Israel Medical Association Journal

Background: Sonographic estimation of birth weight may differ among evaluators due to its operator-dependent nature.

Objectives: To compare the accuracy of estimation of fetal birth weight by sonography between ultrasound-certified physicians and registered diagnostic medical technicians.

Methods: The authors reviewed ultrasound examinations that had been performed by either technicians or ultrasound-certified obstetricians between 2010 and 2017, and within 2 days of delivery. Inclusion criteria were: singleton viable pregnancy, details of four ultrasound measurements (abdominal circumference, bi-parietal diameter, head circumference, and femur length), and known birth weight. The estimated fetal weight (EFW) was calculated according to the Hadlock formula, incorporating the four ultrasound measurements. The mean percentage error (MPE) was calculated by the formula: (EFW-birth weight) x100 / birth weight.

Results: Technicians performed 9741examinations and physicians performed 352 examinations. The proportion of macrosomic neonates was similar in both groups. Technicians were more accurate than physicians in terms of the MPE, absolute MPE, proportion of estimates that fell within ± 10% of birth weight, and Euclidean distance (P < 0.0001 for all comparisons). They were also more accurate in terms of sensitivity, specificity, positive predictive value, negative predictive value, and area under the receiver operating curve. Furthermore, for fetuses weighing more than 4000 grams the technicians had a lower total false prediction rate.

Conclusions: Medical technicians in our institute performed better than physicians in estimating fetal weight. Further studies are warranted to confirm our findings and better delineate the role of repeat physician’s examination after an initial estimation by an experienced technician.

Background: Untreated dental caries or even dental manipulations, such as a tooth extraction, might cause direct spread of an odontogenic infection and consequently the development of life-threatening conditions such as deep neck infections (DNI). The most common source of DNI is of odontogenic origin (38.8–49%). Abscess formation or cellulitis can lead to life-threatening complications, despite new diagnostic imaging technology and widespread availability of antibiotics. 

Objectives: To demonstrate the dangers of DNI, which can create life-threatening situations.

Methods: Five cases of DNI of odontogenic origin, which were referred to the oral and maxillofacial surgery unit, are presented. 

Results: Clinical manifestations included trismus, dysphagia, dysphonia, dyspnea, and infection symptoms. In all cases, computed tomography confirmed diagnosis and extent of abscess. Complications included mediastinitis, respiratory distress, osteomyelitis of the jaws, and in rare cases the mandibular condyle. Treatment included securing the airway, immediate surgical drainage, removal of the infection source, and antibiotic therapy. All patients were discharged in stable and improved condition.

Conclusions: DNI treatment on an emergency basis requires proper diagnosis and effective management. To confirm diagnosis and prevent serious complications, it is essential for physicians to recognize the spaces of the head and neck that are likely to be affected by DNI. 

 

Background: Evaluation of low rectal anastomosis is often recommended prior to ostomy closure, but the efficacy of such evaluations is uncertain.

Objectives: To assess whether routine colonic preoperative evaluation has an effect on postoperative ileostomy closure results.

Methods: We performed a retrospective study evaluating all patients who underwent ileostomy closure over 9 years. Patient demographics, clinical, surgical details, and surgical outcomes were recorded and analyzed.

Results: The study comprised 116 patients who underwent ileostomy closure, of them 65 were male (56%) with a mean age of 61 years (range 20–91). Overall, 98 patients (84.4%) underwent colonic preoperative evaluation prior to ileostomy closure. A contrast enema was performed on 61 patients (62.2%). Abnormal preoperative results were observed in 12 patients (12.2%). The overall complication rate was 35.3% (41 patients). No differences in postoperative outcome was observed in patient gender (P = 1), age (P = 0.96), body mass index (P = 0.24), American Society of Anesthesiologists score (P = 0.21), and the Charlson Comorbidity Index score (P = 0.93). Among patients who had postoperative complications, we did not observe a difference between patients who underwent preoperative evaluation compared to those who did not (P = 0.42). No differences were observed among patients with preoperative findings interpreted as normal or abnormal (P = 1). The time difference between ileostomy creation and closure had no effect on the ileostomy closure outcome (P = 0.34).

