Israel Medical Association Journal

Background: Lower extremity amputation related to diabetes is a serious outcome, which can have devastating effects on the patient and family. The epidemiology of amputations has recently been used as a possible measure of the adequacy of medical prevention and treatment of diabetes and diabetic foot complications.

Objectives: To report on patients undergoing amputations at one medical center in Israel, their co-morbidities, and the outcomes.

Methods: A retrospective chart study was conducted of amputees operated between 1 September 2017 and 30 September 2018.

Results: The study population comprised 72 patients who had major amputations for diabetes and/or ischemia, mean age 72 ± 10 years, 74% males, 93% with type 2 diabetes. Mean age corrected Charlson Comorbidity Index was 8.2 ± 2.1 with 90% (65 patients) presenting with a score of 6 or higher. Before the recent deterioration, fewer than 20% of the patients exited their home routinely and 24% had an official diagnosis of dementia. There were 31 below knee amputations (BKA) and 41 above knee amputations (AKA). The 30-day, 3-month, 1-year, and 2-year mortality rates were 15.3%, 27.8%, 43.1%, and 54.2% respectively. Median survival period was 20 months. Survival after AKA was 13.4 ± 20, which was significantly less than after BKA (25.4 ± 2.7, P = 0.097).

Conclusions: Factors other than the quality of management of patients with diabetes and complications may contribute to amputation rates; thus, making speculations from international comparisons of raw amputation rates problematic. This population was less healthy than reported in most studies.

Background: Advanced heart failure (HF) carries a high rate of recurrent HF hospitalizations and a very high mortality rate. Mechanical devices and heart transplantation are limited to a select few. Dialysis may be a good alternative for advanced HF patients with volume overload despite maximal pharmacological therapy.

Objectives: To assess the net clinical outcome of peritoneal dialysis or hemodialysis in patients with advanced HF.

Methods: We analyzed all advanced HF patients who were referred for dialysis due to volume overload in our institution. Patients were followed for complications, HF hospitalizations, and survival.

Results: We assessed 35 patients; 10 (29%) underwent peritoneal dialysis and 25 (71%) underwent hemodialysis; 71% were male; median (interquartile range) age was 74 (67–78) years. Estimated glomerular filtration rate was 20 (13–32) ml/min per 1.73 m². New York Heart Association functional capacity was III. Median follow-up time was 719 days (interquartile range 658–780). One-year mortality rate was 8/35 (23%) and overall mortality rate was 16/35 (46%). Three patients (9%) died during the first year due to line or peritoneal dialysis related sepsis, and 6 (17%) died during the entire follow-up. The median number of HF hospitalizations was significantly reduced during the year on dialysis compared to the year prior to dialysis (0.0 [0.0–1.0] vs. 2.0 [0.0–3.0], P < 0.001).

Conclusions: Dialysis is reasonably safe and significantly reduced HF hospitalization in advanced HF patients. Dialysis could be a good alternative for advanced HF patients with intractable volume overload.

Background: Environmental, social, and governance (ESG) is a form of international private business self-regulation that aims to contribute to society from a philanthropic, activist, or charitable nature by engaging in or supporting volunteering or ethically oriented practices. The major benefit of ESG is having the organization’s workers recruited for the goal of making the world a better place. There is a growing understanding regarding the extent of the environmental impacts of health services. Therefore, the interest in measuring and reporting the sustainability of health system performance is becoming crucial. As population aging and growth in healthcare demand are two of the main challenges of the current and mainly future health services, performance, and quality measurement as well as sustainability metrices are relevant more than ever.

Objectives: To review the ESG activities at Assuta Medical Centers (AMC) that helped the organization earn the Maala Index Platinum + grade in 2021.

Methods: We reviewed the ESG elements that were implemented at AMC.

Results: AMC entered an ESG process in November 2019 and earned Platinum and Platinum+ grades from the Maala Index in 2020 and 2021, respectively. AMC won the Workforce Diversity prize for having many employees over 60 years of age. AMC activities are detailed as a case study for other health organizations in Israel and worldwide.

Conclusions: A big leading health organization can spearhead sustainable development goals model in Israel and worldwide.

