Israel Medical Association Journal

Background: Omega-3 fatty acids promote fertility in males and females and constitute an important factor in the normal development of the fetus.

Objectives: We investigated the effect of omega-3 supplements during ovulation induction treatment in women with polycystic ovary syndrome (PCOS)-related infertility.

Methods: A randomized, double-blind study was conducted for 60 treatment cycles in 34 women with PCOS-related oligo/anovulation referred to the fertility clinic at the Bikur Cholim/Shaare Zedek Medical Center in Jerusalem, who underwent ovulation induction with clomiphene citrate (50 mg). Seventeen women (mean age 33.9 ± 0.9 years) received omega-3 supplements (3 × 600 mg/day) and 17 received placebo capsules (mean age 32.7 ± 0.9 years) for a maximum of two cycles. We recorded their characteristics and data from their serial hormonal blood tests and ultrasound examinations. We also conducted both univariate and multivariate analyses. The primary endpoint was conception.

Results: There were clinical pregnancies in 8/30 (26.7%) treatment cycles for women receiving omega-3 supplements versus 4/30 (13.3%) cycles with placebo. Among overweight/obese women (body mass index [BMI] 25–35), there were clinical pregnancies in 8/27 cycles (29.6%) versus 1/19 (5.3%) with placebo (P < 0.04). For overweight/obese PCOS women, omega-3, lower BMI rates, and higher values of the endometrium’s thickness increased the odds of becoming pregnant. No harmful side effects from the omega-3 treatment were reported.

Conclusions: Omega-3 supplements demonstrated beneficial effects for fertility in women diagnosed with PCOS. Among the overweight/obese participants, the increased clinical pregnancy rate was significant.

Background: Pediatric patients with newly diagnosed type 1 diabetes mellitus (T1DM) are commonly treated with daily multiple insulin injections or an insulin pump. They tend to have higher body mass index-standard deviation scores (BMI-SDS) than non-diabetic children.

Objectives: To identify patterns in the changes in BMI in the 3 years after T1DM diagnosis, and to discover factors that relate to excessive weight gain.

Methods: This retrospective study included clinical and laboratory data for 194 boys and girls aged 2–18 years at the time of diagnosis and at 1, 2, and 3 years after. Their BMI values were compared to non-diabetic children using BMI percentile and z-score (standard deviation) based on the U.S. Centers for Disease Control and Prevention (CDC) growth charts.

Results: Both males and females had low mean BMI-SDS at diagnosis (-0.4499 ± 1.38743 male, 0.3050 ± 1.29887 female) that increased after 1 year (-0.0449 ± 1.14772 male, 0.1451 ± 0.98893 female). Lower glycated hemoglobin (HbA1c) at 1 year correlated with higher BMI-SDS (r = -0.215, P = 0.011). No such correlation was found in the following 2 years. The daily dose of basal insulin correlated with higher BMI-SDS at 1 year (r = 0.183, P = 0.026) and 3 years (r = 0.297, P < 0.01). No association was found between the use of an insulin pump or continuous glucose monitoring and higher BMI-SDS.

Conclusions: BMI-SDS of children with T1DM was lower than average at the time of diagnosis and rose higher than average in the 3 years following. Higher BMI-SDS was not significantly associated with sex or ethnicity. The most prominent increase happened in the first year.

Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP1-RA) are new antidiabetic drugs that are recommended by current guidelines as a class I novel glucose-lowering treatment that improves cardiovascular outcome in type 2 diabetes mellitus (T2DM), particularly in patients with cardiovascular disease.

Objectives: To evaluate adherence to the current guidelines for treatment with SGLT2i and GLP1-RA drugs in patients referred to ambulatory consultant cardiology clinics with pre-existing T2DM.

Methods: We studied consecutive new patients with a pre-existing diagnosis of T2DM who were referred to the Clalit Health Services ambulatory consultant cardiology clinic over a 6-month period. The recorded information included demographics, co-morbidities, and prescribed drugs at patient admission.

