Israel Medical Association Journal

Background: The number of patients treated with intravitreal injections has increased significantly over the past few years, mainly following the introduction of anti-vascular endothelial growth factor antibody intraocular medications. Bevacizumab is mostly used in this group of medications.

Objectives: To describe persistent elevation of intraocular pressure (IOP) following intravitreal injection of bevacizumab.

Methods: We reviewed consecutive cases of persistent IOP elevation after intravitreal bevacizumab injection for exudative age-related macular degeneration (AMD). A total of 424 patients (528 eyes) met the inclusion criteria and received 1796 intravitreal injections of bevacizumab. Persistent IOP elevation was found in 19 eyes (3.6%, 19/528) of 18 patients (4.2%, 18/424) with IOP elevated 30–70 mmHg, 3–30 days after injection.

Results: Mean IOP was 42.6 mmHg (range 30–70); IOP elevations occurred after an average of 7.8 injections of bevacizumab (range 3–13). Injected eyes (19/528) had a significantly higher incidence of elevated IOP than uninjected eyes (fellow eyes), 1/328, P < 0.001.

 Conclusions: Like other anti-vascular endothelial growth factor (VEGF) substances reported in a few recent studies, intravitreal injection of bevacizumab for neovascular AMD may be associated with persistent IOP elevation. Providers should be aware that significant IOP elevation might occur after repeated treatments. 

Objectives: To investigate the predictive value of BNP levels regarding the severity of the postoperative course in infants undergoing surgical repair of congenital heart disease.

Methods: We conducted a prospective comparative study. Plasma BNP levels in infants aged 1–12 months with congenital heart disease undergoing complete repair were measured preoperatively and 8, 24 and 48 hours postoperatively. Demographic and clinical data included postoperative inotropic support and lactate level, duration of mechanical ventilation, intensive care unit (ICU) and hospitalization stay.

Results: Cardiac surgery was performed in 19 infants aged 1-12 months. Preoperative BNP level above 170 pg/ml had a positive predictive value of 100% for inotropic score ≥ 7.5 at 24 hours (specificity 100%, sensitivity 57%) and 48 hours (specificity 100%, sensitivity 100%), and was associated with longer ICU stay (P = 0.05) and a trend for longer mechanical ventilation (P = 0.12). Similar findings were found for 8 hours postoperative BNP above 1720 pg/ml. BNP level did not correlate with measured fractional shortening.

Conclusions: In infants undergoing heart surgery, preoperative and 8 hour BNP levels were predictive of inotropic support and longer ICU stay. These findings may have implications for preplanning ICU loads in clinical practice. Further studies with larger samples are needed.

Objectives: To evaluate common misinterpretations of head CT scans by radiology residents in a level I trauma center ED.

Methods: We studied 960 head CT scans of patients admitted to our ED from January 2010 to May 2011. They were reviewed separately by two senior neuroradiologists and graded as being unimportant (score of 1), important but not requiring emergent treatment (score of 2), and important requiring urgent treatment (score of 3). We recorded the time of day the examination was performed, the year of residency, the site, subsite and side of the lesion, the pathology, the anatomical mistake, false-positive findings, and the attending neuroradiologists' score.

Results: A total of 955 examinations were interpreted of which 398 had misinterpreted findings that were entered into the database, with the possibility of multiple errors per examination. The overall misinterpretation rate was 41%. The most commonly missed pathologies were chronic infarcts, hypodense lesions, and mucosal thickening in the paranasal sinuses. The most common sites for misdiagnosis were brain lobes, sinuses and deep brain structures. The highest percentage of misinterpretation occurred between 14:30 and 20:00, and the lowest between 00:00 and 08:00 (P < 0.05). The overall percentage of errors involving pathologies with a score of 3 by at least one of the neuroradiologists was 4.7%. Third-year residents had an overall higher error rate and first-year residents had significantly more false-positive misinterpretations compared to the other residents.

Conclusions: The percentage of errors made by our residents in cases that required urgent treatment was comparable to the published data. We believe that the intense workload of radiology residents contributes to their misinterpretation of head CT findings.

