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: Local anesthetics are used in various sites and mechanisms to maximize perioperative analgesia and reduce opioid use and side effects. Pain management in the bariatric setting is challenging and the efficacy of local anesthetics intraoperatively is under current evaluation.

Objectives: To determine the safety and efficacy of a new intra-abdominal anesthetic technique performed during laparoscopic bariatric operations: visceral block.

Methods: During this prospective randomized double-blinded pilot study, 16 patients undergoing bariatric surgery were treated with the injection of ropivacaine to the anterior esophagogastric junction fat, and 15 were injected with saline as control.

Results: The procedure was shown to be safe, and no adverse events nor side effects were encountered. A non-statistically significant trend toward the use of a non-opioid analgesia was documented during the first postoperative hours.

Conclusions: Visceral block is a safe and feasible intraoperative procedure. A trend toward its efficacy warrants future larger scale studies.

Gastric perforation secondary to foreign body ingestion is rare. While obvious signs of acute abdomen usually lead to a prompt diagnosis by emergency department (ED) staff, this can be delayed in non-responsive or mentally disabled patients. An altered pain perception has been described in schizophrenia, as part of a complex phenomenon, which is thought to be unrelated to changes in nociceptive pathways. Cognitive impairment and negative symptoms may strongly influence the patient’s expression of pain [1].

Background: Recent studies have suggested that urgent cholecystectomy is the preferred treatment for acute cholecystitis. However, initial conservative treatment followed by delayed elective surgery is still common practice in many medical centers.

Objectives: To determine the effect of percutaneous cholecystostomy on surgical outcome in patients undergoing delayed elective cholecystectomy.

Methods: We conducted a retrospective analysis of all patients admitted to our medical center with acute cholecystitis who were treated by conservative treatment followed by delayed cholecystectomy between 2004 and 2013. Logistic regression was calculated to assess the association of percutaneous cholecystostomy with patient characteristics, planned surgical procedure, and the clinical and surgical outcomes.

Results: We identified 370 patients. Of these, 134 patients (36%) underwent cholecystostomy during the conservative treatment period. Patients who underwent cholecystostomy were older and at higher risk for surgery. Laparoscopic cholecystectomy was offered to 92% of all patients, yet assignment to the open surgical approach was more common in the cholecystostomy group (16% vs. 3%). Cholecystostomy was associated with significantly higher conversion rates to open approach (26% vs. 13%) but was not associated with longer operative time, hemorrhage, surgical infections, or bile duct or organ injuries.

Conclusions: Treatment with cholecystostomy is associated with higher conversion rates but does not include other major operative-related complications or poorer clinical outcome.

Background: The detection and correction of refractive errors is one of the priorities of the World Health Organization Initiative Vision 2020.

Objectives: To determine the factors related to a child having an ocular abnormality (poor vision, refractive error or other abnormality) among schoolchildren in northern Israel.

Methods: A cross-sectional population-based study was conducted among 2113 students aged 6-7 and 13-14 years old in 70 schools in northern Israel. Medical examination included vision history, clinical eye examination and vision testing. If a parent’s informed consent was available, eye drops (cycloplegia) were delivered for fundus and retinoscopy testing. An ophthalmologist was asked to determine the need for the child’s referral for further diagnostic procedures, treatment and/or follow-up. Multivariate analysis was limited to 1708 children, using data pertaining to the ophthalmologist’s decision regarding referral, as well as vision and retinoscopy results.

Results: Vision and/or ocular abnormality was prevalent in 21.5% (95% confidence interval 17.4–26.6%), predominantly among 13-14 year olds and Jewish children. Abnormal clinical findings were found in 5.7% of the students. Retinoscopy showed a higher prevalence of hypermetropia among 6-7 year olds and a higher prevalence of myopia and astigmatism among the 13-14 year olds. The multivariate analysis suggests an independent effect of retinoscopy abnormality (odds ratio = 3.85), vision abnormality (OR [1]= 2.42), Jewish ethnicity (OR = 1.62) and 13-14 year old age group (OR = 1.26) on the ophthalmologist’s referral decision.

