Israel Medical Association Journal

Background: Coronavirus disease-2019 (COVID-19) chest computed tomography (CT) involves ground-glass opacity (GGO) and denser consolidations, which are crucial for diagnosis.

Objectives: To determine optimal window settings for characterization and detection of GGO and dense consolidation on CT imaging in COVID-19 patients using a Simplex-based approach.

Methods: The study included 54 conventional CTs of COVID patients in two phases. First, CT images of 14 patients with GGO and 4 with dense consolidation were included. Seven radiologists evaluated representative images in different windows of varied width and center. They were graded for adequacy of characterization and detection. A Simplex algorithm was used to iteratively determine the optimal window settings. Surface response maps expressing the relationship between window settings and overall reader grades were constructed. Next, the reviewers compared manufacturer recommendations to the new optimal windows found on CT images of 40 patients.

Results: Overall, 12 different window settings were evaluated over a total of 1176 reads. Optimal characterization and detection of pure GGO was seen with a center of 630 HU and width 1460 HU, producing higher grades for both detection and characterization than the manufacturer window settings (P = 0.005). Optimal windowing for dense consolidation was like manufacturer measures (-585 HU and 1800 HU). In phase 2, an overwhelming preference of 78% favoring the optimal window compared to conventional settings was found.

Conclusions: GGO lung opacities characteristic for COVID-19 can be best seen using a lower CT windowing width than the manufacturer's recommendations, unlike denser consolidations, possibly due to differences in underlying pathophysiology.

Background: BRCA1/BRCA2 female pathogenic sequence variant (PSV) carriers in Israel are offered semiannual cancer antigen 125 (CA125) serum level determination and transvaginal ultrasound until performing risk reducing salpingo-oophorectomy (RRSO), even with the lack of proven efficacy of these procedures in providing adequate early detection of ovarian cancer.

Objectives: To report the results of longitudinal CA125 measurements in BRCA1/BRCA2 carriers as a tool for ovarian cancer detection in a single medical center in Israel.

Methods: Asymptomatic BRCA1/BRCA2 PSV carriers attending the Meirav High Risk Clinic at Sheba Medical Center for more than 3 years were eligible. Data on specific PSV, risk reducing surgeries, and cancer diagnoses were obtained from participant records. We used chi-square and Wilcoxon-Rank tests for statistical analyses.

Results: Overall, 739 (399 BRCA1, 336 BRCA2, 4 BRCA1 + BRCA2) PSV carriers were included. Mean age at the start of follow-up was 38.96 ± 11.13 years, mean follow-up time was 7.93 ± 2.34 years, (5860.80 women/years). Most participants (490/739 [66.3%]) had stable CA125 levels (± 5 U/µl). Of participants, 61 had CA125 levels > 35 U/µl at least twice (n=42) or at least doubling of marker levels to a minimum of 20 U/µl (n=19), results that have led to further cancer defining investigations. Of these, 14 and 4 were diagnosed with breast and ovarian cancer, respectively.

Conclusions: Longitudinally stable CA125 levels were noted in most BRCA1/BRCA2 PSV carriers and elevated levels were a poor marker for ovarian cancer development.

Background: Colorectal cancer (CRC) is the third most commonly occurring cancer worldwide. There are conflicting reports on whether colonoscopies performed during the morning shift have higher adenoma detection rates.

Objectives: To investigate the differences in polyp detection rate (PDR) in colonoscopies between morning and afternoon shifts.

Methods: In a retrospective, multicenter study involving a large cohort, we analyzed all colonoscopies conducted between 2016 and 2023 across seven endoscopy departments. The PDR was compared between morning and afternoon shifts.

Results: We included 368,997 colonoscopies: 213,795 (57.9%) performed during the morning shift and 155,202 (42.1%) during the afternoon shift. Patients undergoing colonoscopies during the morning shift were more frequently female (53.8% vs. 51%, P < 0.001) and tended to be older compared to those in the afternoon shift (average age of 56.97 ± 12.6 vs. 55.6 ± 12.9, P < 0.001). Colonoscopies conducted during the morning shift exhibited a higher cecum intubation rate (CIR) (96.7% vs. 95.6%, P < 0.001). During the morning shift, higher rates of PDR (32.9% vs. 29.9%, P < 0.001) were observed. In the multivariate analysis, after adjusting for other variables, age, male sex, polyp follow-up, fecal occult blood test, morning shift, familial history of CRC, and rectal bleeding demonstrated statistically significant associations (P < 0.001) for PDR.

Conclusions: Colonoscopies during the morning shift yielded a higher PDR and CIR than those in the afternoon. To improve this rate, endoscopists working the afternoon shift must be provided with the right conditions.

