Israel Medical Association Journal

Background: Adjuvant radiotherapy for breast cancer reduces local recurrence and improves survival. In patients with left sided breast cancer, anterior heart position or medial tumor location may cause inadequate breast coverage due to heart shielding. Respiration gating using the Real-time Position Management (RPM) system enables pushing the heart away from the tangential fields during inspiration, thus optimizing the treatment plan.

Objectives: To compare breathing inspiration gating (IG) techniques with free breathing (FB), focusing on breast coverage.

Methods: The study comprised 49 consecutive patients with left sided breast cancer who underwent lumpectomy and adjuvant radiation. RPM was chosen due to insufficient breast coverage caused by an anterior heart position or medial lumpectomy cavity. FB and IG computed tomography simulations were generated for each patient. Breast (PTVbreast) and lumpectomy cavity (CTVlump) were defined as the target areas. Optimized treatment plans were created for each scan. A dosimetric comparison was made for breast coverage and heart and lungs doses.

Results: PTVbreast V95% and mean dose (Dmean) were higher with IG vs. FB (82.36% vs. 78.88%, P = 0.002; 95.73% vs. 93.63%, P < 0.001, respectively). CTVlump V95% and Dmean were higher with IG (98.87% vs. 88.92%, P = 0.001; 99.14% vs. 96.73%, P = 0.003, respectively). The cardiac dose was lower with IG. The IG left lung Dmean was higher. No statistical difference was found for left lung V20.

Conclusions: In patients with suboptimal treatment plans due to anterior heart position or medial lumpectomy cavity, RPM IG enabled better breast/tumor bed coverage and reduced cardiac doses.

Background: Door-to-balloon time (DTBT) ≤ 90 minutes has become an important quality indicator in the management of ST-elevation myocardial infarction (STEMI). We identified three specific problems in the course from arrival of STEMI patients at our emergency department to initiation of balloon inflation and determined an intervention comprised of specific administrative and professional steps. The focus of the intervention was on triage within the emergency department (ED) and on increasing the efficiency and accuracy of electrocardiography interpretation.

Objectives: To examine whether our intervention reduced the proportion of patients with DTBT > 90 minutes.

Methods: We compared DTBT of patients admitted to the ED with STEMI during the year preceding and the year following implementation of the intervention.

Results: Demographic and clinical characteristics at presentation to the ED were similar for patients admitted to the ED in the year preceding and the year following intervention. The year preceding intervention, DTBT was > 90 minutes for 19/78 patients (24%). The year after intervention, DTBT was > 90 minutes for 17/102 patients (17%). For both years, the median DTBT was 1 hour. Patients with DTBT > 90 minutes tended to be older and more often female. Diagnoses in the ED were similar between those with DTBT ≤ 90 minutes and > 90 minutes. In-hospital mortality was 17% (13/78) and 14% (14/102) for the respective time periods.

Conclusions: An intervention specifically designed to address problems identified at one medical center was shown to decrease the proportion of patients with DTBT > 90 minutes.

Background: Although exercise has been shown to improve mood and well-being, the precise mechanism remains unknown. Neurosteroids are important neuroactive molecules with demonstrated involvement in several neurophysiological and disease processes. Previous research has noted neurosteroid changes in dehydroepiandrosterone (DHEA) levels following exercise.



Objectives: To determine whether changes in DHEA levels are associated with mood improvement after exercise and whether there are any differences in the effects on younger and older individuals. 



Methods: Individuals ≤ 50 years of age or > 65 years of age were recruited for study participation. Before and after 30 minutes of a standardized cycling regimen, each patient provided a blood sample and completed a questionnaire on mood and well-being. 



Results: Findings confirmed a significant increase in DHEA levels post-exercise. A decrease in negative factors (fatigue, tension, depression, anger) and an increase in positive mood factors were noted. No difference in change of measures was noted between younger and older subjects. A positive correlation was noted between mood change and DHEA blood-level changes in older subjects. Among older males, DHEA appeared to be associated with mood change after exercise. 



Conclusions: While preliminary, findings indicate a possible association between mood improvement following exercise and DHEA blood level changes. Understanding the biological mechanisms of exercise-induced mood changes is critical to utilizing exercise as a treatment for mood disorders.