Results: During the study period, 1782 patients visited our outpatient cardiology clinic. At screening, T2DM was present in 428 patients (24%); 77 (18%) were being treated with SGLT2i, and 39 (9.1%) with GLP1-RA. Patients receiving SGLT2i and GLP1-RA were younger and had more coronary artery disease, lower mean left ventricular ejection fraction, and higher mean estimated glomerular filtration rates than those who were not receiving these drugs. HbA1C was > 7 in 205 (47.9%) patients and > 7.5 in 136 patients (31.8%). Body mass index was > 30 kg/m² in 231 (54%) patients.

Conclusions: GLP1-RA and SGLT2i drugs were found to be administered more frequently than previously reported, but they are not yet satisfactorily prescribed.

Background: Due to the high variability in malignancy rate among cytologically indeterminate thyroid nodules (Bethesda categories III–V), the American Thyroid Association recommends that each center define its own categorical cancer risk.

Objectives: To assess cancer risk in patients with cytologically indeterminate thyroid nodules who were operated at our center.

Methods: In a retrospective study, we analyzed the pathology results of all the patients whose fine needle aspiration results showed Bethesda III–V cytology and who subsequently underwent total thyroidectomy or lobectomy from December 2013 to September 2017.

Results: We analyzed 56 patients with indeterminate cytology on fine needle aspiration. Twenty-nine (52%) were defined as Bethesda III, 19 (34%) Bethesda IV, and 8 (14%) Bethesda V category. Malignancy rates were 38%, 58%, and 100% for Bethesda categories III, IV, and V, respectively. Most malignancies in Bethesda categories III and IV were follicular in origin (follicular thyroid carcinoma and follicular type papillary thyroid carcinoma), while 100% of the patients with Bethesda category V were diagnosed with classical papillary thyroid carcinoma. No correlation was found between sonographic and cytological criteria of nodules with Bethesda categories III and IV and rates of malignancy.

Conclusions: We found higher than expected rates of malignancy in indeterminate cytology. This finding reinforces the guidelines of the American Thyroid Association to establish local malignancy rates for thyroid nodules with indetermined cytology.

Twenty years after being closed due to unfavorable results, a new lung transplant program was started at the Sheba Medical Center. The new team included an experienced lung transplant surgeon, an anesthesiologist, an intensive care specialist, and a pulmonologist with extensive experience in the field.

Takotsubo syndrome (TTS) often develops following stressors such as cardiac surgery. It may be fatal in rare cases. Our 70-year-old female patient presented with a rare case of tricuspid valve papillary fibroelastoma, which was complicated by fatal TTS after successful resection. The patient had a right atrial mass that was investigated with computed tomography and transesophageal echocardiography (TTE). She was scheduled for surgery. Pathology findings were consistent with papillary fibroelastoma of the tricuspid valve. Three weeks after successful surgery, the patient was admitted due to cardiogenic shock with echocardiographic findings of apical ballooning and left ventricular outflow tract obstruction consistent with TTS. The patient died one hour after her admission despite optimal medical therapy.

Leonardo da Vinci was a man of art and science. He became the archetype of the Renaissance era. Leonardo exhaustively studied the proportions of the body, drawing Vitruvian Man in 1490. It is regarded as a universal cultural icon. Leonardo's anatomical illustrations were of notable precision, and he is still considered as the pioneer of modern anatomy. We focus on Leonardo's masterpiece Virgin of the Rocks, which displays the intersection between his prodigious artistic talent and his commitment to science. This master painting discloses discordance between the artist's vast anatomical knowledge and its actualization in the painting. Consequently, many enigmas arise: How could the expert of anatomy, considered as the canon man of proportions, paint anatomical errors and why did he not actualize his knowledge in the painting? Was this an error or intentional? Could the painting techniques he used explain optical illusions that distorted the images? Was he so far ahead of his time that he did not feel compelled to paint realistically, but rather preferred to let his imagination and creativity run free? Some 500 years after Leonardo da Vinci's death, there is no one answer, but there is room for much speculation.

The coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), impacted global health, human behavior, economics, and even politics. Two years after the start of the pandemic, the scientific community was still learning about COVID-19 infections. One of the major lessons was the association between SARS-CoV-2 and diverse autoimmune manifestations, including multiple autoantibodies and various autoimmune diseases that developed in COVID-19 patients.