Background: Self-management, an active life routine, and adherence to physical activity are effective in the management of low back pain (LBP). However, delivering effective education and reassurance to patients can be a difficult for practitioners. The enhanced transtheoretical model intervention (ETMI) has shown to be successful and cost effective. The intervention focuses on educating practitioners to reassure patients, empower them to increase physical activity, and improve their self-efficacy.

Objectives: To assess whether ETMI can be implemented among primary care practitioners and to examine whether it reduces pain, disability, and fear avoidance as well as decreasing healthcare utilization. This protocol outlines the methodology for the implementation of ETMI through a hybrid implementation–effectiveness design.

Methods: Two qualitative and mixed-method studies provided a basis for an implementation prospective cohort study. Discussions are followed by a prospective cohort study with pre-and post-intervention measures as well as descriptions retrieving economic and therapeutic outcome data from the Maccabi Healthcare Services (MHS) databases. In addition, a fourth qualitative study was conducted at the midpoint of the implementation to evaluate the process by measuring the perceptions and practice of practitioners. The intervention group was 220 primary care practitioners and their patients (~n=10,000) from the central district of MHS. The control data was provided by other care districts with similar socioeconomic makeup (~n=40,000).

Conclusions: We evaluated the process and outcomes of the implementation of ETMI. We investigated the relationship between the care received (ETMI against treatment as usual) and healthcare utilization, costs, and patient-clinical outcomes.

Background: Over the past several years there has been a marked increase in the number of Israel Defense Forces (IDF) soldiers having hip arthroscopy based on magnetic resonance arthrography diagnosis of hip labral tears and/or impingement.

Objectives: To detail characteristics of soldiers who underwent hip arthroscopy and assess outcomes and rate of return to duty.

Methods: A retrospective chart review was conducted of all soldiers who underwent hip arthroscopy 2018 to 2020, and soldiers referred for hip arthroscopy during 2021. Demographic, medical, and military service data were collected from the computerized patient record.

Results: Our study comprised 117 soldiers (29% combatants, 24% females) who underwent hip arthroscopy, mean age 22 ± 3 years, range 18–42; 45% had physiotherapy before surgery; 31% were diagnosed during or within 3 months of having back pain and 20% had been referred for psychological assistance (not related to the hip pain); 15.4% had serious adverse events. The mean time to return to any duty (including clerical work) was 8.0 ± 0.6 months; 56% of the soldiers never returned to service and were discharged from the military. During the one-year follow-up, only 6% returned to their full pre-symptom activity.

Conclusions: The short-term results of IDF soldiers who underwent hip arthroscopy during the study period were much inferior to those reported among athletes. The lack of specificity of the diagnostic tools (history, examination, and imaging) used to determine whether surgery for hip pain is likely to be beneficial in this population may be contributing to over-diagnosis and over-treatment.

Background: There has been a rapid increase in vulnerable subpopulations of very old with co-morbidity, dementia, frailty, and limited life expectancy. Being treated by many specialists has led to an epidemic of inappropriate medication use and polypharmacy (IMUP) with negative medical and economic consequences. For most medications there are no evidence-based studies in older people and treatments are based on guidelines proven in much younger/healthier populations.

Objectives: To evaluate whether the benefits of reducing IMUP by poly-de-prescribing (PDP) outweighs the negative outcomes in older people with polypharmacy.

Methods: The Garfinkel method and algorithm were used in older people with polypharmacy (≥ 6 prescription drugs).

Results: We found that in nursing departments, of 331 drugs de-prescribed only 32 (10%) had to be re-administered. Annual mortality and severe complications requiring referral to acute care facility were significantly reduced in PDP (P < 0.002). In community dwelling older people, successful de-prescribing was achieved in 81% with no increase in adverse events or deaths. Those who de-prescribed ≥ 3 prescription drugs showed significantly more improvement in functional and cognitive status, sleep quality, appetite, serious complications, quality of life, and general satisfaction compared to controls who stopped ≤ 2 medications (P < 0.002). Rates of hospitalization and mortality were comparable. Clinical improvement by polydeprescribing was usually evident within 3 months and persisted for several years. The main barrier to polydeprescribing was physician’s unwillingness to deprescribe (P < 0.0001)

Conclusions: Applying the Garfinkel method of PDP may improve the lives of older people and save money.

Background: Data on how the coronavirus disease 2019 (COVID-19) affected consultations in ophthalmic departments are sparse.

