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עמוד בית
Sat, 20.07.24

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June 2024
Ehud Jacobzon MD, Avital Lifschitz RN, Danny Fink MD, Tal Hasin MD

Background: Left ventricular assist devices (LVAD) are a staple element in contemporary treatment of advanced heart failure. LVAD surgeries are mostly done in heart transplantations centers, as a destination therapy or as a bridge to heart transplantation.

Objectives: To describe our step-by-step experience in establishing and implementing a new LVAD program in a non-heart transplant center. To give insight to our short- and long-term results of our first 25 LVAD patients.

Methods: Preliminary steps included identifying the need for a new program and establishing the leading team. Next is defining protocols for pre-operative evaluation, operating room, post-operative management, and outpatient follow-up. The leading team needs to educate other relevant units in the hospital that will be involved in the care of these patients. It is essential to work in collaboration with a heart transplant center from the very beginning. Patient selection is of major importance especially in the early experience. Initially “low risk” patients should be enrolled.

Results: We describe our first 25 LVAD patients. Our first five patients all survived beyond 2 years, with no major complications. Overall, there was one operative death due to massive GI bleeding. There were four late deaths due to septic events.

Conclusions: Establishing a new LVAD program can be successful also with small- and medium-size programs. With careful and meticulous planning LVAD implantation can be extended to more centers thus offering an excellent solution for advanced heart failure patients.

June 2023
Jonathan D. Cohen MBBCh FCP (SA), Tomer Kaplan BEMS MPH, Tammy Fink RN, Kyrill Grozovsky RN, Refael Strugo MD, Ilya Kagan MD, Tamar Ashkenazi RN PhD

Background: A limited program for kidney donation from uncontrolled donation after cardiocirculatory determination of death (uDCDD) was implemented at four hospitals in Israel in close cooperation with Magen David Adom (MDA), the national emergency medical service.

Objectives: To assess the outcome of transplantations performed between January 2017 and June 2022.

Methods: Donor data included age, sex, and cause of death. Recipient data included age, sex, and yearly serum creatinine levels. A retrospective study of out-of-hospital cardiac arrest cases treated by MDA during 2021 were analyzed to assess their compatibility as potential uDCDD donors.

Results: In total, 49 potential donors were referred to hospitals by MDA. Consent was obtained in 40 cases (83%), organ retrieval was performed in 28 cases, and 40 kidneys were transplanted from 21 donors (75% retrieval rate). At 1-year follow-up, 36 recipients had a functioning graft (4 returned to dialysis) and mean serum creatinine 1.59 ± 0.92 mg% (90% graft survival). Outcome after transplantation showed serum creatinine levels (mg%) at 2 years 1.41 ± 0.83, n=26; 3 years 1.48 ± 0.99, n=16; 4 years 1.07 ± 1.06, n=7; and 5 years 1.12 ± 0.31, n=5. One patient died of multiple myeloma at 3 years. The MDA audit revealed an unutilized pool of 125 potential cases, 90 of whom were transported to hospitals and 35 were declared dead at the scene.

Conclusions: Transplant outcomes were encouraging, suggesting that more intensive implementation of the program may increase the number of kidneys transplanted, thus shortening recipient waiting lists.

September 2022
Avi Benov MD MHA, Shaul Gelikas MD MBA, Noam Fink MD, and Elon Glassberg MD MHA MBA

War is as old as history. Some may say it is older. The first Biblical war, dated 1880–1875 BCE, is depicted in the book of Genesis between nine kings in the vicinity of the Jordan river near Jericho. By the end of the war, Abraham (Abram) gets involved in saving his nephew Lot.

In addition to war, military medicine also has its roots in historical times. Hippocrates (460–377 BCE), the father of medicine, derived his medical knowledge from the battlefield, and Sushruta [1], the father of plastic surgery, mentioned the physician's preventive role in noting environmental hazards: "A common practice of the enemy is to poison the wells on the roadside, the articles of food, the shades of trees, and the fuel and forage for cattle; hence, it is incumbent on a physician marching with the troops to inspect, examine, and purify these before using any of them, in case they are poisoned."

The Greeks stated new ideas of military health, pointing to fitness promotion, gymnastics, and healthy diets to prevent illness. Over the centuries, from Alexander the Great to Napoleon’s army and wars in the 20th century, military conflicts have led to the death of hundreds of millions of people from trauma and war-related disease. Amazingly analyses of the 18th and 19th centuries have shown that 80% of the soldiers died from disease, and historians and military personnel agree that during armed conflicts in known history, only a minority of soldiers perished by the sword.