Background: About half of all patients with heart failure are diagnosed with heart failure preserved ejection fraction (HFpEF). Until now, studies have failed to show that medical treatment improves the prognosis of patients with HFpEF.

Objectives: To evaluate changes in exercise capacity of patients with HFpEF compared to those with heart failure with reduced ejection fraction (HFrEF) following an exercise training program.

Methods: Patient data was retrieved from a multi-center registry of patients with heart failure who participated in a cardiac rehabilitation program. Patients underwent exercise testing and an echocardiogram prior to entering the program and were retested6  months later.

Results: Of 216 heart failure patients enrolled in the program, 170 were diagnosed with HFrEF and 46 (21%) with HFpEF. Patients with HFpEF had lower baseline exercise capacity compared to those with HFrEF. Participating in a 6 month exercise program resulted in significant and similar improvement in exercise performance of both HFpEF and HFrEF patients: an absolute metabolic equivalent (MET) change (1.45 METs in HFrEF patients vs. 1.1 in the HFpEF group, P = 0.3).

Conclusions: An exercise training program resulted in similar improvement of exercise capacity in both HFpEF and HFrEF patients. An individualized, yet similarly structured, cardiac rehabilitation program may serve both heart failure groups, providing safety and efficacy.

Background: Acute musculoskeletal pain is one of the most commonly reported symptoms among patients visiting the emergency department (ED). Treatment with over-the-counter pain medications, given by nurses, results in improved pain management and reduces the waiting time to drug administration without significant side effects. Opioid analgesics are extensively used for acute pain in the ED. Compared to morphine, oxycodone has a much more specific pharmacological activity, higher analgesic potential, and more tolerable side effects.

Objectives: To assess the degree of pain reduction using different protocols, including dypirone and oxycodone given by nurses, in treating acute musculoskeletal pain in the emergency department (primary outcome) and to evaluate the need for rescue medications (secondary outcome).

Methods: This observational prospective clinical trial compared two groups of 50 patients, each one visiting the ED due to musculoskeletal pain. One group was treated with dipyrone syrup and the other was treated with oxycodone syrup. The primary outcome was pain reduction measured by the Numeric Rating Scale (NRS). The secondary outcome was the difference in need for rescue medications.

Results: The reduction in the NRS was greater in the patients treated with oxycodone. This finding was statistically and clinically significant (P < 0.001). The need for rescue medications was also significantly reduced in this group of patients (P = 0.007).

Conclusions: This study showed that the administration of over-the-counter oxycodone syrup by nurses decreases the post-treatment pain reported by patients, reduces the need for rescue medications, and increases the satisfaction of the medical staff.

The discovery of Jewish babies who were born in Nazi concentration camps and survived seems miraculous, but this phenomenon did occur toward the end of World War II. The lives of a small group of mothers and surviving children are of both historical and medical interests. Their survival shows additional support for the hypothesis that maternal nutrition can induce metabolic syndrome and bone demineralization in their offspring. Information obtained through direct contact with some of the surviving children is the basis for this article.

In this article, we offer a brief summary of the report from the Task Force for the Promotion of the Status of Women in Medicine in Israel. The task force, formed by the Israel Medical Association in 2013, published a comprehensive report in May 2015 dedicated to the promotion of equal opportunities for female doctors in the Israeli healthcare system and in the academic world. The aim of this paper is to present the work of the task force and to highlight its main principles and recommendations against the backdrop of the gender revolution in the Israeli healthcare system and worldwide.

Background: Nebulized hypertonic saline (HS) treatment is unavailable to large populations worldwide.

Objectives: To determine the bacterial contamination and electrolyte concentrations in homemade (HM-HS) vs. pharmacy made (PM-HS).

Methods: We conducted three double-blind consecutive trials: 50 boiled-water homemade 3%-HS (B-HM-HS) bottles and 50 PM-HS. The bottles were cultured after 48 hours. Electrolyte concentrations were measured in 10 bottles (5 per group). Forty bottles (20 per group) were distributed to volunteers for simulation of realistic treatment by drawing 4 ml HS three times daily. From each bottle, 4 ml samples were cultured after 1, 5, and 7 days. Volunteers prepared 108 bottles containing 3%-HS, sterilizing them using a microwave oven (1100–1850W). These bottles were cultured 24 hours, 48 hours, and 1 month after preparation.

