Israel Medical Association Journal

Background: This study provides valuable insight on the importance of antenatal follow-up, despite advances in medical capabilities.

Objectives: To provide current information on mortality rates and causes including demographic parameters.

Methods: A total of 3362 infants were admitted to the neonatal intensive care unit at Kaplan Medical Center between 2009 and 2021. Retrospective data were extracted from a computerized prospective database and further divided to two groups: 2009–2014 and 2015–2021. For sequential variables, we calculated the mean, standard deviation, and median. For categorical variables we calculated the prevalence and performed a chi-square test. The sequential variables did not show a normal distribution according to the Shapiro-Wilk test. Therefore, the A-parameter Mann-Whitney test was used. Results were considered significant when the P-value < 0.05.

Results: A decrease in the death rate was found, but when evaluating the infants who died, a decrease in full antenatal follow-up from 55.2% to 31.5% was seen (P-value = 0.06).

Conclusions: Despite advancements in medical knowledge and capabilities, an association was found between increased mortality and reduced antenatal follow-up.

Background: Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by fibrosis of the skin and internal organs. Its expression can vary across ethnic groups.

Objectives: To compare clinical and serological manifestations of SSc between Jewish and Arab patients in Israel.

Methods: We conducted a retrospective single-center study included 100 patients with SSc selected from our rheumatology clinic at Meir Medical Center, comprising 50 Jewish and 50 Arab patients with available complete clinical and laboratory data. Demographic characteristics, disease features, autoantibody profiles, organ involvement, and treatment patterns were collected.

Results: Most clinical, laboratory, and treatment variables did not differ significantly between Jewish and Arab patients. Significant difference was the higher prevalence of skin telangiectasia in Jewish patients (86%) compared to Arab patients (38%) (P < 0.001) as well as Raynaud phenomenon and pulmonary hypertension. Other manifestations, including organ involvement and autoantibody prevalence, were similar across the groups.

Conclusions: This study reveals significant similarities in the clinical and serological expression of SSc between Jewish and Arab patients in Israel. The higher prevalence of telangiectasia in Jewish patients suggests a possible ethnic or environmental influence on vascular manifestations. Further research is needed to explore the potential genetic or environmental factors contributing to this difference and to assess if this impacts disease progression or treatment outcomes.

Background: Gait disturbances are common in patients undergoing hemodialysis and are associated with increased fall risk, mobility decline, and adverse health outcomes. Prior research suggests that hemodialysis may impact gait parameters such as speed, stride length, and variability; however, findings are inconsistent.

Objectives: To evaluate acute changes in gait metrics before and after hemodialysis using an artificial intelligence (AI) based video gait analysis system.

Methods: We initially enrolled 38 hemodialysis patients, two were excluded due to clothing interference with video analysis (27.8% female, 72.2% male). AI-driven gait analysis was performed immediately before and after dialysis. The system extracted spatiotemporal gait and joint range of motion. Statistical analyses included the Shapiro-Wilk test for normality, Wilcoxon signed-rank tests for non-normally distributed data, and paired t-tests for normally distributed data (P < 0.05).

Results: Gait speed (0.59 m/sec pre-dialysis) remained unchanged post-dialysis (P = 0.876), as did cycle length and time. However, step length significantly decreased post-dialysis (P = 0.001), suggesting a more conservative gait pattern. Knee flexion and extension increased slightly but did not reach statistical significance.

Conclusions: Dialysis does not acutely affect overall gait speed but significantly reduces stride length. Post-dialysis fatigue or hemodynamic shifts may alter walking patterns, highlighting the need for fall prevention strategies and physical rehabilitation interventions in dialysis care. AI-based gait analysis may provide a practical tool for monitoring mobility changes in hemodialysis patients.

Background: Prophylactic intravenous antibiotics are not routinely administered prior to direct peroral cholangiopancreatoscopy. The frequency of post-procedure bacteremia has not been well studied.

Objectives: To evaluate the risk of bacteremia following endoscopic retrograde cholangiopancreatography (ERCP) with cholangiopancreatoscopy. To assess the prevalence of other infectious complications and the effect of real-life practices regarding prophylactic antibiotic administration.

