Israel Medical Association Journal

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.

Diagnosis and treatment of posterior hip pain has increased due to advancements in clinical, anatomical, biomechanical, and related pathological understandings of the hip. Due to its complexity and close anatomical relationship with many osseous, neurovascular, and musculotendinous structures, posterior hip pain must be appropriately categorized based on its origin. Therefore, it is crucial that clinicians are able to determine whether patient complaints are of extra-articular or intra-articular nature so that they can implement the optimal treatment plan. In the current review article, we discussed posterior hip pain with an emphasis on the main differential diagnoses of deep gluteal syndrome, ischiofemoral impingement, and hamstring tear/hamstring syndrome. For the appropriate diagnosis and etiology of posterior hip pain, a thorough and conclusive clinical history is imperative. Physicians should rule out the possibility of spinal involvement by physical examination and if necessary, by magnetic resonance imaging (MRI). Furthermore, because of the vicinity to other, non-orthopedic structures, an obstetric and gynecologic history, general surgery history, and urologic history should be obtained. Following the collection of patient history clinicians should adhere to an established and efficient order of evaluation starting with standing then to seated, supine, lateral, and prone testing. Imaging assessment of posterior hip pain begins with a standard anterior-posterior pelvic radiograph, in addition to frog-leg lateral. MRI is pivotal for assessing soft tissue-related extra-articular causes of hip in patients with posterior hip pain. Non-surgical treatment is preferred in most cases of deep gluteal syndrome, ischiofemoral impingement, pudendal nerve entrapment, and proximal hamstring pathologies. Surgical treatment is saved as a last resort option in cases of failed non-surgical treatment

Background: The long-term significance of apparent life-threatening events (ALTE) has not been thoroughly studied. 

Objectives: To evaluate, at age 5 years, the health status of consecutive children diagnosed with ALTE in infancy. 

Methods: Based on the diagnostic workup, patients were classified into two groups: a ‘broad’ evaluation group (at least one test/procedure related to each of the five main causes: infectious, metabolic, cardiopulmonary, gastroenterological, neurological), and a ‘narrow’ workup group whose evaluation did not cover all five domains. Health status around age 5 was obtained from hospital records, community clinics and parents/caregivers.

Results: We identified 132 children with ALTE. Choking (49.2%) was the most common description, followed by apnea (13.6%), suspected seizure (12.9%), cyanosis (12.1%), breath-holding spell (8.3%), and pallor (3.8%). A broad diagnostic workup was performed in 62.1% of the infants, and a narrow workup in 37.9%. At age 5 years, 56.8% of the children were healthy; 27.3% reported chronic conditions unrelated to ALTE. Twenty-one children (15.9%) had unrelated neurodevelopmental conditions, mostly attention deficit disorder. One of the 132 ALTE patients relapsed and was eventually diagnosed with epilepsy.

Conclusions: A single episode of ALTE in infancy was neither predictive of nor associated with chronic systemic or neurological disease at age 5 years. 

 

Methods: In this retrospective multicenter open-label study we examined the efficacy and tolerability of VNS in patients in five adult and pediatric epilepsy centers in Israel. All patients had drug-resistant epilepsy and after VNS implantation in 2006–2007 were followed for a minimum of 18 months. Patients were divided into two age groups: < 21 and > 21 years old.

Results: Fifty-six adults and children had a stimulator implanted in 2006–2007. At 18 months post-VNS implantation, none of the patients was seizure-free, 24.3% reported a reduction in seizures of ≥ 75%, 19% reported a 50–75% reduction, and 10.8% a 25–50% reduction. The best response rate occurred in patients with complex partial seizures. Among these patients, 7 reported a ≥ 75% reduction, 5 patients a 50–75% reduction, 3 patients a 25–50% reduction, and 8 patients a < 25% reduction. A comparison of the two age groups showed a higher reduction in seizure rate in the older group (< 21 years old) than the younger group.

Conclusions: VNS is a relatively effective and safe palliative method for treating refractory epilepsy in both adults and children. It is an alternative treatment for patients with drug-resistant epilepsy, even after a relatively longed disease duration, who are not candidates for localized epilepsy surgery.

Background: Since clinical signs of meningeal irritation in infants may be absent or misleading, the American Academy of Pediatrics in 1996 recommended that a lumbar puncture be performed in young children following a febrile seizure. Recent evidence supports a conservative approach in children who do not look ill at the time of the physician's assessment. Moreover, seizures as the presenting or sole symptom of bacterial meningitis are very rare.

Objectives: To assess physicians’ compliance with the Academy’s recommendations and to determine the incidence of meningitis among febrile seizure patients, including those who did not undergo the puncture.

Methods: We conducted a retrospective analysis of the number of punctures obtained in febrile seizure patients aged 6–24 months, focusing on the clinician's indications for performing the procedure and on the clinical course of children who did not undergo the puncture.

