Israel Medical Association Journal

Background: Vitamin B6 is an essential cofactor in amino acid metabolism. Its deficiency is linked to neuropathy, anemia, and cardiovascular risk. Deficiency is common among hemodialysis patients due to dialytic losses and restrictive diets; however, data related to high-flux (HF) dialysis membranes and Mediterranean dietary patterns are scarce.

Objectives: To assess the prevalence and determinants of deficiency in unsupplemented Israeli hemodialysis patients.

Methods: This retrospective chart review, utilizing a cross-sectional design, was conducted in August 2024. We included 27 chronic hemodialysis patients not receiving vitamin B6 supplementation, representing the available unsupplemented cohort from a unit of approximately 150 patients. Vitamin B6 status was assessed by measuring plasma pyridoxal-5'-phosphate (PLP); deficiency < 20 ng/ml. Clinical and nutritional parameters were evaluated to identify deficiency.

Results: Vitamin B6 deficiency was noted in 63% of patients (median PLP 18 ng/ml, interquartile range 13–23). The cohort was 67% male, median age 74 years. All patients were treated with HF dialyzers. No significant correlations were found between PLP levels and nutritional indices or laboratory markers. A non-significant trend was observed between older age and lower PLP levels (r = -0.35, P = 0.098).

Conclusions: Vitamin B6 deficiency was common among Israeli hemodialysis patients treated with HF dialyzers, despite a presumed Mediterranean diet. It was not associated with nutritional status, suggesting dialysis-related losses, potentially augmented by high-flux membranes, may outweigh intake. Given the high prevalence of deficiency and low cost, routine low-dose vitamin B6 supplementation may be warranted, particularly in older patients.

Background: Elbow range of motion (ROM) is commonly assessed during initial evaluation and follow-up. While goniometry is considered the current gold standard, previous studies have raised concerns regarding its user dependence and measurement consistency.

Objective: To evaluate whether smartphone application-based elbow ROM measurements are comparable to visual estimation and goniometry in patients following elbow trauma.

Methods: We conducted a prospective cohort study of 18 patients with elbow injuries. Demographic and medical data were collected. Maximal flexion-extension active ROM was measured by goniometry, smartphone application, and visual estimation by orthopedic surgeons. Measurements were compared to determine agreement and accuracy among different modalities.

Results: Eighteen patients with elbow injuries were included. Inter-rater reliability was good to excellent across all rater groups (intraclass correlation coefficient 0.78–0.93). Using paired t-tests with Bonferroni correction, only one attending surgeon showed a significant underestimation of extension compared to goniometry (16.9° vs. 22.5°, P < 0.05). No significant differences were found for residents, other attendings, or smartphone measurements in either extension or flexion (P > 0.05). Bland-Altman analysis revealed modest mean bias within ± 6° for all methods, although limits of agreement were wide (up to ± 20–30°). Smartphone-based measurements demonstrated significantly higher and less variable Pearson correlation coefficients with goniometry compared to surgeon visual estimations (0.91–0.95 vs. 0.81–0.93, P < 0.05).

Conclusions: Smartphone-based elbow ROM measurements were statistically comparable to goniometry and demonstrated superior correlation and accuracy relative to clinical visual assessments. These findings support the integration of smartphone tools in the clinical setting.

Agammaglobulinemia was the first primary immunodeficiency identified in humans. It is characterized by an absent or significantly reduced number of mature B cells, decreased serum immunoglobulins, and recurrent infections beginning in infancy. The entity was first described in 1952 by Colonel Ogden Bruton at the Walter Reed Army Hospital in the United States. Bruton reported on an 8-year-old boy who had experienced 19 episodes of pneumonia over 4 years and was found to have a complete absence of antibody-containing γ-globulins in his serum [1].

Over time, through improvement in the immune and genetic investigations, our understanding of agammaglobulinemia has expanded enabling earlier diagnosis and treatment resulting in a change of the disease course.

Background: Mucopolysaccharidosis type II (Hunter syndrome [MPS II]) is a rare, progressive, lysosomal storage disorder, often diagnosed late due to nonspecific early features and limited clinical awareness.

Objectives: To highlight the role of pediatric surgeons in early recognition based on clinical and surgical presentations.

Methods: We retrospectively reviewed patients diagnosed with MPS II at our institution focusing on presenting symptoms, timing of diagnosis, and factors leading to diagnostic suspicion and treatment.