Background: Uninterrupted antithrombotic treatment (ATT) during cardiac implantable electronic device (CIED) implantation increases bleeding and device-related infections (DRI) risk. The wide-awake-local-anesthesia-no-tourniquet (WALANT) technique, using large-volume local anesthesia and adrenaline, is successful in hand surgeries but its potential to mitigate bleeding risk in CIED implantations remains unknown.

Objectives: To investigate whether WALANT protocol for CIED implantations reduces clinically significant pocket hematoma in patients with a high bleeding risk or is a contraindication for interrupting ATT.

Methods: We conducted a prospective, double-blind, randomized controlled trial with CIED surgery patients on uninterrupted ATT. They received WALANT protocol (lidocaine 1% with adrenaline 1:100,000) or standard protocol (lidocaine 1%). Following implantation, patients were blindly monitored in the ward and pacemaker clinic. Patients were monitored for bleeding outcomes post-implantation.

Results: Forty-six consecutive patients (73.6 ± 9 years, 72% male) were enrolled. In the WALANT group (n=24) no intra-pocket pro-hemostatic agents were needed, compared to 45% in the control group (P = 0.0002). Postoperative pressure dressings were used in 12.5% vs. 68% (P = 0.0002). WALANT patients had smaller hematoma areas (median 3.7 cm² IQR [1–39] vs. 46 cm² [IQR 24–76], P = 0.0004) 1-day postoperative. ATT interruption occurred in 12.5% vs. 18% (P = 0.7). Superficial skin infection rates were 4% vs. 9% (P = 0.6). No DRI occurred. No WALANT-related side effects were observed.

Conclusions: WALANT protocol in CIED implantation with uninterrupted ATT reduced pro-hemostatic agents, pressure-dressing need, and hematoma size. Larger studies are needed to assess its impact on infection rates.

We presented the emergent development of pulmonary hypertension and right ventricular impairment in a 64-year-old woman with metastatic breast cancer undergoing carboplatin–gemcitabine combination therapy. The patient's acute decompensation, characterized by dyspnea and desaturation, occurred 2 days after chemotherapy initiation. Clinical assessments revealed right ventricular dilation and systolic dysfunction, a rare manifestation not previously associated with the administered drugs, but which may be associated with cardiopulmonary toxicity of gemcitabine therapy. Prompt discontinuation of chemotherapy and initiation of diuretic therapy resulted in clinical improvement and resolution of the right ventricular dysfunction within several weeks. While a definitive causal link to gemcitabine remains inconclusive, this report highlights a potential and under-reported side effect, emphasizing the need for increased awareness and further investigation into the cardiopulmonary effects of gemcitabine.

Fasting, a practice with deep historical roots, has gained scientific attention for its potential benefits on human health, particularly in autoimmune diseases. In this review, we explored the impact of fasting on immune function and autoimmunity. Autoimmune diseases, characterized by the immune system's attack on the body’s own tissues, are influenced by genetic, environmental, and dietary factors. Various forms of fasting (intermittent, water fasting, calorie restriction, ketogenic diets, and time-restricted feeding) affect metabolism, immune modulation, and inflammation reduction. These changes can promote autophagy, stem cell renewal, and immune system rebalancing by offering potential therapeutic effects for autoimmune conditions. Although more research is needed, fasting may serve as an adjunctive therapy for immune-mediated diseases by reducing symptoms and promoting remission. However, fasting must be approached with caution, particularly for individuals with specific autoimmune disorders. We reviewed the physiological changes during fasting, types of fasting regimens, and the clinical relevance in autoimmunity. Further studies are needed to validate these observations in patient populations.

Standup paddleboard surfing (SUP) is a sports activity in which a person stands upright on a surfboard and propels the board using a single paddle. It is an emerging recreational activity that is attracting public attention and gaining popularity because it promotes fitness, strength, and improved balance. In this review, we discuss the outcomes after severe cardiac events in SUP surfers. We report on six fit individuals (five males and one female, age range 41–69 years) who experienced sudden cardiac arrest (n=3) or acute myocardial infarction occurring during SUP. Cardiopulmonary resuscitation was initiated in three patients on presentation due to ventricular fibrillation. In four patients the culprit coronary artery was the left anterior descending artery treated by percutaneous coronary intervention. All patients were discharged alive. A review of the literature showed a paucity of scientific evidence to substantiate the proposed health benefits of SUP surfing. Our cluster of acute cardiac events occurring during this activity calls for heightened public awareness to better understand the physical demand required to practice SUP. There is a need for more data regarding the cardiovascular clinical aspects of this water activity, and the risks it entails.

Background: Ascites is a product of fluid accumulation within the peritoneal cavity. Underlying etiologies include cirrhosis, congestive heart failure (CHF), nephrotic syndrome, and malignancies. Patients with cirrhotic ascites are at increased risk for infections, especially spontaneous bacterial peritonitis (SBP), which is associated with high rates of morbidity and mortality. Ascites is diagnosed both clinically and sonographically. SBP is diagnosed via abdominal paracentesis, a relatively safe and effective procedure. However, abdominal paracentesis carries risks such as bleeding, bowel perforation, and infection.

