Israel Medical Association Journal

Background: During Operation Roaring Lion, Carmel Medical Center, a 500-bed tertiary hospital, relocated nearly half of its inpatient activity to the fortified underground facility of Rambam Health Care Campus while maintaining independent clinical and managerial responsibility. Returning patients after hostilities subsided represented a complex organizational transition requiring preservation of patient safety and continuity of care.

Objectives: To describe a multidisciplinary operational leadership model and evaluate the use of failure mode and effects analysis (FMEA) to support safe wartime hospital relocation.

Methods: A prospective quality improvement study used multidisciplinary FMEA before patient relocation. The relocation pathway was divided into four phases, and potential failure modes were scored by severity, occurrence, and detectability to prioritize mitigation strategies. Interventions included centralized command, real-time patient tracking, structured clinical handoffs, standardized transfer checklists, medication reconciliation, risk stratification, and enhanced post-transfer monitoring. Outcomes included patient safety events, falls, resuscitation events, unplanned intensive care unit (ICU) admissions within 24 hours, multidrug-resistant organism (MDRO) cross-transmission, and departmental feedback.

Results: During 55 days of wartime activity, 843 patients were hospitalized in the underground facility. In total, 84 medically complex patients were relocated in three operational waves. The highest-risk domains involved communication, documentation, operational coordination, staffing, and clinical monitoring. No predefined patient safety events, falls, resuscitation events, unplanned ICU admissions within 24 hours, or documented MDRO cross-transmission were identified. Department leaders reported high organizational preparedness and improved operational control.

Conclusions: A multidisciplinary operational leadership model integrating proactive FMEA enabled coordinated management of clinical, informational, operational, and infection-related risks during complex wartime hospital relocation.

Background: Greater occipital nerve (GON) blocks are used in migraine management. While ultrasound-guided proximal GON blocks at the C2 level (GONC2) have been suggested to provide more sustained benefit, distal landmark-guided GON blocks are used due to their simplicity and accessibility.

Objectives: To evaluate distal GON blocks as an initial procedural approach for migraine; to assess the effect of subsequent proximal GONC2 blocks in patients who did not respond to an initial distal block.

Methods: We conducted a retrospective cohort study of adult migraine patients treated at a tertiary pain clinic between May 2022 and July 2023. Patients received either distal landmark-guided GON blocks or ultrasound-guided proximal GONC2 blocks as part of routine clinical care. Monthly migraine days (MMD) were assessed at baseline, 1 month, and 3 months following treatment.

Results: The cohort included 54 patients (27 distal, 27 GONC2). Baseline characteristics were comparable between groups. A significant overall effect of time on MMD was observed (P = 0.017). In the distal group, MMD decreased significantly at 1 month (P < 0.001) but not at 3 months. In the GONC2 group, MMD decreased significantly at both 1 month (P < 0.001) and 3 months (P = 0.001). No significant between-group differences were found at 1 month (P = 0.142) or 3 months (P = 0.509).

Conclusions: Distal GON blocks provide meaningful short-term reduction in migraine frequency and represent an effective, accessible initial interventional option. Proximal GONC2 blocks demonstrate sustained benefit and may be considered in selected patients. These findings support a pragmatic, stepwise approach to procedural migraine management.

Gallstone ileus is an uncommon complication of cholelithiasis. It accounts for less than 1–4% of all small bowel obstructions [1]. The condition involves the passage of a gallstone into the gastrointestinal tract through a biliary-enteric fistula, often resulting in obstruction at the ileum or, less commonly, the duodenum. This condition is known as Bouveret syndrome [1]. Management can be surgical (gastrotomy, intragastric laparoscopy, pyloromyotomy, duodenotomy, enterotomy) or endoscopic (removal with nets/baskets, electrohydraulic lithotripsy [EHL], extracorporeal shockwave lithotripsy [ESWL]). Endoscopic management is preferred due to its lower morbidity and mortality rates [2,3].

Patient Safety and Risk Management in Medicine: From Theory to Practice by Yaron Niv and Yossi Tal, published in 2023 by Springer Nature, is a comprehensive and timely resource dedicated to the theory and practical aspects of patient safety and risk management and focusing on the systemic approach to minimizing harm in healthcare settings.

In 1999, the U.S. Institute of Medicine (IOM) declared that rather than assigning blame for medical errors, professional investigations should be conducted to identify what caused them and how to prevent similar events from occurring in the future. The focus was on systemic factors. It is estimated that in the United States alone, there are between 250,000 and 400,000 preventable deaths annually due to medical errors, costing over US$15 billion per year.

Ossifying fibroma (OF) of the jaws presents as a slow-growing, benign, fibro-osseous lesion that poses a risk for significant local destruction. Effective treatment of OF usually requires wide resection, which may lead to substantial morbidity. There are no alternative treatment options reported to date. Osteoclasts, a type of multinucleate giant cell that expresses receptor activator of nuclear factor-kappa B ligand (RANKL), play a major role in OF pathogenesis as well as in central giant cell granuloma (CGCG). CGCG is currently treated with denosumab, a human monoclonal antibody that inhibits bone lysis by binding to RANKL.

