Israel Medical Association Journal

Background: Door-to-balloon time (DTBT) ≤ 90 minutes has become an important quality indicator in the management of ST-elevation myocardial infarction (STEMI). We identified three specific problems in the course from arrival of STEMI patients at our emergency department to initiation of balloon inflation and determined an intervention comprised of specific administrative and professional steps. The focus of the intervention was on triage within the emergency department (ED) and on increasing the efficiency and accuracy of electrocardiography interpretation.

Objectives: To examine whether our intervention reduced the proportion of patients with DTBT > 90 minutes.

Methods: We compared DTBT of patients admitted to the ED with STEMI during the year preceding and the year following implementation of the intervention.

Results: Demographic and clinical characteristics at presentation to the ED were similar for patients admitted to the ED in the year preceding and the year following intervention. The year preceding intervention, DTBT was > 90 minutes for 19/78 patients (24%). The year after intervention, DTBT was > 90 minutes for 17/102 patients (17%). For both years, the median DTBT was 1 hour. Patients with DTBT > 90 minutes tended to be older and more often female. Diagnoses in the ED were similar between those with DTBT ≤ 90 minutes and > 90 minutes. In-hospital mortality was 17% (13/78) and 14% (14/102) for the respective time periods.

Conclusions: An intervention specifically designed to address problems identified at one medical center was shown to decrease the proportion of patients with DTBT > 90 minutes.

Background: Cardiac damage caused by oncological therapy may manifest early or many years after the exposure.

Objectives: To determine the differences between sub-acute and late-onset cardiotoxicity in left ventricular ejection fraction (LVEF) recovery as well as long-term prognosis.

Methods: We studied 91 patients diagnosed with impaired systolic function and previous exposure to oncological therapy. The study population was divided according to sub-acute (from 2 weeks to ≤ 1 year) and late-onset (> 1 year) presentation cardiotoxicity. Recovery of LVEF of at least 50% was defined as the primary end point and total mortality was the secondary end point.

Results: Fifty-three (58%) patients were classified as sub-acute, while 38 (42%) were defined as late-onset cardiotoxicity. Baseline clinical characteristics were similar in the two groups. The mean LVEF at presentation was significantly lower among patients in the late-onset vs. sub-acute group (28% vs. 37%, respectively, P < 0.001). Independent predictors of LVEF recovery were trastuzumab therapy and a higher baseline LVEF. Although long-term mortality rates were similar in the groups with sub-acute and late-onset cardiotoxicity, improvement of LVEF was independently associated with reduced mortality.

Conclusions: Our findings suggest that early detection and treatment of oncological cardiotoxicity play an important role in LVEF recovery and long-term prognosis.

Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) (such as canagliflozin, empagliflozin, and dapagliflozin) are widely used to treat patients with type 2 diabetes mellitus (T2DM) to improve glycemic, cardiovascular and renal outcomes. However, based on post-marketing data, a warning label was added regarding possible occurrence of acute kidney injury (AKI).

Objectives: To describe the clinical presentation of T2DM patients treated with SGLT2i who were evaluated for AKI at our institution and to discuss the potential pathophysiologic mechanisms.

Methods: A retrospective study of a computerized database was conducted of patients with T2DM who were hospitalized or evaluated for AKI while receiving SGLT2i, including descriptions of clinical and laboratory characteristics, at our institution.

Results: We identified seven patients in whom AKI occurred 7–365 days after initiation of SGLT2i. In all cases, renin-angiotensin-aldosterone system blockers had also been prescribed. In five patients, another concomitant nephrotoxic agent (injection of contrast-product, use of nonsteroidal anti-inflammatory drugs or cox-2 inhibitors) or occurrence of an acute medical event potentially associated with AKI (diarrhea, sepsis) was identified. In two patients, only the initiation of SGLT2i was evident. The mechanisms by which AKI occurs under SGLT2i are discussed with regard to the associated potential triggers: altered trans-glomerular filtration or, alternatively, kidney medullary hypoxia.

Conclusions: SGLT2i are usually safe and provide multiple benefits for patients with T2DM. However, during particular medical circumstances, and in association with usual co-medications, particularly if baseline glomerular filtration rate is decreased, patients treated with SGLT2i may be at risk of AKI, thus warranting caution when prescribed.

