Israel Medical Association Journal

Background: Upper eyelid blepharoplasty surgery is one of the most common plastic surgeries. Khat is used topically to reduce tissue edema.

Objectives: To evaluate the effect of topical khat administration after eyelid surgery on postoperative healing.

Methods: Our prospective comparative study included 24 patients who underwent upper eyelid blepharoplasty or ptosis surgery between 2019 and 2020. Patients were randomly assigned to 48 hours of cold dressing with frozen khat leaves and frozen peas dressing (common practice). Postoperative photographs of the eyes were evaluated for the degree of ecchymosis and edema on postoperative days (PODs) 1, 3, and 7 by three blinded observers. Measures included tissue swelling and hemorrhage on PODs 1, 3, and 7.

Results: The mean age of the cohort was 67 ± 7 years; 17 females (71%). Khat application was associated with lower postoperative ecchymosis at each time point. Females had lower levels of postoperative ecchymosis on POD 7 (P = 0.07). Eyelid edema was more pronounced in the khat group on PODs 1 and 3, but this was reversed on POD 7. There was good agreement among all three observers in grading ecchymosis and edema (P < 0.001).

Conclusions: The use of khat was associated with less tissue ecchymosis after oculoplastic surgery, although this was not statistically significant even following sub-population analysis. The outcome can be attributed to the active ingredients of cathinone and cathine, which cause vasoconstriction and lipolysis, and to the anti-inflammatory and anti-oxidative flavonoids and phenolic compounds. These encouraging preliminary findings warrant additional studies on a biochemical/cellular level.

Background: Reliable vascular access is a fundamental tool for providing effective hemodialysis. Vascular access dysfunction is associated with increased morbidity and mortality among hemodialysis patients. Current vascular access guidelines strongly recommend creating an arteriovenous fistula (AVF) as the first option; however, a substantial proportion of new AVFs may not be usable.

Objectives: To assess possible predictors of primary and secondary failure of vascular access.

Methods: This retrospective cohort study included all vascular access sites created at Meir Medical Center from 2006 through 2012. Vascular access site, primary and secondary failure rates, and relevant demographic and clinical data were recorded during 60 months of follow-up.

Results: A total of 612 vascular accesses were created and followed for a median of 32 ± 29.4 months. Of these, 490 (80%) were suitable for initiating hemodialysis. Vascular access site was the most important predictor of primary failure but did not predict secondary failure. Co-morbidities such as diabetes mellitus and congestive heart failure, as well as the use of antiplatelet agents did not predict primary or secondary failure. Preoperative vascular mapping using Doppler ultrasonography was performed in 36.4% of cases and was not associated with lower rates of primary or secondary failure.

Conclusions: Vascular access site is an important predictor of primary failure. We did not find a benefit of pre-operative vessel mapping or chronic antiplatelet therapy in terms of decreasing primary and secondary failure rates. Physicians should carefully consider the characteristics of the patient and blood vessels before creating vascular access in patients requiring chronic hemodialysis.

Background: Laparoscopic removal of ovarian dermoid cysts has been associated with increased risk for recurrence.

Objectives: To investigate the risk factors associated with recurrence of dermoid cysts.

Methods: We conducted a retrospective review of all women who underwent cystectomy for ovarian dermoid cysts by laparoscopy or laparotomy. At discharge, patients were instructed to undergo a yearly ultrasound exam. A follow-up telephone call was conducted to assess whether an additional surgery for dermoid cysts was required and whether ultrasound recurrence of dermoid cysts was suspected.

Results: The study cohort included 102 participants (92 [90.2%] operated by laparoscopy and 10 [9.8%] by laparotomy). The mean follow-up from the index surgery to the interview was 72.1 ± 38.2 months. The rates of recurrent surgery were similar among women who underwent laparoscopic cystectomy compared with laparotomy (5/92 [5.4%] vs. 1/10 [10.0%], respectively; P = 0.5), while the rates of reported ultrasound recurrence were significantly lower in the laparoscopy group compared with the laparotomy group (10/102 [10.9%] vs. 4/10 [40.0%], respectively; P = 0.03). Additional factors including age, cyst diameter, diagnosis of torsion, intraoperative cyst spillage, estimated blood loss, intraperitoneal adhesions, and postoperative fever were not associated with recurrence.

