Israel Medical Association Journal

Background: Transurethral prostatectomy is the gold standard surgical treatment of bladder outlet obstruction due to benign enlargement of the prostate, with more than 30,000 procedures performed annually in the United States alone. The success rate of this minimally invasive procedure is high and the results are durable. The development of urethral stricture is a long-term complication of the procedure and is noted in about 2% of patients. The stricture narrows the urethral lumen, leading to re-appearance of obstructive urinary symptoms. Traditionally, the evaluation of the stricture was performed by retrograde urethrography. Advancements in the fields of flexible endoscopy allowed rapid inspection of the urethra and immediate dilatation of the stricture in selected cases.

Objectives: To compare the efficacy of urethrography versus cystoscopy in the evaluation of urethral strictures following transurethral prostatectomy.

Methods: A retrospective review was conducted of a series of 32 consecutive patients treated due to post-transurethral resection of prostate (TURP) urethral stricture.

Results: Twenty patients underwent both tests. In 16 there was concordance between the two tests. Four patients had no pathological findings in urethrography but had strictures in cystoscopy. All strictures were short (up to 10 mm) and were easily treated during cystoscopy, with no complaints or re-surgery needed in 24 months follow-up.

Conclusions: Cystoscopy was superior to urethrography in the evaluation of post-TURP strictures. Strictures where often short and treated during the same procedure. We recommend that cystoscopy be the procedure of choice in evaluating obstructive urinary symptoms after TURP, and retrograde urethrography be preserved for selected cases.

Background: Autologous hematological stem cell transplantation (HSCT) is a novel therapy for systemic sclerosis (SSc) that has been validated in three randomized controlled trials.

Objectives: To report the first Israeli experience with HSCT for progressive SSc and review the current literature.

Methods: Five SSc patients who were evaluated in our department and were treated by HSCT were included. Medical records were evaluated retrospectively. Demographic, clinical, and laboratory data were recorded. Continuous data are presented as the mean ± standard deviation. Categorical variables are presented as frequencies and percentages.

Results: Five SSc patients were treated with HSCT. Four patients were adults (mean age 53 ± 12 years) and one was a 12-year-old pediatric patient. All patients were female. HSCT was initiated 1.4 ± 0.8 years after diagnosis. Two patients were RNA POLIII positive, two were anti-topoisomerase 1 positive, and one only antinuclear antibodies positive. All patients had skin and lung involvement. The mean modified Rodnan Skin Score was 29 ± 4.7 before HSCT, which improved to 10.4 ± 9.6 after HSCT. The forced vital capacity improved from 68 ± 13% to 90 ± 28%. Diffusing capacity of the lungs for carbon monoxide increased by 6%. Among severe adverse events were cyclophosphamide-related congestive heart failure, antithymocyte globulin-related capillary leak syndrome, and scleroderma renal crisis. All symptoms completely resolved with treatment without sequela. No treatment related mortality was recorded.

Conclusions: HSCT is an important step in the treatment of progressive SSc in Israel. Careful patient selection reduces treatment related morbidity and mortality.

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. 

Background: Falls are a common complication in persons with stroke (PwS). Reliable assessment of balance responses to unexpected loss of balance has the potential to identify risk for falls. 

Objectives: To examine inter-observer reliability of balance responses to unannounced surface perturbations in PwS and to explore the concurrent validity of a balance recovery assessment protocol.

Methods: Two observers evaluated balance recovery strategies and fall threshold (a fall into a harness system) in 15 PwS and 15 healthy adults who were exposed to forward, backward, right, and left unannounced surface translations in six increasing intensities while standing. 

Results: Observer agreement was 100% for the fall threshold. Kappa coefficients for step strategies were 0.960–0.988 in PwS and 0.886–0.938 in healthy adults, 0.905–0.988 for arm reactions in PwS and 0.754–0.926 in healthy adults. Significant correlations were found between fall threshold and Berg Balance Scale (r = 0.691), 6-minute walk test (r = 0.599), and fall efficacy scale-international (r= -0.581). 

Conclusions: A trained examiner can reliably classify reactive balance responses to surface perturbations. The high frequency of falls observed in PwS highlights the importance of assessing reactive balance responses to different directions and intensities of surface translations.

Background: Older age is an independent predictor of worse outcome from traumatic brain injury (TBI). No clear guidelines exist for the management of TBI in elderly patients.

Objectives: To describe the outcomes of elderly patients presenting with TBI and intracranial bleeding (ICB), comparing a very elderly population (≥ 80 years of age) to a younger one (70–79).

Methods: Retrospective analysis of the outcomes of elderly patients presenting with TBI with ICB admitted to a level I trauma center.