In Israel, the Israel Defense Forces-Medical Corps (IDF-MC) holds a unique position embedded in military and civilian national medicine. All medical personnel (e.g., physicians, nurses, technicians, veterinarians) who work in the IDF-MC receive their diplomas from civilian universities, train in civilian hospitals, and continue to practice in the national health system. The majority of these professionals continue to work in different civilian medical platforms in Israel after finishing their mandatory service. The IDF-MC's primary mission is to provide optimal medical care to IDF soldiers at all times (including wartime), to prevent disease and promote health, advance military medicine, and aid the civilian sector as ordered by the Government of Israel.

In this special issue of Israel Medical Association Journal (IMAJ) is to expose readers to the continuous efforts of the IDF-MC to fulfill its mission by promoting research in multiple medical fields, including trauma, ambulatory care, health administration. In addition, in this issue of IMAJ, authors discuss the unique collaboration with the civilian system during the coronavirus disease 2019 (COVID-19) pandemic.

Trauma and trauma-related injuries are the main focus of military medical research. Ben-Avi and colleagues [2] described outcomes of emergent exploratory thoracotomies on military casualties and addresses parameters that may impact the survival of these casualties. Minervini [3] further discussed the issue. Bez et al. [4] researched the impact of isolated versus non-isolated traumatic brain injuries on injury identification and decision-making by care providers in austere scenarios. Tsur and co-authors [5] described the characteristics of a unique type of terror attack: vehicle ramming.

Additional examples of treatments provided in the military prehospital arena were analyzed by Nakar and colleagues [6] who discussed how to assess pain medications administered to trauma casualties in the past two decades by IDF-MC care providers. Rittblat et al. [7] further described the use of freeze-dried plasma, a blood component used in the prehospital arena and administered via intraosseous vascular access.

The IDF-MC is a continuously changing organization emphasizing the adoption of advanced technologies and devices. Chen et al. [8] presented a blinded study on the use of point-of-care ultrasound and remote telementored ultrasound by inexperienced operators, and Sorkin et al. [9] described the BladeShield 101: a novel device for the battlefield designed to continuously measure vital signs and medical treatment provided and to transfer data through roles of care.

In this special issue of IMAJ, authors also discusse gender-related aspects at the core of medical treatment. Segal et al. [10] examined whether missed injuries were related to the medical provider's gender, while Gelikas et al. [11] assessed whether treatment with analgesia was associated with casualty gender in the military prehospital trauma setting

Over the past two and a half years, the COVID-19 pandemic has been a significant part of our lives. During these years, medical systems and teams throughout Israel and around the world struggled to adapt to this new disease and save lives fighting the pandemic. Geva et al. [12] and Shental et al. [13] discussed the impact of COVID-19 on the IDF medical system, lessons learned during the outbreak, and effects of different diseases during these times on medical treatment provided by the IDF to soldiers.

Gil A. Geva MD, Maya Nitecki MD, Itay Ketko MSc, Itay Toledo BSc, Sagi A. Shpitzer MD, Avi Benov MD MHA, Noam Fink MD, and Ariel Furer MD MBA

Background: To mitigate the spread of coronavirus disease 2019 (COVID-19), national guidelines, in accordance with international health authorities, mandated 14 days of quarantine for every close contact of a confirmed COVID-19 patient. Although health benefits are obvious, consequences are profound, especially for organizations required to maintain operational preparedness.

Objectives: To present the Israel Defense Force (IDF) experience with outbreaks regarding quarantined individuals. To weigh the consequences of quarantined individuals needed for workforce and operation.

Methods: All positive COVID-19 cases in the IDF, as measured by a positive rRT-PCR test result, between 29 February and 18 May 2020 were evaluated. Numbers of positive individuals, quarantined individuals, and confirmatory exams conducted were collected. We compared the events in four units with the largest outbreaks and assessed the impact of confirmed cases, tests conducted, and workforce loss due to quarantine.

Results: Of the 187 soldiers who tested positive for COVID-19, source of infection was traced to 140 soldiers (75%). Almost no medical treatment was delivered, and hospitalization was rare. We found a median of 15.2% (interquartile range 5.3–34) for decline in unit workforce due to quarantine measures. Maximum reduction reached 47% of the workforce in one unit.

Conclusions: Despite a relatively small number of confirmed cases, units underwent a substantial change in mode of operation due to the toll of quarantined individuals. In certain populations and organizations, perhaps a more liberal application of isolation and contact tracing is suitable due to the heavy economic burden and consequences in term of operational readiness.

