Israel Medical Association Journal

There has been a general reduction over the last 20 years in the incidence within Israel of gastric cancer (GC). This has particularly been noted in the Jewish population with a slight increase in the incidence of cancer of the gastroesophageal junction among Jews of Sephardi origin. Given the diversity of individual ethnic subpopulations, the effects of GC incidence in second-generation immigrant Jews, particularly from high prevalence regions (e.g., the former Soviet Union, Iraq, and Iran), awaits determination. There are currently no national data on GC-specific mortality. The most recent available cross-correlated Israeli National Cancer Registry (INCR) and International Association for Cancer Research (IARC) incidence data for GC of the body and antrum in Israel are presented. Some of the challenges associated with GC monitoring in the changing Israeli population are discussed. We propose the establishment of a national GC management committee designed to collect demographic and oncological data in operable cases with the aim of recording and improving GC-specific outcomes. We believe that there is value in the development of a national surgical planning program, which oversees training and accreditation in a dynamic environment that favors the wider use of neoadjuvant therapies, minimally invasive surgery and routine extended (D2) lymphadenectomy. These changes should be supported by assessable enhanced recovery programs

Background: A paraovarian cyst (POC) is located between the ovary and the fallopian tube. In many cases POCs are diagnosed and managed as ovarian cysts. But since POC are a distinct entity in their clinical presentation and surgical intervention, they should be better defined.

Objectives: To describe the clinical perioperative and operative characteristics of patients with POCs in order to improve pre-operative diagnosis and management.

Methods: A retrospective cohort study of patients with an operative diagnosis of POC between 2007 and 2019 in a single university-affiliated tertiary care medical center was included. Demographic characteristics as well as symptoms, sonographic appearance, surgery findings, and histology results were retrieved from electronic medical records.

Results: During the study period 114 patients were surgically diagnosed with POC, 57.9% were in their reproductive years and 24.6% were adolescents. Most presented with abdominal pain (77.2%). Preoperative sonographic exams accurately diagnosed POC in only 44.7% of cases, and 50.9% underwent surgery due to suspected torsion, which was surgically confirmed in 70.7% of cases. Among women with confirmed torsion, 28.9% involved the fallopian tube without involvement of the ipsilateral ovary. Histology results showed benign cysts in all cases, except two, with a pathological diagnosis of serous borderline tumor.

Conclusions: POC should always be part of the differential diagnosis of women presenting with lower abdominal pain and sonographic evidence of adnexal cysts. If POC is suspected there should be a high level of suspicion for adnexal torsion and low threshold for surgical intervention, especially in adolescent, population who are prone to torsion

Background: The increased susceptibility of cancer patients to coronavirus disease-2019 (COVID-19) infections and complications calls for special precautions while treating cancer patients during COVID-19 pandemics. Thus, oncology departments have had to implement a wide array of prevention measures.

Objectives: To address issues associated with cancer care during the COVID-19 pandemic and to assess the implementation of measures aimed at containment of COVID-19 diffusion while allowing continuation of quality cancer care.

Methods: A national survey among oncology departments in Israel was conducted between 12 April 2020 and 14 April 2020. Eighteen heads of hospital-based oncology departments completed a self-report questionnaire regarding their institute's preparedness for treatment of cancer patients during the COVID-19 pandemic.

Results: In this national survey, prevention measures against COVID-19 spread were taken prior to patients' arrival and at arrival or while staying in the departments. Most participants (78–89%) reported using a quick triage of patients and caregivers prior to their entrance to the oncology units, limiting the entrance of caregivers, and reducing unnecessary visits to the clinic. Switching to oral therapies rather than intravenous ones when possible was considered by 82% and shortage in personal protective equipment was reported by five (28%) heads of oncology departments. Some differences between large and small/medium sized medical centers were observed regarding issues related to COVID-19 containment measures and changes in treatment.

