Israel Medical Association Journal

Background: At the beginning of the coronavirus disease 2019 (COVID-19) pandemic, many patients presented with acute hypoxemic respiratory failure, requiring ventilatory support. One treatment method was the addition of a reservoir mask to a high flow nasal cannula (HFNC) (dual oxygenation).

Objectives: To evaluate the clinical outcomes of combining reservoir mask on top of a high-flow nasal cannula.

Methods: A retrospective cohort of adult patients who were admitted due to COVID-19 during the first year of the pandemic to Rambam Health Care Campus. The primary endpoint was 30-day mortality. Secondary endpoints were incidence of invasive positive pressure ventilation initiation and admission to the intensive care unit (ICU). Patients who received positive pressure ventilation for reasons other than hypoxemic respiratory failure or who were transferred to another facility while still on HFNC were excluded.

Results: The final analysis included 333 patients; 166 were treated with dual oxygenation and 167 with HFNC only (controls). No significant differences in baseline characteristics were noted between the groups. The dual oxygenation group was slightly older (69.2 ± 14.8 years vs. 65.6 ± 15.5 years, P = 0.034). The 30-day mortality (24.1% vs. 36.5%, P = 0.013), rates of invasive positive pressure ventilation (47% vs. 59.3%, P = 0.024), and ICU admissions (41.6% vs. 52.7%, P = 0.042) were all significantly lower in the dual oxygenation group.

Conclusions: The addition of reservoir masks to HFNC may improve the oxygenation and overall prognosis in patients with severe hypoxemia due to COVID-19.

Background: The growing popularity of trampoline jumping in the past years has led to an increase in trampoline-related injuries. The risk is particularly high in large trampoline parks, which are attended by many individuals of various sizes and ages.

Objective: To describe a tertiary pediatric center experience in Israel.

Methods: The database of a tertiary pediatric medical center was retrospectively reviewed for all trampoline-associated admissions to the emergency department in 2015–2018. Data were collected on patient demographics and injury characteristics with an emphasis on type and venue.

Results: Of the 23,248 admissions for orthopedic trauma during the period, 244 children were admitted for 246 trampoline-related injuries. Injuries involved the lower limb in 130 children (53%), upper limb in 87 (36%), spine in 20 (8%), and other sites in 9 (3%). Almost half of the injuries (113/246, 46%) were fractures, 27% required either closed or open reduction in the operating room. Large trampoline centers were responsible for half of the cases.

Conclusions: Trampoline injuries accounted for 1.05% of all emergency department admissions at a tertiary pediatric hospital in 2015–2018. Nearly half of the trampoline-related injuries were fractures. Large trampoline centers pose a potential risk for more serious injuries. We raise awareness of the risks of trampoline jumping, considering increasing popularity of trampoline parks, and encourage the authorities to implement safety regulations.

Background: Handheld ultrasound devices present an opportunity for prehospital sonographic assessment of trauma, even in the hands of novice operators commonly found in military, maritime, or other austere environments. However, the reliability of such point-of-care ultrasound (POCUS) examinations by novices is rightly questioned. A common strategy being examined to mitigate this reliability gap is remote mentoring by an expert.

Objectives: To assess the feasibility of utilizing POCUS in the hands of novice military or civilian emergency medicine service (EMS) providers, with and without the use of telementoring. To assess the mitigating or exacerbating effect telementoring may have on operator stress.

Methods: Thirty-seven inexperienced physicians and EMTs serving as first responders in military or civilian EMS were randomized to receive or not receive telementoring during three POCUS trials: live model, Simbionix trainer, and jugular phantom. Salivary cortisol was obtained before and after the trial. Heart rate variability monitoring was performed throughout the trial.

Results: There were no significant differences in clinical performance between the two groups. Iatrogenic complications of jugular venous catheterization were reduced by 26% in the telementored group (P < 0.001). Salivary cortisol levels dropped by 39% (P < 0.001) in the telementored group. Heart rate variability data also suggested mitigation of stress.

Conclusions: Telementoring of POCUS tasks was not found to improve performance by novices, but findings suggest that it may mitigate caregiver stress.

Background: Kidney transplantation is associated with early improvement in cardiac function and structure; however, data on cardiac adaptation and its relation to kidney allograft function remain sparse.

Objectives: To investigate the relationship between post-transplant kidney function and echocardiographic measures in patients with normal/preserved pre-transplant cardiac structure and function.