Background: When a breast lesion is suspected based on a physical exam, mammography, or ultrasound, a stereotactic core needle biopsy (CNB) is usually performed to help establish a definitive diagnosis. CNBs are far less invasive than excisional biopsies, with no need for general anesthetics or hospitalization, and no recovery period. However, since only samples of the mass are removed in a CNB and not the whole mass, sampling errors can occur.

Objectives: To compare the degree of agreement between the pathological data from CNBs and excisional biopsies from a single tertiary referral hospital.

Methods: The concordance of pathological data was compared in patients who underwent CNBs and had their surgical procedures at the same medical center.

Results: From the 894 patients who underwent CNBs, 254 (28.4%) underwent subsequent excisional biopsies at our medical center. From the total of 894 patients, 227 (25.3%) who underwent a CNB were diagnosed with a malignancy, with the rest of the CNBs being diagnosed as benign pathologies. The pathological findings in the CNBs and in the excisional biopsies concurred in 232/254 (91.3%) of the cases.

Conclusions: A CNB to confirm mammographic or clinical findings of breast lesions is an accurate method to establish a pathological diagnosis of breast lesions. The accuracy is higher for invasive carcinomas than for non-invasive cancers. Excisional biopsies are necessary for lesions with anticipated sampling errors or when the core needle biopsy findings are discordant with clinical or mammographic findings.

Background: Although exercise has been shown to improve mood and well-being, the precise mechanism remains unknown. Neurosteroids are important neuroactive molecules with demonstrated involvement in several neurophysiological and disease processes. Previous research has noted neurosteroid changes in dehydroepiandrosterone (DHEA) levels following exercise.



Objectives: To determine whether changes in DHEA levels are associated with mood improvement after exercise and whether there are any differences in the effects on younger and older individuals. 



Methods: Individuals ≤ 50 years of age or > 65 years of age were recruited for study participation. Before and after 30 minutes of a standardized cycling regimen, each patient provided a blood sample and completed a questionnaire on mood and well-being. 



Results: Findings confirmed a significant increase in DHEA levels post-exercise. A decrease in negative factors (fatigue, tension, depression, anger) and an increase in positive mood factors were noted. No difference in change of measures was noted between younger and older subjects. A positive correlation was noted between mood change and DHEA blood-level changes in older subjects. Among older males, DHEA appeared to be associated with mood change after exercise. 



Conclusions: While preliminary, findings indicate a possible association between mood improvement following exercise and DHEA blood level changes. Understanding the biological mechanisms of exercise-induced mood changes is critical to utilizing exercise as a treatment for mood disorders.

Background: The most common complication after tonsillectomy is bleeding. We investigated whether performing the procedure during the summer or the winter affects the bleeding rate.

Objectives: To investigate whether there is an association between meteorological conditions and the occurrence of post-tonsillectomy hemorrhage (PTH) in the southern Israel Negev region.

Methods: All patients who underwent tonsillectomy from 2001–2013 at the Soroka Medical Center were included. We collected patient demographic data and indications for surgery. Meteorological data were obtained from a weather station operated by the Israel Ministry of Environmental Protection.

Results: Of 4438 patients who underwent tonsillectomy, with or without adenoidectomy, 432 (9.73%) experienced hemorrhage. Patients who suffered from PTH were significantly older: median age 9.61 years vs.4.7 years, P < 0.0001. When comparing patients without PTH to those who bled within 0–3 days after surgery, there was a higher risk for bleeding during the warmer seasons: relative risk (RR) 1.38, 95% confidence interval ([95%CI] 1.07–1.77), RR 1.45 (95%CI 1.17–1.80), and 1.62 (95%CI 1.27–2.06) comparing the winter to spring, summer, and fall, respectively. A statistically significant positive association was also found with the average temperature on the day of surgery. Bleeding more than 3 days after surgery was less likely in summer: RR 0.82, 95%CI 0.69–0.97. We found no association with temperature on the day of surgery and PTH after postoperative day 3.

Conclusions: Seasonality, and to an extent temperature, seem to play only a minor role in PTH.

Background: Wandering spleen is a rare entity that may pose a surgical emergency following torsion of the splenic vessels, mainly because of a delayed diagnosis. Complications after surgery for wandering spleen may necessitate emergency treatment.