Conclusions: Ultrasound recurrence of dermoid cysts is not uncommon and could be associated with the surgical approach.

Background: Changes accommodating requirements of religious authorities in Israel resulted in the Brain and Respiratory Death Determination Law (BRDDL), which came into effect in 2009. These included considering patient wishes regarding the brain respiratory death determination (BRDD), mandatory performance of apnea and ancillary testing, establishment of an accreditation committee, and accreditation required for physicians performing BRDD.

Objectives: To assess the impact of the legislation from 2010–2019.

Methods: Data collected included the number of formal BRDDs and accredited physicians. Obstacles to declaring brain death and interventions applied were identified.

Results: Obstacles included lack of trained physicians to perform BRDD and interpret ancillary test results, inability to perform apnea or ancillary testing, and non-approach to next-of-kin objecting to BRDD. Interventions included physician training courses, additional ancillary test options, and legal interpretation of patient wishes for non-determination of BRD. As a result, the number of non-determinations related to next-of-kin objecting decreased (26 in 2010 to 5 in 2019), inability to perform apnea or ancillary testing decreased (33 in 2010 to 2 in 2019), and number of physicians receiving accreditation increased (210 in 2010 to 456 in 2019). Last, the consent rate for organ donation increased from 49% to 60% in 2019.

Conclusions: The initial decrease in BRDDs has reversed, thus enabling more approaches for organ donation. The increased consent rate may reflect in part the support of the rabbinate and confidence of the general public that BRDD is performed and monitored according to strict criteria.

Background: Hepatitis D virus may cause a disease at various severities in the presence of hepatitis B virus, using hepatitis B surface antigen (HBsAg) on the external envelope in its replication process. Thus, people identified with HBsAg in blood tests should also be tested for hepatitis D virus.

Objectives: To describe the situation of performance of blood tests for detection of hepatitis D virus in patients positive for hepatitis surface antigen during 9 years in a population with heterogeneous origins in the north region of Israel.

Methods: We conducted a retrospective study using the database of Clalit Health Services.

Results: We found 3367 people were positive for HBsAg during the study period; 613 (18%) were tested for hepatitis D. People who tested for hepatitis D were younger (47.3 ± 15 years vs. 50.5) and showed a higher rate of visiting the gastroenterology clinic (80.6% vs. 41%). The rate of positive blood tests for hepatitis D was too small for analysis, but it still demonstrated tendency for higher rates in the Ethiopian Jewish group.

Conclusion: The recommendation for performance of blood test for hepatitis D virus was followed to a small extent. Considering the ethnic diversity of the population in Israel, activities to raise rates of performance should be considered.

Background: Some studies have shown that patients who are hospitalized with severe COVID-19 also have low levels of vitamin D. It is known that vitamin D can reduce the risk of infections and down regulate the immune/inflammatory reaction.

Objectives: To investigate the association between vitamin D status and lymphocyte subpopulations in hospitalized pneumonia COVID-19 patients.

Methods: In 33 positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) patients with radiologic evidence of interstitial pneumonia and in 16 healthy control subjects matched for age, sex, and seasonality lymphocyte subpopulations and vitamin D levels were evaluated.

Results: The majority of patients with COVID-19 pneumonia (70.8%) presented vitamin D deficiency. The percentages of neutrophils presented a negative correlation (r = -0.74; P < 0.001), whereas the percentages of lymphocytes presented a positive correlation (r = 0.43; P < 0.01) with 25(OH)D. Moreover, vitamin D levels were positively correlated with CD3+ (r = 0.37, P < 0.05), CD4+ (r = 0.41, P < 0.05), CD8+ (r = 0.32, P < 0.07), and CD19+ (r = 0.38, P < 0.05).