Results: Four boys were diagnosed between 2012 and 2021. Three were diagnosed at 2.5–4 years of age following typical systemic manifestations. The fourth patient was suspected earlier by a pediatric surgeon, whose prior familiarity with similar reported cases enabled recognition of the clinical pattern and led to an earlier diagnosis.

Conclusions: Increased awareness and clinical familiarity among pediatric surgeons are essential for early recognition of MPS II. Recognition of early surgical patterns, such as hernias and recurrent procedures in early childhood, highlights the role of pediatric surgeons in raising diagnostic suspicion, facilitating earlier diagnosis, and enabling earlier initiation of enzyme replacement therapy before disease progression, ultimately improving clinical outcomes.

Nothing better reflects the times in which we live–amid missile barrages, air-raid sirens, sheltering in protected rooms, and yet continuing our daily routines and work–than the annual meeting of the editorial boards of the medical journals IMAJ and HaRefuah

Background: Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) can lead to a wide spectrum of clinical severity. The gold standard diagnosis of infection is reverse transcription polymerase chain reaction of nasopharyngeal swabs, which also provides a semiquantitative assessment of viral loads by measuring cycle threshold (CT) values.

Objective: To assess whether CT values at admission can predict mortality and oxygen needs among individuals hospitalized for coronavirus disease 2019 (COVID-19).

Methods: The retrospective study included adults hospitalized for COVID-19 between 1 August 2020 and 30 April 2021 at Barzilai University Medical Center. Patients were categorized according to initial CT values as high (≥ 25) or low (< 25) values. The primary outcome was the association between CT values during admission and overall mortality.

Results: The study group included 636 patients, with a mean age of 67.2 years, 54.4% males. Overall mortality of patients with CT values < 25 was significantly higher (odds ratio for mortality 1.78 vs. patients with CT ≥ 25, P = 0.002). Significantly more patients in the low CT group required oxygen support than in the high CT group, 50% vs. 31.9% (P < 0.001). An inverse association between CT values and mortality rates remained significant in multivariate regression analysis, such that a 1-unit decrease in CT was associated with a 6% increased mortality.

Conclusions: Lower CT values at admission were associated with increased mortality among patients hospitalized for COVID-19. CT values can be used to predict outcomes among such patients.

Background: Locally advanced gastric adenocarcinomas are treated with neoadjuvant chemotherapy, surgery, and adjuvant chemotherapy. Since 2019 the standard of care for perioperative chemotherapy has been FLOT protocol. Concerns regarding the use of FLOT in elderly patients ≥ 65 years of age emerged due to the relatively high toxicity of this protocol.

Objectives: To evaluate the toxicity profile of FLOT and clinical outcome in elderly patients.

Methods: We conducted a retrospective analysis of patients with locally advanced gastric adenocarcinomas treated with FLOT between 2017–2023 at the Sheba Medical Center. The cohort was stratified by age (≥ or < 65 years). The primary outcome was overall survival (OS). Secondary outcomes were treatment-related toxicity. Kaplan-Meier analysis and Cox proportional hazard regression model were used to analyze the effect of exposure variables on OS.

Results: The study cohort included 91 patients. The median age was 60 years (IQR 50–67); 32 patients were included in the ≥ 65 years group, and 59 patients were included in the < 65 years group. Median follow-up was 40 months (IQR 17–58). Patients ≥ 65 years old received fewer cycles of FLOT compared to those < 65 years old (4.5 vs. 7 cycles, respectively, P = 0.03). Despite the difference in treatment intensity and cumulative chemotherapy dose, there was no difference in median OS between patients ≥ 65 years old compared with those < 65 years old (P = 0.68).

Conclusions: Elderly patients with locally advanced gastric adenocarcinomas received fewer cycles of perioperative FLOT without compromising clinical outcomes.

Ventriculoperitoneal shunt (VPS) placement is a standard treatment for pediatric hydrocephalus. However, infection remains a significant complication, occurring in 5–27% of cases, with coagulase-negative staphylococci (CONS) and Staphylococcus aureus being the most common pathogens [1]. Current guidelines recommend empirical antibiotic treatment and surgical removal of the infected shunt [2]. While shunt removal and replacement are recommended for managing shunt infections, these procedures subject the child to the risks associated with multiple surgeries. However, recent approaches have suggested that in certain cases antibiotics alone may suffice, thus avoiding the risks of surgery [3].