Results: Contamination rates of B-HM-HS and PM-HS after 48 hours were 56% and 14%, respectively (P = 0.008). Electrolyte concentrations were similar: 3.7% ± 0.4 and 3.5% ± 0.3, respectively (P = NS). Following a single day of simulation B-HM-HS bottles were significantly more contaminated than PM-HS bottles: 75% vs. 20%, respectively (P < 0.01). By day 7, 85% of PM-HS bottles and 100% of B-HM-HS bottles were contaminated (P = 0.23). All 108 microwave-oven prepared bottles (MICRO-HS) were sterile, which was significantly better than the contamination rate of B-HM-HS and PM-HS (P < 0.001). Calculated risk for a consecutive MICRO-HS to be infected was negligible.

Conclusion: Microwave preparation provides sterile HS with adequate electrolyte concentrations, and is a cheap, fast, and widely available method to prepare HS.

Background: A good physical exam is necessary to help pediatricians make the correct diagnosis and can save unnecessary imaging or invasive procedures. Distraction by medical clowns may create the optimal conditions for a proper physical examination.

Methods: Children aged 2–6 years who required physical examination in the pediatric emergency department were recruited and randomly assigned to one of two groups: physical exam by a pediatrician in the presence of caregivers vs. physical exam with the assistance of a medical clown. Outcome measures consisted of the level of child's discomfort, anxiety, and the quality of the physical examination.

Results: Ninety three children participated. Mean age was 3.3 ± 3.6 years (range 2–6). The duration of the physical exam was similar between the clown and control groups (4.6 ± 1.4 minutes vs. 4.5 ± 1.1 minutes (P = 0.64). The duration of discomfort was shorter in the clown group (0.2 ± 0.6 minutes) than the control group(1.6 ± 2.0 minutes, P = 0.001). In the medical clown group, 94% of pediatricians reported that the medical clown improved their ability to perform a complete physical examination. A trend of less hospitalization in the medical clown group was also noticed (11.3% in the medical clown group vs. 18.3% in the control group, P = 0.1); however, further study is required to verify this observation.

Conclusions: Integration of a medical clown in physical examination improves the overall experience of the child and the caregivers and helps the pediatrician to perform a complete physical examination.

Background: Blogs have become a major venue of information sharing and emotional release for people worldwide. Illness blogs are a specific type of blog in which patients describe their experience with illness and coping with disease. Illness blog research has been conducted on several disorders; however, blogs by Parkinson's disease (PD) patients have been neglected.

Objectives: To categorize the characteristics of PD patients from blogs and explore whether we can learn about the medical issues with which they are most concerned, as conveyed through their blog posts.

Methods: Using located PD patients' blogs, we analyzed the contents of 78 blogs, and employed thematic analysis of eight arbitrarily selected blogs.

Results: The majority of blog authors in our sample (N=78) were from the United States (42%). The number of blogs written by male and female authors was fairly similar: 49% and 44%, respectively, while gender was unknown for 7%. Blogs were written by both early- and late-onset PD patients. The thematic analysis revealed five major themes: diagnosis, symptoms, treatment, coping mechanisms, and information.

Conclusions: Thematic analysis of blogs by PD patients provided considerable information and insight regarding the experience of these patients, which is significant to other patients and their families, as well as to medical professionals. Further qualitative studies of larger blog samples utilizing data mining techniques are needed to further explore the subjective experiences of patients.

Background: Neoadjuvant chemo-radiation therapy (CRT) dosages in locally advanced non-small cell lung cancer (NSCLC) were traditionally limited to 45 Gray (Gy).

Objectives: To retrospectively analyze outcomes of patients treated with 60 Gy CRT followed by surgery.

Methods: A retrospective chart review identified patients selected for CRT to 60 Gy followed by surgery between August 2012 and April 2016. Selection for surgery was based on the extent of disease, cardiopulmonary function, and response to treatment. Pathological response after neoadjuvant CRT was scored using the modified tumor regression grading. Local control (LC), disease free survival (DFS), and overall survival (OS) were estimated by the Kaplan–Meier method.