Conclusions: This preliminary study confirms the high prevalence of vitamin D deficiency in patients with COVID-19 pneumonia and that vitamin D deficiency is associated with a reduction of lymphocyte subsets and altered T-lymphocyte activation. This finding may contribute to clarify the mechanisms by which vitamin D influences the course and outcome of COVID-19 pneumonia.

Background: National registries for acromegaly and population-based data make an important contribution to disease understanding and management. Data concerning the epidemiology of acromegaly in Israel is scanty.

Objectives: To evaluate the epidemiology of acromegaly in different industrial areas in northern Israel.

Methods: Data from adult patients diagnosed with acromegaly from 2000 to 2020, living in Haifa and the western Galilee District were collected using the electronic database and medical records from Clalit Health Services. The prevalence of acromegaly in three distinct areas and overall were reported. In addition, other epidemiological data including associated co-morbidities, pituitary tumor size, and treatment modalities were collected.

Results: We identified 77 patients with a confirmed diagnosis of acromegaly. The overall prevalence was 155 cases/10⁶ inhabitants without statistically significant differences between the three areas. The mean age at diagnosis was 50 ± 1.8 years and the male to female ratio was 1.1. Macroadenoma and microadenoma were identified in 44 (57%) and 25 (33%), respectively. The frequency rate of acromegaly-associated co-morbidities such as diabetes, hypertension, carpal tunnel syndrome, and osteoporosis was similar to previously reported studies. The mean body mass index (BMI) was 29 ± 5.6 kg/m² .Obesity, with a BMI ≥ of 30 kg/m², was found in 29 patients (38%). The majority of patients underwent transsphenoidal surgery 67 (87%). Normalized insulin-like growth factor 1 was reported in 64 (83%).

Conclusions: A high prevalence of acromegaly was found in northern Israel. The pituitary microadenoma frequency rate is the highest reported.

Background: Anorexia nervosa (AN) is a severe psychiatric disease that is refractory to treatment. To date, there is no effective pharmacological therapy and existing psychotherapy treatment is only partially effective. In neuropsychological terms, AN is characterized by cognitive inflexibility and an overly detailed processing style. Creating artwork and drawing requires integrative thinking that encompasses the big picture.

Objectives: To describe preliminary observations of drawing treatment modality based on precise scientific drawing.

Methods: The artwork method is based on the classic work by squares and on additional techniques from scientific drawing. The method was developed and implemented in a sheltered home for patients with eating disorders in Parma, Italy. Five patients, four women and one man, agreed to participate in a 10-session workshop as a part of multidisciplinary intervention. The ages of participants were 17–28 years and all had presented with AN for several years.

Results: Using the method of copying drawings on squares made it possible to identify features that were common to all the patients, such as focusing on the external form of the drawing rather than on the internal details, exerting strong pressure on the pencil without consideration of the need for future corrections, drawing distorted perceptions of curves, and the adding of significant volume.

Conclusions: Precise scientific drawing could be a useful instrument in the understanding and correction of a patient’s distorted world and self-perspective. More evidence could be provided by further studies with a larger sample and a control group.

Background: Dysphagia is a common symptom with diverse etiologies and refers to disorders of the process of swallowing food or fluids. Many studies have reported the anatomical and functional differences between men and women in swallowing in healthy patients; however, sex discrepancies in symptomatic patients have not often been studied.

Objectives: To compare the performance of men and women with dysphagia using videofluoroscopy.

Methods: To compare the performance of men and women with dysphagia using videofluoroscopy.

Results: A total of 203 patients met the inclusion criteria, 106 men (52%) and 97 women (48%). Men complained significantly more about choking on liquids (P = 0.002) and in swallowing pills (P = 0.004) compared to women. Men had more abnormalities in the pharyngeal phase (P = 0.015) and at the upper esophageal sphincter (P = 0.056). The prevalence of aspiration, penetration, and barium residue in the hypopharynx and in the vallecula were significantly greater in men as well.

Conclusions: In patients with dysphagia, women had fewer subjective symptoms and performed better than men in videofluoroscopy especially in the pharyngeal phase. These differences are probably due to different anatomical and functional swallowing characteristics. A better understanding of these discrepancies can be useful in offering tailored treatment in clinical practice.