Methods: We conducted a retrospective analysis on consecutive patients (2016–2022) who underwent cholangiopancreatoscopy using the single-operator SpyGlass System (Boston Scientific Corporation, USA). Prophylactic antibiotic treatment was administered based on clinical discretion. Demographic and clinical data, including procedure indication, procedure reports, blood culture results, pre- and post-procedure antibiotic treatment, hospital length, mortality, and infectious and non-infectious complications, were collected.

Results: Our single-center cohort included 75 patients who underwent ERCP with direct cholangiopancreatoscopy. We involved 63 patients in the analysis. In 17/63 patients (27%), post-procedural blood cultures were drawn based on clinical suspicion of infection. Positive cultures were found in 4/17 (23.5%) of all cultures and 4/63 (6.3%) of the entire cohort; 2/63 (3.2%) had clinically significant bacteremia. Antibiotic prophylaxis was administered to 35 patients (55.6%), with no evidence of significant reduction in bacteremia, cholangitis, hospitalization length, or mortality rates when compared to patients who did not receive prophylactic antibiotics (P > 0.05). Post-procedural cholangitis was observed in 5/63 patients (7.9%). There were no cases of acute cholecystitis or liver abscess.

Conclusions: The prevalence of bacteremia and cholangitis following ERCP with direct cholangiopancreatoscopy was 6.3% and 7.9%, respectively. Prophylactic antibiotics did not reduce post-procedural infectious adverse events.

Genitourinary syndrome of menopause (GSM) has gained increasing attention in recent years, with growing literature on its pathophysiology, clinical presentation, and treatment options. A bibliometric analysis helps identify high-quality research based on citation rates and journal impact factors. In this review, our objective was to analyze the key themes and topics in GSM literature. We conducted a bibliometric analysis using the Thomson Reuters Web of Science database to identify the top 100 most-cited articles on GSM published over the past 50 years. Data were categorized into manuscript type, theme, author, country of origin, journal impact factor, and citation rate. The mean citation count per article was 67, ranging from 405 to 5. The most-cited paper, authored by the North American Menopause Society, had the highest citation rate of 45.0 citations per year. The majority of articles (n=65) were published between 2010 and 2019. Randomized controlled trials comprised the largest publication type (29%). Most articles (n=65) were published in Q1-ranked journals. Although GSM is a relatively recent concept, the most-cited articles from the past 50 years generally focus on its medical and surgical treatments, as well as its epidemiology. This bibliometric analysis is the first to evaluate the top 100 most influential publications on GSM.

Background: Interpretation of blood gases is essential for the correct practice of medicine. Normal ranges for arterial blood gases (ABG) have not been extensively studied in the older population. Also, venous blood gases and venous-arterial pCO₂ gradient have not been studied in this population, even though they signify the majority of hospitalized patients.

Objectives: To determine the normal range for ABG and the bias limits of agreement for arterial-venous difference in the elderly population.

Methods: We recruited 130 elderly patients (> 70 years) and obtained blood gas measurements from venous and arterial blood. Patients were divided into four categories: healthy patients, patients with stable chronic pulmonary disease, hospitalized patients with acute respiratory illness, and hospitalized patients without respiratory disease. Samples were analyzed in a point of care analyzer.

Results: Mean PaCO₂ was 36.9 ± 4.2 mmHg for the healthy control group, 37.0 ± 4.8 mmHg in the stable chronic respiratory group, 37.0 ± 5.0 mmHg in the non-respiratory hospitalization group, and 42.3 ± 11.4 mmHg for the respiratory hospitalization group, Kruskall-Wallis, P <0.0025. Mean bias between venous and arterial CO₂ was +10.0 mmHg with 95% limits of agreement between 2.7 mmHg and -22.8 mmHg.

Conclusions: In elderly patients, the range of PaCO₂ measurements was similar to the accepted normal range in clinical practice. Venous-arterial PCO₂ gradient had high bias and wide limits of agreement, similar to previously published studies.

Background: Lung transplantation (LT) is a viable option for end-stage chronic obstructive pulmonary disease (COPD) patients when conventional treatments fail. However, sex disparities in mortality outcomes among COPD patients awaiting LT remain understudied. LT waiting lists are generally shorter in Western countries compared to Israel.

Objectives: To evaluate sex-specific differences in mortality and co-morbidities among COPD patients awaiting lung transplantation, to identify key risk factors influencing survival.

Methods: We assessed associations between sex, co-morbidities, exacerbations, and mortality using Cox regression models, adjusting for confounders. Survival curves for lung transplant candidates were stratified by sex using Fine and Gray models.

