Israel Medical Association Journal

Background: Electrocardiogram (ECG) may detect atrial fibrillation (AF), but the true rate of ECG performance is unknown.

Objectives: To explore the performance rate of ECG testing in patient populations at high risk for AF in a real-world cohort and to explore the incidence of newly diagnosed AF.

Methods: This retrospective observational cohort study included de-identified data of members of Maccabi Health Services older than 65 years, excluding patients with prior AF and other cardiac diseases. Patients were followed between 1 January 2016 and 30 September 2020. The number of ECGs performed in an outpatient setting for each patient was reported.

Results: In total, 211,515 patients (59.8% female) were included. The mean age was 70.3 ± 6.6 years, with a mean CHA₂DS₂-VASc score of 2.6 ± 1.0. During the study period, over half of the patients (n=112,340; 53.1%) did not undergo any ECG tests, 51,644 patients (24.4%) had one ECG, 24,914 patients (11.8%) had two, while 22,617 patients (10.7%) had more than three. Of the patients referred for an ECG, 67,433 (81.1%) underwent ECG testing within 2 months following the referral. The median time from ECG referral to ECG testing was 5 days.

Conclusions: Most patients older than 65 years had no ECG tests within a 5-year period. However, when referred to an ECG test, most patients complied within a median of 5 days.

Background: Postoperative atrial fibrillation (POAF) is well recognized after cardiac surgery; however, its incidence and clinical course following non-cardiac surgery (NCS) remain unclear.

Objectives: To evaluate the association between POAF after NCS, patient co-morbidities, and type of surgery.

Methods: In this retrospective cohort study, patients who underwent NCS at a private hospital network between 2016 and 2023 were included. Patients with a history of atrial fibrillation (AF) were excluded. Patients who developed POAF within 24-48 hours were compared with those who did not. To address baseline differences, propensity score matching (1:10) and inverse probability weighting combined with Firth’s penalized logistic regression were applied. Odds ratios with 95% confidence intervals were calculated.

Results: POAF developed in 174 patients within 24–48 hours postoperatively, compared with 391,329 controls. Older age, ischemic heart disease, diabetes, and prior stroke were associated with increased odds of POAF, although significance diminished after multivariable adjustment. Weighted regression confirmed these findings with narrower confidence intervals. Higher POAF risk was observed after laparoscopic pancreatectomy, hepatectomy, rectopexy, synovectomy, and gastrectomy. Total knee replacement was the most common procedure among POAF cases, representing 22% of cases and a fourfold increased risk.

Conclusions: Advanced age and cardiovascular co-morbidities were associated with increased POAF risk after NCS, although attenuated after adjustment. Consistent findings across statistical models support the robustness of the results. Targeted monitoring in high-risk patients may improve postoperative outcomes.

Surgical aortic valve replacement (SAVR) is the treatment of choice for patients with severe aortic stenosis (sAS). Balloon aortic valvuloplasty (BAV) was developed 40 years ago, and it was an alternative to conventional SAVR in elderly and frail patients for whom there were no other effective therapeutic options [1].

Transcatheter aortic valve intervention (TAVI) has expanded its indications during the last 20 years, from prohibitively high surgical risk of mortality to intermediate risk patients [2].

We reported a case of BAV that was used as a bridge to TAVI in an elderly patient with sAS, congestive heart failure (CHF), and ischemic hepatitis (IH).

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.

Background: Decompression sickness (DCS) is a clinical syndrome caused by a substantial reduction in barometric pressure. DCS is more common among divers but may also occur during flight or altitude chamber (hypobaric chamber) training. DCS is classified according to symptoms as either Type 1 (musculoskeletal and skin involvement) or Type 2 (neurological and pulmonary involvement). DCS may be life threatening and often necessitates treatment with hyperbaric oxygen therapy (HBOT).

Objectives: To examine the risk for altitude decompression sickness (ADCS) in altitude chamber training and to compare ADCS symptoms and treatment to those of DCS in divers (DDCS).

Methods: We conducted a retrospective cohort study that included all cases of ADCS in the Israeli Air Force between 2015 to 2022. We collected demographic, flight platform, altitude chamber training, clinical manifestations, and treatment data. Data regarding DDCS was obtained via a literature review.

Results: There were 2279 altitude chamber trainees and aviation physiology instructors. Of these, 11 presented ADCS, leading to a calculated ADCS risk of 0.5%. An additional four cases were reported following combat flights. Musculoskeletal involvement was the most common symptom in both DDCS and ADCS. A shorter HBOT protocol was used in 53% of the ADCS cases but only in 30% of the DDCS cases.

Conclusions: Overall, ADCS is a rare event, occurring in less than 1% of altitude chamber trainees. The common manifestation is of musculoskeletal involvement, and the mainstay of treatment remains HBOT.

Background: This study provides valuable insight on the importance of antenatal follow-up, despite advances in medical capabilities.

Objectives: To provide current information on mortality rates and causes including demographic parameters.

Methods: A total of 3362 infants were admitted to the neonatal intensive care unit at Kaplan Medical Center between 2009 and 2021. Retrospective data were extracted from a computerized prospective database and further divided to two groups: 2009–2014 and 2015–2021. For sequential variables, we calculated the mean, standard deviation, and median. For categorical variables we calculated the prevalence and performed a chi-square test. The sequential variables did not show a normal distribution according to the Shapiro-Wilk test. Therefore, the A-parameter Mann-Whitney test was used. Results were considered significant when the P-value < 0.05.

