Israel Medical Association Journal

Background: The correlation between epidural analgesia and successful Trial of Labor After Cesarean delivery (TOLAC) remains controversial.

Objectives: To explore this correlation considering the indication for previous cesarean section (CS).

Methods: We accessed an electronic database of an obstetrics department at a university tertiary medical center. All patients admitted for a TOLAC at term with a live singleton fetus with cephalic presentation between January 2015 and December 2021 were included. The primary outcome was the mode of delivery, based on the previous CS indication. Univariate and multivariate analyses were performed to identify the effect of epidural analgesia on TOLAC success.

Results: Overall, 1522 candidates for TOLAC were included, with previous CS due to arrest of descent in 261 cases (17.1%). Epidural analgesia was administered in 1098 deliveries (72.1%), and 282 women (18.5%) underwent a repeat CS. Women in the epidural group were younger, had higher body mass index, lower parity, and more frequent induction of labor. Prior vaginal birth after cesarean was more common in the non-epidural group. Univariate analysis showed a higher rate of epidural analgesia in repeat CS cases. However, in multivariable logistic regression, epidural analgesia was not significantly associated with the risk of repeat CS, both among women whose prior CS was for arrest of descent and among those with other indications.

Conclusions: The employment of epidural analgesia seems to have no observable influence on successful outcomes of TOLAC, regardless of the indication for the preceding CS. These findings imply that epidural anesthesia in TOLAC is safe.

Background: Hypertensive disorders during pregnancy can lead to significant adverse outcomes. Currently, no established and effective tests have a high predictive value for preeclampsia toxemia (PET) severity and its associated adverse outcomes.

Objectives: To investigate the correlation between the aspartate aminotransferase-to-platelet ratio index (APRI) and the risk of obstetrical and neonatal adverse outcomes in women with PET.

Methods: We conducted a population-based cohort study at a tertiary medical center, which included all women who delivered between the years 2020 and 2022 and were diagnosed with PET. Women with incomplete records, multiple gestations, and fetal malformations were excluded. The median APRI of the cohort was the cut-off point to compare the risk of obstetrical and neonatal complications between low and high APRI scores. A multivariable logistic regression was used to adjust for confounders.

Results: The study included 513 women with PET who met the inclusion criteria. The median APRI score was used as a cut-off value, resulting in 255 women with an APRI score < 0.26 and 258 with a score > 0.26. A higher APRI score was significantly correlated with a small for gestational age (SGA) newborn and preterm delivery before 34 weeks after controlling for parity, previous cesarean delivery (CD), and maternal age (adjusted odds ratio 1.60, 95% confidence interval 1.01–2.55; P = 0.047, adjusted hazard ration 1.75, 95% confidence interval 1.12–3.09, P = 0.047).

Conclusions: In patients with PET, an APRI score > 0.26 was associated with an increased risk for SGA and preterm deliveries.

Background: Cesarean section (CS) comprised almost one-third of all births. One of the complications after CS is intra-abdominal and pelvic adhesions formation.

Objectives: To investigate whether a previous CS poses an additional perioperative or postoperative risk for complications when performing a total laparoscopic hysterectomy (TLH).

Methods: We conducted a retrospective cohort study of women who had undergone a TLH between 2014 and 2020. Perioperative and postoperative complications were assessed according to the Clavien-Dindo classification system. Descriptive statistics were used to analyze the results.

Results: In total, 190 women underwent TLH during the study period, 50 (26.5%) had a previous CS (study group) and 140 (73.5%) had no history of CS. The complication rates using the Clavien-Dindo classification system were similar in both groups; however, the major complications rate was not significantly higher in the study group (CS 6% vs. no CS 1.4%, P = 0.08). Urethral injury was the most common major complication (2, 4% vs. 1, 0.7%). The duration of surgery (125 min vs. 112 min, P = 0.02), estimated blood loss (174 ml vs. 115 ml, P = 0.02), and additional postoperative endoscopic interventions (4% vs. 0%, P = 0.01) and were significantly greater in patients with a previous CS.

Conclusions: Although the need for postoperative endoscopic interventions, surgery duration, and estimated blood loss were significantly higher in patients with a previous CS, TLH remains a safe and recommended procedure for these patients. Major complications are rare and do not occur more frequently following a previous CS.

Methotrexate, a folate analog antimetabolite, is one of the oldest cytotoxic drugs still in use. It is active against a variety of malignancies including bladder and breast cancer, head and neck tumors, gestational choriocarcinoma, osteogenic sarcoma, lymphomas, and leukemias.