Alex Sorkin MD, Avishai M. Tsur MD MHA, Roy Nadler MD, Ariel Hirschhorn MD, Ezri Tarazi BDes, Jacob Chen MD MHA, Noam Fink MD, Guy Avital MD, Shaul Gelikas MD MBA, and Avi Benov MD MHA

Background: The Israeli Defense Forces-Medical Corps (IDF-MC) focuses on reducing preventable death by improving prehospital trauma care. High quality documentation of care can serve casualty care and to improve future care. Currently, paper casualty cards are used for documentation. Incomplete data acquisition and inadequate data handover are common. To resolve these deficits, the IDF-MC launched the BladeShield 101 project.

Objectives: To assess the quality of casualty care data acquired by comparing standard paper casualty cards with the BladeShield 101.

Methods: The BladeShield 101 system consists of three components: a patient unit that records vital signs and medical care provided, a medical sensor that transmits to the patient unit, and a ruggedized mobile device that allows providers to access and document information. We compared all trauma registries of casualties treated between September 2019 and June 2020.

Results: The system was applied during the study period on 24 patients. All data were transferred to the military trauma registry within one day, compared to 72% (141/194) with a paper casualty card (P < 0.01). Information regarding treatment time was available in 100% vs. 43% (P < 0.01) of cases and 98% vs. 67% (P < 0.01) of treatments provided were documented comparing BladeShield 101 with paper cards, respectively.

Conclusions: Using an autonomous system to record, view, deliver, and store casualty information may resolve most current information flow deficits. This solution will ultimately significantly improve individual patient care and systematic learning and development processes.

June 2022
Doron Garfinkel MD, and Yuval Levy MD

Background: There has been a rapid increase in vulnerable subpopulations of very old with co-morbidity, dementia, frailty, and limited life expectancy. Being treated by many specialists has led to an epidemic of inappropriate medication use and polypharmacy (IMUP) with negative medical and economic consequences. For most medications there are no evidence-based studies in older people and treatments are based on guidelines proven in much younger/healthier populations.

Objectives: To evaluate whether the benefits of reducing IMUP by poly-de-prescribing (PDP) outweighs the negative outcomes in older people with polypharmacy.

Methods: The Garfinkel method and algorithm were used in older people with polypharmacy (≥ 6 prescription drugs).

Results: We found that in nursing departments, of 331 drugs de-prescribed only 32 (10%) had to be re-administered. Annual mortality and severe complications requiring referral to acute care facility were significantly reduced in PDP (P < 0.002). In community dwelling older people, successful de-prescribing was achieved in 81% with no increase in adverse events or deaths. Those who de-prescribed ≥ 3 prescription drugs showed significantly more improvement in functional and cognitive status, sleep quality, appetite, serious complications, quality of life, and general satisfaction compared to controls who stopped ≤ 2 medications (P < 0.002). Rates of hospitalization and mortality were comparable. Clinical improvement by polydeprescribing was usually evident within 3 months and persisted for several years. The main barrier to polydeprescribing was physician’s unwillingness to deprescribe (P < 0.0001)

Conclusions: Applying the Garfinkel method of PDP may improve the lives of older people and save money.

May 2022
Moria Mahanaimy MD MPH, Uriah Finkel MA, Noam Barda MD PhD, Eytan Roitman MD, Ran Balicer MD PhD MPH, Adi Berliner Senderey MSc MPH, and Becca Feldman ScD

Background: The association between use of renin-angiotensin-aldosterone (RAAS) inhibitors and both SARS-CoV-2 infection and the development of severe COVID-19 has been presented in the recent medical literature with inconsistent results.

Objectives: To assess the association between RAAS inhibitor use and two outcomes: infection with SARS-CoV-2 (Model 1) and severe COVID-19 among those infected (Model 2).

Methods: We accessed used electronic health records of individuals from Israel who were receiving anti-hypertensive medications for this retrospective study. For Model 1 we used a case-control design. For Model 2 we used a cohort design. In both models, inverse probability weighting adjusted for identified confounders as part of doubly robust outcome regression.

Results: We tested 38,554 individuals for SARS-CoV-2 who had hypertension and were being treated with medication; 691 had a positive test result. Among those with a positive test, 119 developed severe illness. There was no association between RAAS inhibitor use and a positive test. Use of RAAS inhibitors was associated with a decreased risk for severe COVID-19 (adjusted odds ratio [OR] 0.47, 95% confidence interval [95%CI] 0.29–0.77) compared with users of non-RAAS anti-hypertensive medication. The association remained significant when use of angiotensin-converting-enzyme inhibitors (adjusted OR 0.46, 95%CI 0.27–0.77) and angiotensin II receptor blockers (adjusted OR 0.39, 95%CI 0.16–0.95) were analyzed separately.