Conclusions: Oncology departments in Israel were able to prepare and adapt their services to guidelines and requirements related to the COVID-19 pandemic with little harm to their treatment capacity

Leonardo da Vinci, the artist and scientist, was an archetype figure of the Renaissance era. He was an autodidactic polymath in natural sciences, engineering, and physical sciences, imbued with universality, prodigious inventive imagination, and curiosity to know and understand the world around him. Among his myriad activities, anatomy, physiology, and biomechanics of the musculoskeletal system and the underlying systems fully engaged him. Leonardo dissected dozens of human and animal corpses to study. His anatomical illustrations were precise, combining art and science with an impeccable integration of both. Multiple drawings, diagrams, sketches, and designs are found in his notes. Leonardo’s style was intensely personal, unveiling his thoughts, passions, and emotions. We analyzed significant biographic aspects of Leonardo's life, remarking on his scientific and life conceptions and their manifestation in his anatomical designs. The contribution of preceding anatomists is reported as a source of his inspiration as well as motivation to successors. Leonardo da Vinci left no publications, but rather an extensive collection of personal notebooks. Leonardo's contribution to modern anatomy was enormous and he is considered by the scientific and medical community as the father of the modern anatomy

Background: Point shear-wave elastography (pSWE) is a new method to assess the degree of liver fibrosis. It has been shown to be effective in detecting stiffness in viral hepatitis.

Objectives: To determine the feasibility of pSWE for assessing liver stiffness and fibrosis in liver diseases of different etiologies.

Methods: This prospective single-center study included a population of adult patients with chronic liver diseases from different etiologies, who were scheduled for liver biopsy, and a control group of healthy adults who prospectively underwent pSWE. Ten consecutive pSWE measurements of the liver were performed using a Philips iU22 ultrasound system. Stiffness degree was compared to liver biopsy results. Fibrosis degree was staged according to METAVIR scoring system.

Results: The study group was comprised of 202 patients who underwent liver biopsy and pSWE test and a control group consisting of 14 healthy adults who underwent pSWE for validation. In the study group, the median stiffness was 5.35 ± 3.37 kilopascal (kPa). The median stiffness for F0–1, F2, F3, and F4 as determined by liver biopsy results were 4.9 kPa, 5.4 kPa, 5.7 kPa, and 8 kPa, respectively. The median stiffness in the control group was 3.7 ± 0.6 kPa. Subgroup analyses were conducted for viral hepatitis vs. non-viral hepatitis and steatohepatitis vs. non-steatohepatitis groups.

Conclusions: pSWE is a reproducible method for assessing liver stiffness and is in a linear relationship with fibrosis degree as seen in pathology. Compared with patients with non-significant fibrosis, healthy controls showed significantly lower values

Background: Following an intestinal anastomotic leak, stoma creation may be the safest approach. However, this method may be challenging and cause significant morbidity. In selected cases, a T drain approach can be beneficial and a stoma can be avoided.

Objectives: To present one group's experience with a T drain approach for anastomotic leaks.

Methods: Data on patients who underwent emergent re-laparotomy following gastrointestinal anastomotic leaks were retrieved retrospectively and assessed with a new intra-operative leak severity score.

Results: Of 1684 gastrointestinal surgeries performed from 2014 to 2018, 41 (2.4%) cases of anastomotic leaks were taken for re-laparotomy. Cases included different sites and etiologies. Twelve patients were treated with a T-tube drain inserted through the leak site, 18 had a stoma taken out, 6 re-anastomosis, 4 were treated with an Endosponge, and one primary repair with a proximal ileostomy was conducted. T drain approach was successful in 11 of 12 patients (92%) with full recovery. One patient did not improve and underwent reoperation with resection and re-anastomosis. A severity score of anastomotic integrity is provided to help surgeons in decision making.

Conclusions: A T drain approach can be an optimal solution in selected cases following an intestinal anastomotic leak. When the leak is limited, the remaining anastomosis is intact and the abdominal environment allows it, a T drain can be used and a stoma can be avoided.

Background: Hepatitis C virus (HCV) is a leading cause of cirrhosis and hepatocellular carcinoma worldwide. Several viral and host factors related to viral response have been reported in the era of treatment with pegylated (PEG)-interferon and ribavirin.

Objectives: To quantify histological findings from patients with chronic HCV using computerized morphometry and to investigate whether the results can predict response to medical treatment with peg-interferon and ribavirin.

Methods: We followed 58 patients with chronic HCV infection with METAVIR score F1 and F2 in our liver unit who were grouped according to treatment response sustained viral response (SVR) and non-SVR. Liver needle biopsies from these patients were evaluated and histological variables, such as inflammatory cells, collagen fibers and liver architecture, were quantified using computerized morphometrics. The pathologist who performed the histomorphometric analysis was blinded to previous patient clinical and histological information.

Results: Histomorphometric variables including the density of collagen fibers were collected. The number of inflammatory cells in the portal space and textural variable were found to be statistically significant and could be used together in a formula to predict response to treatment, with a sensitivity of 93% and a 100% specificity.

Conclusions: Histomorphometry may help to predict a patient's response to treatment at an early stage.

