Israel Medical Association Journal

Background: Primary retroperitoneal neoplasms (PRN) arise from diverse retroperitoneal tissues. Soft tissue sarcomas (STS) comprise the majority and are well studied. Other non-sarcomatous PRN are very rare and less familiar.

Objectives: To evaluate the clinicopathologic and radiologic features of non-sarcomatous PRN, as well as the outcome of complete tumor resection (TR).

Methods: Retrospective data were collected on consecutive patients (June 2006 to January 2015) who underwent resection of retroperitoneal lesions at our department. Final pathology of non-sarcomatous PRN was included.

Results: The study population included 36 patients (26% with PRN). PRN were neurogenic (17%), fat-containing (3%), and cystic (6%). The preoperative diagnosis was correct in only 28%. All patients underwent TR via laparotomy (72%) or laparoscopy (28%), for mean operative time of 120 ± 46 minutes. En bloc organ resection was performed in 11%. Complete TR was achieved in 97%. Intra-operative spillage occurred in 8%. Intra-operative, 90-day postoperative complications, and mortality rates were 11%, 36%, and 0%, respectively. The mean length of stay was 6.5 ± 5.5 days. The median overall survival was 53 ± 4.9 months.

Conclusions: Familiarity with radiologic characteristics of PRN is important for appropriate management. Counter to STS, other PRN are mostly benign and have an indolent course. Radical surgery is not required, as complete TR confers good prognosis. Expectant management is reserved for small, asymptomatic, benign neoplasms.

Background: The use of graphic depictions (pictorials) to represent medical conditions is an accepted method that can complement standard methodology of comprehensive geriatric assessment.

Objectives: To use the clinical pathway method to develop a comprehensive geriatric genogram assessment tool (CGGAT), which could supplement the written summary letter and recommendations.

Methods: We used the critical paths method to develop a tool to facilitate implementation of the comprehensive geriatric assessment recommendations. A multidisciplinary group of clinicians used the critical pathways method to develop a CGGAT.

Results: We used the CGGAT to depict the physical and functional status of patients and to complement the textual historical information, family dynamics, and current patient issues. CGGAT is a simple instrument that provides a visual structure and it can facilitate the sharing of information among team members, encourage interdisciplinary dialogue, enhance understanding and adherence on the part of patients and professionals, and reduce the burden on the clinicians who conduct the initial comprehensive geriatric assessment.

Conclusions: We showed the benefits and obstacles related to the adaptation of this new tool and provide recommendations for further development. 

Background: Sonographic estimation of birth weight may differ among evaluators due to its operator-dependent nature.

Objectives: To compare the accuracy of estimation of fetal birth weight by sonography between ultrasound-certified physicians and registered diagnostic medical technicians.

Methods: The authors reviewed ultrasound examinations that had been performed by either technicians or ultrasound-certified obstetricians between 2010 and 2017, and within 2 days of delivery. Inclusion criteria were: singleton viable pregnancy, details of four ultrasound measurements (abdominal circumference, bi-parietal diameter, head circumference, and femur length), and known birth weight. The estimated fetal weight (EFW) was calculated according to the Hadlock formula, incorporating the four ultrasound measurements. The mean percentage error (MPE) was calculated by the formula: (EFW-birth weight) x100 / birth weight.

Results: Technicians performed 9741examinations and physicians performed 352 examinations. The proportion of macrosomic neonates was similar in both groups. Technicians were more accurate than physicians in terms of the MPE, absolute MPE, proportion of estimates that fell within ± 10% of birth weight, and Euclidean distance (P < 0.0001 for all comparisons). They were also more accurate in terms of sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating curve. Furthermore, for fetuses weighing more than 4000 grams the technicians had a lower total false prediction rate.

Conclusions: Medical technicians in our institute performed better than physicians in estimating fetal weight. Further studies are warranted to confirm our findings and better delineate the role of repeat physician’s examination after an initial estimation by an experienced technician.

The Roux-en-Y gastric bypass (RYGB) surgery helps patients achieve excellent excess weight loss, with subsequent improvement or resolution of co-morbidities. However, up to 20% of all RYGB patients, and 40% of the super morbidly obese, experience significant weight regain. The etiology of weight regain is multifactorial; hence, multidisciplinary management is mandatory. Revision options for failed conservative and medical management include resizing the restrictive component of the bypass or intensifying malabsorption. While improvement of restriction generally has limited efficacy, intensifying malabsorption achieves significant long-term excess weight loss. The optimal surgical option should be personalized, considering eating behavior and psychological issues, surgical anatomy of the bypass, and anesthetic and surgical risks.

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. It is assumed that sleep is involved in the pathogenesis of BPPV, and that habitual head-lying side during sleep correlates with the affected side in the posterior semicircular canal BPPV.

Objectives: To investigate the relationship between the preferred sleeping position and the affected semicircular canal in patients with BPPV.

