Israel Medical Association Journal

Background: Limited data exist regarding the association between marital status and outcomes among octogenarian and nonagenarian patients with heart failure (HF).

Objectives: To examine the association between marital status and outcomes of octogenarian and nonagenarian patients with HF.

Methods: We conducted a retrospective analysis of 1371 octogenarians and nonagenarians who were hospitalized with HF and enrolled in the multicenter national survey in Israel between March and April 2003. The patients were followed until December 2014. Patients were classified into married (n=562) and unmarried (n=809). The clinical characteristics of the patients by marital status categories were compared by using Student's t-test for continuous variables and the chi-square test for categorical variables. Kaplan–Meier survival analysis was used to present survival estimates according to the different marital status categories and the subsequent 4-year survival probability. Multivariate stepwise Cox proportional hazard regression modeling was used to assess the independent predictors of mortality among the study population.

Results: Married patients were more likely to be male, to smoke, and to have past myocardial infarction and previous revascularization. They tended to have higher rates of peripheral vascular disease and dyslipidemia. Survival analysis showed that 4-year mortality rates were similar between married and unmarried patients. The main consistent independent predictors of 4-year mortality were age, advanced HF (New York Heart association (NYHA) > 2), advanced renal failure, low hemoglobin, high Charlson Comorbidity Index, and low admission systolic blood pressure.

Conclusions: Among the octogenarian and nonagenarian population with HF, being unmarried does not confer an increased risk of mortality. Nevertheless, unmarried patients had a different clinical profile. Higher risk profile, co-morbidities, and advanced age impact mortality among octogenarian and nonagenarian patients.

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.

Background: Breast reconstruction following oncological resection offers psychosocial benefits. Various factors influence patient reconstruction decisions, including ethnicity, socioeconomic status, and education. We investigated disparities in breast reconstruction among Bedouin and non-Bedouin women in the Negev region.

Objectives: To investigate the influence of ethnicity in breast reconstruction decisions between Bedouin and non-Bedouin women in Israel and to identify factors influencing the choice of reconstruction following oncological breast surgery.

Methods: In this retrospective cohort study, we examined women undergoing breast cancer surgery, with or without reconstruction, between 2015 and 2021 in a breast cancer referral center. Demographics and detailed medical data were collected from electronic health records. We analyzed the factors that influenced decisions regarding breast reconstruction.

Results: The study included 1415 patients who underwent breast resection. Age was a significant factor in breast reconstruction choices, with younger patients being more likely to choose reconstruction. Marital status and education level influenced the decision, whereas socioeconomic status and number of children did not. Ethnicity analysis highlighted distinct demographic and socioeconomic differences between Bedouin and non-Bedouin women. Despite these disparities, surgical choices did not differ significantly between ethnicities.

Conclusions: Significant disparities exist between Bedouin and non-Bedouin women in terms of sociodemographic factors. However, these disparities did not affect their breast reconstruction decisions. Age, marital status, and education level influenced the decision to reconstruct the breast.

We report a rare case of an epidural abscess caused by Aggregatibacter aphrophilus in a 69-year-old healthy woman. The patient, presented with neck pain, high fever, and chills following dental treatment. A magnetic resonance imaging (MRI) scan revealed an epidural abscess with moderate spinal cord compression at the C4–C5 level. Surgical intervention and antibiotic therapy with ceftriaxone led to complete recovery. This case underscores the significance of considering A. aphrophilus as a potential pathogen in patients with neck pain and fever post-dental procedures and as a cause of abscesses in apparently healthy patients.

A. aphrophilus, a gram-negative coccobacillus, is part of the HACEK group (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella), a group of bacteria mainly known for its association with endocarditis [1]. However, A. aphrophilus is an uncommon pathogen for epidural abscesses [2]. Our case illustrates its potential to cause an epidural abscess after dental manipulation.

Background: Pediatric urolithiasis is relatively uncommon and is generally associated with predisposing anatomic or metabolic abnormalities. In the adult population, emergency department (ED) admissions have been associated with an increase in ambient temperature. The same association has not been evaluated in the pediatric population.

Objectives: To analyze trends in ED admissions due to renal colic in a pediatric population (≤ 18 years old) and to assess the possible effect of climate on ED admissions.

Methods: We conducted a retrospective, multicenter cohort study, based on a computerized database of all ED visits due to renal colic in pediatric patients. The study cohort presented with urolithiasis on imaging during their ED admission. Exact climate data was acquired through the Israeli Meteorological Service (IMS).