Results: The authors analyzed 100 consecutive patients aged 70–79 and 100 patients aged 80 and older. In-hospital mortality rates were 9% and 21% for groups 70–79 and ≥ 80 years old, respectively (P = 0.017). Patients 70–79 years old showed a 12-month survival rate of 73% and a median survival of 47 months. In patients ≥ 80 years old, 12-month survival was 63% and median survival was 27 months (P = NS). In patients presenting with a Glasgow Coma Scale score of ≥ 8, the in-hospital mortality rates were 41% (n=5/12) and 100% (n=8/8). Among patients ≥ 80 years old undergoing emergent surgical decompression, in-hospital mortality was 66% (n=12/18). Survivors presented with a severe drop in their functional score. Survival was dismal in patients ≥ 80 years old who were treated conservatively despite recommended operative guidelines.

Conclusions: There is a lack of reliable means to evaluate the outcome in patients with poor functional status at baseline. The negative prognostic impact of severe TBI is profound, regardless of treatment choices.

Background: Untreated dental caries or even dental manipulations, such as a tooth extraction, might cause direct spread of an odontogenic infection and consequently the development of life-threatening conditions such as deep neck infections (DNI). The most common source of DNI is of odontogenic origin (38.8–49%). Abscess formation or cellulitis can lead to life-threatening complications, despite new diagnostic imaging technology and widespread availability of antibiotics. 

Objectives: To demonstrate the dangers of DNI, which can create life-threatening situations.

Methods: Five cases of DNI of odontogenic origin, which were referred to the oral and maxillofacial surgery unit, are presented. 

Results: Clinical manifestations included trismus, dysphagia, dysphonia, dyspnea, and infection symptoms. In all cases, computed tomography confirmed diagnosis and extent of abscess. Complications included mediastinitis, respiratory distress, osteomyelitis of the jaws, and in rare cases the mandibular condyle. Treatment included securing the airway, immediate surgical drainage, removal of the infection source, and antibiotic therapy. All patients were discharged in stable and improved condition.

Conclusions: DNI treatment on an emergency basis requires proper diagnosis and effective management. To confirm diagnosis and prevent serious complications, it is essential for physicians to recognize the spaces of the head and neck that are likely to be affected by DNI. 

 

Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. It is assumed that sleep is involved in the pathogenesis of BPPV, and that habitual head-lying side during sleep correlates with the affected side in the posterior semicircular canal BPPV.

Objectives: To investigate the relationship between the preferred sleeping position and the affected semicircular canal in patients with BPPV.

Methods: We performed a retrospective data review of patients seeking help for vertigo/dizziness who had undergone clinical evaluation including a Dix–Hallpike test. Patients diagnosed with posterior canal BPPV (p-BPPV) were asked to define their preferred lying side (right, left, supine, or variable) during the night sleep. Affected semicircular canal (right posterior or left posterior) was registered along with demographic data.

Results: In all, 237 patients were diagnosed with p-BPPV. Patients with horizontal semicircular canal BPPV (n=11) were excluded. Patient mean age was 57 years (range 14–87). There were 150 patients with right p-BPPV and 87 patients with left p-BPPV. Among the patients, 122 (52%) habitually slept on the right side. Of those, 102 (84%) were diagnosed with right p-BPPV (P = 0.0006), while 82 patients (34%) habitually slept on the left side. Fifty-three (65%) were diagnosed with left p-BPPV (P < 0.0001). There were no differences in right vs. left p-BPPV in the 33 patients (14%) who expressed no preference concerning their sleeping positions.

Conclusions: Our study highlights the etiology of BPPV and showed that changing sleep position habits might be helpful in preventing recurrent BPPV.

Background: Male breast cancer (MBC) is a rare disease representing less than 1% of breast cancers. In the absence of a screening program, such as for females, the diagnostic workup is critical for early detection of MBC.

Objectives: To summarize our institutional experience in the workup of male patients referred for breast imaging, emphasizing the clinical, imaging, and histopathological characteristics of the MBC cohort.

Methods: All male patients who underwent breast imaging between 2011 and 2016 in our institution were retrospectively reviewed. Clinical, radiological, and histopathological data were collected and statistically evaluated. All images were reviewed using the American College of Radiology Breast Imaging Reporting and Data System.

Results: 178 male patients (average age 61 years, median age 64), underwent breast imaging in our institution. The most common indication for referral was palpable mass (49%) followed by gynecomastia (16%). Imaging included mostly mammography or ultrasound. Biopsies were performed on 56 patients, 38 (68%) were benign and 18 (32%) were malignant. In all, 13 patients had primary breast cancer and 5 had metastatic disease to the breast. Palpable mass at presentation was strongly associated with malignancy (P = 0.007).

Conclusion: Mammography and ultrasound remain the leading modalities in breast imaging among males for diagnostic workup of palpable mass, with gynecomastia being the predominant diagnosis. However, presentation with palpable mass was also associated with malignancy. Despite a notable MBC rate in our cohort, the likelihood of cancer is low in young patients and in cases of gynecomastia.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare, distinct pulmonary vascular disease, which is caused by chronic obstruction of major pulmonary arteries. CTEPH can be cured by pulmonary endarterectomy (PEA). PEA for CTEPH is a challenging procedure, and patient selection and the perioperative management are complex, requiring significant experience.

