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עמוד בית
Tue, 11.02.25

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December 2024
Hagai Landov MD, Sharon Baum MD, Raneen Mansour MD, Boaz Liberman MD, Aviv Barzilai MSc MD, Joseph Alcalay MD FACM

Background: Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive, soft-tissue sarcoma. The treatment is surgical and includes wide local excision (WLE) or Mohs micrographic Surgery (MMS). There is no consensus regarding the preferred type of surgery.

Objectives: To compare the outcomes of the two types of surgery (WLE and MMS).

Methods: This retrospective cohort study was based on the medical records of 59 patients with DFSP treated at Sheba Medical Center (using the WLE method) or Assuta Medical Center (using the MMS method) between 1995 and 2018. The data included demographics, clinical presentations, imaging, types of wound closures, pathological margin status, surgical defect sizes, recurrences, and follow-up.

Results: Of the 59 included patients, 18 (30.5%) underwent WLE and 41 (69.5%) underwent MMS. The mean age at diagnosis was 40.1 ± 14.4 years. The male-to-female ratio was 1.5:1. The main tumor location was the trunk (50% for WLE and 41.5% for MMS). The main type of closure for both procedures was primary closure. In 72.2% of WLE and 78.8% of MMS cases, the margins were free. The difference between the final surgical defect and the original tumor size was statistically significantly smaller in patients who underwent MMS. The median duration of follow-up was 6.6 years. There was no significant difference in the rate of recurrence.

Conclusions: MMS enables better tissue preservation and results in a minor surgical defect compared to WLE, with no difference in tumor recurrence between the two methods.

Lital Oz-Alcalay MD, Gil Klinger MD, Nir Sokolover MD, Paul Merlob MD, Tommy Scheinfeld MD

Esophageal lung is a rare congenital malformation. We present a case of a full-term infant with an esophageal lung presenting as a white lung combined with VACTERL association (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities) and dysmorphic features. A right pneumonectomy was successfully performed.

Joseph Alcalay MD FACMS

Almost three-quarters of a century ago an American surgeon named Frederick Edward Mohs, had the idea of excising skin cancers and examining the margins before the closure of the surgical wound. In this manner he thought the patient would get better treatment with the best cosmetic result.

Mohs micrographic surgery (MMS) in its present format has been used as a surgical method for treating skin cancers for the last 70 years. The method became popular with American dermatologists 54 years ago when the original Mohs technique was modified into its fresh tissue modality [2] and in the rest of the Western world and Israel more than 35 years ago. Variations of MMS started to appear and indications for surgery also expanded. At the beginning, MMS was indicated mainly for basal and squamous cell carcinomas–nonmelanoma skin cancers (NMSC). Knowledge has been collected and today the method is applicable for a variety of other skin cancers such as melanoma in situ, microcystic adnexal carcinoma, dermatofibrosarcoma protuberans (DFSP), and other adnexal and spindle cell tumors. In this issue of the Israel Medical Association Journal (IMAJ), Landov and colleagues [3] showed the value of MMS for the treatment of DFSP.

Avishay Elis MD, Ela Giladi MD

Despite the application of recommended guideline-driven therapies and optimal medical interventions, individuals with established cardiovascular disease remain susceptible to additional cardiovascular incidents, a phenomenon referred to as residual risk. Analyses of clinical trial data reveal significant residual cardiovascular risk in all treated patients, even in the setting of optimal LDL-C reduction, thus enforcing the need to revise the algorithms beyond focusing on LDL-C levels. We present a case that highlights the problem of residual risk upon well controlled LDL-C levels and provide insights for additional measures for residual risk reduction.

November 2024
Moshe Salai (Col res) MD, Michael Malkin (Lt Col) MD, Amir Shlaifer (Col) MD, Itay Fogel (Col) MD, Avi Shina (Col) MD, Liron Gershowitz (Col) MD, Elon Glasberg (Brg Gen) MD

Background: Military medicine has evolved significantly over the past 50 years, advancing from basic treatments and limited evacuations to sophisticated combat casualty care. Innovations such as hemorrhage control, early blood product administration, and telemedicine have greatly improved battlefield care. Rapid evacuation systems and skilled medical teams have reduced mortality and morbidity rates.

Objectives: To review the transformation of the Israel Defense Forces Medical Corps (IDF-MC) in combat casualty care over the past 50 years, focusing on recent applications during the Iron Swords war.

Methods: Data were collected from the personal experiences of IDF-MC doctors, IDF archives, and relevant military medical literature, with an emphasis on life-saving strategies, personnel, equipment, mental health support, and civil–military cooperation.

Results: Rapid evacuation and immediate care have improved survival rates, while increased front-line deployment of medical staff has enhanced response capabilities. Modern medical tools and techniques, such as tourniquets and blood products, have been widely adopted. Improved psychological support strategies ensure better mental health outcomes for soldiers. Enhanced coordination with civilian trauma systems optimizes care and resource allocation, leading to more efficient and effective casualty treatment.