Methods: The study included 113 patients who underwent kidney transplantation at a single tertiary medical center from 2000 to 2012. The patients were evaluated by echocardiography before and after transplantation, and the relation between allograft function and echocardiographic changes was evaluated. Echocardiography was performed at a median of 510 days after transplantation.

Results: The post-transplantation estimated glomerular filtration rate (eGFR) was directly correlated with left ventricular (LV) systolic function and inversely correlated with LV dimensions, LV wall thickness, left atrial diameter, and estimated systolic pulmonary arterial pressure. In patients with significant allograft dysfunction (eGFR ≤ 45 ml/min), LV hypertrophy worsened, with no improvement in LV dimensions. In contrast, in patients with preserved kidney function, there was a significant reduction in both LV diameter and arterial pulmonary systolic pressure.

Conclusions: Our results show that in kidney transplant recipients, allograft function significantly affects cardiac structure and function. Periodic echocardiographic follow-up is advisable, especially in patients with kidney graft dysfunction.

Background: In recent years cardioversion of atrial fibrillation has become a routine procedure, enabling symptomatic functional improvement in most cases. However, some patients develop complications after cardioversion. Identifying these individuals is an important step toward improving patient outcome.

Objectives: To characterize those patients who may not benefit from cardioversion or who may develop complications following cardioversion.

Methods: We retrospectively analyzed 186 episodes of cardioversion in 163 patients with atrial fibrillation who were admitted to our cardiology department between 2008 and 2013 based on their clinical and echocardiographic data. Patients were divided into two groups: those with uncomplicated cardioversion, and those who developed complications after cardioversion.

Results: Of the 186 episodes, cardioversion was done in 112 men (60%) and 74 women (40%), P < 0.00001. Complications after cardioversion occurred in 25 patients (13%). These patients were generally older (72 vs. 65 years, P < 0.01), were more often diabetic (52% vs. 27%, P = 0.005), had undergone emergency cardioversion (64% vs. 40%, P = 0.01), had left ventricular hypertrophy (left ventricular mass 260 vs. 218 g, P = 0.01), had larger left atrium (left atrial volume 128 vs. 102 ml, P < 0.009), and more often died from complications of cardioversion (48% vs. 16%). They had significant mitral regurgitation (20% vs. 4%, P = 0.03) and higher pulmonary artery pressure (50 vs. 42 mm Hg, P < 0.02).

Conclusions: People with complications after cardioversion tend to be older, are more often diabetic and more often have severe mitral regurgitation. In these patients, the decision to perform cardioversion should consider the possibility of complications.

Background: Prophylaxis for hospitalized venous-thromboembolic events (VTEs) is frequently underutilized, in part due to lack of a simple risk assessment model (RAM). 

Objectives: To compare patient selection and administration of VTE prophylaxis according to the American College of Chest Physicians (ACCP) 2008 guidelines versus the newer 2012 guidelines, and assess the feasibility of developing simpler local RAMs.

Methods: We conducted a prospective assessment of VTE risk among 300 unselected consecutive patients admitted to a medical hospital ward, using the 2008 and 2012 ACCP guidelines. The frequency and relative weight of each risk factor in the 2012 ACCP guidelines were used to develop a local VTE RAM.

Results: VTE prophylaxis was indicated by the 2008 and 2012 ACCP guidelines in 40% and 42% of the cohort respectively, and was administered in 28% and 26% of eligible patients, respectively. Contraindication to VTE prophylaxis was found in 29% of patients according to both guidelines. In comparison to the 2008 guidelines, sensitivity and specificity of the 2012 guidelines were 96% and 88%, respectively. A local RAM based on the following concise score, comprising age, malignancy and immobility, correctly identified 99% of at-risk patients based on the 2012 guidelines, with a sensitivity and specificity of 98% and 95%, respectively.

Conclusions: Both guidelines performed to a similar degree and were poorly implemented in daily practice. A simplified RAM accurately identified the vast majority of these eligible patients. The development of local RAMs is feasible and may result in higher utilization rates.

 

Background: Brief episodes of atrial tachycardia are a common finding in the Holter monitor recordings of elderly patients. Episodes of atrial tachycardia may convert to atrial fibrillation. Current guidelines do not recommend anticoagulant therapy in patients with atrial tachycardia and risk factors for embolism. 

Objectives: To assess the incidence of atrial tachycardia in a 24 hour Holter monitor recording of patients admitted to hospital with ischemic stroke. 