Conclusions: Abnormal findings in preoperative colonic evaluation prior to ileostomy closure were not associated with worse postoperative outcome.

Background: Anastomotic leakage (AL) is a major complication following colorectal surgery, with many risk factors established to date. The incidence of AL varies in the medical literature and is dependent on research inclusion criteria and diagnostic criteria.

Objectives: To determine the incidence of and the potential risk factors for AL following colorectal surgery at a single academic medical center.

Methods: We retrospectively reviewed all operative reports of colorectal procedures that included bowel resection and primary bowel anastomosis performed at Sheba Medical Center during 2012. AL was defined according to the 1991 United Kingdom Surgical Infection Study Group criteria. Data were assessed for leak incidence within 30 days. In addition, 17 possible risk factors for leakage were analyzed. A literature review was conducted.

Results: This cohort study comprised 260 patients, and included 261 procedures performed during the study period. The overall leak rate was 8.4%. In a univariate analysis, male sex (odds ratio [OR] 3.37, 95% confidence interval [95%CI] 1.21–9.43), pulmonary disease (OR 3.99, 95%CI 1.49–10.73), current or past smoking (OR 2.93, 95%CI 1.21–7.10), and American Society of Anesthesiologist score ≥ 3 (OR 3.08, 95%CI 1.16–8.13) were associated with an increased risk for anastomotic leakage. In a multivariate analysis, male gender (OR 3.62, 95%CI 1.27–10.33) and pulmonary disease (OR 4.37, 95%CI 1.58–12.10) were associated with a greater risk.

Conclusions: The incidence of AL in the present study is similar to that found in comparable series. Respiratory co-morbidity and male sex were found to be the most significant risk factors.

Background: Transesophageal endoscopic ultrasound-guided fine-needle aspiration using a bronchoscope (EUS-B-FNA) allows clinicians to determine mediastinal staging and lung mass evaluation of lesions not accessible by endobronchial ultrasound (EBUS) or where endobronchial ultrasound-guided transbronchial needle aspiration might not be safe.

Objectives: To evaluate the safety, diagnostic accuracy, and feasibility of EUS-B-FNA.

Methods: The study comprised patients who underwent a pulmonologist-performed EUS-B-FNA of mediastinal lymph nodes and parenchymal lung lesions between June 2015 and September 2017 at the Carmel Medical Center, Haifa, Israel.

Results: EUS-B-FNA was performed in 81 patients. The transesophageal procedure was performed for easier accessibility (49.4%) and in high-risk patients (43.3%). The most frequently sampled mediastinal stations were left paratracheal and sub-carinal lymph nodes or masses (38.3% and 56.7%, respectively). There were no complications (e.g., acute respiratory distress, esophageal perforation, or bleeding). An accurate diagnosis was determined in 91.3% of cases.

Conclusions: Pulmonologist-performed EUS-B-FNA is safe and accurate for evaluating mediastinal and parenchymal lung lesions and lymphadenopathy. Diagnostic accuracy is high. EUS-B-FNA may allow access to sites not amenable to other forms of bronchoscopic sampling, or may increase diagnostic accuracy in patients where anatomic position predicts a low diagnostic yield.

Background: The frequency of increased high-sensitivity C-reactive protein (hs-CRP) and the time course of evolution of their levels in patients with acute idiopathic pericarditis (AIP) are not well established.

Objective: To assess the time course of evolution of hs-CRP levels and the possible clinical significance of maximal hs-CRP levels in patients with AIP

Methods: We retrospectively reviewed the medical files of 241 patients admitted to the hospital with a diagnosis of AIP between March 2006 and March 2017. Data on demographics, time of symptom onset, laboratory and imaging findings, and outcome were collected.