In this study, we assessed whether denosumab could be used to treat OF while avoiding surgery. Denosumab successfully treated an aggressive craniofacial ossifying fibroma, circumventing the need for invasive surgery.

Tracheobronchial injuries (TBI) are rare but potentially fatal complications of blunt thoracic trauma. Recent literature supports conservative management in selected stable cases. In this study, we describe the case of a pediatric patient with a tracheal tear that was managed successfully without surgical intervention.

In hemodynamically stable pediatric patients, even high-grade tracheal injuries may be managed conservatively with close intensive care unit (ICU) monitoring. Early multidisciplinary evaluation is essential.

TBI following blunt trauma is an uncommon but life-threatening condition, particularly in children. Blunt trauma accounts for approximately 94% of TBIs in pediatric cases, in contrast to penetrating trauma which predominates in adults [1]. Management options are typically guided by injury classification, such as the (American Association for the Surgery of Trauma [AAST] Grade III, Cardillo Level IIIA). Non-operative treatment may be appropriate in specific stable cases even in high-grade injuries, as illustrated in former literature [2,3].

Background: Several studies have shown an association between increased red blood cell distribution width (RDW) and adverse outcomes in various acute diseases. Small studies have suggested that RDW is a useful predictor of acute pancreatitis severity.

Objectives: To determine the association between RDW at admission and early mortality in acute pancreatitis. To assess whether RDW adds to the predictive ability of the Glasgow Imrie Score.

Methods: In this observational study, we included all adult patients admitted with a primary diagnosis of acute pancreatitis between January 2008 and June 2021. Patients were divided into two groups according to RDW: normal RDW (RDW ≤ 14.5%) and elevated RDW (RDW > 14.5%).

Results: Within 30 days of admission, 29/438 patients (6.6%) with increased RDW and 20/1250 patients (1.6%) with normal RDW had died: univariate analysis (odds ratio 4.6, 95% confidence interval 2.45–7.9, P < 0.001), fully adjusted model (odds ratio 3.29, 95% confidence interval 1.75–6.26, P < 0.001). We calculated receiver operating characteristic curve (ROC) for RDW alone, Glasgow Imrie Score alone, and a combination of Glasgow Imrie Score with RDW. We assessed their ability to predict 30-day mortality. Area under the ROC curve (AUC) of RDW alone was 0.671 and Glasgow Imrie Score AUC was 0.682; Glasgow Imrie Score plus RDW had an AUC of 0.769.

Conclusions: In patients with acute pancreatitis, elevated RDW at admission was independently associated with increased 30-day mortality. The addition of RDW to a pancreatitis prognostic tool such as the Glasgow Imrie Score improves its predictive ability.

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: One-third of patients with acute decompensated heart failure (ADHF) develop worsening kidney function, known as type I cardiorenal syndrome (CRS). CRS is linked to higher mortality rates, prolonged hospital stays, and increased readmissions.

Objectives: To explore the impact of real-time monitoring of urinary output (UO) trends on personalized pharmacologic management, fluid balance, and clinical outcomes of patients with ADHF admitted to a cardiac intensive care unit.

Methods: Our study comprised 35 patients who were hospitalized with ADHF and continuously monitored for UO (UO_elec). Standard diuretic and fluid protocols were implemented after 2 hours of oliguria, and patient outcomes were compared to a historical matched control (HMC) group. Patients were assessed for daily and cumulative fluid balance (over 72 hours) as well as for the occurrence of acute kidney injury (AKI).

Results: Significantly more patients in the UO_elec group demonstrated negative fluid balance daily and cumulatively over time in the intensive care unit compared to the HMC group: 91% vs. 20%, respectively (P < 0.0001 for 72-hour cumulative fluid balance). The incidence of AKI was significantly lower in the UO_elec monitoring cohort compared to the HMC: 23% vs. 57%, respectively (P = 0.003). Moreover, higher AKI resolution, and lower peak serum creatinine levels were demonstrated in the UO_elec group vs. the HMC group.

Conclusions: Implementing real-time monitoring of UO in ADHF patients allowed for early response to oliguria and goal-directed adjustment to treatment. This finding ultimately led to reduced congestion and contributed to early resolution of AKI.

Background: Patients with mechanical prosthetic heart valves must be treated with vitamin K antagonists (VKA) due to an increased risk of valve thrombosis and systemic embolism.

Objectives: To assess the effects of the COVID-19 pandemic on VKA treatment control in patients with mechanical prosthetic heart valves.

Methods: We conducted a retrospective nationwide cohort study using the Clalit Health Services database. The cohort included patients who underwent either aortic or mitral valve replacement using a prosthetic mechanical valve. The primary outcomes included the overall time in therapeutic range (TTR) and the percent of patients with a TTR < 50% during the first year of the COVID-19 pandemic compared to preceding year.