Conclusions: The IDF-MC's advancements in rapid evacuation and front-line medical support have significantly improved combat casualty outcomes. Continued innovation and collaboration with civilian systems are essential for further progress in military medicine. Future technological advancements are anticipated to further enhance military medical care.

Ronit Lev Kolnik MD, Idan Bergman MD, Avishay Elis MD

Background: The Agatston coronary artery calcium (CAC) score is a decision-guiding aid for risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease.

Objectives: To explore the real-life clinical experience of CAC testing by characterizing its indications, significance of scores, and corresponding lipid-lowering treatments.

Methods: A retrospective descriptive study of patients treated at the lipids clinic at Rabin Medical Center (Beilinson Campus), who underwent CAC score evaluation between 2017 and 2022 was conducted. The data collected from electronic medical files included demographics, co-morbidities, indications for the test, CAC score levels, and the recommended therapeutic regimen.

Results: The study cohort included 88 patients. The main indication was assessment of the existence of atherosclerosis in cases where there was no clear indication for lipid lowering treatment (65, 74%). In most patients, there was no evidence of atherosclerosis (CAC = 0 AU, n=30) or only mild disease (CAC=1–99 AU, n=35). As the CAC score increased, more patients were prescribed lipid lowering treatments, from very few prescriptions in those with a CAC score of 0 AU and almost 100% among those with score of ≥ 400 AU. The factors that predicted CAC > 0 AU were male sex and older age.

Conclusions: CAC scores should be used more often to determine risk assessment. Further analysis of the implications of scores between 0–400 AU is needed.

May Simshon-Turgeman MD, Eliahu Rosenberg MD, Amir Bartal MD, Carmi Bartal MD MHA

IgG4-related disease (IgG4-RD) is an immune-mediated fibroinflammatory condition. Accumulated research and data since 2003 have increasingly affirmed its classification as a systemic disease. Although IgG4-RD generally presents with involvement of one or several organ systems, it can affect almost any organ. The disease manifests gradually with the development of tumor-like lesions.

Constitutional symptoms, such as systemic fever and elevated inflammatory markers, are generally absent in association with this pathological condition. However, it is common for patients to exhibit allergy characteristics in addition to a slight increase in peripheral blood eosinophilia. The clinical manifestations of the disease exhibit variability on the specific organ system affected. Specific involvement of organs can ultimately result in organ failure. For example, retroperitoneal fibrosis commonly leads to post-renal failure [1]. The 2020 Revised Comprehensive Diagnostic (RCD) criteria for IgG4-RD include three components for diagnosis: clinical and radiological components (1), serological diagnosis (2), and unique pathological diagnosis (3). When all three are present it is a definitive diagnosis. The presence of components 1 + 3 constitutes a probable diagnosis, while the presence of components 1 + 2 indicates possible diagnosis [2].

Testicular involvement of IgG4-RD has been described in a few case reports. However, the uniqueness of our case is the manifestation of a testicular mass as a different target organ of relapse in a patient in remission from retroperitoneal fibrosis.

October 2024
Maya Paran MD, Osnat Konen MD, Tal May MD, Moussa Totah MD, Michael Levinson MD, Michael Segal MD, Dragan Kravarusic MD, Inbal Samuk MD

Background: Cloacal malformation represents the rarest and most complex congenital anorectal malformation in females and is characterized by the convergence of urinary, gynecological, and intestinal systems within a single common channel. Three-dimensional computed tomography reconstruction (3D CT cloacagram) has emerged as a valuable method for anatomical assessment and preoperative planning.

Objectives: To evaluate our experience with 3D CT cloacagram and assess its results.

Methods: This retrospective case series included all patients with cloacal malformation who underwent preoperative 3D CT cloacagram at a single institution during 2019–2023. Collected data included patient characteristics, timing of the 3D CT cloacagram, results of the 3D CT cloacagram, comparison with endoscopic results, surgical procedures, and postoperative outcome.

Results: Six patients with cloacal malformation were included in this study, including two with posterior cloaca. The median common channel length on 3D CT cloacagram was 24.5 mm (range 9–48 mm) and the median urethral length was 15.5 mm (range 13-24 mm). The surgical approach involved a combined abdominoperineal approach in three patients and posterior sagittal anorectal vaginal urethral plasty in one patient. Two patients were awaiting surgical reconstruction at the time of publication.

Conclusions: Our implementation of 3D cloacagram has facilitated precise measurements of both the urethra and common channel lengths, two key factors in formulating surgical strategies for cloacal reconstruction. Moreover, this technique has markedly improved our capacity for surgical planning contributing to colorectal, gynecological, and urological perspectives.