Results: Between January 2010 and December 2020, 609 patients, ≤ 18 years, were admitted to EDs in five medical centers with renal colic: 318 males (52%), 291 females (48%). The median age was 17 years (IQR 9–16). ED visits oscillated through the years, peaking in 2012 and 2018. A 6% downward trend in ED admissions was noted between 2010 and 2020. The number of ED admissions in the different seasons was 179 in autumn (30%), 134 in winter (22%), 152 in spring (25%), and 144 in summer (23%) (P = 0.8). Logistic regression multivariable analysis associated with ED visits did not find any correlation between climate parameters and ED admissions due to renal colic in the pediatric population.

Conclusions: ED admissions oscillated during the period investigated and had a downward trend. Unlike in the adult population, rates of renal colic ED admissions in the pediatric population were not affected by seasonal changes or rise in maximum ambient temperature.

Background: Adherence to treatment by adolescents and adults with cystic fibrosis (CF) is often poor.

Objectives: To assess the impact of a focused clinical intervention on adherence in individual patients, including help in problem-solving key barriers to adherence. To implement a patient-centered problem-solving intervention using CF My Way tools. To identify and overcome a selected barrier to adherence.

Methods: Medication possession ratios (MPRs), number of airway clearance sessions, forced expiratory volume (FEV₁), body mass index (BMI), and health-related quality of life (HRQoL) were measured before and after the intervention.

Results: Sixteen patients with CF, aged 23.4 ± 6.7 years, participated. MPR increased for colistimethate sodium and tobramycin inhalations from a median of 21 (range 0–100) to 56 (range 0–100), P = 0.04 and 20 (range 0–100) to 33.3 (range 25–100), P = 0.03, respectively. BMI standard deviation score rose from -0.37 to -0.21, P = 0.05. No significant improvements were found in FEV₁, airway clearance, or HRQoL scores.

Conclusions: The CF My Way problem-solving intervention increased adherence to medical treatments by removing barriers directly related to the needs and goals of young adults with CF

Background: Osteoporosis is a common medical condition in older ages. A devastating result of osteoporosis may be a hip fracture with up to 30% mortality rate in one year. The compliance rate of osteoporotic medication following a hip fracture is 20% in the western world.

Objectives: To evaluate the impact of the fracture liaison service (FLS) model in the orthopedic department on patient compliance following hip fracture

Methods: We performed a retrospective review of all patients with hip fracture who were involved with FLS. We collected data regarding kidney function, calcium levels, parathyroid hormone levels, and vitamin D levels at admission. We educated the patient and family, started vitamin D and calcium supplementation and recommended osteoporotic medical treatment. We phoned the patient 6–12 weeks following the fracture to ensure treatment initiation.

Results: From June 2018 to June 2019 we identified 166 patients with hip fracture who completed at least one year of follow-up. Over 75% of the patients had low vitamin D levels and 22% had low calcium levels at admission. Nine patients (5%) died at median of 109 days. Following our intervention, 161 patients (96%) were discharged with a specific osteoporotic treatment recommendation; 121 (73%) received medication for osteoporosis on average of < 3 months after surgery. We recommended on injectable medications; however, 51 (42%) were treated with oral biphsophonate.

Conclusions: FLS improved the compliance rate of osteoporotic medical treatment and should be a clinical routine in every medical center

Background: The effect of repeated intravenous amantadine (IVAM) in advanced Parkinsonism has not been studied in depth.

Objectives: To report the experience of our medical center with repeated IVAM infusions in patients with advanced Parkinsonism.

Methods: Thirty patients with advanced Parkinsonism of various etiologies were enrolled in an open-label retrospective study. All patients were treated with IVAM infusions in a neurological daycare center. Treatment was initiated with a loading dose of 200/400 mg per day for 5 days followed by a once-daily maintenance dose of 200/400 mg every 1 to 3 weeks. Patients and their caregivers participated in a structured interview and independently completed a clinical global impression of changes scale questionnaire on various motor and non-motor symptoms.

Results: Patient mean age was 73.3 ± 9.7 years, average disease duration was 6.2 ± 5.7 years, and mean Hoehn and Yahr score was 3.2 ± 0.84. Mean duration of the IVAM treatment was 15.1 ± 11.6 months. An improvement in general function was reported by 91% of the patients and 89% of the caregivers. Most of the patients reported improvement in tremor and rigidity, as well as in gait stability, freezing of gait, and reduced falls. The treatment was safe with few side effects.