We describe two children with VPS infections caused by CONS who were successfully treated with vancomycin and rifampicin alone, without the need for shunt removal.

Background: In times of war, healthcare systems face the dual challenge of attending to the medical needs of injured soldiers and civilians as well as struggling to meet the everyday healthcare demands of civilians.

Objectives: To assess the correlation between exposure to war and the likelihood of spontaneous abortion (SAB) and to compare it to a similar period in previous years.

Methods: We conducted a retrospective study comparing the rate of SAB during war to the previous years.

Results: During the Iron Swords war, 381 patients out of 3245 (11.74%) were diagnosed with SAB, compared to 530 of 4080 (13%) in 2022, 536 of 3387 (13.8%) in 2021, and 516 of 3798 (13.6%) in 2020. The median gestational age at diagnosis was similar between the groups, with most cases identified during the first trimester. The study group exhibited a significantly higher prevalence of smoking (18.47% vs. 7.75% vs. 6.3% vs. 9.3%, P = 0.03), with no differences in the prevalence of chronic diseases and in the method of pregnancy termination.

Conclusions: Exposure to stress due to war during early pregnancy appears to have no significant impact on the rate of SAB.

Background: Patients with mechanical prosthetic heart valves must be treated with vitamin K antagonists (VKA) due to an increased risk of valve thrombosis and systemic embolism.

Objectives: To assess the effects of the COVID-19 pandemic on VKA treatment control in patients with mechanical prosthetic heart valves.

Methods: We conducted a retrospective nationwide cohort study using the Clalit Health Services database. The cohort included patients who underwent either aortic or mitral valve replacement using a prosthetic mechanical valve. The primary outcomes included the overall time in therapeutic range (TTR) and the percent of patients with a TTR < 50% during the first year of the COVID-19 pandemic compared to preceding year.

Results: The cohort included 2381 patients. The percentage of patients who had at least two international normalized ratio (INR) tests during the first year of the COVID-19 pandemic was significantly lower compared to the year preceding the pandemic (81% and 87%, respectively, P < 0.001). In both years, the percentage of patients without any documented INR test was high (31.5% in the first COVID-19 pandemic year and 28.9% in the preceding year, P < 0.001). TTR was significantly lower during the 1st year of the COVID-19 pandemic compared to the preceding year (68.1% ± 26 and 69.4% ± 24, P = 0.03). A TTR > 50% was demonstrated in 78% and 81% during the pandemic and the preceding year, P = 0.009.

Conclusions: We noted overall poor VKA control in patients with mechanical heart valves. During the COVID-19 pandemic, VKA control became even worse as reflected by significantly lower TTR and INR tests rates.

Background: Fetal weight estimation at term is a challenging clinical task.

Objectives: To evaluate the association between peripheral white blood cell (WBC) count of the laboring women and neonatal birth weight (BW) for term uncomplicated pregnancies.

Methods: We conducted a single-center, retrospective cohort study (2006–2021) of women admitted in the first stage of labor or planned cesarean delivery. Complete blood counts were collected at admission. BW groups were categorized by weight (grams): < 2500 (group A), 2500–3499 (group B), 3500–4000 (group C), and > 4000 (group D). Two study periods were used to evaluate the association between WBC count and neonatal BW.

Results: There were a total of 98,632 deliveries. The dataset analyses showed a lower WBC count that was significantly and linearly associated with a higher BW; P for trend < 0.001 for women in labor. The most significant association was noted for the > 4000-gram newborns; adjusted odds ratio 0.97, 95% confidence interval 0.96–0.98; P < 0.001; adjusted for hemoglobin level, gestational age, and fetal sex. The 2018–2021 dataset analyses revealed WBC as an independent predictor of macrosomia with a significant incremental predictive value (P < 0.0001). The negative predictive value of the WBC count for macrosomia was significantly high, 93.85% for a threshold of WBC < 10.25 × 10³/µl.

Conclusions: WBC count should be considered to support the in-labor fetal weight estimation, especially valuable for the macrosomic fetus.

Background: Hemodialysis requires reliable, recurrent access to the circulatory system. Central venous tunneled dialysis catheters (TDC) are frequently used for patients receiving hemodialysis as a bridge to permanent vascular access or as a final option. TDC are prone to complications such as infection and dysfunction.

Objective: To assess the prevalence and predictors of TDC dysfunction in a cohort of chronic hemodialysis patients.