Methotrexate is given mostly intravenously (IV), usually at standard doses (milligrams). It can also be delivered in much higher doses (grams), which is known as high-dose methotrexate (HDMTX). The intrathecal (IT) route is used particularly in children with acute lymphoblastic leukemia (ALL) and in adults with meningeal carcinomatosis. The drug may be administered orally as well, mainly in non-oncological conditions such as rheumatoid arthritis and other autoimmune diseases.

Plastic and reconstructive surgery is a specialty that has an important place in the surgical field. Plastic surgeons cooperate with all surgical disciplines to solve complex multidisciplinary surgical cases. This issue of the Israel Medical Association Journal (IMAJ) covers some of the groundbreaking treatments being performed by plastic surgeons in Israel.

The articles show the wide and complex range of issues where plastic surgery is needed, including hospital-based breast reconstructions, oncologic resections, and innovative lymphedema surgery, as well as aesthetic procedures. The efforts of plastic surgeons have been especially highlighted due to the Iron Swords war, which started on 7 October 2023. Injuries included complex burns and amputations that required attention under fire. In addition, advances were achieved through cutting‑edge reconstructive microsurgical traumatic solutions. Together, these articles highlight how Israeli teams have leveraged experience in trauma, high‑volume civilian and military caseloads and innovative inspirations that have generated knowledge that may be broadly applicable to surgeons worldwide.

Background: Soft-tissue defects of the lower limb pose a reconstructive challenge. Soft tissue loss with exposed bone, tendon, or cartilage often requires free flap reconstruction. Dermal substitutes are used for treatment of extensive burns to replace damaged skin and may be ideal for lower limb reconstruction in selected cases.

Objectives: To present our experience with reconstruction of lower limb wounds using Integra® Bilayer Wound Matrix (Integra LifeSciences Corp., Plainsboro, NJ, USA) and MatriDerm® (MedSkin Solutions Dr. Suwelack AG, Billerbeck, Germany).

Methods: This single center retrospective study comprised 10 patients who underwent reconstruction of extensive tissue defects of the distal lower limbs with dermal matrices and split-thickness skin grafts.

Results: All patients were successfully reconstructed and resumed normal ambulation. Six patients had complete and four partial graft takes that was treated conservatively until full wound healing. Older patients with medical co-morbidities or history of wound infection were more likely to have partial graft take. One postoperative infection was recorded in the study.

Conclusions: Dermal substitutes are easy to apply and safe, show minimal donor site morbidity, provide good functional and aesthetic outcomes, and should be used for reconstruction of complex lower limb wounds.

Background: Merkel cell carcinoma (MCC) is a rare and aggressive neuroendocrine skin tumor with an increasing incidence in Western countries. Predominantly affecting older individuals, MCC represents less than 1% of malignant skin tumors.

Objectives: To characterize the clinical presentation, therapeutic interventions, and follow-up outcomes of MCC patients. To promote heightened clinical awareness regarding the early recognition and diagnosis of MCC.

Methods: We conducted a retrospective cohort study analyzing medical records of MCC patients at the Shaare Zedek Medical Center between 2015–2022. From 19 initially identified patients, 17 met the inclusion criteria. Data collection included demographic, epidemiological, clinical, and pathological characteristics.

Results: The study included 17 patients, predominantly of Jewish origin, with a mean age of 70.06 years; 58.8% female. Medical co-morbidities included 64.7% hypertension and 35.3% diabetes. MCC tumors were predominantly left-sided (58.8%), with varied locations including limbs, trunk, and face. Surgical treatment consisted of excision and primary closure (64.7%) or skin grafting (23.5%). The average tumor diameter was 3.41 cm clinically and 3.83 cm pathologically. Lymph node involvement occurred in 29.4% of cases; 23.5% showed metastatic disease at diagnosis, with metastases diffused in different body areas. Kaplan-Meier survival analysis showed no statistically significant differences across most variables, except for a significantly lower survival rate in patients with ischemic heart disease (P = 0.009).

Conclusions: Our study reveals unique characteristics of MCC, predominance of female patients, and a slightly younger average diagnosis age compared to existing literature. The 2-year survival rate in our cohort was 82%. The study underscores the importance of early detection and diagnosis of MCC, thereby enhancing clinical awareness and improving patient outcomes.

We summarized the role of lung ultrasound for diagnosing and monitoring various pediatric respiratory diseases. We began with an overview of the basics of the tool, followed by describing its use in conditions such as pneumonia, pleural effusion, bronchiolitis, atelectasis, pneumothorax, bronchiectasis, and interstitial lung disease. We highlighted the sensitivity and specificity of lung ultrasound for the various diseases described. Furthermore, we included a comparison of this modality to other commonly used imaging techniques.