Methods: The patient cohort included two groups: 134 patients admitted with a diagnosis of ischemic stroke (the study group), and 68 consecutive patients admitted with a diagnosis of syncope (the control group). Both groups used a Holter monitor.

Results: There was no difference in the incidence of atrial tachycardia runs between the groups. Patients who suffered a stroke were more likely to be hypertensive (P < 0.05) and more likely to have a CHA2DS2-VASc score of ≥ 3 (P = 0.05).

Conclusions: Atrial tachycardia as recorded on a Holter monitor was not more prevalent in patients presenting with ischemic stroke. The occurrence of atrial tachycardia is not an indication for systemic anticoagulation. 

 

Background: Sudden death in athletes can occur during sport activities and is presumably related to ventricular arrhythmias.

Objectives: To investigate the long-term follow-up of athletes with ventricular arrhythmias during an exercise test.

Methods: From a database of 56,462 athletes we identified 192 athletes < 35 years old who had ventricular arrhythmias during an exercise test. Ninety athletes had ≥ 3 ventricular premature beats (VPB) (group A) and 102 athletes had ventricular couplets or non-sustained ventricular tachycardia (NSVT) during an exercise test (group B). A control group of 92 athletes without ventricular arrhythmias was randomly selected from the database (group C). Of the 192 athletes 39 returned for a repeat exercise test after a mean follow-up period of 70 ± 25 months and they constitute the study population.

Results: Twelve athletes from group A, 21 from group B and 6 from group C returned for a repeat exercise test. The athletes reached a significantly lower peak heart rate during their follow-up exercise test (P = 0.001). More athletes were engaged in competitive sports during their initial exercise test than in the follow-up test (P = 0.021). Most of the athletes who had VPB and/or ventricular couplets and/or NSVT during their initial exercise test had far fewer ventricular arrhythmias in the follow-up exercise test (P = 0.001).

Conclusions: Athletes engaged in competitive sports are more likely to develop ventricular arrhythmias during exercise. These arrhythmias subside over time when athletes are engaged in non-competitive sports. 

Background: Microvolt T-wave alternans (MTWA) measures subtle beat-to-beat fluctuations in the T-wave amplitude. It was found to be associated with cardiac electrical instability in patients with ischemic and dilated cardiomyopathy.

Objectives: To investigate the reproducibility of the MTWA test results in patients with ischemic heart disease.

Methods: The study group comprised patients with ischemic heart disease who participated in a rehabilitation program at the Assaf Harofeh Medical Center. MTWA was measured during a bicycle exercise test at the first encounter and repeated after one week.

Results: Of the 40 study patients with coronary artery disease, 4 had an indeterminate result and were excluded from the data analysis; 5 had a positive MTWA in the first and second study (14%), 27 had a negative MTWA in the first and second study (75%), and 4 had a negative MTWA in the first study and a positive MTWA in the second study (11%). Overall, there was a correlation between the results of the first and the second study in 89% of the patients (kappa = 0.652, P = 0.0001).

Conclusions: MTWA measurements are reproducible in the short term in patients with coronary artery disease.

Background: Sudden death in athletes can occur during sport activities and is presumably related to ventricular arrhythmias. There are no guidelines concerning athletes who develop ventricular arrhythmias during an exercise test. It is unclear whether they should be allowed to continue with their competitive activity or not.

Objectives: To investigate the long-term follow-up of athletes with ventricular arrhythmias during an exercise test.

Methods: From a database of 56,462 athletes we identified 192 athletes, less than 35 years old, who had ventricular arrhythmias during an exercise test. Ninety athletes had ≥ 3 ventricular premature beats (group A) and 102 athletes had ventricular couplets or non-sustained ventricular tachycardia during an exercise test (group B). A control group of 92 athletes without ventricular arrhythmias was randomly selected from the database (group C).

Results: All athletes, except one who died from a dilated cardiomyopathy, were alive during a follow-up period of 70 ± 25 months. An abnormal echocardiogram was obtained in seven athletes from group A (10%), four from group B (5%), and one from group C (3%) (not significant). An abnormal echocardiogram was more likely to be present in competitive athletes (P = 0.001) and in female athletes (P = 0.01).

Conclusions: Our results showed that ventricular arrhythmias during exercise are more commonly associated with cardiovascular abnormalities in young competitive athletes and in female athletes. When present, they necessitate a thorough investigation and follow-up.