Objectives: To describe and identify clinical characteristics, prognostic factors and visual outcome in a group of patients with OGI in southern Israel.

Methods: We conducted a retrospective review of all cases of OGI examined in the ophthalmology department at Soroka University Medical Center, Beer Sheva, Israel, from 1996 to 2005. A total of 118 eyes with OGI were detected and analyzed statistically. We recorded demographic data, cause of injury, initial visual acuity (VA), associated globe morbidity and injuries, Ocular Trauma Score (OTS), surgical procedures, postoperative complications, and final VA.

Results: The mean age of the study group was 36.1 years and included 84% males. The median follow-up was 13.3 months (range 6–66 months). The annual incidence of open globe injuries was 3.1 cases/100,000. In 84 cases (71%) the mechanism of open eye injury was laceration. Most of the injuries were work related (45%). Bilateral injury was observed in two patients. An intraocular foreign body was observed in 45 eyes (38%). Primary surgical repair was performed in 114 eyes. Six patients (5.1%) had complications with post-traumatic endophthalmitis and 12 patients (10.1%) underwent evisceration or enucleation. Clinical signs associated with poor visual outcomes included reduced initial VA, eyelid injury, and retinal detachment at presentation.

Conclusions: In our study population the most important prognostic factors in open globe injury were initial VA, eyelid injury and retinal detachment.

Objectives: To assess the reasons given by gynecologists why they failed to insert a LNG-IUS.

Methods: We obtained data from the sole distributor in Israel that prospectively recorded these cases when contacted by gynecologists following an insertion failure.

Results: The mean rate of failed insertions was 0.95% (range 0.77–1.03%) for the 5 year study period 2006–2010. The most common reasons reported by gynecologists for LNG-IUS insertion failure were loss of sterility of the device, inability to insert the device due to a stenotic cervical canal, accidental removal of the device following a successful insertion due to hasty removal of the inserter or the use of blunt scissors, and removal of the newly inserted LNG-IUS following ultrasound evidence that it was misplaced.

Conclusions:  Gynecologists should be aware of the common pitfalls associated with insertion of an LNG-IUS. Several techniques that may aid in avoiding these mishaps are described.

 Background: Hemorrhagic radiation cystitis (HRC) is a significant clinical problem that occurs after pelvic radiation therapy and is often refractory.

Objectives: To evaluate the efficacy and safety of hyperbaric oxygen therapy (HBO) for HRC.

Methods: Daily 90 minute sessions of HBO at 2 ATM 100% oxygen were given to 32 HRC patients with American Society of Therapeutic Radiology and Oncology (ASTRO) grades 3-4 hematuria.

Results: The median age was 72.5 (48–88 years). The median time interval between radiation therapy and HBO was 4 years (1–26 years). The patients received a median of 30 HBO sessions (3–53). Hematuria resolved in 27 patients (84%) and persisted in 5. Cystectomy was required in two, and ileal-conduit and bilateral percutaneous nephrostomies were performed in one and two patients, respectively. With a median follow-up of 12 months (5–74 months), the hematuria cleared completely in 16 patients (59%) and mild hematuria requiring no further treatment recurred in 10 others. Another patient with ASTRO grade 4 hematuria needed bladder irrigation and blood transfusions. Complications included eardrum perforation in four patients and transient vertigo and mild hemoptysis in one case each. None of them required HBO discontinuation.

Conclusions: HBO controlled bleeding in 84% of the patients. A durable freedom from significant hematuria was achieved in 96% of the patients. HBO seems to be an effective and safe modality in patients with HRC.

Objectives: To determine the effect of the Dead Sea climatotherapy on the quality of life of patients with psoriasis vulgaris and psoriatic arthritis.

Methods: A total of 119 patients participated in an observational prospective study carried out at the Deutsches Medizinisches Zentrum clinic, a medical skin care center specializing in climatotherapy. The patients completed questionnaires (Skindex-29) to quantify their quality of life at different time points: the day of arrival, the day of departure, and 3 and 6 months after the end of treatment.