Results: Among 278 patients (84% simple febrile seizure), 52 (18.7%) underwent the procedure. It was performed in 38% of 45 complex febrile seizure cases and in 48% of 91 infants younger than 12 months of age. Aseptic meningitis occurred in two infants, both with post-ictal apathy. Bacterial meningitis was not found and in none of the patients who did not undergo the puncture was meningitis later diagnosed.

Conclusions: Compliance with the Academy’s recommendations was low, as emergency room physicians based their decision whether to obtain a lumbar puncture solely on clinical grounds. No case of bacterial meningitis was detected among 278 young children with a febrile seizure, including those who did not undergo the puncture.
 

Background: Myotonic dystrophy type 2 (DM2) is an autosomal dominant, multisystem disorder caused by a CCTG tetranucleotide repeat expansion located in intron 1 of the zinc finger protein 9 gene (ZNF9 gene) on chromosome 3q 21.3.

Objectives: To describe the clinical, electrophysiologic and pathologic findings in patients with myotonic dystrophy 2.

Methods: We evaluated 10 patients genetically, clinically and electrophysiologically during the years 2007 to 2008.

Results: All patients were of Jewish European ancestry. Among affected individuals, eight patients had symptoms of proximal muscle weakness, two had muscle pain, and two exhibited myotonia. On physical examination six patients had severe weakness of hip flexor muscles. Seven individuals underwent cataract surgery, and cardiac involvement was seen in one case. On the initial electromyographic (EMG) examination five patients demonstrated myotonic discharges; repeated studies showed these discharges in nine cases. Six muscle biopsies showed non-specific pathological changes. Seven patients had an affected first-degree relative with either a diagnosed or an undiagnosed muscular disorder, consistent with an autosomal dominant trait.

Conclusions: DM2 may often present with proximal muscle weakness without myotonia. EMG may initially fail to show myotonic discharges, but these discharges may eventually show in most cases on repeated EMG. Thus, DM2 may be underdiagnosed and should be included in the differential diagnosis of adult patients of Jewish European ancestry presenting with proximal lower limb weakness.
 

Background: Hepatotoxicity due to intravenous amiodarone (HIVAD) is a rare side effect with a distinct pattern of enzyme disturbances compared to liver damage from oral amiodarone. Intravenous amiodarone is administered for acute arrhythmias often causing heart failure. The enzyme abnormalities and clinical setting are very similar to that of ischemic hepatitis, a far more common condition.

Objectives:  To ascertain if acute HIVAD exists as a separate entity or whether reported cases may be explained by ischemic hepatitis.

Methods: In this case-control retrospective study the files of hospitalized patients with markedly elevated aminotransferases were reviewed for the diagnoses of HIVAD or ischemic hepatitis. Medline was searched for published cases of HIVAD. Pooled data of all patients with HIVAD were compared to a control group with ischemic hepatitis.

Results: There were no significant differences in the clinical characteristics, laboratory results or histological findings between HIVAD and ischemic hepatitis patients.

Conclusions: In our opinion, there is currently insufficient data to support the existence of distinct HIVAD, and ischemic hepatitis is a more probable diagnosis in most reported cases. Withdrawing amiodarone because of assumed hepatic damage could deprive patients of a life-saving therapy.
 

Background: Early-onset neonatal sepsis is a major cause of morbidity and mortality among newborn infants.

Objectives: To determine the incidence, type of pathogens and resistance to antibiotics among newborns with early-onset neonatal sepsis, and to identify the risk factors predisposing infants to resistant pathogens in order to reevaluate antibiotic regimens appropriate for resistant bacteria in these high risk neonates.

Methods: We retrospectively studied maternal and neonatal variables of 73 term and near-term infants and 30 preterm infants, born over a period of 10.5 years and exhibiting early-onset neonatal sepsis (positive blood cultures in the first 72 hours of life).

Results: Predominant pathogens in term and near-term infants were gram-positive compared with gram-negative organisms (mostly Escherichia coli) in preterm infants. Mothers of infants with antibiotic-resistant organisms were more likely to have prolonged rupture of membranes and prolonged hospitalization before delivery and to be treated with antibiotics. No trends towards more resistant strains of pathogens were recorded over the 10.5 years of the study period.

Conclusions: Early-onset neonatal sepsis in term infants differs in bacterial species from that in preterm infants, with predominantly gram-positive organisms in term and near-term infants and gram-negative organisms in preterms. Rates of bacterial resistance to the combination of ampicillin and gentamicin, though higher among infants born to mothers with prolonged hospitalization who had been treated with antibiotics, still remained very low in our department. Thus, it seems that our classic antibiotic regimen is still appropriate for both term and preterm newborns.
 