Objectives: To describe the clinical course and treatment for children who underwent emergency surgeries for wandering spleen at a tertiary pediatric medical center over a 21 year period and to indicate the pitfalls in diagnosis and treatment as reflected by our experience and in the literature.

Methods: The database of a tertiary pediatric medical center was searched retrospectively for all children who underwent emergency treatment for wandering spleen between 1996 and 2017. Data were collected from the medical files. The relevant literature was reviewed.

Results: Of ten patients who underwent surgery for wandering spleen during the study period, five underwent seven emergency surgeries. One patient underwent surgery immediately at initial presentation. In the other four, surgical treatment was delayed either due to misdiagnosis or for repeated imaging studies to confirm the diagnosis. Emergency laparotomy revealed an ischemic spleen in all patients; splenectomy was performed in two and the spleen was preserved in three. Four of the seven emergency operations were performed as the primary surgery and three were performed to treat complications.

Conclusions: Wandering spleen should ideally be treated on an elective or semi-elective basis. Surgical delays could be partially minimized by a high index of suspicion at diagnosis and by eliminating unnecessary and time-consuming repeated imaging studies.

Background: Increasing antibiotic resistance in the community results in greater use of empiric broad spectrum antibiotics for patients at hospital admission. As a measure of antibiotic stewardship it is important to identify a patient population that can receive narrow spectrum antibiotics.

Objectives: To evaluate resistance patterns of Escherichia coli bloodstream infection (BSI) from strictly community-acquired infection and the impact of recent antibiotic use on this resistance.

Methods: This single center, historical cohort study of adult patients with E. coli BSI was conducted from January 2007 to December 2011. Patients had no exposure to any healthcare facility and no chronic catheters or chronic ulcers. Data on antibiotic use during the previous 90 days was collected and relation to resistance patterns was assessed.

Results: Of the total number of patients, 267 BSI cases met the entry criteria; 153 patients (57%) had bacteria sensitive to all antibiotics. Among 189 patients with no antibiotic exposure, 61% of isolates (116) were pan-sensitive. Resistance to any antibiotic appeared in 114 patients and 12 were extended-spectrum beta-lactamase (ESBL) producers. Quinolone use was the main driver of resistance to any antibiotic and to ESBL resistance patterns. In a multivariate analysis, older age (odds ratio 1.1) and quinolone use (odds ratio 7) were independently correlated to ESBL.

Conclusions: At admission, stratification by patient characteristics and recent antibiotic use can help personalize primary empirical therapy.

Background: Limited information exists about detailed clinical characteristics and management of the small subset of Brugada syndrome (BrS) patients who had an arrhythmic event (AE).

Objectives: To conduct the first nationwide survey focused on BrS patients with documented AE.

Methods: Israeli electrophysiology units participated if they had treated BrS patients who had cardiac arrest (CA) (lethal/aborted; group 1) or experienced appropriate therapy for tachyarrhythmias after prophylactic implantable cardioverter defibrillator (ICD) implantation (group 2).

Results: The cohort comprised 31 patients: 25 in group 1, 6 in group 2. Group 1: 96% male, mean CA age 38 years (range 13–84). Nine patients (36%) presented with arrhythmic storm and three had a lethal outcome; 17 (68%) had spontaneous type 1 Brugada electrocardiography (ECG). An electrophysiology study (EPS) was performed on 11 patients with inducible ventricular fibrillation (VF) in 10, which was prevented by quinidine in 9/10 patients. During follow-up (143 ± 119 months) eight patients experienced appropriate shocks, none while on quinidine. Group 2: all male, age 30–53 years; 4/6 patients had familial history of sudden death age < 50 years. Five patients had spontaneous type 1 Brugada ECG and four were asymptomatic at ICD implantation. EPS was performed in four patients with inducible VF in three. During long-term follow-up, five patients received ≥ 1 appropriate shocks, one had ATP for sustained VT (none taking quinidine). No AE recurred in patients subsequently treated with quinidine.

Conclusions: CA from BrS is apparently a rare occurrence on a national scale and no AE occurred in any patient treated with quinidine.

Background: Previous studies have demonstrated the utility of exercise hemodynamics during right heart catheterization (RHC) in the diagnosis of diastolic dysfunction (DD). Little data exists regarding exercise hemodynamics during RHC in symptomatic systemic sclerosis (SSc) patients. 