Conclusions: Among individuals with hypertension using RAAS inhibitors, we found a lower risk of severe disease compared to those using non-RAAS anti-hypertensive medications. This finding suggests that RAAS inhibitors may have a protective effect on COVID-19 severity among individuals with medically treated hypertension.

April 2022
Ilan Merdler MD MHA, Shir Frydman MD, Svetlana Sirota MSc, Amir Halkin MD, Arie Steinvil MD, Ella Toledano MD, Maayan Konigstein MD, Batia Litmanowicz MD, Samuel Bazan MD, Atalia Wenkert BA, Sapir Sadon BA, Shmuel Banai MD, Ariel Finkelstein MD, and Yaron Arbel MD

Background: Neutrophil-to-lymphocyte ratio (NLR) is a simple and cost-effective marker of inflammation. This marker has been shown to predict cardiac arrhythmias, progression of valvular heart disease, congestive heart failure decompensation, acute kidney injury, and mortality in cardiovascular patients. The pathologic process of aortic stenosis includes chronic inflammation of the valve and therefore biomarkers of inflammation might offer additive prognostic value.

Objectives: To evaluate NLR and its association with long term mortality in transcatheter aortic valve implantation (TAVI) patients.

Methods: We evaluated data of 1152 consecutive patient from the Tel Aviv Medical Center TAVI registry who underwent TAVI. Data included baseline clinical, demographic, and echocardiographic findings; procedural complications; and post-procedure mortality. Patients were compared by using the median NLR value (4.1) and evaluated for long-term mortality.

Results: Patients with NLR above the median had higher mortality rates (26.4% vs. 16.3%, P < 0.001) at 3 years post-procedure. A multivariable analysis found NLR to be an independent risk factor for mortality (hazard ratio = 1.47, 95% confidence interval 1.09–1.99, P = 0.013). In addition, high NLR was linked to complicationsduring and after the procedure.

Conclusion: NLR is an independent prognostic marker among TAVI patients. This marker may represent an increased inflammatory response and should be added to previous known prognostic factors.

January 2022
Ron Skorochod B MED Sc, Daniel Fink MD, Victoria Doviner MD, and Gideon Nesher MD
May 2021
Naama Bursztyn MD, Tomer Arad MD, Tamar Fink RN, Jonathan Cohen MD, and Michael Stein MD

Background: Consent rates for organ donation remain one of the most important factors determining the number of organs available for transplantation. Trauma casualties constitute a substantial part of the deceased organ donor pool and have unique characteristics that distinguish them from the general donor population. However, this group has not been extensively studied.

Objectives: To identify donor factors associated with positive familial consent for solid organ donation among trauma casualties.

Methods: This retrospective study included all trauma casualties who were admitted to the Rabin Medical Center, Beilinson hospital, during the period from January 2008 to December 2017, who were potential organ donors. Data collected included demographic features, the nature of the injury, surgical interventions, and which organs were donated. Data was collected from the Rabin Medical Center Trauma Registry.

Results: During the study period 24,504 trauma patients were admitted and 556 died over their hospital course. Of these 76 were potential donors, of whom 32 became actual donors and donated their organs. Two factors showed a statistically significant correlation to donation, namely female gender (P = 0.018) and Jewish religion of the deceased (P = 0.032).

Conclusions: Only a small group of in hospital trauma deaths were potential solid organ donors (13.7%) and less than half of these became actual donors. Consent rates were higher when the deceased was female or Jewish

January 2020
Elizabeth Dudnik MD, Aaron M. Allen MD, Natalia Michaeli MD, Aleksandra Benouaich-Amiel MD, Tzippy Shochat, Nir Peled MD PhD FCCP, Inbar Finkel MD, Alona Zer MD, Ofer Rotem MD and Shlomit Yust-Katz MD

Background: Prophylactic cranial irradiation (PCI) exclusion in favor of brain magnetic resonance imaging (MRI) staging and surveillance in the management of small cell lung cancer (SCLC) is controversial yet accepted by some centers. The use of MRI suggests performing stereotactic radiosurgery (SRS) treatment for limited brain metastases. Data regarding SRS efficacy in this setting is limited.

Objectives: To assess intracranial objective response rate (iORR), progression-free survival (iPFS), intracranial failure patterns, overall survival (OS) and time-to-whole-brain radiation therapy (WBRT)/death, whichever occurred first (TTWD) with SRS in SCLC.

Methods: The study comprised 10 consecutive SCLC patients with brain metastases treated with SRS and followed-up at Davidoff Cancer center between Aug 2012 and March 2019. Brain MRI images were reviewed by a neuro-radiology specialist.