Background: Persistent creatine kinase elevation is occasionally encountered in subjects without any clinical manifestation of a neuromuscular disorder or any condition known to be associated with increased serum CK[1] levels. It is still unresolved whether extensive investigations and specifically a muscle biopsy should be performed in clinically normal individuals with elevated CK levels.

Objective: To study the muscle pathology of patients with asymptomatic or minimally symptomatic hyperCKemia.

Methods: The clinical and laboratory data of patients with persistent hyperCKemia and normal neurologic examination were reviewed and their muscle biopsies evaluated.

Results: The study group included 40 patients aged 7–67 years; the male to female ratio was 3:1. Nineteen patients were completely asymptomatic, 20 had mild non-specific myalgia, and 1 had muscle cramps. Electromyography was performed in 27 patients and showed myopathic changes in 7 (26%). Abnormal muscle biopsy findings (e.g., increased variation in fiber size, increased number of central nuclei and occasional degenerating fibers) were detected in 22 of the 40 patients (55%). No fat or glycogen accumulation was detected. Immunohistochemistry demonstrated abnormal dystrophin staining in 3 patients (8%), resembling the pathologic changes of Becker muscular dystrophy. No abnormal findings were detected on immunohistochemical staining for merosin, dysferlin, caveolin 3, or alpha and gamma sarcoglycans. The EMG[2] findings did not correlate with the pathologic findings.

Conclusions: Abnormal muscle biopsies were found in 55% of patients with asymptomatic or minimally symptomatic hyperCKemia. Specific diagnosis of muscular dystrophy, however, was possible in only 8% of the patients.

Objectives: To compare the hemostatic efficacy of the second-generation surgical sealant (Quixil™ in Europe and Israel, Crosseal™ in the USA) to that of nasal packing in endonasal surgery.

Methods: We conducted a prospective randomized trial that included 494 patients (selected from 529 using exclusion and inclusion criteria and completed follow-up) undergoing the above-mentioned endonasal procedures. Patients were assigned to one of three surgical groups: septoplasty + conchotomy + nasal packing or fibrin sealant (Group 1); ESS[1] + nasal packing or fibrin sealant (Group 2); and ESS + septoplasty + conchotomy + nasal packing or fibrin sealant (Group 3). The hemostatic effects were evaluated objectively in the clinic by anterior rhinoscopy and endoscopy and assessed subjectively by the patients at follow-up visits.

Results: Postoperative hemorrhage occurred in 22.9–25% of patients with nasal packing vs. 3.12–4.65% in the fibrin sealant groups (late hemorrhage only). Drainage and ventilation of the paranasal sinuses, which are impaired in all cases of packing, remained normal in the fibrin sealant group. There were no allergic reactions to the sealant.

Conclusions: Our results show that fibrin sealant by aerosol spray in endonasal surgery is more effective and convenient than nasal packing. It requires no special treatment, i.e., antibiotics, which are usually used if nasal packing is involved.

_____________________

[1] ESS = endoscopic sinus surgery

Objectives: To evaluate the accuracy of 16-slice multi-detector CT angiography in the diagnosis of coronary artery disease, and assess coronary bypass grafts and coronary anomalies.

Methods: We conducted a retrospective study of 223 patients who were examined at our medical center over a period of 2 years with a 16-slice CT angiography scanner and retrospective electrocardiographic gating.

Results: There were no significant complications, and good visualization of the coronary arteries was achieved in all but eight patients. A high correlation with the results of the invasive angiography was noted (sensitivity 85%, specificity 93%, negative predictive value 98%). Altogether, 131 bypass conduits were examined with excellent graft visualization. Several coronary anomalies were detected, as were significant extra-cardiac findings.

Conclusions: Multi-slice CT angiography is a reliable non-invasive diagnostic procedure for demonstration of the coronary arteries and bypass grafts. In the future it will probably replace part of the diagnostic invasive coronary angiography and, as a result, a large proportion of coronary angiography procedures will be therapeutic.

Objectives: To evaluate the sensitivity, specificity, accuracy, and positive and negative predictive values of FNAB[1] in cases of a solitary thyroid nodule.

Methods: The preoperative FNAB results of 170 patients who underwent thyroidectomy due to a solitary thyroid nodule were compared retrospectively with the final postoperative pathologic diagnoses.

Results: In cases of a solitary thyroid nodule, FNAB had a sensitivity of 79%, specificity of 98.5%, accuracy of 87%, and positive and negative predictive values of 98.75% and 76.6% respectively. All cases of papillary carcinoma diagnosed by FNAB proved to be malignant on final histology, while 8 of 27 cases of follicular adenoma detected by preoperative FNAB were shown to be malignant on final evaluation of the surgical specimen.

Conclusions: FNAB cytology reduces the incidence of thyroidectomy since this method has excellent specificity and sensitivity and a low rate of false-negative results. It proved to be cost-effective and is recommended as the first tool in the diagnostic workup in patients with thyroid nodules.