Results: We identified 385 COPD patients listed for LT at Rabin Medical Center. Females exhibited higher rates of asthma (P = 0.008), anxiety (P = 0.005), and depression (P = 0.002); males were more frequently diagnosed with ischemic heart disease (26.5% vs. 10.83%, P = 0.001) and had a higher lung transplant rate (24.9% vs. 15%, P = 0.029). Multivariate analysis revealed that female sex (hazard ratio [HR] 1.55, 95% confidence interval [95%CI] 1.06–2.29, P = 0.025), older age (HR 1.02, 95%CI 1.002–1.054, P = 0.035), ischemic heart disease (HR 1.69, 95%CI 1.12–2.48, P = 0.011), and depression (HR 1.81, 95%CI 1.15–2.83, P < 0.01) were significantly associated with increased mortality. Females showed higher 1-year mortality rates than males (40.3% vs. 29.8%, P < 0.001).

Conclusions: Female sex is a significant risk factor for increased mortality among COPD patients awaiting LT, likely due to a higher burden of co-morbidities.

Background: Pediatric urinary tract infections (UTIs) are a significant health concern, with rising antibiotic resistance complicating treatment decisions. We investigated pathogen distribution, antibiotic susceptibility patterns, and the cost-effectiveness of treatment options among hospitalized children at a tertiary medical center in Israel.

Objectives: To assess antibiotic susceptibility patterns of UTI pathogens in hospitalized children and evaluate cost-effective alternatives to gentamicin.

Methods: A retrospective analysis of 1649 pediatric UTI cases (January 2010–May 2022) at Galilee Medical Center examined patient demographics, urine culture results, and antibiotic susceptibility. A cost-effectiveness analysis was performed using incremental cost-effectiveness ratios (ICERs), based on susceptibility rates from the study and antibiotic costs from the Israel Ministry of Health, with gentamicin as the comparator.

Results: Escherichia coli was the most common pathogen (63.7%). High susceptibility rates were observed for carbapenems and amikacin (> 99%), with lower rates for gentamicin (91.7%) and ceftriaxone (87.6%). Treatment costs ranged from US$2.54 (trimethoprim/sulfamethoxazole) to US$307.80 (ertapenem). Fosfomycin demonstrated higher susceptibility than gentamicin (94.2% vs 91.7%) and lower cost (US$3.77 vs US$8.05), dominating gentamicin in cost-effectiveness analysis. Piperacillin/tazobactam and ceftriaxone were dominated by gentamicin in terms of cost-effectiveness.

Conclusions: E. coli was the predominant pathogen in pediatric UTIs among hospitalized children. Carbapenems and amikacin showed high susceptibility but were costly. Fosfomycin demonstrated high susceptibility, favorable cost-effectiveness, and the advantage of oral administration, making it a promising option for empiric treatment. Empiric antibiotic selection should integrate susceptibility patterns, clinical context, and economic considerations.

Chronic obstructive pulmonary disease (COPD) is a disease state characterized by persistent respiratory symptoms and airflow obstruction determined by spirometry, including emphysema, chronic bronchitis, and small airway disease. Traditional treatment settings for COPD exacerbations typically involve in-hospital care. However, hospital-at-home (HaH) programs have emerged as an innovative model to provide hospital-level care at a patient's home. I synthesized available randomized controlled trials (RCTs) and compared the outcomes of COPD management in HaH and in-hospital settings. I searched for English language medical literature studies of COPD patients in HaH programs compared to in-hospital. Searches were performed in PubMed, EMBASE, Scopus, and CENTRAL. Outcomes were compared, meta-analyses were performed, and pooled odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated. Heterogeneity was evaluated and I² statistic was used to measure the proportion of inconsistency in individual studies. Potential publication bias was also calculated. Seven controlled studies representing 19 sub-studies (data sets) were selected according to the inclusion criteria. The OR of the HaH and in-hospital comparison was 0.542, 95%CI 0.379–0.774, P = 0.001. The different clinical outcomes of HaH were better or similar to those at regular hospitals, but with higher patient preference (OR 0.316, 95%CI 0.198–0.506). Heterogeneity and inconsistency were small, with no significant publication bias. HaH may be recommended for COPD patients' hospitalization when needed according to the specific indications and patients matching HaH criteria.