Results: iORR was 57% as assessed by response assessment in neuro-oncology brain metastases. Intracranial progression developed in 8 patients. Median iPFS was 4.0 months (95% confidence interval [95%CI] 1.7–7.2). In-site, off-site and combined pattern of intracranial failure was seen in 0, 5, and 3 patients, respectively; median number of new brain lesions following SRS was 4 (range, 1–12). SRS was performed 10 additional times in 6 patients (median number of lesions irradiated per round was 1, range 1–5). WBRT was administered in 3 patients. Median TTWD was 20.9 months (95% CI, 1.9–26.8). Median OS since SRS administration was 23.2 months (95% CI, 4.2–not reached).

Conclusions: MRI surveillance with multiple rounds of SRS may serve a reasonable alternative to PCI or therapeutic WBRT in SCLC. 

December 2019
Oholi Tovia-Brodie MD, Sevan Letourneau-Shesaf MD, Aviram Hochstadt MD, Arie Steinvil MD, Raphael Rosso MD, Ariel Finkelstein MD and Yoav Michowitz MD

Background: Patients with right bundle branch block (RBBB) prior to transcatheter aortic valve implantation (TAVI) are at high risk for immediate post-procedural heart block and long-term mortality when discharged without a pacemaker.

Objectives: To test whether prophylactic permanent pacemaker implantation (PPI) is beneficial.

Methods: Of 795 consecutive patients who underwent TAVI, 90 patients had baseline RBBB. We compared characteristics and outcomes of the prophylactic PPI with post-TAVI PPI. Need for pacing was defined as  greater than 1% ventricular pacing.

Results: Forty patients with RBBB received a prophylactic PPI (group 1), and in 50 the decision was based on standard post-procedural indications (group 2). There were no significant differences in clinical baseline characteristics. One patient developed a tamponade after a PPI post-TAVI. A trend toward shorter hospitalization duration in group 1 patients was observed (P = 0.06). On long-term follow-up of 848 ± 56 days, no differences were found in overall survival (P = 0.77), the composite event-free survival of both mortality and hospitalizations (P = 0.66), or mortality and syncope (P = 0.65). On multivariate analysis, independent predictors of the need for pacing included baseline PR interval increase of 10ms (odds ratio [OR] 1.21 per 10 ms increment 95% confidence interval [95%CI] 1.02–1.44, P = 0.028), and the use of new generation valves (OR 3.92, 95%CI 1.23–12.46, P = 0.023).

Conclusions: In patients with baseline pre-TAVI RBBB, no outcome differences were found with prophylactic PPI. On multivariate analysis, predictors of the need for pacing included baseline long PR interval, and the use of newer generation valves.

April 2018
Vitaly Finkelshtein MD, Yair Lampl MD, Mordechai Lorberboym MD, Andrew Kanner MD, Dominique Ben-Ami Raichman MD, Ron Dabby MD and Amir Tanay MD
March 2017
Uri Landes MD, Arthur Kerner MD, Amit Segev MD, Haim Danenberg MD, Yaron Shapira MD, Ariel Finkelstein MD and Ran Kornowski MD FESC FACC

Background: Transcatheter tricuspid valve-in-valve implantation (TVIV) is an attractive yet under-explored alternative to redo valve surgery. 

Objectives: To report the multicenter TVIV experience in Israel.

Methods: We approached multiple centers and collected data regarding seven TVIV cases. 

Results: The study group comprised seven participants: five females and two males, with a mean age of 63 ± 12 years and EuroSCORE-II 13.6 ± 3.3%. Follow-up ranged from 3 to 21 months (mean 8 ± 6 months). All presented with advanced heart failure. The indication for valve intervention was a predominant tricuspid stenosis in three patients, significant tricuspid regurgitation in one and a mixture in three. Six procedures were conducted via a transfemoral approach and one by transatrial access. The Edwards SAPIENTM XT valve was used in four cases and the SAPIENTM 3 in three. Without pre-stenting/rapid pacing, all participants underwent successful valve implantation. Mean transvalvular gradient decreased from 11 ± 3 mmHg to 6 ± 3 mmHg (P = 0.003) and regurgitation decreased from moderate/severe (in four cases) to none/trace (in six of the seven cases). One patient remained severely symptomatic and died 3.5 months after the implantation. All others achieved a functional capacity improvement and amelioration of symptoms soon after the implantation, which persisted during follow-up. 

Conclusions: TVIV may be a safe and effective strategy to treat carefully selected patients with degenerated bioprosthetic tricuspid valve at high operative risk. 

 

December 2016
Noam Behr MD, Evan A. Alpert MD, Shuli Silberman MD and Daniel Fink MD
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