Objectives: To identify new inflammatory markers as alternative or replacement methods for accurately evaluating patients before and after abdominal paracentesis and how these new inflammatory markers can be evaluated from a simple, inexpensive, and routinely performed blood sample.

Methods: A total of 106 patients admitted with ascites were classified into three groups based on the underlying etiology of their condition: malignant ascites (30 patients), ascites secondary to CHF (30 patients), and ascites secondary to cirrhosis (46 patients). Levels of neutrophil-lymphocyte ratio (NLR), mean platelet volume, and C-reactive protein among the study groups were examined through blood samples and subsequently compared

Results: NLR values within malignant ascites and CHF ascites were significantly higher than cirrhotic ascites (P = 0.002). In addition, among risk factors for developing ascites, significant correlations were found among the three groups in hypertension (P < 0.001), diabetes mellitus (P = 0.003), hyperlipidemia (P = 0.002), CHF (P < 0.001), and ischemic heart disease (P < 0.001) variables.

Conclusions: NLR may be a prognostic tool in patient evaluation of ascites.

Background: Solid organ transplant (SOT) recipients represent a particularly vulnerable group due to their reliance on immunosuppressive therapies. Previous studies indicated a mortality rate of 20%-30% among SOT recipients with coronavirus disease 2019 (COVID-19). With the advent of the Omicron variant in November 2021, characterized by milder symptoms and lower mortality rates in the general population, safety measures relaxed, potentially impacting vulnerable populations like SOT recipients.

Objectives: To investigate mortality and morbidity among hospitalized SOT recipients with COVID-19 infection during the Omicron wave.

Methods: A retrospective, propensity-matched cohort study conducted at the Rabin Medical Center, Israel, spanned from November 2021 to June 2023. Adult SOT recipients hospitalized with COVID-19 were compared to matched controls.

Results: Among 139 hospitalized SOT recipients and 209 controls, SOT recipients hospitalized with COVID-19 displayed higher in-hospital mortality (19% vs. 11%) and 90-day all-cause mortality (30% vs. 17%). In addition, the 90-day readmission rate was significantly higher among SOT recipients (43% vs. 31%). Multivariable analysis confirmed these trends, with SOT recipients exhibiting increased risk for mortality, readmission, invasive ventilation, and intensive care unit admission.

Conclusions: The heightened vulnerability of hospitalized SOT recipients during the Omicron wave was characterized by higher mortality and readmission rates compared to matched controls. Despite the perceived milder nature of the Omicron variant, SOT recipients remain disproportionately affected. Continued vigilance and targeted interventions are necessary for this population including vaccinations and adherence to preventive measures. Investigating this population’s outcomes through the changing COVID-19 variants is still warranted.

Crohn's disease patients undergoing anti-tumor necrosis factor (anti-TNF) therapy such as infliximab face potential risks from opportunistic infections. We introduce the unique case of a 66-year-old male Crohn's patient, previously in remission, presenting with gastrointestinal symptoms following a trip to the Czechia. Despite concerns of reactivated tuberculosis due to infliximab, his biopsies showed the presence of Mycobacterium simiae (M. simiae). Despite this, anti-TNF therapy was continued and resulted in clinical improvement. This is a case report of M. simiae in intestinal biopsies of an immunocompromised Crohn's patient is a clinical challenge. The findings suggest the benign colonization of M. simiae potentially influences future treatment considerations in similar clinical scenarios.

Background: Enterovirus meningitis (EM) is a common central nervous system (CNS) infection with a seasonal peak in summer and fall.

Objective: To describe the epidemiologic and clinical patterns of EM in children before (2017–2019 years) and during the coronavirus disease 2019 (COVID-19) pandemic (2020–2022).

Methods: This retrospective study included children (age 0–16 years) hospitalized in a pediatric department in Israel diagnosed with EM: January 2017–December 2019 and January 2020–December 2022. The seasonal peak for each period was defined as the maximal incidence in particular months. EM was diagnosed by reverse transcription polymerase chain reaction of cerebrospinal fluid (CSF) for enteroviruses.

Results: During the study period, EM was diagnosed in 134 cases (median age 5 months [1–51], 76 [57%] males); 72 during 2017–2019 and 62 during 2020–2022. The most common presentation was fever. C-reactive protein (CRP) was elevated in 57 cases (43%). CSF profile showed pleocytosis in 130 cases (97%) and elevated protein in 80 (60%). In the 2020–2022 group, fewer patients were febrile, CRP was higher, and CSF profile showed a higher glucose level compared to the 2017–2019 group. Seasonal peaks in 2017–2019 occurred June–August, and in 2020–2022 February–April.