Background: Implant-related spinal infections are a surgical complication associated with high morbidity. Due to infection, hardware removal may be necessary, which could lead to pseudarthrosis and the loss of stability and alignment.

Objectives: To evaluate the accuracy and diagnostic value of ¹⁸F-fluorodeoxyglucose positron-emission tomography/computed tomography (¹⁸F-FDG PET/CT) in the workup of patients with suspected implant-related infections of the spine and to assess the clinical impact of PET/CT results on the management of these infections.

Methods: The study included nine consecutive patients with a history of spinal surgery who underwent PET/CT for evaluation of suspected spinal implant related infection. All imaging studies were performed between January 2011 and December 2013. All ¹⁸F-FDG PET/CT scans were performed on an 8 slice PET/CT following an ¹⁸F-FDG injection. Images were scored both visually and semi-quantitatively by a radiology expert. Results were compared to additional imaging studies when available, which were correlated to clinical and bacteriological findings allowing calculation of sensitivity, specificity and accuracy.

Results: Among the patients, five experienced hardware-related spinal infection. ¹⁸F-FDG PET/CT sensitivity was 80%, specificity 100%, and accuracy 88.9%. One scan produced a false negative; however, a second PET/CT scan revealed an infection.

Conclusions: PET/CT was found to be valuable for the diagnosis of postoperative hardware-related spinal infection, especially when other imaging modalities were uninformative or inconclusive. As such, PET/CT could be useful for management of infection treatment.

Global trends, such as the population aging, the increase of chronic morbidity, soaring costs of healthcare services, and work overload in hospitals raise the need to find innovative solutions for providing quality medical services. One solution adopted by healthcare systems around the world is "home hospitalization," that is, providing an array of necessary health services in the patient's home, instead of in the hospital department. The aim of this focus article is to explore the spread of home hospitalization worldwide and examine the challenges and pathways for its adoption and implementation. Many countries, including the United States, Canada, the United Kingdom, and Australia, operate home-based hospitalization programs. In Israel, the service is in its infancy, but in view of the extreme workload and the high mortality rate from infections in acute care hospitals, home hospitalization has recently gained public interest and political support, which may encourage its further development.

Background: Dialysate purity contributes to the inflammatory response that afflicts hemodialysis patients.

Objectives: To compare the clinical and laboratory effects of using ultrapure water produced by a water treatment system including two reverse osmosis (RO) units in series, with a system that also includes an ultrapure filter (UPF).

Methods: We performed a retrospective study in 193 hemodialysis patients during two periods: period A (no UPF, 6 months) and period B (same patients, with addition of UPF, 18 months), and a historical cohort of patients treated in the same dialysis unit 2 years earlier, which served as a control group.

Results: Mean C-reactive protein, serum albumin and systolic blood pressure worsened in period B compared to period A and in the controls.

Conclusions: A double RO system to produce ultrapure water is not inferior to the use of ultrapure filters.

Background: Evidence has been emerging that Helicobacter pylori may also impact colorectal cancer (CRC). Positron emission tomography/computed tomography (PET/CT) imaging can predict overall survival in CRC patients.

Objectives: To determine a possible association between H. pylori seropositivity and all-cause mortality among CRC patients evaluated by PET/CT scans.

Methods: This prospective cohort study was comprised of 110 consecutive CRC patients who had undergone a PET/CT evaluation in a tertiary academic medical center. Data included demographics, body mass index (BMI), tumor node metastasis stage at diagnosis, treatment, time from diagnosis to PET/CT, and PET/CT findings. All patients were tested for anti-H. pylori immunoglobulin G (IgG) antibodies and followed for 36 months from the day of the PET/CT scan. Mortality was documented. Univariate and multivariate Cox regression was used to estimate the hazard ratio (HR) of H. pylori serological status.

Results: During the follow-up period, of the 110 CRC patients 41 (37.3%) died and 69 (62.7%) survived. Of the 41 patients, 26 (63.4%) were H. pylori seropositive and 15 (36.6%) were seronegative. Multivariate analysis showed that H. pylori seropositivity was associated with increased mortality (HR 3.46, 95% confidence interval 1.63–7.32), stage IV at diagnosis, metastatic disease found on PET/CT, longer time from diagnosis to PET/CT, lower BMI, and older age.

Conclusions: Our findings suggest that H. pylori infection may be a risk factor for all-cause mortality among CRC patients who are evaluated by PET/CT. Multicenter studies with larger patient groups are needed to confirm our findings.

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.