Conclusions: Our data suggest that repeated IVAM infusions could be an effective treatment against various motor symptoms and for improvement of mobility in patients with advanced Parkinsonism. Further randomized clinical trials with a larger sample size using objective measures are warranted to validate our results.

Background: Breast implant-associated anaplastic large cell lymphoma (ALCL) is a rare type of non-Hodgkin's lymphoma that is found around breast implants. ALCL was discovered only two decades ago. In Israel we currently have four diagnosed cases (as of 2018). Until recently, the estimated incidence was 1:300,000 women with breast implants, while recent reports range from 1:3817 to 1:30,000. 

Objectives: To determine the occurrence of breast implant-ALCL in Israel.

Methods: We conducted a retrospective analysis of the four patients diagnosed with ALCL in Israel. Cytology was confirmed and the clinical data was collected. Based on the estimated number of women with breast implants in Israel, a calculation of the true incidence was completed.

Results: The incidence in Israel is significantly higher than the older incidence reports indicate. We estimated that the lifetime prevalence of the disease is 4:60,000 women with a textured breast implant, or 1:15,000 women with a textured breast implant in Israel.

Conclusions: ALCL is not common. We support the claim that the prevalence is significantly higher than what was initially described. This finding has clinical and medicolegal implications that should be addressed accordingly.

Background: Acute non-traumatic abdominal pain is typically evaluated by abdomino-pelvic computed tomography (CT) with oral and venous contrast. The accuracy of unenhanced CT for diagnosis in this setting has not been widely studied.

Objectives: To assess the accuracy of unenhanced CT in establishing the etiology of acute non-traumatic abdominal pain.

Methods: We retrospectively reviewed the medical and imaging records of patients aged ≥ 18 years who presented to the emergency department (ED) during a 6-month period with acute non-traumatic abdominal pain of unknown etiology, and who were evaluated with non-contrast CT within 24 hours of ED admission. Clinical details were recorded. A presumptive clinical diagnosis and CT diagnosis were compared to the discharge diagnosis which was considered the reference standard. The requirement for informed consent was waived.

Results: Altogether, 315 patients met the inclusion criteria – 138 males (44%) and 177 females (56%); their mean age was 45 years (range 18–90). Clinical diagnosis correlated with the CT findings in 162 of the cases (51%). CT was accurate in 296/315 cases (94%). The leading diagnosis in cases of a mismatch between CT diagnosis and discharge diagnosis was infection mostly in the urinary tract (12/18). Sensitivity, specificity, positive predictive value and negative predictive value were 91%, 99%, 91% and 85% respectively. The discharge diagnosis was unchanged in the patients who returned to the ED within 1 week of the first admission.

Conclusions: In this study, unenhanced CT proved to be a feasible, convenient and legitimate examination for the evaluation of patients with acute non-traumatic abdominal pain presenting to the ED.

Background: Family physicians and internal medicine specialists play an essential role in treating cancer patients. Modern technological advances in radiotherapy are not widely appreciated by primary care physicians. Bone metastases are a frequent complication of cancer. Palliative radiation therapy, as a component of modern advances in radiation treatments, should not subject normal bodily structures to excessive doses of irradiation. The sacrum is a common destination site for bone metastases, yet its concave shape along with its proximity to the rectum, intestines, and femoral heads creates treatment-planning challenges.

Objectives: To investigated whether the volumetric modulated arc therapy (VMAT) technique is preferable to more conventional radiation strategies.

Methods: The study comprised 22 patients with sacral metastases who were consecutively treated between 2013 and 2014. Two plans were generated for the comparison: three-dimensional (3D) and VMAT.

Results: The planning target volume (PTV) coverage of the sacrum was identical in VMAT and 3D planning. The median values for the rectal dose for 3D and VMAT were 11.34 ± 5.14 Gy and 7.7 ± 2.76 Gy, respectively. Distal sacral involvement (S4 and S5) was observed in only 2 of 22 cases, while the upper pole of the rectum ended at the level above S3 in just 3 cases.

Conclusions: Radiation therapy continues to be an integral component of the palliative armamentarium against painful metastases. Radiation oncologist, in conjunction with referral physicians, can tailor treatment plans to reflect the needs of a given patient.