Background: Abdominoplasties are among the most common procedures in aesthetic plastic surgery. The target audience are patients after massive weight loss who are left with excess skin and post-partum patients. Due to the efficacy of abdominoplasties in improving the abdominal contour, it became a mainstay procedure in plastic surgery. Claims have been made that abdominal surgeries can be safely combined with breast surgeries, and thereby decrease the risk associated with anesthesia for two separate procedures as well as the recovery period. The benefits of the combined procedures led to a surplus of patients seeking consultations.

Objectives: To examine the safety of the mommy makeover procedure compared to sole abdominoplasty.

Methods: Patients who previously underwent abdominoplasty by the senior author were divided into two groups based on whether breast surgery was performed in addition to the abdominoplasty. Groups were compared based on demographical, clinical, and surgical variables.

Results: The study cohort included 726 patients, of whom 15% underwent "Mommy-makeovers". Groups differed only in liposuction volume, resection weight and number of drains. Regarding surgical outcomes, surgical site infections were seen at a greater rate in the isolated abdominoplasty procedure. Further analyses accounting for potential confounders found no difference between the groups in terms of adverse events.

Conclusions: Mommy makeovers do not display a safety concern when compared to isolated abdominoplasties. Surgeons must consider various patient characteristics to ensure optimal results.

Background: The increasing use of micromobility solutions (MMS), including electric scooters, electric, and non-motorized bicycles, has revolutionized urban transportation. We addressed the rising incidence of injuries related to pedestrian-MMS accidents, with a specific focus on pedestrian injuries.

Objectives: To improve clinician comprehension of patient characteristics and injuries associated with pedestrian-MMS accidents and to provide insights for injury prevention, policy making, and urban planning.

Methods: We conducted a retrospective analysis, June 2017 to January 2023, of pedestrians who were admitted to the emergency department post-MMS accidents. Data included patient characteristics, type of MMS, time of the accident, and outcome variables including type of injury, hospitalization, and surgical treatment.

Results: The study cohort included 498 pedestrians (57.7% women), with a mean age of 42.3 ± 21.8 years. Nighttime accidents were 53.2% of cases. Fractures were the dominant type of injury (18.3% of the total cohort). Age, particularly those ≥ 60 years, significantly (P < 0.05) influenced fracture, hospitalization, and surgery rates (30.6%, 22.4%, and 12.6%, respectively). The odds ratio of having a fracture for pedestrians ≥ 60 years was 5.35 (P = 0.008). Interestingly, the type of MMS did not significantly affect outcomes.

Conclusions: Age emerged as a critical factor in injury severity, emphasizing the need for age-specific safety measures in urban environments. The type of MMS did not show a significant influence on outcomes, emphasizing the importance of a comprehensive regulation of all MMS types. The high rate of accidents during nighttime calls for focused interventions during this period to prevent accidents.

Background: Giant cell arteritis (GCA) is a large vessel vasculitis predominantly affecting patients over 50 years, typically managed with glucocorticoids, with treatment varying on individual patient needs. While effective for GCA, long-term glucocorticoids use poses significant risks, including the development of osteoporosis, a metabolic bone disease common in older individuals. This overlap poses a significant clinical challenge, as the treatment for GCA inadvertently raises the risk of osteoporosis and necessitates careful balance to manage both conditions effectively.

Objectives: To investigate the occurrence of osteoporosis and other co-morbid conditions in patients with GCA treated with glucocorticoids.

Methods: A retrospective cross-sectional analysis of GCA patients examined the correlation between GCA and osteoporosis by searching the Clalit Health Service database for patients over 50 years of age from January 2002 to January 2018. In addition, we conducted a logistic regression analysis stratifying for other co-morbidities to evaluate the independent association between GCA and osteoporosis.

Results: In total, 6607 GCA patients were compared with 36,066 age- and sex-matched controls. The study revealed a higher prevalence of osteoporosis in the GCA group (43%) compared to controls (27%) (odds ratio [OR] 2.06, 95% confidence interval [95%CI] 1.95–2.17). In addition, hypertension, hyperlipidemia, diabetes mellitus, and ischemic heart disease were more prevalent among GCA patients. After stratifying for cardiovascular co-morbidities, GCA remained independently associated with osteoporosis (OR 2.1, 95%CI 1.96–2.26, P < 0.001).