Results: Data on serum hs-CRP levels were available for 225 patients (age 18–89 years, 181 men). Fever, pleural effusion, and age were independently associated with hs-CRP levels. Major cardiac complications (MCC) (death, cardiac tamponade, cardiogenic shock, large pericardial effusion, ventricular tachycardia, pericardiocentesis, or pericardiectomy) were more common in patients with hs-CRP levels above the median compared to those below (21.2% vs. 4.5%, respectively, P < 0.001). Hs-CRP levels were independently associated with MCC (odds ratio [OR] 1.071, 95% confidence interval [95%CI] 1.016–1.130, P = 0.011). Hs-CRP levels were elevated in 76.0%, 92.3% and 96.0% of the patients tested <6 hours, 7-12 hours, and >12 hours of symptom onset, respectively (P = 0.003). The frequency of elevated hs-CRP among patients tested > 24 hours was 98.1%.

Conclusions: Hs-CRP levels rise rapidly among patients with AIP. Maximal hs-CRP levels are associated with MCC. A normal hs-CRP level is rare among patients tested > 24 hours of symptom onset.

In non-ambulatory patients with cerebral palsy, the presence of scoliosis has a major impact on health and quality of life. The aim of this review is to raise awareness of caregivers from various professions to the extent of the problem, to explain the natural history of neuromuscular scoliosis and its pathophysiology, and to describe up-to-date optional conservative and surgical treatments.

Background: Surgery is a core activity in hospitals. Operating rooms have some of the most important and vital functions in medical centers. The operating rooms and their staff are a valuable infrastructure resource and their availability and preparedness affect human life and quality of care.

Objectives: To prepare operational suggestions for improving operating room utilization by mapping current working processes in the operating rooms of a large private medical center.

Methods: Data on 23,585 surgeries performed at our medical center between August 2016 and March 2017 were analyzed by various parameters including utilization, capacity, working hours, and surgery delays.

Results: Average operating room utilization was 79%, while 21% was considered lost operating room time. The two major factors that influenced the lost operating room time were the time intervals between planned usage blocks and the partial utilization of operating room time. We calculated that each percent of utilized operating room time translates into 440 surgeries annually, resulting in a potential annual increase in income.

Conclusions: Increasing operating room utilization would result in an improvement of operating room availability and an increased number of procedures. Our analysis shows that operating room utilization in the private healthcare system is efficient compared to the public healthcare system in Israel. Therefore the private healthcare system should be treated as a contributing factor to help lower surgery waiting times and release bottlenecks, rather than being perceived as contributing to inequality.

Background: Recurrent miscarriages are associated with a high prevalence of thrombophilia. Use of a calibrated automated thrombogram (CAT) can serve as a universal test for thrombophilia.

Objectives: To examine whether thrombin generation measured by CAT is elevated during the first trimester in women with unexplained recurrent miscarriages.

Methods: This study comprised 25 pregnant women with recurrent pregnancy loss referred for thrombophilia screening and treated with low-molecular-weight heparin (LMWH). Thrombin generation parameters were measured in women who had miscarriages or live births and who were diagnosed as positive or negative for thrombophilia.

Results: Of the pregnancies, 76% resulted in live birth and 24% ended in miscarriages. Among the women, 76% were positive for thrombophilia. Thrombin generation parameters between pregnancies that ended in miscarriage compared to live births were not significantly different, and CAT parameters failed to predict pregnancy outcome. Although the CAT parameters demonstrated a trend toward a hypercoagulable state in women with thrombophilia, there was no statistical significance (P > 0.05).

Conclusions: Women with unexplained pregnancy loss demonstrated similar thrombin generation in the first trimester, regardless of the pregnancy outcome. CAT parameters failed to predict pregnancy outcome in women with recurrent unexplained pregnancy loss. Our results should be interpreted with caution due to the small number of participants.

Background: The potential for full rehabilitation following amputation among end-stage renal disease patients is poor.

Objectives: To evaluate the functional outcomes and survival among amputees treated with hemodialysis at the end of the rehabilitation procedure.

Methods: We recruited 46 patients after lower limb amputation. Of these individuals, 19 (41.3%) were treated with dialysis and 27 (58.7%) were non-dialysis-dependent patients (NDDP). Both groups were divided into three sub-groups according to their independence with regard to activities of daily living (ADL) and their ability to walk with prostheses.