Methods: We performed a retrospective data review of patients seeking help for vertigo/dizziness who had undergone clinical evaluation including a Dix–Hallpike test. Patients diagnosed with posterior canal BPPV (p-BPPV) were asked to define their preferred lying side (right, left, supine, or variable) during the night sleep. Affected semicircular canal (right posterior or left posterior) was registered along with demographic data.

Results: In all, 237 patients were diagnosed with p-BPPV. Patients with horizontal semicircular canal BPPV (n=11) were excluded. Patient mean age was 57 years (range 14–87). There were 150 patients with right p-BPPV and 87 patients with left p-BPPV. Among the patients, 122 (52%) habitually slept on the right side. Of those, 102 (84%) were diagnosed with right p-BPPV (P = 0.0006), while 82 patients (34%) habitually slept on the left side. Fifty-three (65%) were diagnosed with left p-BPPV (P < 0.0001). There were no differences in right vs. left p-BPPV in the 33 patients (14%) who expressed no preference concerning their sleeping positions.

Conclusions: Our study highlights the etiology of BPPV and showed that changing sleep position habits might be helpful in preventing recurrent BPPV.

Background: Statins and selective serotonin reuptake inhibitors (SSRIs) have beneficial effects on health outcomes in the general population. Their effect on survival in debilitated nursing home residents is unknown.

Objectives: To assess the relationships between statins, SSRIs, and survival of nursing home residents.

Methods: Baseline patient characteristics, including chronic medications, were recorded. The association of 5-year survival with different variables was analyzed. A sub-group analysis of survival was performed according to baseline treatment with statins and/or SSRIs.

Results: The study comprised 993 residents from 6 nursing homes. Of them, 285 were males (29%), 750 (75%) were fully dependent, and 243 (25%) were mobile demented. Mean age was 85 ± 7.6 years (range 65–108). After 5 years follow-up, the mortality rate was 81%. Analysis by sub-groups showed longer survival among older adults treated with only statins (hazard ratio [HR] for death 0.68, 95% confidence intervals [95%CI] 0.49–0.94) or only SSRIs (HR 0.6, 95%CI 0.45–0.81), with the longest survival among those taking both statins and SSRIs (HR 0.41, 95%CI 0.25–0.67) and shortest among residents not taking statins or SSRIs (P < 0.001). The survival benefit remained significant after adjusting for age and after conducting a multivariate analysis adjusted for sex, functional status, body mass index, mini-mental state examination, feeding status, arrhythmia, diabetes mellitus, chronic kidney disease, and hemato-oncological diagnosis.

Conclusion: Treatment with statins and/or SSRIs at baseline was associated with longer survival in debilitated nursing home residents and should not be deprived from these patients, if medically indicated. 

Background: The need for postnatal monitoring of infants exposed to intrauterine beta blockers (BBs) has not been clearly defined.

Objectives: To evaluate infants exposed to intrauterine BBs in order to estimate the need for postnatal monitoring.

Methods: This retrospective case-control study comprised 153 term infants born to mothers who had been treated with BBs during pregnancy. Treatment indications included hypertension 76 mothers (49.7%), cardiac arrhythmias 48 (31.4%), rheumatic heart disease 14 (9.1%), cardiomyopathy 11 (7.2%) and migraine 4 (2.6%). The controls were infants of mothers with hypertension not exposed to BBs who were born at the same gestational age and born closest (before or after) to the matched infant in the study group.

Results: Compared to the control group, the infants in the study group had a higher prevalence of early asymptomatic hypoglycemia (study 30.7% vs. control 18.3%, P = 0.016), short symptomatic bradycardia events, other cardiac manifestations (P = 0.016), and longer hospitalization (P < 0.001). No life-threatening medical conditions were documented. The birth weight was significantly lower for the high-dose subgroup compared to the low-dose subgroup (P = 0.03), and the high-dose subgroup had a higher incidence of small-for-gestational-age (P = 0.02).

Conclusions: No alarming or life-threatening medical conditions were observed among term infants born to BB treated mothers. These infants can be safely observed for 48 hours after birth close to their mothers in the maternity ward. Glucose follow-up is needed, especially in the first hours of life.

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.

Background: Complete hydatidiform mole and a co-existing normal fetus (CHMCF) is associated with a high complication rate. A possible association with assisted conception might increase the prevalence of CHMCF.

Objectives: To study the potential association between assisted conception and the risks of CHMCF.

Methods: Case series at a single university hospital from 2008 to 2018 are presented and contrasted with data from a comprehensive literature review (1998–2018). Cases were identified from the institutional database that matched the sonographic criteria for CHMCF. A literature review showed comparable cases.

Results: None of the three pregnancies presented in this article resulted in a viable fetus, all were aborted. One of the three patients needed chemotherapy due to gestational trophoblastic neoplasia (GTN). A literature search identified 248 reported cases in which 22 fetuses (9%) reached term, 88/248 (35%) progressed to GTN, and 25/120 (21%) were conceived following assisted conception. From 2008 until 2018 at our medical facility, there were 3144 twin pregnancies of which 1667 (53%) were conceived using assisted conception. In our cohort, there was no statistical trend for assisted conception as an etiological factor for CHMCF.