Conclusions: Glucocorticoid-treated GCA is independently associated with osteoporosis. Healthcare providers must consider this added aspect of GCA for the treatment and management of patients.

Background: The prognostic significance of diabetes mellitus (DM) on hospitalization outcomes of patients with acute decompensated heart failure (ADHF) remains inconclusive.

Objectives: To comprehensively assess the clinical outcomes of patients with and without DM hospitalized for ADHF.

Methods: This single center retrospective cohort study included consecutive hospitalized patients with a principal diagnosis of ADHF between 1 January 2010 and 31 December 2019. Patients were categorized into diabetic and non-diabetic groups. The primary outcomes assessed were in-hospital mortality, 1-year overall mortality, and readmission rate within a year of follow-up.

Results: The final analysis involved 787 ADHF patients, with 62% having a pre-existing diagnosis of DM. Despite a higher burden of co-morbidities in diabetic patients, there were no differences in clinical outcomes when compared to non-diabetic counterparts. Specifically, there were no differences in overall hospital mortality (10% vs. 10%, P = 0.675), 1-year mortality (22% vs. 25%, P = 0.389), and re-admissions (51% vs. 56%, P = 0.154). Notably, the 1-year mortality among diabetic patients was not influenced by HbA1c levels documented before or during admission.

Conclusions: The clinical outcomes of patients hospitalized with ADHF did not differ by the presence of diabetes. Instead, our findings emphasize the importance of early heart failure prevention and subsequent hospitalization. Considering the evolving landscape of disease-modifying therapies for heart failure, achieving this goal becomes increasingly feasible.

Background: The impact of the coronavirus disease 2019 (COVID-19) pandemic on patient populations can be divided to direct consequences of the disease and indirect implications of changes imposed on the national healthcare systems. The impact of the later survival of chronic hemodialysis patients is still unknown.

Objectives: To examine the impact of quarantine on health outcomes of dialysis patients.

Methods: In a retrospective case-controlled study, we compared chronic hemodialysis patients from two separate timeframes: during a quarantine period and a parallel time without quarantine.

Results: The study included 344 hemodialysis patients. Baseline characteristics were compared between those enrolled in 2015 and those enrolled in 2020. Despite comparable clinical parameters, a statistically significant increase in the 6-month mortality rate was observed in 2020 (1.2% vs. 6.7%, P = 0.01), primarily attributed to sepsis. Notably, no deaths were attributed to COVID-19 in 2020. Interdialytic weight gain and dialysis quality remained similar between the two groups, with a mild trend toward excessive weight gain in 2020. Secondary outcomes after 6 months did not significantly differ, except for lower sodium values in 2015 compared to 2020.

Conclusions: Dialysis patients experienced disproportionate effects from the COVID-19 pandemic, even with continuous care and no direct virus-related fatalities. The findings showed unintended consequences of quarantine measures, highlighting adverse impact on both physical and mental health. Recognizing and addressing these consequences are imperative for minimizing their impact in future pandemics, emphasizing the importance of proactive measures in healthcare planning.

Colorectal cancer (CRC) is a major health concern, ranking as the third most common cancer in the United States. Screening programs, especially colonoscopy, play a crucial role in preventing CRC by removing and detecting polyps or early-stage cancers. Despite inherent risks, colonoscopy's effectiveness in saving lives is significant. In this review, we analyzed the outcomes of screening colonoscopies in an asymptomatic population for 15 years, focusing on detection rates and complications. We compared the data with previous meta-analyzes to evaluate changes in efficacy and safety. We conducted a systematic search of medical literature databases (1 January 2012 to 31 December 2023) for English-language studies on CRC screening colonoscopy. Our inclusion criteria comprised complete articles with over 500 participants with extractable data and a focus on screening colonoscopy outcomes in average-risk populations. In total, 2,897,025 people were screened, most (99.6%) were asymptomatic and were an average-risk population. Colonoscopy was complete and reached the cecum in 97–99% of the procedures. CRC was found in 0.5% (95% confidence interval [95%CI] 0.4–0.7%) of the participants. Advanced adenoma was found in 7.6% (95%CI 6.2–9.3%) of the cases. Complications were rare. Perforation developed in 0.022% of the cases and bleeding in 0.148%. Our findings exhibited a significant increase in the detection yield of adenomas and advanced adenomas with low complication rates, which shows that colonoscopy is feasible and suitable for screening for CRC in asymptomatic people.