a complication that required a laparotomy 2 days after his discharge. A recurrent incarceration occurred in 23%, 60% of them underwent successful repeated MCR and the others underwent emergency surgery. Six patients (1.4%) had a bowel perforation after a failed MCR.

Conclusions: MCR can be performed safely in the emergency department and should be consider as an option to treat IAWH, especially in high operative risk patients

Background: New direct acting antiviral agent (DAA) therapies are associated with a high sustained virological response rate (SVR) in hepatitis C virus (HCV) patients. The understanding of the impact of SVR on fibrosis stage is limited.

Objectives: To determine the effect of treatment with the DAAs on long-term liver fibrosis stages, as determined by shear-wave elastography (SWE) or FibroTest©.

Methods: Fibrosis stage was determined at baseline and at 6-month intervals after end of treatment (EOT), using two‐dimensional SWE or FibroTest©; APRI and FIB-4 scores.

Results: The study comprised 133 SVR12 patients. After a median follow-up of 15 months (range 6–33), liver fibrosis stage decreased by at least 1 stage in 75/133 patients (56%). Cirrhosis reversal was observed in 24/82 (29%). Repeated median liver stiffness SWE values in cirrhotic patients were 15.1 kPa at baseline (range 10.5–100), 13.4 kPa (range 5.5–51) at 6 months, and 11.4 kPa (range 6.1–35.8) at 12 months after EOT, P = 0.01. During the second year after EOT, no statistically significant differences in liver fibrosis stage in 12, 18, and 24 months were found. Splenomegaly was the only significant negative predictor of liver fibrosis regression during all time points of repetitive noninvasive assessment.

Conclusions: Following successful DAA treatment, the majority of our HCV patients with advanced fibrosis demonstrated significant improvement, as assessed by non-invasive methods. Advanced fibrosis stage was a negative predictor of fibrosis regression. Longer follow-up periods are required to further establish the impact of DAAs treatment in HCV patients with advanced fibrosis

Background: Extra peritoneal packing (EPP) is a quick and highly effective method to control pelvic hemorrhage.

Objectives: To determine whether EPP can be as safely and efficiently performed in the emergency department (ED) as in the operating room (OR).

Methods: Retrospective study of 29 patients who underwent EPP in the ED or OR in two trauma centers in Israel 2008–2018.

Results: Our study included 29 patients, 13 in the ED-EPP group and 16 in the OR-EPP group. The mean injury severity score (ISS) was 34.9 ± 11.8. Following EPP, hemodynamic stability was successfully achieved in 25 of 29 patients (86.2%). A raise in the mean arterial pressure (MAP) with a median of 25 mmHg (mean 30.0 ± 27.5, P < 0.001) was documented. All patients who did not achieve hemodynamic stability after EPP had multiple sources of bleeding or fatal head injury and eventually succumbed. Patients who underwent EPP in the ED showed higher change in MAP (P = 0.0458). The overall mortality rate was 27.5% (8/29) with no difference between the OR and ED-EPP. No differences were found between ED and OR-EPP in the amount of transfused blood products, surgical site infections, and length of stay in the hospital. However, patients who underwent ED-EPP were more prone to develop deep vein thrombosis (DVT): 50% (5/10) vs. 9% (1/11) in ED and OR-EPP groups respectively (P = 0.038).

Conclusions: EPP is equally effective when performed in the ED or OR with similar surgical site infection rates but higher incidence of DVT

Background: The novel coronavirus disease (COVID-19) pandemic changed medical environments worldwide.

Objectives: To evaluate the impact of the COVID-19 pandemic on trauma-related visits to the emergency department (ED).

Methods: A single tertiary center retrospective study was conducted that compared ED attendance of patients with injury-related morbidity between March 2020 (COVID-19 outbreak) and pre-COVID-19 periods: February 2020 and the same 2 months in 2018 and 2019.

Results: Overall, 6513 patients were included in the study. During the COVID-19 outbreak, the daily number of patients visiting the ED for acute trauma declined by 40% compared to the average in previous months (P < 0.01). A strong negative correlation was found between the number of trauma-related ED visits and the log number of confirmed cases of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) in Israel (Pearson's r = -0.63, P < 0.01). In the COVID-19 period there was a significant change in the proportion of elderly patients (7% increase, P = 0.002), admissions ratio (12% increase, P < 0.001), and patients brought by emergency medical services (10% increase, P < 0.001). The number of motor vehicle accident related injury declined by 45% (P < 0.01).

Conclusions: A significant reduction in the number of trauma patients presenting to the ED occurred during the COVID-19 pandemic, yet trauma-related admissions were on the rise

Background: Dietary modifications and patient-tailored medical management are significant in controlling renal stone disease. Nevertheless, the literature regarding effectiveness is sparse.

Objectives: To explore the impact of dietary modifications and medical management on 24-hour urinary metabolic profiles (UMP) and renal stone status in recurrent kidney stone formers.

Methods: We reviewed our prospective registry database of patients treated for nephrolithiasis. Data included age, sex, 24-hour UMP, and stone burden before treatment. Under individual treatment, patients were followed at 6–8 month intervals with repeat 24-hour UMP and radiographic images. Nephrolithiasis-related events (e.g., surgery, renal colic) were also recorded. We included patients with established long-term follow-up prior to the initiation of designated treatment, comparing individual nephrolithiasis status before and after treatment initiation.

Results: Inclusion criteria were met by 44 patients. Median age at treatment start was 60.5 (50.2–70.2) years. Male:Female ratio was 3.9:1. Median follow-up was 10 (6–25) years and 5 (3–6) years before and after initiation of medical and dietary treatment, respectively. Metabolic abnormalities detected included: hypocitraturia (95.5%), low urine volume (56.8%), hypercalciuria (45.5%), hyperoxaluria (40.9%), and hyperuricosuria (13.6%). Repeat 24-hour UMP under appropriate diet and medical treatment revealed a progressive increase in citrate levels compared to baseline and significantly decreased calcium levels (P = 0.001 and 0.03, respectively). A significant decrease was observed in stone burden (P = 0.001) and overall nephrolithiasis-related events.

Conclusions: Dietary modifications and medical management significantly aid in correcting urinary metabolic abnormalities. Consequently, reduced nehprolithiasis-related events and better stone burden control is expected.

Background: Benign tracheal stenosis has emerged as a therapeutic challenge for physicians involved in the care of survivors of critical care units. Although the traditional mainstay of open surgical reconstructive treatment is still considered the gold standard, endoscopic therapies such as laser re-canalization, balloon dilation, or stenting are commonly practiced in invasive bronchology. Recurrent obstructing granulomas pose a challenge for bronchoscopists. Mitomycin C (MyC) is a cytotoxic agent that is isolated from Streptomyces caespitosus and acts by inhibiting DNA and RNA synthesis through alkylation and cross-linkages. Topical MyC is commonly used in indirect laryngoscopies for the treatment of granulation tissue in the trachea by using saturated pledgets.

Objectives: To describe fiberoptic bronchoscopic submucosal injection of MyC as a treatment for recurrent bening tracheal stenosis.

Methods: The authors report their successful experience with submucosal intralesional injection of MyC in the management of recurrent obstructing granulomas/stenosis using the flexible fiberoptic bronchoscope in a series of 10 patients between 2005 and 2019.

Results: The results suggest that intralesional injection of MyC using the flexible bronchoscope after the endoscopic treatment of the stenotic lesion may reduce the rate of subsequent formation of granulation tissue and scarring without side effects.

Conclusions: The efficacy of MyC injection should be studied prospectively.