Background: Radiofrequency-skin interaction is considered self-limited for treating acquired pigmentation such as melasma. Alternatively, skin perforation with microneedling radiofrequency (MNRF) may increase skin bioavailability for depigmenting-mediated ingredients or drugs for the treatment of melasma.

Objectives: To examine the clinical feasibility of topical tranexamic acid (TA) mediated with MNRF-assisted transepidermal delivery in patients with mixed melasma.

Methods: The study protocol included 14 women with centrofacial or malar pattern of distribution of melasma (skin types II-VI; age 35–48 years). Patients underwent four treatments at 3-week intervals between treatments. Treatment protocol included non-insulated MNFR (Intensif, EndyMed Ltd, Caesarea, Israel) followed by TA (hexakapron 4%) solution application. The improvement was evaluated based on clinical photographs (Quantificare, Biot, France) and modified Melasma Area and Severity Index (mMASI) scores. Baseline Photographs were analyzed 3 months after the last treatment.

Results: In 13 patients (93%), mMASI scores were significantly lower after 3 months (mean 3.6) than at baseline (5.22). In one patient, mMASI was higher at 3 months compared to baseline. Overall, mMASI improved by 31% (P < 0.01). Physician and patient satisfaction was high. Minimal adverse reactions were recorded.

Conclusions: MNRF-assisted transepidermal delivery with topical TA is a safe and effective modality for the treatment of melasma.

Background: Prior to the coronavirus disease 2019 (COVID-19) pandemic, bronchiolitis caused by respiratory syncytial virus (RSV) was primarily observed during the winter months. Recently, however, an increase in incidence during the warmer months has been noted. This trend suggests an interaction between RSV and coronavirus, as well as the impact of public health measures, such as hand hygiene, mask-wearing, and social distancing.

Objectives: To characterize bronchiolitis cases in children under 2 years old caused by RSV during the COVID-19 pandemic in Israel from 2018 to 2022.

Methods: We conducted retrospective study by analyzing medical records of children hospitalized with bronchiolitis from January 2018 to December 2022. A comparison was made between cases before and after the first COVID-19 lockdown.

Results: A total of 922 children with bronchiolitis were studied: 276 cases occurred before the lockdown and 646 cases afterward. We found an increase in bronchiolitis frequency during the summer following the lockdown and a decrease during the winter (P < 0.0001). In addition, there was a shift in the pathogenic profile, with a notable rise in mixed infections after the lockdown (P < 0.0001). No significant differences in clinical presentation were observed between pre- and post-lockdown periods.

Conclusions: There was a change in bronchiolitis seasonality after the lockdown, with a significant increase in cases during the summer and a rise in mixed infections. Further studies are needed to assess whether this shift is a lasting consequence of the pandemic or a temporary change.

Background: Community-acquired pneumonia (CAP) is a prevalent bacterial infection in children. Lung ultrasound (LUS) is gaining popularity as a diagnostic tool for pneumonia, with the added potential for monitoring disease progression. However, research on the benefits of this modality for monitoring disease progression remains limited.

Objectives: To categorize the follow-up sonographic findings of lung inflammation in pediatric patients performed 10–14 days after being diagnosed with CAP.

Methods: We conducted a prospective observational study of children aged 0–18 years, diagnosed with CAP between 2020 and 2022. LUS findings at the time of diagnosis and 10–14 days later were recorded and documented.

Results: In total, 47 children were recruited, and 22 were included in the analysis. At the time of diagnosis, 20 patients (90%) had B-lines. Air bronchograms were found in all patients, and consolidation findings were observed in seven of the examined patients (32%). At the follow-up LUS 10–14 days later, B-lines were observed in six patients (27%). Air bronchograms were observed in eight patients, and consolidation findings were observed in six (27%). In 13 patients (59%), the follow-up LUS was completely normal. These patients were younger and had lower body weights. Pathological findings persisted in 41% of the patients.

Conclusions: For most patients, LUS demonstrated a resolution. Further large-scale studies are needed to validate the findings and determine the role of LUS in pediatric CAP.

Background: Several studies have shown an association between increased red blood cell distribution width (RDW) and adverse outcomes in various acute diseases. Small studies have suggested that RDW is a useful predictor of acute pancreatitis severity.