Results: The cohort included 2381 patients. The percentage of patients who had at least two international normalized ratio (INR) tests during the first year of the COVID-19 pandemic was significantly lower compared to the year preceding the pandemic (81% and 87%, respectively, P < 0.001). In both years, the percentage of patients without any documented INR test was high (31.5% in the first COVID-19 pandemic year and 28.9% in the preceding year, P < 0.001). TTR was significantly lower during the 1st year of the COVID-19 pandemic compared to the preceding year (68.1% ± 26 and 69.4% ± 24, P = 0.03). A TTR > 50% was demonstrated in 78% and 81% during the pandemic and the preceding year, P = 0.009.

Conclusions: We noted overall poor VKA control in patients with mechanical heart valves. During the COVID-19 pandemic, VKA control became even worse as reflected by significantly lower TTR and INR tests rates.

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.

Background: Data regarding the management of adnexal torsion (AT) during the coronavirus disease 2019 (COVID-19) pandemic are scarce.

Objectives: To study the effects of actions to limit the spread of COVID-19 on AT management.

Methods: We conducted a retrospective cohort study of all women who underwent laparoscopy for suspected AT between March 2011 and February 2021. We compared the COVID-19 pandemic period, (15 March 2020–2 August 2021, group A) to a parallel period (2019–2020, group B), and a 9-year period preceding the pandemic (March 2011–February 2020, group C).

Results: We performed 97 laparoscopies in group A, 82 in group B, and 635 in group C. The proportion of women presenting following in vitro fertilization treatment was lower (odds ratio [OR] 0.22, 95% confidence interval ]95%CI] (0.06–0.86), P < 0.023). Time from admission to decision to operate was shorter (2.7 vs. 3.9 hours, P = 0.028) in group A than group B. Time from admission to surgery was shorter (9.1 vs. 12.5 hours, P = 0.005) and the rate of surgically confirmed AT was lower (59 [60.8%] vs. 455 [71.7%], P = 0.030, OR 0.61, 95%CI 0.39–0.95) in group A than group C. Among surgically confirmed AT cases only, mean time from admission to decision was shorter in group A than group B (2.6 vs. 4.6 hours, P = 0.014).

Conclusions: We identified differences in time from admission to clinical decision and from admission to surgery among women with suspected AT during the COVID-19 pandemic.

Late arrival ST-segment elevation myocardial infarction (STEMI) is defined as a patient-related delay > 12 hours. It is estimated to represent a significant portion of STEMI patients. As reflected by society guidelines, this group of patients impose great therapeutic challenge, namely due to controversy in the literature regarding optimal care, together with major adverse clinical outcomes [1]. In addition to a possible myocardial infarction (MI), mechanical complications include ventricular septal defect (VSD), left ventricular (LV) free wall, or papillary muscle rupture. Prompt diagnosis and intervention are crucial to improve outcomes as post-infarction ventricular septal defect (PIVSD) carries a high mortality rate. We describe the successful management of a large VSD complicated by cardiogenic shock in a latecomer STEMI patient with complex coronary artery disease (CAD).

Echinococcus infections of the liver and lungs are well-known, but cardiac echinococcus is rare, requiring further understanding. A 19-year-old male presented with chest pain, shortness of breath and palpitations. Changes in an electrocardiogram, increased troponin, and a computed tomography (CT) scan revealed a cardiac cyst at the left ventricle’s posterior lateral wall. Medical management included albendazole and praziquantel for 2 weeks followed by surgical cyst removal.

Clinical presentation of cardiac involvement of echinococcus granulosis is variable, requiring high clinical suspicion. Cardiac CT scan and echocardiography provided sufficient information for the diagnosis. The treatment included surgical removal of the cyst and albendazole administration.

Hydatid cyst is a rare zoonotic disease caused by the parasite Echinococcus granulosus [1]. The incidence in endemic areas is about 1–200 cases per 100,000 in population [2].

The liver (60–70% of cases) and lungs (20–30%) are the most common locations of hydatid cysts, with rare cardiac involvement of only 0.05% to 2% of all cases [3], with the left ventricle most frequently involved (60%) [2,4].

A rise in the incidence of chronic health conditions, notably heart failure, is expected due to demographic shifts. Such an increase places an onerous burden on healthcare infrastructures, with recurring hospital admissions and heightened mortality rates being prominent factors. Efficient chronic disease management hinges on regular ambulatory care and preemptive action. The application of intelligent computational models is showing promise as a key resource in the ongoing management of chronic diseases, particularly in forecasting disease trajectory and informing timely interventions. In this review, we explored a pioneering intelligent computational model by Diagnostic Robotics, an Israeli start-up company. This model uses data sourced from insurance claims to forecast the progression of heart failure. The goal of the model is to identify individuals at increased risk for heart failure, thus enabling interventions to be initiated early, mitigating the risk of disease worsening, and relieving the pressure on healthcare facilities, which will result in economic efficiencies.