Or Segev MD, Christopher Hoyte MD, Nicole Taylor MD, Amanda Katz MD, Dennis Scolnik MB ChB, Efrat Zandberg MD, Eyal Hassoun MD, Miguel Glatstein MD

Background: Clinical toxicology is not a certified specialty in Israel, consequently there are a limited number of toxicologists and toxicology services available for consultation.

Objectives: To establish a medical toxicology consultation service focusing on bedside consultations, which had not previously been available in Israel.

Methods: This single-center, retrospective chart review of toxicology consults was conducted during the first years after the initiation of a new toxicology service.

Results: From September 2017 to December 2021, 1703 toxicology consultations were conducted. The most common exposures and reasons for consultation included psychotropic medications (427, 23%), analgesics and anti-inflammatory medications (353, 19%), household products (312, 17%), substances of abuse (240, 13%), and natural toxins (142, 8%). Bedside medical toxicology consultations were performed in 1036 cases (62%) during daytime and night shifts. The number of consultation requests increased steadily over the study period.

Conclusions: The new toxicology service led to a significant change in the institution’s approach to toxicological patients. A bedside toxicology service could help reduce the healthcare burden on national poison centers and can offer readily available, personalized, medical toxicology care.

Ahmad Raiyan MD, Avishay Elis MD

Background: Coronary heart disease (CHD) patients are considered high cardiovascular risks. Guidelines recommend low-density lipoprotein cholesterol (LDL-C) target levels below 55 mg/dl with > 50% reduction from baselines. These levels can be reached by a combination of statins, ezetimibe, and anti-protein convertase subtilisin/kexin type 9 (anti-PCSK9) agents. Our clinical impression was that CHD patients do not reach LDL-C target levels, despite the wide availability.

Objectives: To evaluate whether hospitalization would result in changes in lipid lowering regimens and short-term compliance.

Methods: We conducted a retrospective cohort study using data of CHD patients who were admitted to internal medicine wards at Clalit Health Services medical centers because of anginal syndrome during 2020–2022. The data were evaluated for demographic and clinical characteristics; LDL-C level at admission, 6 months previously, and 3 months and 6–9 months after discharge; rates of reaching LDL-C target levels; and lipid lowering treatment at admission, discharge, and 6–9 months after.

Results: The cohort included 10,540 patients. One-third and three-quarters did not have lipids level measurements up to 6 months before and during hospitalization, respectively. Only one-fifth of the patients reached LDL-C values before and during admission (median LDL-C 72 mg/dl; range 53–101). Approximately half were treated with high-dose potent statins. Only 10% were treated with ezetimibe. Hospitalization did not have a clinically significant effect on short-term lipid lowering treatment or LDL-C levels.

Conclusions: Gaps were noted between guidelines and clinical practice for reaching LDL-C target levels. Further education and strict policy are needed.

Shirley Markovich Sholomon MD, Sami Giryes MD, Vika Shataylo BSc, Yolanda Braun-Moscovici MD, Alexandra Balbir-Gurman MD

Background: Serum ferritin is a sensitive inflammatory biomarker reflecting cell damage and oxidative stress in inflammatory rheumatic diseases. The use of ferritin for assessment of systemic sclerosis (SSc) activity, severity, and prognosis has not been fully elucidated.

Objectives: To assess the correlation between serum ferritin levels and SSc disease parameters, complications, and outcome.

Methods: Demographic, clinical, and laboratory data, including blood levels of ferritin, were collected from files of patients with SSc who were treated at the Rheumatology Institute at Rambam Health Care Campus from January 2004 to July 2021. The study compared SSc patients with elevated levels of ferritin to those with normal levels.

Results: We extracted data of 241 SSc patients (80% female, 60% with diffuse SSc, mean age 54 ± 15.4 years, mean disease duration 6.8 ± 4.5 years). During follow-up, 39% died. Elevated ferritin levels positively correlated with male sex; short disease duration; lung, heart, and kidney involvement; higher modified Rodnan skin score; anemia; elevated levels of creatinine kinase, C-reactive protein, creatinine, and troponin; reduced pulmonary function tests (forced vital capacity and diffusion capacity of the lung for carbon monoxide); and left ventricular ejection fraction. There were no correlations between ferritin levels and pulmonary hypertension or gastrointestinal involvement. Levels of ferritin negatively correlated with anti-centromere antibodies.

Conclusions: In SSc, ferritin can serve as a marker for ongoing systemic inflammation and prognosis, particularly in patients with lung and heart involvement. Further studies on serial ferritin measurement in the management of SSc patients are warranted.

