Israel Medical Association Journal

Among the advancements in echocardiography, the introduction of two-dimensional strain marked a pivotal moment in the quantitative evaluation of cardiac function. In fact, Global longitudinal strain (GLS) has emerged as a key focus due to its robust validation and evidence base. GLS provides a comprehensive assessment of left ventricular function, which offers greater sensitivity in detecting subtle changes compared to traditional metrics such as ejection fraction. In this position paper, we elucidate the rationale behind routine global longitudinal strain calculation, offering practical recommendations and insights for its implementation in clinical echocardiography. By bridging technical nuances with clinical relevance, the calculation of longitudinal strain aims to optimize patient care and enhance the diagnostic precision of echocardiographic examinations.

On 9 August 1938, prisoners from Dachau concentration camp near Munich were sent to the town of Mauthausen in Austria to begin building a new camp. The site was chosen because of the nearby granite quarry and its proximity to Linz [1,2].

Mauthausen initially served as a prison camp for common criminals, prostitutes, and other categories of incorrigible law offenders. However, on 8 May 1939, it was converted to a labor camp. Later, Mauthausen KL became a Nazi concentration camp on a hill above the market town of Mauthausen, approximately 20 kilometers from Linz. It was complemented with dozens of subcamps in the surrounding areas.

Background: On 7 October 2023, an armed conflict erupted between Hamas and Israel, leading to numerous combat casualties.

Objectives: To describe computed tomography (CT) findings of combat casualties at a tertiary medical center during the first 3 months of the conflict.

Methods: A retrospective observational study was conducted on patients admitted between 7 October 2023 and 7 January 2024. Adults with conflict-related trauma who underwent chest, abdomen, and pelvis (body) trauma protocol CT scans were included.

Results: Of 272 patients who underwent body trauma protocol CT, 112 combat-related adults were included, mean age of 27 years and one female. In total, 82 patients (73%) underwent additional scans of the head and neck or extremities. Fractures were observed in 53 patients (47%). Vascular injuries were present in 40 patients (35%). Limb injuries were most common, affecting 37 patients (33%), which prompted a protocol update. Lung injuries were the most common in body CT: 30 patients (27%). Head and neck injuries were seen in 21 patients (18%). Multisystem trauma was present in 24 patients (21%). A total of 83 patients (74%) underwent surgery, mostly orthopedic/soft tissue surgeries (63%); 15 (13%) underwent abdominal surgery, with bowel injuries confirmed in eight cases.

Conclusions: CT scans are an important tool in conflict trauma management. Limb injuries were the most frequent, necessitating protocol adjustments. Lung injuries were the most common body injury; 21% of patients had multisystem trauma. Most patients required surgery.

Background: Management of patients with reported iodinated contrast media (ICM) allergy is not supported by sufficient data. It is assumed that these patients are at risk for severe reactions, and that premedication provides protection.

Objective: To examine current practice and prognosis in hospitalized patients with ICM allergy.

Methods: In this retrospective study, we analyzed data of 17,356 patients who were hospitalized between 2018 and 2022 and referred for imaging. No-allergy and allergy groups were matched by age, sex, co-morbidities, and indications for imaging. Statistical analysis compared demographic, clinical, and imaging-related parameters.

Results: Our study included records of 501 patients with ICM allergy and 16,855 with no allergy. Patients with allergy were older (70.92 ± 16.25 vs. 59.02 ± 23.74 years, P < 0.001), female preponderance (male proportion 42.5% vs. 54%, P < 0.001), and those with increased cardiovascular and metabolic co-morbidities. The rate of ICM injection was similar among patients with ICM allergy (34%) and no allergy (36%). Most patients with ICM allergy did not receive premedication. Allergic patients demonstrated increased mortality (25.9% vs. 16.5%, P < 0.001); however, this result was not associated with the diagnosis of allergy, anaphylactic reactions, or premedication.

Conclusions: ICM allergy is mostly reported in patients with advanced age and multiple co-morbidities. Mortality was not increased when compared to matched non-allergic individuals. Among patients with reported allergy who were injected with ICM, anaphylaxis was not a cause of death, although fewer than half received premedication. Prospective trials are warranted to revise the clinical approach to ICM allergy.

Background: The impact of the coronavirus disease 2019 (COVID-19) pandemic on patient populations can be divided to direct consequences of the disease and indirect implications of changes imposed on the national healthcare systems. The impact of the later survival of chronic hemodialysis patients is still unknown.

Objectives: To examine the impact of quarantine on health outcomes of dialysis patients.

Methods: In a retrospective case-controlled study, we compared chronic hemodialysis patients from two separate timeframes: during a quarantine period and a parallel time without quarantine.