Methods: This single-center, retrospective study was based on data from an electronic database of chronic hemodialysis patients during 5 years of follow-up.

Results: A total of 625 TDC were inserted in 361 patients, of which 234 (37.4%) were replaced due to dysfunction. The main insertion site was the right internal jugular vein. Diabetes mellitus was an important predictor of TDC dysfunction and was significantly correlated with TDC extraction. Chronic anticoagulation and antiplatelet treatment did not affect the rate of TDC dysfunction or replacement.

Conclusions: TDC use for chronic dialysis patients is increasing and dysfunction is a major problem. In our study, we highlighted the high prevalence of TDC dysfunction and the need for further research to improve hemodialysis access as well as TDC patency and function.

Idiopathic eosinophilic vasculitis is a newly recognized form of hypereosinophilic syndrome. While little is understood about the condition, criteria for its definition have been proposed. We aimed to determine whether three patients with eosinophilia and vasculitis could be retrospectively diagnosed with this condition. We performed a retrospective descriptive analysis on three cases with hypereosinophilia and vasculitis who were treated in Sheba Medical Center, Sourasky Medical Center, and Meir Medical Center in Israel between 2009 and 2021. A thorough review of all three cases was conducted. The findings were compared to the suggested criteria for idiopathic eosinophilic vasculitis.

All patients shared the symptoms of progressive limb ischemia, eosinophilic rash, and peripheral neuropathy that are consistent with vasculitis. No lower or upper respiratory abnormalities or the presence of anti-neutrophil cytoplasmic antibodies (ANCA) autoantibodies associated with eosinophilic granulomatosis with polyangiitis were detected. Primary monoclonal abnormalities, drug interactions, infections, allergy, and other secondary causes of hypereosinophilia were excluded. After a thorough review, we suggest that our three patients with previously unexplained hypereosinophilia and vasculitis fit the diagnosis of idiopathic eosinophilic vasculitis. These results highlight the existence of this novel condition and the importance of its recognition and consideration as part of the differential diagnosis in patients with marked eosinophilia and vasculitis. Further research for elucidating the mechanisms and treatment approach for this potentially severe condition is urgently needed.

Twenty-five years ago, we, the undersigned together with the chairman of the Israel Medical Association at the time, Prof. Yoram Blachar, and the Secretary General of the Israel Medical Association, Adv. Leah Wapner, joined forces to found an Israeli medical journal in English. The purpose of this journal was to present to the world Israeli clinical medicine and medical research. That journal is none other than the Israel Medical Association Journal (IMAJ), and in 2023 its 300th issue was published. In 2024 we keep going, taking pride in the fact that every one of those past 300 issues has been published and dispatched on time, without delay, regardless of any circumstances.

Background: The administration of antenatal corticosteroids (ACS) is standard practice for management of threatened preterm birth. Its benefit, especially in small for gestational age (SGA) late preterm, is unclear.

Objectives: To evaluate the impact of ACS on perinatal outcome of late preterm SGA neonates.

Methods: We conducted a retrospective cohort study of all women carrying a singleton gestation who had late preterm delivery (34–36 gestational weeks) of SGA neonates at a single tertiary university-affiliated medical center (July 2012–December 2017). Exclusion criteria included termination of pregnancy, intrauterine fetal death, and birth weight ≥ 10th percentile. Outcomes were compared between ACS and non-ACS treatment prior to delivery. Neonatal composite outcome included neonatal intensive care unit (NICU) admission, respiratory distress syndrome, mechanical ventilation, and transient tachypnea.

Results: Overall, 228 women met inclusion criteria; 102 (44.7%) received ACS and 126 did not (55.3%). Median birth weight among the non-ACS group was significantly higher (1896.0 vs. 1755.5 grams P < 0.001). Rates of NICU and jaundice requiring phototherapy were higher among the ACS group (53.92% vs. 31.74%, P = 0.01; 12.74% vs. 5.55%, P = 0.05, respectively). Composite neonatal outcome was significantly higher among the ACS group (53.92% vs. 32.53%, odds ratio [OR] 2.42, 95% confidence interval [95%CI] 1.41–4.15, P = 0.01). After adjustment for potential confounders, this association remained significant (OR 2.15, 95%CI 1.23–3.78, P = 0.007).

Conclusions: ACS given during pregnancy did not improve respiratory outcome for SGA late preterm neonates. ACS may be associated with a worse outcome.