A 65-year-old male with a medical history of diabetes mellitus, chronic kidney failure, and ulcerative colitis arrived at our facility with knee monoarthritis. The knee was tapped with 40 cc pus-like discharge [Figure 1A]. He was referred for a knee lavage with a working diagnosis of septic arthritis. The patient was afebrile, denied trauma, without neutrophilia on blood count.

Acute cholecystitis is a common surgical diagnosis. If not addressed properly, it can potentially lead to sepsis, perforation of the gallbladder, and even death.

The most frequent pathogens isolated from bile cultures of patients with cholecystitis are anaerobes and Enterbacterales such as E. coli, Klebsiella species, and Streptococcus species [1].

Streptococcus gordonii belongs to the Viridians streptococci group of oral bacteria and is commonly associated with dental caries. S. gordonii has been previously reported as the causative pathogen in both endocarditis and spondylodiskitis [2]. However, it has rarely been associated with biliary infections. In this report, we presented a patient diagnosed with cholecystitis associated with S. gordonii infection.

Serum sickness is an immune-complex-mediated hypersensitivity reaction that classically presents with fever, rash, polyarthritis, or poly arthralgias. Damage is caused by formation or deposition of antigen-antibody complexes in vessels or tissues. Deposition of immune complexes causes complement activation and/or recruitment of neutrophils by interaction of immune complexes with Fc immunoglobulin G receptors. The condition was first recognized as an entity in the early 1900s in patients who had received heterologous antisera, which was historically used to treat infectious diseases. The symptoms typically occur one to two weeks after exposure to an offending agent and resolve within several weeks of discontinuation [1].

Docetaxel (Taxotere®), obtained from the European yew Taxus baccata, is a widely used chemotherapeutic agent active against a variety of solid tumors including breast, lung, ovarian, gastric, head and neck, and prostate cancers. The drug is administered intravenously on a weekly or three-weekly schedule. Its main side effects include myelosuppression, fatigue, myalgias, arthralgias, fluid retention, peripheral neuropathy, paronychia, and lacrimation [1]. Myositis, however, has rarely been reported.

We describe a breast cancer patient who developed severe acute myositis while on treatment with docetaxel.

A 64-year-old male, with antineutrophil cytoplasmic antibody-associated vasculitis was being treated with methotrexate and low dose prednisone. He arrived at the clinic with bluish discoloration of the toes. Inflammatory markers and urine were normal. No history of chilblains or Raynoud's phenomena was noted. He recovered recently from mild coronavirus disease 2019 (COVID-19). A diagnosis of COVID toes (COVID digits) was made [Figure 1].

Coronavirus disease 2019 (COVID-19), first identified in 2019, constitutes a global major public health burden. Most of morbidity and mortality is derived by the severe inflammatory reaction (cytokine release syndrome) that ensues in later stages. Baricitinib, a selective JAK inhibitor primarily used for the treatment of rheumatoid arthritis (RA) [1], was shown to reduce mortality in COVID-19 hospitalized patients in combination with remdesivir [2].

Background: Clinical dysentery causes hundreds of thousands of deaths annually worldwide. However, current recommendations reserve antibiotics for those either clinically sick or with highly suspected cases of shigellosis. This treatment stems from rising antibiotic resistance. Children diagnosed with clinical dysentery in the pediatric emergency department (PED) are regarded more cautiously.

Objectives: To explore the use of antibiotics in children diagnosed with clinical dysentery in the PED.

Methods: A retrospective case study of children with clinical dysentery at a single PED during the years 2015 and 2018. Demographics as well as clinical findings were compared to culture results and antibiotic treatment.

Results: The study included 281 children who were diagnosed with clinical dysentery during the study period; 234 (83%) were treated with antibiotics. However, cultures were positive in only 162 cases (58%). Only 32% were Shigella spp. Younger age, fever, and leukocytosis were related to antibiotic treatment.

Conclusions: The diagnosis of clinical dysentery is misgiven commonly in the PED leading to widespread use of antibiotics when not indicated. This treatment may impact antibiotic resistance patterns. Further studies and interventions are necessary to create clear guidelines in the PED setting.