Results: The study included 344 hemodialysis patients. Baseline characteristics were compared between those enrolled in 2015 and those enrolled in 2020. Despite comparable clinical parameters, a statistically significant increase in the 6-month mortality rate was observed in 2020 (1.2% vs. 6.7%, P = 0.01), primarily attributed to sepsis. Notably, no deaths were attributed to COVID-19 in 2020. Interdialytic weight gain and dialysis quality remained similar between the two groups, with a mild trend toward excessive weight gain in 2020. Secondary outcomes after 6 months did not significantly differ, except for lower sodium values in 2015 compared to 2020.

Conclusions: Dialysis patients experienced disproportionate effects from the COVID-19 pandemic, even with continuous care and no direct virus-related fatalities. The findings showed unintended consequences of quarantine measures, highlighting adverse impact on both physical and mental health. Recognizing and addressing these consequences are imperative for minimizing their impact in future pandemics, emphasizing the importance of proactive measures in healthcare planning.

Background: Little is known about audiovestibular function in psoriasis, a chronic systemic inflammatory disease that affects 2% of the world’s population.

Objective: To investigate audiovestibular function in patients with psoriasis.

Methods: In this prospective case-control trial, we enrolled 33 patients with psoriasis and 30 healthy controls. Audiologic testing included audiometry, tympanometry, and otoacoustic emissions recording. The vestibular investigation consisted of a dizziness handicap inventory questionnaire, a complete clinical vestibular examination, and video head impulse testing.

Results: The psoriasis group showed significantly higher average hearing thresholds in both ears at all frequencies. Otoacoustic measurements differed significantly at 3000 Hz in the right (P = 0.026) and left ear (P = 0.034). The average dizziness handicap score was considerably higher in the psoriasis group, with a mean difference of 7.70 (P = 0.025). The number of patients with abnormal right anterior semicircular canal gain values was significantly higher in the psoriasis group (P = 0.047). Saccade analysis in the psoriasis group showed significantly higher number of patients with covert corrective saccades of the left posterior canal (P = 0.037) and significantly higher number of patients with abnormal interaural difference of corrective saccades in the plane of the right anterior-left posterior canals (P = 0.035).

Conclusions: The study demonstrates an association between psoriasis and audiovestibular impairment, which can affect quality of life. These results suggest that patients with psoriasis may be evaluated with audiometry for possible hearing loss. Vestibular testing may be pursued as clinically indicated.

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.

Background: One of the major causes of reversible visual impairment is a refractive error, which can be corrected through refractive surgery. Data regarding the outcomes and complications of these procedures exist; however, there is a notable gap in understanding the factors leading to patient rejection, particularly in diverse populations like Israel.

Objectives: To detect clinical risk factors of patients who intend to undergo LASIK procedure and to improve the conversion rates of LASIK procedure in this population.

Methods: The study included a retrospective analysis of patients who were rejected from having refractive surgery in two Enaim Refractive Surgery Centers: Jerusalem and Tel Aviv. Comparisons between centers were conducted using the t-test for continuous variables and Fisher's exact test for categorical data.

Results: Our study included 337 patients who were rejected from having refractive surgery, including 152 (45.1%) who were rejected permanently and 185 (54.9%) rejected temporarily. The most common reasons for permanent rejection were corneal irregularity (n=81, 53.3%), keratoconus (n=27, 17.8%), thin corneas (n=13, 8.6%), and amblyopia (n=10, 6.6%). The most common temporary reasons were unstable refraction (n=96, 51.9%), prolonged use of contact lenses (n=54, 29.2%), and corneal irregularity (n=16, 8.6%).

Conclusions: The leading permanent cause of rejection for refractive surgery was a corneal irregularity, whereas the primary temporary cause was unstable refraction. In a time of rapid technological advancements and growing demand for freedom from glasses, there is an increasing need for more informed and patient-focused refractive correction approaches.

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.

Colorectal cancer (CRC) is a major health concern, ranking as the third most common cancer in the United States. Screening programs, especially colonoscopy, play a crucial role in preventing CRC by removing and detecting polyps or early-stage cancers. Despite inherent risks, colonoscopy's effectiveness in saving lives is significant. In this review, we analyzed the outcomes of screening colonoscopies in an asymptomatic population for 15 years, focusing on detection rates and complications. We compared the data with previous meta-analyzes to evaluate changes in efficacy and safety. We conducted a systematic search of medical literature databases (1 January 2012 to 31 December 2023) for English-language studies on CRC screening colonoscopy. Our inclusion criteria comprised complete articles with over 500 participants with extractable data and a focus on screening colonoscopy outcomes in average-risk populations. In total, 2,897,025 people were screened, most (99.6%) were asymptomatic and were an average-risk population. Colonoscopy was complete and reached the cecum in 97–99% of the procedures. CRC was found in 0.5% (95% confidence interval [95%CI] 0.4–0.7%) of the participants. Advanced adenoma was found in 7.6% (95%CI 6.2–9.3%) of the cases. Complications were rare. Perforation developed in 0.022% of the cases and bleeding in 0.148%. Our findings exhibited a significant increase in the detection yield of adenomas and advanced adenomas with low complication rates, which shows that colonoscopy is feasible and suitable for screening for CRC in asymptomatic people.