Conclusions: Vision and/or ocular abnormality is an important health problem among schoolchildren in northern Israel. The independent effect of ethnicity and age on the ophthalmologist’s referral decision should be further explored.

Background: The incidence of cutaneous leishmaniasis in northern Israel began to rise in 2000, peaking at 41.0 per 100,000 in the Kinneret subdistrict during the first half of 2003.

Objectives: To examine the morbidity rates of CL[1] in northern Israel during the period 1999–2003, which would indicate whether new endemic areas were emerging in this district, and to identify suspicious hosts.

Methods: The demographic and epidemiologic data for the reported cases (n=93) were analyzed using the GIS and SPSS software, including mapping habitats of suspicious hosts and localizing sites of infected sand flies.

Results: The maximal incidence rate in the district was found in the city Tiberias in 2003: 62.5/100,000 compared to 0–1.5/100,000 in other towns. The cases in Tiberias were centered on the peripheral line of two neighborhoods, close to the habitats of the rock hyraxes. Sand flies infected with Leishmania tropica were captured around the residence of those affected. Results of polymerase chain reaction were positive for Leishmania tropica in 14 of 15 tested patients.

Conclusions: A new endemic CL area has emerged in Tiberias. The most suspicious reservoir of the disease is the rock hyrax.

Background: Uncorrected refractive error is the leading cause of visual impairment in children. In 2002 a screening project was launched in Israel to provide data on the effectiveness of the illiterate E-chart in identifying Jewish and Arab schoolchildren in need of a comprehensive eye examination.

Objectives: To present the aims, design and initial results of the visual screening project and the prevalence of vision abnormality in the study population.

Methods: A cross-sectional population-based study was conducted during 2002–2003 among first- and eighth-graders in 70 schools in northern Israel. The nurse's test included use of the illiterate E-chart to measure visual acuity. The medical examination included vision history, clinical eye examination, VA[1] and retinoscopy. The ophthalmologist's evaluation as to whether a child needed a referral for diagnostic procedures, treatment and/or follow-up was recorded and compared with explicit referral criteria formulated after data collection.

Results: Of 1975 schoolchildren, 31% had abnormal VA, defined as VA worse than 6/6 in at least one eye, and a quarter had VA equal or worse than 6/12 in both eyes. The prevalence of vision abnormality among the children was 22.4% when based on the evaluation of the field ophthalmologist and 26.1% when based on two sets of explicit severity scores and referral criteria.

Conclusions: Vision abnormality is a significant health problem among northern Israeli schoolchildren. This project is unique in scope and importance, providing evidence to assist policy making with regard to vision screening for schoolchildren (including data on test reliability and validity) and optimal VA cutoff level, and confirming the need for clinical guidelines regarding referral criteria.

Objectives: To evaluate factors that might influence the decision of pregnant women to choose chorionic villous sampling for prenatal testing.

Methods: The study group comprised 239 women referred for prenatal diagnosis who elected to undergo CVS[1]. The data were analyzed according to indication, ethnic group and religion.

Results: Among women undergoing CVS because of advanced maternal age and because of anxiety, we noted a significantly high proportion of unbalanced families, i.e., with three or more children of the same gender and deviated gender ratio. We found a significant excess of males among the Jewish families and a significant excess of females among the non-Jewish families. Jews were over-represented in the monogenic group while Christian Arabs were over-represented in the maternal age/anxiety group.

Conclusions: The proportion of women who chose CVS for prenatal diagnosis varied according to indication, ethnic group and religion. The data in this study indicate that CVS may have been utilized for balancing families with ≥ 3 or more children of the same sex. Christian Arabs chose CVS more often than the other groups. Jewish women may have utilized CVS for family balancing of both sexes, while non-Jews may have utilized CVS for balancing families with ≥ 3 daughters.