Conclusions: No association between assisted conception and the risk for CHMCF was established at our hospital, although approximately one-quarter of all reported CHMCF pregnancies are attributed to assisted conception technology. However, these data are not always reported, making it difficult to draw definitive conclusions.

Background: The incidence of Clostridium difficile-associated diarrhea (CDAD) is increasing and is associated with significant morbidity and mortality. Therefore, there is a need to find new tools to determine the severity of the disease.

Objectives: To investigate the prognostic values of inflammatory markers such as mean platelet volume (MPV), neutrophil-lymphocyte ratio (NLR), and C-reactive protein (CRP) in patients with CDAD.

Methods: The study comprised of 100 patients diagnosed with CDAD. The study included an additional control group of 69 patients with diarrhea who were negative for C. difficile toxin. The control group was age- and sex-matched and hospitalized at the same time period. NLR and MPV were obtained from complete blood count results. Serum CRP levels were measured by the latex particle enhanced immunoturbidimetric assay. Blood samples for all inflammatory markers were collected at time of diagnosis and prior to initiating the antibiotic therapy. Demographic, clinical, laboratory, and prognostic data were collected from medical records for a period of 90 days from the initial diagnosis of CDAD.

Results: The mean age of the CDAD group was 68.6 ± 21.5 years compared to 65.6 ± 24.5 in the control group (P = 0.29). Our findings show that patients with CDAD had significantly higher NLR, MPV and serum CRP levels compared to the control group (P < 0.001)). Moreover, significantly higher levels were observed when CDAD was fatal (P < 0.001).

Conclusions: Elevated NLR, MPV, and serum CRP levels may serve as biomarkers for prediction of recurrence and mortality in patients with CDAD.

Background: Recently, Israel established the first national-level adult cardiac surgery database, which was linked to the Society of Thoracic Surgeons (STS).

Objectives: To validate and compare the STS predicted risk of mortality (PROM) to logistic EuroSCORE I (LESI) and EuroSCORE II (ESII) in Israeli patients undergoing cardiac surgery.

Methods: We retrospectively studied 1279 consecutive patients who underwent cardiac surgeries with a calculable PROM. Data were prospectively entered into our database and used to calculate PROM, LESI, and ESII. Scores were normalized and correlated using linear regression and Pearson's test. To examine model calibration, we plotted the total observed versus expected mortality for each score and across five risk-score subgroups. Model discrimination was assessed by measuring the area under the receiver operating curves.

Results: The observed 30-day operative mortality was 1.95%. The median (IQ1; IQ3) PROM, LESI, and the ESII scores were 1.45% (0.69; 3.22), 4.54% (2.28; 9.27), and 1.88% (1.18; 3.54), respectively, with observed over expected ratios of 0.63 (95% confidence interval [95%CI] 0.42–0.93), 0.59 (95%CI 0.40–0.87), and 0.24 (95%CI 0.17–0.36), respectively, (STS vs. ESII P = 0.36, STS vs. LESI P = 0.0001). There was good correlation among all scores. All models overestimated mortality. Model discrimination was high and similar for all three scores. Model calibration of the STS, PROM, and ESII were more accurate than the LESI, particularly in higher risk subgroups.

Conclusions: All scores overestimated mortality. In Israeli patients, the STS, PROM, and ESII risk-scores were more reliable metrics than LESI, particularly in higher risk patients.

Background: In developed countries, hepatitis A virus (HAV) infection occurs mainly in adults. It is usually symptomatic and may cause acute liver failure (ALF). In patients with chronic liver disease, serum ferritin levels (SFL) can predict short-term prognosis.

Objectives: To determine whether admission SFL can serve as a prognostic marker in patients with HAV infection.

Methods: A retrospective analysis of 33 adults with HAV infection was conducted. Because none of our patients presented with ALF, the parameter "length of hospital stay," was used as a surrogate marker of disease severity.

Results: The mean (± SD) at admission SFL was 2529 ± 4336 ng/ml. SFL correlated with the levels of international normalized ratio (INR), liver enzymes, and degree of hemolysis that occurred during the disease course. SFL did not correlate with the levels of either albumin or bilirubin or with the length of the hospital stay. The mean length of hospital stay was 5.1 ± 2.0 days, which correlated with the levels of INR, albumin, and bilirubin as well as the degree of hemolysis. However, in multivariate analysis only albumin and bilirubin predicted the length of the hospital stay. Follow-up SFL, which were available only in eight patients, decreased during the hospital stay.

Conclusions: In adults with acute HAV infection, SFL may be increased. SFL correlated with the degree of liver injury and hemolysis that occur during the disease. However, in our cohort of HAV patients, who had a relatively benign disease course, SFL were of no prognostic value.