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.

Background: The massive terrorist attack on a mixed population of civilians, soldiers, and foreigners on October 7, 2023, resulted in 1200 casualties and led to many major personal identification issues. At the Israel National Center for Forensic Medicine (INCFM), addressing the mass casualty incidents required precision that included technical, ethical, and humanitarian dimensions. Many obstacles arose that were attributable to the vast number and diversity of victims and the heavy workload in the setting of a small forensic team.

Objectives: To define the various methods utilized for victim identification.

Methods: The different types of identification were visual, primary, and circumstantial. Primary methods compared unique and stable characters of the human body, including fingerprints, comparisons of dental data, X-rays, and medical databases. We implemented other methods (anthropology, genetics) and novel creative strategies (digital photography taken by random individuals using mobile phones) and computed tomography (CT) scan at another designated site other than at the INCFM.

Results: Often, visual recognition and extraction of DNA were impossible because of burnt human remains. Hence, a comparison method of antemortem and postmortem CT findings became imperative for many unidentified victims. The more complex cases included the finding of body parts of more than one individual in different body bags (comingled remains). In such situations, we matched the body parts by utilizing DNA methods. We present seven case challenges.

Conclusions: We utilized various known and novel methods for victim identification in the aftermath of the events of 7 October 2023 while addressing ethical issues in a case series.

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.

Background: Cardiac implantable electronic devices (CIEDs) with endocardial leads crossing the tricuspid valve can lead to or worsen tricuspid regurgitation (TR), causing substantial morbidity and mortality. Despite a recent randomized controlled study revealing a low short-term incidence of device-related TR (DRT) post-CIED implantation, uncertainties persist regarding the efficacy of intra-procedural 2-dimensional transthoracic echocardiography (2DTTE) in preventing long-term TR.

Objectives: To conduct a long-term follow-up study on patients with CIED implants based on a previous study conducted at our hospital.

Methods: In a retrospective study at Assuta Ashdod Medical Center (2018–2019), patients undergoing de-novo CIED implantation with (n=39, group 1) or without (n=51, group 2) intra-procedural 2DTTE were analyzed. Clinical, demographic, and long-term (> 1 year) echocardiographic data were collected and compared.

Results: The study included 90 patients (mean age 72.3 ± 11.0 years, 63% male, 23% ICD, 50% active leads, follow-up 32.8 ± 11 months). TR aggravation was found in 25% of patients (13 in group 1, 10 in group 2), with no statistical difference between groups. Multivariate analysis identified a history of atrial fibrillation (AF) as the sole significant factor in long-term TR deterioration (OR=3.44, 95%CI 1.13–10.43, P = 0.029). Other clinical, demographic, echocardiographic, and device-related factors did not significantly contribute to long-term DRT.

Conclusions: After one-year post-CIED implantation, the incidence of DRT significantly increases. Intra-procedural 2DTTE does not effectively reduce long-term DRT, suggesting that implantation-related mechanisms are less likely the primary cause. AF likely plays a major role in the pathogenesis of long-term TR in this subset post-CIED implantation.

Background: Cardiac implantable electronic devices (CIEDs) are associated with risks of device-related infections (DRI) impacting major adverse outcomes. Staphylococcus aureus (SA) is a leading cause of early pocket infection and bacteremia. While studies in other surgical contexts have suggested that nasal mupirocin treatment and chlorhexidine skin washing may reduce colonization and infection risk, limited data exist for CIED interventions.

Objectives: To assess the impact of SA decolonization on DRI rates.

Methods: We conducted a retrospective, single-center observational study on consecutive patients undergoing CIED interventions (March 2020–March 2022). All patients received pre-procedure antibiotics and chlorhexidine skin washing. Starting in March 2021, additional pre-treatment with mupirocin for SA decolonization was administered. DRI rates within 6 months post-implantation were compared between patients treated according to guidelines (Group 1) and those receiving mupirocin in addition to the recommended guidelines (Group 2).

Results: The study comprised 276 patients (age 77 ± 10 years; 60% male). DRI occurred in five patients (1.8%);80% underwent cardiac resynchronization therapy procedures. In Group 1 (n=177), four patients (2.2%) experienced DRI 11–48 days post-procedure; three with pocket infection (two with negative cultures and one with local Pseudomonas) and one with methicillin-sensitive SA endocarditis necessitating device extraction. In Group 2 (n=99), only one patient (1%) had DRI (Strep. dysgalactiae endocarditis) 135 days post-procedure (P = NS).

Conclusions: The routine decolonization of SA with mupirocin, in addition to guideline-directed protocols, did not significantly affect DRI rates. Larger prospective studies are needed to evaluate the preventive role of routine SA decolonization in CIED procedures.