Results: Our cohort included 52 patients: 75% (39/52) were stage IIIA. A radiation dose of 60 Gy (range 50–62Gy) was delivered in 82.7%. Surgeries performed included: lobectomy, chest-wall resection, and pneumonectomy in 67.3%, 13.4%, and 19.2%, respectively. At median follow-up of 22.4 months, the 3 year OS was 74% (95% confidence interval [CI] 52–87%), LC was 84% (95%CI 65–93), and DFS 35% (95%CI 14–59). Grade 4–5 postoperative complications were observed in 17.3% of cases and included chest wall necrosis (5.7%), bronco-pleural fistula (7.7%), and death (3.8%). A major pathologic regression with < 10% residual tumor occurred in 68.7% of patients (36/52) and showed a trend to improved OS (P = 0.1). Pneumonectomy cases had statistically worse OS (P = 0.01).

Conclusions: Major pathologic regression was observed 68.7% with 60 Gy neoadjuvant CRT with a trend to improved survival. Pneumonectomy correlated with worse survival.

Background: Management of postoperative pain has become a growing concern, even for minor gynecological procedures. Proper postoperative pain management has been shown to lead to earlier mobilization, shortened hospital stay, and increased patient satisfaction. The optimal means of reducing the pain of pregnancy termination has not yet been determined.

Objectives: To compare the efficiency in pain management of two drugs, lornoxicam and paracetamol, given intravenously postoperatively to women who underwent abortion with dilation and curettage. 

Methods: The cohort comprised 80 women scheduled for dilation and curettage for pregnancy termination at 6–12 gestational weeks. The anesthesiologist gave 1000 mg paracetamol or 20 mg lornoxicam soon after starting the procedure, according to a randomization table. The medical staff and the patients were blinded to the drug that was administered. Pain levels were evaluated by a 10 cm visual analogue scale (VAS) at 15, 30, 60, 90, and 120 minutes following arrival at the postoperative care unit. 

Results: Mean levels of pain decreased from 60 minutes postoperative until the end of recording, reaching minimum levels at 120 minutes: 0.8 ± 0.19 and 1.5 ± 0.28, for lornoxicam and paracetamol, respectively. The differences between the groups were statistically significant (P < 0.05 from 60 minutes after the procedure until the time of discharge. 

Conclusions: Compared to women who received paracetamol, women who received lornoxicam after dilation and curettage for termination of pregnancy reported lower levels of pain, from 30 minutes postoperative until the time of discharge following the procedure. 

Background: Maternal cardiac arrest during gestation constitutes a devastating event. Training and anticipant preparedness for prompt action in such cases may save the lives of both the woman and her fetus. 

Objectives: To address a previous Jewish guideline that a woman in advanced pregnancy should not undergo any medical procedure to save the fetus until her condition is stabilized. 

Methods: Current evidence on perimortal cesarean section shows that immediate section during resuscitation provides restoration of the integrity of the mother’s vascular compartment and increases her probability of survival. We analyzed Jewish scriptures from the Talmud and verdicts of the oral law and revealed that the Jewish ethical approach toward late gestational resuscitation was discouraged since it may jeopardize the mother. 

Results: We discuss the pertinent Jewish principles and their application in light of emerging scientific literature on this topic. An example case that led to an early perimortem cesarean delivery and brought about a gratifying, albeit only partially satisfying outcome, is presented, albeit with only a partially satisfying outcome. The arguments that were raised are relevant to such cases and suggest that previous judgments should be reconsidered.  

Conclusions: The Jewish perspective can guide medical personnel to modify and adapt the concrete rules to diverse clinical scenarios in light of current medical knowledge. With scientific data showing that both mother and fetus can prosper from immediate surgical extrication of the baby during resuscitation of the advanced pregnant woman, these morals should dictate training and practice in urgent perimortal cesarean sections whenever feasible. 

 

Starvation in early life can lead to premature metabolic syndrome and bone demineralization. Osteoporosis in the Jewish population may not yet be a recognized syndrome, but the harsh conditions to which Holocaust survivors were exposed may have increased the incidence of the condition. Immigrants and refugees who came to Israel from East Africa and Yemen – whether decades ago or more recently – may have been at increased risk of under-nutrition during pregnancy, affecting both the mother and consequently the offspring. This malnutrition may be further exacerbated by rapid overfeeding in the adopted developed country. This problem was also recognized at the turn of the 21st century in poor and underdeveloped countries and is becoming a global public health issue. In this review, the risks for premature metabolic syndrome and bone demineralization are enumerated and preventive measures outlined.