Conclusions: The COVID-19 pandemic altered the clinical characteristics of EM and its seasonal peak. Clinicians should be aware of changes in epidemiological patterns of EM to make appropriate diagnoses in viral infection in order to avoid unnecessary antibiotic treatment.

Background: Hyponatremia is common among hospitalized children, including those with community acquired pneumonia. The prevalence and severity of hyponatremia were reported to correlate with disease. However, data regarding the association between hyponatremia and causative infectious pathogens are limited and results are inconsistent.

Objectives: To investigate the associations between sodium levels, severity and causative pathogen in children with pneumonia.

Methods: A retrospective study of all children (< 18 years) hospitalized with pneumonia from 1 January 2018 to 31 December 2020. Admission sodium levels were compared to the presumed etiological pathogens, clinical parameters, and inflammatory markers.

Results: Among 751 (52% males) children, 10 (1%) had sodium levels < 130 mEq/L, 187 (25%) had mildly decreased levels 130–134 mEq/L, and the remaining 554 (74%) had normal levels 135–145 mEq/L. Sodium levels < 130 mEq/L were found in 7/236 (3%) of the patients with presumed bacterial pneumonia, in 0/20 of patients with presumed atypical-bacterial, and in only 3/495 (0.6%) of the patients with a presumed viral infection, P < 0.001. Sodium levels < 135 mEq/L conferred an odds ratio of 3.1 (95% confidence interval [95%CI] 2.1–4.3) and levels < 130 mEq/L an odds ratio of 6.8 (95%CI 1.8–33.0) for bacterial infection, P < 0.001 for both. Hyponatremia was also inversely associated with high white blood cell counts, absolute neutrophil cell counts, and C-reactive protein levels.

Conclusions: Hyponatremia was common among children hospitalized with pneumonia and was associated with elevated inflammatory markers and presumed bacterial pneumonia.

Background: Botulinum toxin (BT) can alleviate limb dystonia, but limited insurance coverage hinders its utilization.

Objectives: To compare the therapeutic efficacy of BT injections for spasticity and dystonia of the limbs.

Methods: BT injections of hypertonic limbs were administered under ultrasound guidance between 2019 and 2024 for either limb dystonia or limb spasticity.

Results: Of 74 patients included, 57 were diagnosed with spasticity and 17 with dystonia. In total, 276 therapeutic cycles were administered. The dropout rates were 45.6% in the spasticity group and 41.2% in the dystonia group (P = 0.48). There was no significant difference in subjective motor improvement between dystonia and spasticity (P = 0.16). Dystonia patients reported significantly better pain relief (98.5 ± 4.9% vs. 72.4 ± 35.6% respectively, P < 0.001). Notably, 74.3% of dystonia treatments reported moderate or marked improvement, whereas only 54.0% of spasticity treatments did (P > 0.05), based on patient the global impression of change (PGI-C) scale. Side effects were infrequent.

Conclusions: BT injections for limb spasticity and dystonia are partially effective. Nonetheless, the dropout rate is high. While BT injections are more effective in relieving pain for dystonia compared to spasticity, disease severity gradually improves over time in treated patients with spasticity but not with dystonia.

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: Acute cholecystitis (ACC) is one of the most common diagnoses encountered in surgical wards. A number of treatment modalities are available, and various guidelines have been developed to help decision making. Many factors influence treatment strategies, including patient age and frailty. Due to the increasing proportion of older patients, consideration into the best treatment modalities for this population are warranted.

Objectives: To determine outcomes of elderly patients with ACC according to different treatment strategies.

Methods: A retrospective analysis of consecutive patients aged ≥ 80 years who were admitted with a diagnosis of ACC between 2015 and 2019 to a single academic center. Patients were divided into three groups according to treatment: percutaneous cholecystostomy tube placement, cholecystectomy, intravenous antibiotic treatment only.

Results: Overall, 466 patients were included in the cohort. The majority (approximately 75%) were treated with antibiotics only, 17% underwent percutaneous cholecystostomy, and 8% underwent laparoscopic cholecystectomy. One-year mortality was 28.1%. The highest mortality rate was 41.6% in the cholecystostomy group (P = 0.002). In multivariable analysis age, functional status, C-reactive protein, and albumin levels were found to be independent risk factors for 1-year mortality (hazard ratio [HR] 1.08, 0.56, 0.98, 0.4, respectively). Cholecystostomy increased risk of one-year mortality compared to cholecystectomy and antibiotics alone (HR 0.61, 0.23, respectively).

Conclusions: The use of cholecystostomy for ACC in older adults is an independent risk factor for 1-year mortality. Its use in older adults should be reserved for carefully selected cases.