Results: The survival of lower limb amputees treated with dialysis was shorter compared to NDDP. Survival after amputation among the NDDP who were fully or partially independent in ADL and with regard to mobility, was longer compared to the non-mobile amputees as with the patients treated with dialysis.

Conclusions: Survival was significantly longer in lower limb amputees NDDP and shorter in patients who did not achieve a certain level of functioning.

Uveitis is an inflammatory disorder of the uveal tract of the eye that can affect both adults and children. Non-infectious uveitis can be an expression of a systemic autoimmune condition, or it can be idiopathic. It is a serious disease, associated with possible severe complications leading to visual impairment and blindness. For this reason, a prompt diagnosis and assessment of an appropriate treatment, with the collaboration of specialists such as ophthalmologists and rheumatologists, are extremely important. Many treatment options may be associated to side effects; therefore, clinicians should follow a stepladder approach starting with the least aggressive treatments to induce remission of inflammation. In this review, we reported the current evidence-based treatments for non-infectious uveitis in pediatric and adult patients with particular attention to the biologic response modifier treatment options. Important multicenter studies have demonstrated the efficacy of adalimumab, both in adults (VISUAL I, VISUAL II, VISUAL III) and in children (SYCAMORE, ADJUVITE), while for other agents data are still scarce.

Background: Selective management of stable patients with anterior abdomen stab wounds (AASWs) has become a gold standard management approach throughout the world. Evidenced-based options for supporting selective management include clinical follow-up, local wound exploration with or without diagnostic peritoneal lavage, diagnostic laparoscopy, and abdominal computerized tomography. The presence of multiple AASWs might signify a more aggressive attack and limit the safety of a selective management approach.

Objectives: To evaluate whether multiple AASWs are associated with an increased risk of intra-abdominal injury requiring emergency surgery.

Methods: We retrospectively reviewed all AASW patients admitted to Assaf Harofeh Medical Center, Zerifin, Israel, and Hillel Yaffe Medical Center in Hadera, Israel, from 2007 to 2015. Patients were divided into two groups based on the number of stab wounds: single or multiple. Data were coded for demographics, severity of injury, presence of intra-abdominal injury, laparotomy rate, length of hospital stay (LOS), length of stay in the intensive care unit (LICU), and survival.

Results: The study included 169 patients. Of these, 143 patients had a single AASW and 26 had multiple AASWs. There were no differences between the groups regarding demographics, severity of injury, intra-abdominal penetration, specific organ injury, LOS, or LICU. There was no difference in the percentage of patients requiring laparotomy. The overall mortality was 2.36% (4/169). There was no significant difference in the mortality rate between the groups (P = 0.11).

Conclusions: The presence of multiple AASWs is not a risk factor for increased frequency and severity of intra-abdominal injury.

Background: There are several methods for primary breast reconstruction following oncologic resection, including alloplastic and autologous-based reconstruction. Major complications that can lead to re-operation and reconstruction failure occur in up to 25% of the patients and necessitate salvage procedures.

Objectives: To present the authors' experience using a pedicled latissimus dorsi (LD) flap for the salvage of complicated and impending failed breast reconstruction.

Methods: A retrospective cohort study was conducted of all patients who underwent breast reconstruction salvage by means of an LD flap in our institution during a 5-year period. Demographic, oncologic, surgical, and postoperative data were collected and analyzed.

Results: Seventeen patients underwent breast reconstruction salvage with the LD flap. Fourteen patients had alloplastic reconstruction and three patients had autologous reconstruction. Postoperative complications included wound infection in three patients, minor wound dehiscence in two, and donor site seroma in two. One case of postoperative infection required re-operation with exchange of the implant with a tissue expander. All breast reconstructions were salvaged using the LD flap. Only one patient complained of functional limitations in using the arm of the harvested LD.

Conclusions: The LD flap is a valuable and reliable flap for alloplastic or autologous breast reconstruction salvage and has a high rate of salvage success despite the challenging surgical environment. This flap offers a good cosmetic reconstruction outcome with relatively low donor-site morbidity and high patient satisfaction.