Jawad Atrash MD, Omar Abu libdeh MD, Bashar Fteiha MD, Marwan Abu Sneineh MD, Alon Bnaya MD, Linda Shavit MD

Hypokalemia is a frequently encountered electrolyte disturbance, particularly among hospitalized patients. It often arises from increased potassium excretion (via the kidney or gastrointestinal tract) or intracellular shifts [1]. Hypokalemic periodic paralysis (HPP) is an uncommon cause of hypokalemia, with the most common reported mutation found in the dihydropyridine-sensitive calcium channel in skeletal muscles (CACNA1S gene) [2]. We present a case of a young woman with HPP associated with a novel mutation in the chloride voltage-gated channel 1 (CLCN1) gene.

September 2024
Mohamad Arow MD, Yonatan Shneor Patt MD, Zehavit Kirshenboim MD, Roy Mashiach MD, Howard Amital MD MHA

In this case report, we elucidated the complex etiology of new-onset ascites through the unusual presentation of a 32-year-old female with abdominal swelling, oliguria, and acute renal failure. This patient's ascites was attributed to urinary bladder rupture, a rare but critical consideration in differential diagnoses. Highlighting the significance of this case, bladder rupture without recent trauma history, especially post-gynecological surgery, poses a diagnostic challenge due to its rarity and potential for severe morbidity and mortality if not promptly recognized and managed. Our patient's journey, from initial symptoms to the eventual discovery of bladder rupture, underscores the necessity of considering this diagnosis in similar clinical scenarios. The case uniquely demonstrates pseudo-renal failure, a phenomenon resulting from reversed dialysis across the peritoneal membrane, which further complicated the diagnostic process.

Matan Mor MD, Nadav Kugler MD, Moshe Betser MD, Miki Moskovich MD, Yifat Wiener MD, Ron Maymon MD

Background: On 7 October 2023, Hamas lunched a massive terror attack against Israel. The first weeks after were characterized with great uncertainty, insecurity, and fear.

Objectives: To evaluate the effect of the first 2 months of the Iron Swords war on obstetrical emergency attendance and the corresponding perinatal outcomes.

Methods: We conducted a single center retrospective cohort study of all singleton births between 7 October and 7 December 2023. Prenatal emergency labor ward admission numbers and obstetric outcomes during the first 2 months of the war were compared to the combined corresponding periods for the years 2018–2022.

Results: During the initial 2 months of the conflict 1379 births were documented. The control group consisted of 7304 deliveries between 2018 and 2022. There was a decrease in daily emergency admissions to the labor ward during the first 5 weeks of the conflict compared to the corresponding periods in the preceding years (51.8 ± 15.0 vs. 57.0 ± 13.0, P = 0.0458). A notable increase in stillbirth rates was observed in the study group compared to the control group (5/1379 [0.36%] vs. 7/7304 [0.1%]; P = 0.014). Both groups exhibited similar gestational ages at birth, rates of preterm and post-term delivery, neonatal birthweights, mode of delivery, and induction of labor rates.

Conclusions: In the initial weeks following Hamas's attack on Israel, there was a notable decrease in admissions to the prenatal emergency labor ward. This decline coincided with an increase in the rate of stillbirths among a population not directly involved in the conflict.

Raneen Abu Shqara MD, Maya Frank Wolf MD, Jawad Karram MD, Inshirah Sgayer MD, Ala Aiob MD, Lior Lowenstein MD, Susana Mustafa Mikhae MD

Background: Pelvic organ prolapse in pregnancy is rare. Consequent complications include cervical infection, spontaneous abortion, and premature birth. Conservative management by means of a pessary have been described as improving maternal symptomatology and minimizing gestational risk. The delivery mode is controversial.

Objective: To describe the clinical courses of patients diagnosed with pelvic organ prolapse during pregnancy, and to present our multidisciplinary approach.

Methods: In this retrospective case series, we summarized the obstetrical outcomes of women diagnosed with pelvic organ prolapse during pregnancy in a single university-affiliated hospital.

Results: We identified eight women with advanced uterine prolapse at a mean age of 30.3 years. Seven were diagnosed with advanced uterine prolapse (Pelvic Organ Prolapse Quantification [POPQ] stage ≥ 3). All were treated by pessary placement, which was tolerable and provided symptomatic relief. The pessary type was chosen according to the prolapse stage. In women with cervical prolapse POPQ stage > 2 and cervical edema, a support pessary was less beneficial. However, the prolapse was well-controlled with a space-filling Gellhorn pessary. Low complication rates were associated with vaginal deliveries. The few complications that were reported included minor cervical laceration, postpartum hemorrhage, and retained placenta.

Conclusions: Treatment of pelvic organ prolapse during pregnancy must be individualized and requires a multidisciplinary approach of urogynecologists, obstetricians, dietitians, pelvic floor physiotherapists, and social workers. Conservative management, consisting of insertion of a vaginal pessary when prolapse symptoms appeared, provided adequate support for the pelvic floor, improved symptomatology, and minimized pregnancy complications. Vaginal delivery was feasible for most of the women.

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