Objectives: To examine the epidemiology of ophthalmic consultations in a large pediatric emergency medicine department (PED) during the first nationwide COVID-19 lockdown in Israel.

Methods: The database of a tertiary pediatric medical center was retrospectively reviewed for patients aged < 18 years who attended the PED from 17 March to 30 April 2020 (first COVID-19 lockdown) and the corresponding period in 2019. Background, clinical, and disease-related data were collected from the medical charts and compared between groups.

Results: The study included 757 PED visits. There were no significant differences in demographics between the groups. The 2020 period was characterized by a decrease in PED visits (by 52%), increase in arrivals during late afternoon and evening (P = 0.013), decrease in visits of older children (age 5–10 year), and proportional increase in younger children (age 1–5 years) (P = 0.011). The most common diagnoses overall and during each period was trauma followed by conjunctivitis and eyelid inflammation. The mechanisms of trauma differed (P = 0.002), with an increase in sharp trauma and decrease in blunt trauma in 2020 (P < 0.001 for both). In 2020, 95% of traumatic events occurred in the home compared to 54% in 2019 (P < 0.001).

Conclusions: Parents need to learn appropriate preventive and treatment measures to prevent serious and long-term ophthalmic injury while minimizing their exposure to the COVID-19. PEDs and ophthalmic pediatric clinics should consider increasing use of telemedicine and the availability of more senior physicians as consultants during such times.

Background: The influence of the coronavirus disease 2019 (COVID-19) pandemic caused countries worldwide to implement lockdowns. Elective surgeries were temporarily suspended, with surgeries being performed only for emergent/urgent medical conditions such as hip fractures where early surgical intervention has shown decreased rates of morbidity/mortality.

Objectives: To assess the indirect influence of the COVID-19 pandemic and associated lockdown on hip fracture patients, considering factors such as time to surgery, early postoperative complications, and ambulation status.

Methods: A comparative retrospective study was conducted on consecutive patients presenting to our emergency department (ED) with hip fractures that were treated surgically (N=29) during a 1-month period during the government lockdown due to the COVID-19 pandemic. The treatments were compared to consecutive patients who presented with hip fractures and were treated surgically (N=44) during the same timeframe in the previous year (control). Comparisons were made using t-test, ANOVA test, Fisher's exact test, and chi-square test.

Results: The COVID-19 group was operated on sooner (20.34 vs. 34.87 hours), had fewer early postoperative complications (10.3% vs. 31.8%), had better ambulatory status at discharge, and experienced a shorter hospital stay (5.93 vs. 8.13 days) with more patients being discharged home (72.4% vs. 22.7%).

Conclusions: Patients presenting with hip fractures to our ED during the COVID-19 pandemic lockdown indirectly benefited from this situation by undergoing earlier surgical treatment, thus experiencing fewer early postoperative complications, faster ambulation, and sooner discharge.

Background: Patients with autoimmune disease (AID) and coronavirus disease 2019 (COVID-19) could have higher mortality due to the co-morbidity and the use of immunosuppressive therapy.

Objectives: To analyze the risk factors and outcomes of patients with AID and COVID-19 versus a control group.

Methods: A prospective cohort study included patients with and without AID and COVID-19. Patients were paired by age and sex. Clinical, biochemical, immunological treatments, and outcomes (days of hospital stay, invasive mechanical ventilation [IMV], oxygen at discharge, and death) were collected.

Results: We included 226 COVID-19 patients: 113 with AID (51.15 ± 14.3 years) and 113 controls (53.45 ± 13.3 years). The most frequent AIDs were Rheumatoid arthritis (26.5%), systemic lupus erythematosus (21%), and systemic sclerosis (14%). AID patients had lower lactate dehydrogenas, C-reactive protein, fibrinogen, IMV (P = 0.027), and oxygen levels at discharge (P ≤ 0.0001) and lower death rates (P ≤ 0.0001). Oxygen saturation (SaO₂) ≤ 88% at hospitalization provided risk for IMV (RR [relative risk] 3.83, 95% confidence interval [95%CI] 1.1–13.6, P = 0.038). Higher creatinine and LDH levels were associated with death in the AID group. SaO₂ ≤ 88% and CO-RADS ≥ 4 were risk factors for in-hospital mortality (RR 4.90, 95%CI 1.8–13.0, P = 0.001 and RR 7.60, 95%CI 1.4–39.7, P = 0.016, respectively). Anticoagulant therapy was protective (RR 0.36, 95%CI 0.1–0.9, P = 0.041)

Conclusions: Patients with AID had better outcomes with COVID-19 than controls. Anticoagulation was associated with a lower death in patients with AID.