Objectives: To determine the association between RDW at admission and early mortality in acute pancreatitis. To assess whether RDW adds to the predictive ability of the Glasgow Imrie Score.

Methods: In this observational study, we included all adult patients admitted with a primary diagnosis of acute pancreatitis between January 2008 and June 2021. Patients were divided into two groups according to RDW: normal RDW (RDW ≤ 14.5%) and elevated RDW (RDW > 14.5%).

Results: Within 30 days of admission, 29/438 patients (6.6%) with increased RDW and 20/1250 patients (1.6%) with normal RDW had died: univariate analysis (odds ratio 4.6, 95% confidence interval 2.45–7.9, P < 0.001), fully adjusted model (odds ratio 3.29, 95% confidence interval 1.75–6.26, P < 0.001). We calculated receiver operating characteristic curve (ROC) for RDW alone, Glasgow Imrie Score alone, and a combination of Glasgow Imrie Score with RDW. We assessed their ability to predict 30-day mortality. Area under the ROC curve (AUC) of RDW alone was 0.671 and Glasgow Imrie Score AUC was 0.682; Glasgow Imrie Score plus RDW had an AUC of 0.769.

Conclusions: In patients with acute pancreatitis, elevated RDW at admission was independently associated with increased 30-day mortality. The addition of RDW to a pancreatitis prognostic tool such as the Glasgow Imrie Score improves its predictive ability.

Background: Breech presentation is a major indication for cesarean delivery (CD); however, the ideal timing of breech CD is debatable.

Objectives: To study the influence of gestational age at the time of CD in breech presentation on maternal and fetal complications.

Methods: We conducted a retrospective study including term singleton CDs of breech presentation between February 2020 and January 2022 at a tertiary medical center. Maternal and neonatal outcomes were compared by gestational age at the time of CD. Logistic regression models were constructed to adjust for confounders.

Results: The study population included 468 CDs, 227 (48.5%) were at 37 + 0 to 38 + 6 weeks, 168 (36%) were at 39 + 0 to 39 + 6 weeks (comparison group), and 73 (15.5%) were at ≥ 40 weeks at the time of delivery. The rate of emergent CDs was significantly higher in both study groups. The composite of maternal adverse outcomes was also significantly higher at ≥ 40 weeks of gestation. Using logistic regression model, associations remained significant. The adjusted odds ratios (OR) for emergent CDs at 37 + 0 to 38 + 6 weeks and at ≥ 40 weeks were 1.65 (P = 0.018) and 2.407 (P = 0.004), respectively. Adjusted OR for maternal adverse outcomes at ≥ 40 weeks was 2.094 (P = 0.018). Higher rates of emergent CDs in both study groups compared to the comparison group was noted. A composite of maternal adverse outcomes was significantly higher at ≥ 40 weeks of gestation. This association remained significant after controlling for potential confounders.

Conclusions: CDs at 39 + 0 to 39 + 6 weeks are associated with better maternal outcomes and lower rates of emergent CDs.

Background: Myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) is a rare autoimmune demyelinating disorder of the central nervous system. Optic neuritis (ON) is the most common clinical manifestation of MOGAD in adults. In 2023, new MOGAD diagnostic criteria were proposed, highlighting the importance of supplemental criteria when MOG-immunoglobulin G (IgG) titers are unavailable.

Objective: To investigate the applicability of the 2023 MOGAD criteria in patients diagnosed with MOGAD and treated before the availability of MOG-IgG titers.

Methods: We conducted a retrospective chart review of patients classified as MOGAD between 2010 and 2023 at Rabin Medical Center. Patient demographics as well as clinical and imaging data were collected, including visual acuity, expanded disability status score, core demyelinating events, antibody status, and brain and optic nerve magnetic resonance imaging data. Patients fulfilling the 2023 MOGAD criteria were reported as definite MOGAD.

Results: Fifteen patients met the 2023 MOGAD diagnostic criteria despite lack of MOG-IgG titer. The most common supplemental criterion meeting the 2023 MOGAD criteria was optic disc edema (n=12, 80%), followed by longitudinal optic nerve involvement (53%), bilateral ON (40%), and perineural optic sheath enhancement (33%).

Conclusions: All patients with a clinical diagnosis of MOG-ON in our cohort fulfilled the 2023 MOGAD criteria despite the lack of antibody titers. The 2023 MOGAD criteria can be reliably applied to Israeli cohorts, prior to availability of MOGAD IgG titers, with particular attention to additional supplemental criteria. Since the 2023 MOGAD criteria were published, MOGAD IgG titers have been added to routine testing at our facility.

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.