Objectives: To describe the establishment of a national CTEPH–PEA center in Israel and present results of surgery.

Methods: In this study, we reviewed the outcomes of PEA in a national referral, multi-disciplinary center for CTEPH–PEA. The center was established by collaborating with a high-volume center in Europe. A multidisciplinary team from our hospital (pulmonary hypertension specialist, cardiac surgeon, cardiac anesthesiologist and cardiac surgery intensivist was trained under the guidance of an experienced team from the European center.

Results: A total of 38 PEA procedures were performed between 2008 and 2018. We included 28 cases in this analysis for which long-term follow-up data were available. There were two hospital deaths (7%). At follow-up, median New York Heart Association (NYHA) class improved from III to I (P < 0.0001), median systolic pulmonary pressure decreased from 64 mmHg to 26 mmHg (P < 0.0001), and significant improvements were seen in right ventricular function and exercise capacity.

Conclusions: A national center for performance of a rare and complex surgical procedure can be successfully established by collaboration with a high-volume center and by training a dedicated multidisciplinary team.

Background: The sentinel lymph node (SLN) biopsy procedure is a well-known method for identifying solid tumors such as breast cancer, vulvar cancer, and melanoma. In endometrial and cervical cancer, SLN has recently gained acceptance.

Objectives: To evaluate the detection rate of SLN with an indocyanine green and near-infrared fluorescent imaging (ICG/NIR) integrated laparoscopic system in clinically uterine-confined endometrial or cervical cancer.

Methods: Patients with clinically early-stage endometrial or cervical cancer were included in this retrospective study. ICG was injected into the uterine cervix and an ICG/NIR integrated laparoscopic system was used during the surgeries. The National Comprehensive Cancer Network (NCCN) protocol was followed. SLN and/or suspicious lymph nodes were resected. Side-specific lymphadenectomy was performed when mapping was unsuccessful. Systematic lymphadenectomy was completed in patients with high-grade histology or deep myometrial invasion. Enhanced pathology using ultra-staging and immunohistochemistry were performed in all cases.

Results: We analyzed 46 eligible patients: 39 endometrial and 7 cervical cancers. Of these, 44 had at least one SLN (93.6%). In 41 patients (89%) we detected bilateral SLN, in 3 (7%) only unilateral, and in 2 (4%) none were detected. Seven patients presented with lymph node metastasis. All were detected by NCCN/SLN protocol. Of these cases, two were detected with only pathological ultra-staging.

Conclusions: SLN mapping in endometrial and cervical cancer can easily be performed with a high detection rate by integrating ICG/NIR into a conventional laparoscopic system. Precision medicine in patients evaluated by SLN biopsy changes the way patients with endometrial or cervical cancer are managed.

Background: Israel's population is diverse, with people of different religions, many of whom seek spiritual guidance during ethical dilemmas. It is paramount for healthcare providers to be familiar with different religious approaches.

Objectives: To describe the attitudes of the three major monotheistic religions when encountering four complex neonatal situations.

Methods: A questionnaire related to four simulated cases was presented to each participant: a non-viable extremely premature infant (case 1), a severely asphyxiated term infant with extensive brain damage (case 2), a small preterm infant with severe brain hemorrhage and likely extensive brain damage (case 3), and a term infant with trisomy 21 syndrome and a severe cardiac malformation (case 4).

Results: Major differences among the three religious opinions were found in the definition of viability and in the approach towards quality of life.

Conclusions: Neonatologists must be sensitive to culture and religion when dealing with major ethical issues in the neonatal intensive care unit.

Background: Although women comprise only a minority of patients hospitalized due to violence-related injury, the circumstances of attacks against women may make their injuries more severe.

Methods: We conducted a retrospective study using data of 9173 patients with stabbing-related injuries from 19 trauma centers participating in the Israeli National Trauma Registry between 1 January 1997 and 31 December 2014. Male and female patients were compared in terms of demographic and circumstantial factors, clinical characteristics, and outcomes.

Results: Women were found to have greater injury severity according to the Injury Severity Scale (ISS) – 18% vs. 11% of severe (ISS 16+) injuries – requiring more hospital resources. Injuries that contributed most to injury severity in the female population were head and severe abdominal trauma. Women also sustained injuries to more body sites than men; however, regression analysis showed that the contribution of this factor to the overall difference in injury severity was less important than the injured sites. Regression analysis among severely injured patients pointed at injury to lower extremities as an independent factor related to female mortality. Different from men, among women the stabbing injuries to the upper extremities were not a protective factor in terms of mortality.

Conclusions: There are significant differences in the injury profiles of male and female stabbing victims, which can be explained by the different circumstances of the injury event.