Background: The coronavirus disease 2019 (COVID-19) pandemic has had a significant impact on healthcare systems worldwide. The fear of seeking medical attention to avoid the possibility of being infected may have altered the course of some diseases.

Objectives: To describe our experience with the management of patients with acute cholecystitis during the pandemic at our medical center.

Methods: We compared patients treated for acute cholecystitis between 1 March and 31 August 2020 (Group I) to patients admitted with the same diagnosis during the same months in 2019 (Group II). We evaluated demographics, presenting symptoms, laboratory and imaging findings at presentation, the disease's clinical course, management, and outcome.

Results: Group I consisted of 101 patients and group II included 94 patients. No differences were noted for age (66 years, IQR 48–78 vs. 66 years, IQR 47–76; P = 0.50) and sex (57.4% vs. 51.1% females; P = 0.39) between the two groups. The delay between symptom onset and hospital admission was longer for Group I patients (3 days, IQR 2–7 vs. 2 days, IQR 1–3; P = 0.002). Moderate to severe disease was more commonly encountered in Group I (59.4% vs. 37.2%, P = 0.003). Group I patients more often failed conservative management (36% vs. 6%, P = 0.001) and had a higher conversion rate to open surgery (15.4% vs. 0%, P = 0.025).

Conclusions: Patients presenting with acute cholecystitis during the COVID-19 pandemic more often presented late to the emergency department and more showed adverse outcomes

Background: The association between use of renin-angiotensin-aldosterone (RAAS) inhibitors and both SARS-CoV-2 infection and the development of severe COVID-19 has been presented in the recent medical literature with inconsistent results.

Objectives: To assess the association between RAAS inhibitor use and two outcomes: infection with SARS-CoV-2 (Model 1) and severe COVID-19 among those infected (Model 2).

Methods: We accessed used electronic health records of individuals from Israel who were receiving anti-hypertensive medications for this retrospective study. For Model 1 we used a case-control design. For Model 2 we used a cohort design. In both models, inverse probability weighting adjusted for identified confounders as part of doubly robust outcome regression.

Results: We tested 38,554 individuals for SARS-CoV-2 who had hypertension and were being treated with medication; 691 had a positive test result. Among those with a positive test, 119 developed severe illness. There was no association between RAAS inhibitor use and a positive test. Use of RAAS inhibitors was associated with a decreased risk for severe COVID-19 (adjusted odds ratio [OR] 0.47, 95% confidence interval [95%CI] 0.29–0.77) compared with users of non-RAAS anti-hypertensive medication. The association remained significant when use of angiotensin-converting-enzyme inhibitors (adjusted OR 0.46, 95%CI 0.27–0.77) and angiotensin II receptor blockers (adjusted OR 0.39, 95%CI 0.16–0.95) were analyzed separately.

Conclusions: Among individuals with hypertension using RAAS inhibitors, we found a lower risk of severe disease compared to those using non-RAAS anti-hypertensive medications. This finding suggests that RAAS inhibitors may have a protective effect on COVID-19 severity among individuals with medically treated hypertension.

Background: The reduced immune response of maintenance hemodialysis patients to coronavirus disease 2019 (COVID-19) vaccines is a major concern.

Objectives: To analyze the late (6 months after full vaccination) antibody response and compare it to early post-vaccination titer.

Methods: We conducted a multicenter prospective study of 13 hemodialysis units in Israel.

Results: We demonstrated that the low titers observed among ESRD patients 2–3 months after vaccination with the Comirnaty vaccine (median 63.8 AU/ml) declined to critically lower values 6 months after full vaccination. (Mediananti S antibodies, 31 AU/ml). Seropositivity significantly declined among hemodialysis patients from 89% to 74% (P < 0.0001), although it did not significantly change among controls.

Conclusions: We recommend all patients on hemodialysis receive a booster COVID-19 vaccine 6 months after the second dose.