Objectives: To assess the added diagnostic value of using exercise hemodynamics during RHC in assessment of patients with symptomatic SSc.

Methods: We performed 22 RHCs in 17 SSc patients with dyspnea and/or pulmonary arterial hypertension (PAH). Exercise was performed in 15 RHCs using isotonic arm exercises while holding a 1 kg weight in each hand. Measurements of pulmonary arterial pressure (PAP), pulmonary arterial wedge pressure (PAWP), and cardiac output (CO) were taken at rest and during peak exercise. 

Results: Normal resting RHC (PAP 22 ± 3 mmHg, PAWP 11 ± 3 mmHg) was found in seven cases. Of these, exercise induced elevation in PAP was found in three (38 ± 7 mmHg), and exercise induced elevation in PAWP was found in four (24 ± 6 mmHg). Elevated resting PAP was found in 15 (41 ± 11 mmHg) with minor changes in exercise. Of the 22 RHCs, elevation of the PAWP was found in 11 (50%), half of which were in response to exercise. 

Conclusions: In symptomatic SSc patients, exercise hemodynamics provides important information on diastolic dysfunction that is not available with non-invasive testing. Findings on exercise RHC can explain patient symptoms in up to 50% of cases. Earlier and more accurate diagnosis of patient symptoms can aid in tailoring the correct therapy for each.

Background: Erysipelas, an acute infection of the dermal and subcutaneous tissue, is normally treated with antibiotics. Previous data indicated that treatment with prednisone in combination with antibiotics results in significant acceleration of the healing phase.

Objectives: To investigate the effectiveness of corticosteroids combined with antibiotics for the treatment of erysipelas.

Methods: A retrospective study was conducted on hospitalized patients diagnosed with erysipelas between 2004 and 2011 at the Department of Dermatology at Sheba Medical Center, Israel. Data included epidemiology, medical background, and course of the disease as documented at admission and during hospitalization. 

Results: Data were collected on 173 patients (66% males) who were divided into two groups: a control group treated with antibiotics only (97 patients) and a study group treated with antibiotics and prednisone (76 patients). The study group presented with a more severe form of erysipelas (bullous) and those patients were hospitalized for a longer period (8.5 vs. 7 days). Nevertheless, the study group exhibited a 71% clinical improvement shortly after being treated with prednisone, without significant side effects. Short-term follow-up revealed more edema in the study group; however, long-term follow-up revealed a higher incidence of erythema and recurrence of erysipelas in the control group. The return to full function was faster in the study group than in the control group. 

Conclusions: Combining prednisone with antibiotics for the treatment of erysipelas should be considered, especially in severe cases. In addition, a prospective double-blind study should be conducted to verify these conclusions.

Background: Accurate pulse oximetry reading at hospital admission is of utmost importance, mainly for patients presenting with hypoxemia. Nevertheless, there is no accepted or evidence-based protocol for such structured measuring.

Objectives: To devise and assess a structured protocol intended to increase the accuracy of pulse oximetry measurement at hospital admission.

Methods: The authors performed a prospective comparison of protocol-based pulse-oximetry measurement with non-protocol based readings in consecutive patients at hospital admission. They also calculated the relative percentage of improvement for each patient (before and after protocol implementation) as a fraction of the change in peripheral capillary oxygen saturation (SpO₂) from 100%.

Results: A total of 460 patients were recruited during a 6 month period. Implementation of a structured measurement protocol significantly changed saturation values. The SpO₂ values of 24.7% of all study participants increased after protocol implementation (ranging from 1% to 21% increase in SpO₂ values). Among hypoxemic patients (initial SpO₂ < 90%), protocol implementation had a greater impact on final SpO₂ measurements, increasing their median SpO₂ readings by 4% (3–8% interquartile range; P < 0.05). Among this study population, 50% of the cohort improved by 17% of their overall potential and 25% improved by 50% of their overall improvement potential. As for patients presenting with hypoxemia, the median improvement was 31% of their overall SpO₂ potential.

Conclusions: Structured, protocol based pulse-oximetry may improve measurement accuracy and reliability. The authors suggest that implementation of such protocols may improve the management of hypoxemic patients.