Results: Marked improvement in the quality of life scores was measured between the time of arrival to time of departure and to 3 months after the end of treatment.

Conclusions: Dead Sea climatotherapy has a significant positive influence on the quality of life of patients with psoriasis vulgaris and psoriatic arthritis.

Background: Takayasu arteritis (TA) is a rare chronic granulomatous inflammatory disease of the aorta and/or its major branches and more frequently affects female patients before menopause. Since persistent inflammation may lead to arterial ischemia, hypertension is an important complication of TA. Objectives: To evaluate gestational results and complications in patients with TA arteritis.

Methods: We conducted a retrospective analysis of the medical records of patients with TA admitted to the high risk pregnancy clinic for women with systemic autoimmune diseases at Hospital Universitário Pedro Ernesto.

Results: From 1998 to 2011 we followed 11 pregnancies in 9 patients with TA; the patients’ age ranged from 17 to 42 years and disease duration from 2 to 28 years. In 7 of the 11 pregnancies, uncontrolled blood pressure occurred before labor and preeclampsia was diagnosed in one. Two deliveries were preterm, one newborn was treated for sepsis and four (36%) had intrauterine growth restriction (IUGR).

Conclusions: Close monitoring improves the perinatal outcomes in patients with TA who are more prone to develop hypertension, preeclampsia and IUGR. Disease activity was not observed in our group of patients during pregnancy. Coordinated care between the obstetric, rheumatologic and cardiologic teams is the ideal setting to follow pregnant women with TA.

Background: Despite decades of research on religious determinants of health, this subject has not been systematically investigated within Jewish populations, in Israel or the diaspora. The present paper is part of a series of studies using large-scale population data sources to map the impact of religiousness on the physical and mental health of Jews.

Objectives: To identify religious predictors of physical health in a national probability sample of older Israeli Jews.

Methods: The data derive from the Israeli sample of the Survey of Health, Ageing and Retirement in Europe (SHARE), a cross-national survey program involving nearly a dozen nations. The Israeli sample comprises 1287 Jewish respondents aged 50 or over. Outcome measures include single-item assessments of self-rated health, long-term health problems and activity limitation, as well as validated measures of diagnosed chronic diseases, physical symptoms, and activities of daily living (ADL) and instrumental ADL (IADL).

Results: Recent synagogue attendance is a significant predictor of better health for six of the seven health measures, even after adjusting for age and several other covariates and mediators, including measures of health-related behavior and social support. Prayer, by contrast, is inversely associated with health according to five measures, perhaps reflecting its use as a coping mechanism for individuals with health problems.

Conclusions: This study presents modest evidence of a salutary effect of Jewish religiousness on this population of older adults. Religiousness, in the form of synagogue participation, was seen to serve a protective function, and prayer a coping function.

Background: Atherosclerosis is a well-established inflammatory disease in which T helper 1 (Th1) cells play a key role. Regulatory T (Treg) cells drive a shift from Th1 to Th2 response and were shown to be reduced in atherosclerosis. ST2/interleukin (IL)-33 signal was found to promote Th2 response, attenuating atherosclerotic plaque progression.

Objectives: To evaluated the effect of IL-33 on Treg cell number.

Methods: We employed flow cytometry to determine Treg cell number, as well as ST2 levels, among splenocytes of C57BL/6J vs ApoE-/- mice. Soluble ST2 (sST2) levels were detected by enzyme-linked immunosorbent assay. 

Results: IL-33 contributed to an increase in Treg cells, but this association was attenuated in ApoE knockout (ApoE-/-) atherosclerotic mice. As a possible mechanism we demonstrated a reduction in the levels of CD4+ST2+ cells by flow cytometry, which is cotemporary to the previously described decrease in Treg cells in ApoE-/- mice. Additionally, the serum level of the soluble ST2 (sST2) decoy receptor was higher in ApoE-/- mice than in control animals.

Conclusions: Our results suggest that a repressed ST2/IL-33 signaling may contribute to the decrease in Treg cells observed in atherosclerosis.