Results: A decrease in the death rate was found, but when evaluating the infants who died, a decrease in full antenatal follow-up from 55.2% to 31.5% was seen (P-value = 0.06).

Conclusions: Despite advancements in medical knowledge and capabilities, an association was found between increased mortality and reduced antenatal follow-up.

Background: Gait disturbances are common in patients undergoing hemodialysis and are associated with increased fall risk, mobility decline, and adverse health outcomes. Prior research suggests that hemodialysis may impact gait parameters such as speed, stride length, and variability; however, findings are inconsistent.

Objectives: To evaluate acute changes in gait metrics before and after hemodialysis using an artificial intelligence (AI) based video gait analysis system.

Methods: We initially enrolled 38 hemodialysis patients, two were excluded due to clothing interference with video analysis (27.8% female, 72.2% male). AI-driven gait analysis was performed immediately before and after dialysis. The system extracted spatiotemporal gait and joint range of motion. Statistical analyses included the Shapiro-Wilk test for normality, Wilcoxon signed-rank tests for non-normally distributed data, and paired t-tests for normally distributed data (P < 0.05).

Results: Gait speed (0.59 m/sec pre-dialysis) remained unchanged post-dialysis (P = 0.876), as did cycle length and time. However, step length significantly decreased post-dialysis (P = 0.001), suggesting a more conservative gait pattern. Knee flexion and extension increased slightly but did not reach statistical significance.

Conclusions: Dialysis does not acutely affect overall gait speed but significantly reduces stride length. Post-dialysis fatigue or hemodynamic shifts may alter walking patterns, highlighting the need for fall prevention strategies and physical rehabilitation interventions in dialysis care. AI-based gait analysis may provide a practical tool for monitoring mobility changes in hemodialysis patients.

Background: Adolescent suicide attempts have well-established risk factors. The increased number of cases at Laniado Hospital's pediatric department over the past decade prompted our evaluation of the relative importance of these factors.

Objectives: To characterize adolescents presenting after suicide attempts and to use these features to develop a neural network for early identification of at-risk youth.

Methods: We conducted a retrospective study of suicide attempts among adolescents (11–18 years) admitted to Laniado Hospital's pediatric department (2015–2021). The study included 82 patients with a matched control group (n=82). We analyzed epidemiological, medical, and psychosocial characteristics, identifying statistically significant factors associated with suicide attempts. We then built a predictive model using neural networks.

Results: Significant risk factors for suicide attempts included living outside original home (odds ratio [OR] 6.71, P = 0.0002), female gender (OR 12.67, P = 0.0502), unmarried parents (OR=98.51, P < 0.0001), advanced age (95% confidence interval [95%CI] 0.477–1.583, P = 0.0001), higher hemoglobin (95%CI 0.689–1.81, P = 6.30 × 10^-6), higher mean corpuscular volume (MCV) (95%CI 3.61–8.07, P = 0.014), and prior psychiatric diagnosis (OR 71.82, P < 0.0001). Non-Ashkenazi background was more common but not significant (P = 0.074). Our neural network model achieved 99.85% predictive accuracy.

Conclusions: Psychiatric history, unmarried parents, female gender, and living outside the home were the strongest risk factors for adolescent suicide attempts. We observed higher hemoglobin levels and MCV among affected individuals. Our neural network showed high accuracy (99.85%) in distinguishing between adolescents with suicide attempts from matched controls.

Background: Recent guidelines have emphasized the importance of the diagnosis and treatment of obesity in all healthcare settings. However, obesity rarely appears as a chronic diagnosis during hospitalization, and there are few reports of targeted interventions.

Objective: To assess obesity-related diagnoses and interventions during pediatric acute hospitalization.

Methods: A retrospective cohort study was conducted in a pediatric ward. Hospitalization records of all patients aged 2–18 years were retrieved during a 30-month period. Weight percentile for patient age was calculated using the U.S. Centers for Disease Control and Prevention (CDC) age- and sex-adjusted charts. Patients with a weight-percentile-for-age of ≥ 95% were classified as suspected obesity. The characteristics of obesity-diagnosed patients were compared to obesity-overlooked patients.

Results: Of the hospitalized patients, 245/2827 (8.6%) had weight-percentile-for-age of ≥ 95%. Of these, 91/245 (37.4%) had obesity-related references in their medical record; 65/245 (26.5%) had a mean body mass index of 97.66% ± 2.6. Only 38/245 (15.5%) were diagnosed with obesity; weight-related recommendations only appeared in the discharge letter for 44/245 (17.9%). Multivariate analysis indicated that obesity was significantly more overlooked in preschoolers than in adolescents (adjusted odds ratio [OR] 11.78, 95% confidence interval [95%CI] 4.71–29.42), P < 0.001) and in patients, regardless of age, whose chief complaint was not abdominal (OR 7.7, 95%CI 1.92–30.8, P = 0.004).

Conclusions: Low rates of obesity-related diagnoses during pediatric acute hospitalization, especially in younger patients, are frequent. Pediatric staff should note obesity in patients and be trained in non-stigmatizing intervention during hospitalization.

Background: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommends a ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) of less than 70% (FEV1/FVC < 0.7) after bronchodilators as the criteria for obstruction. However, because the FEV1/FVC ratio decreases with age, using a fixed ratio may lead to overdiagnosis of obstruction in the geriatric population. Using the lower limit of normal (LLN) as threshold for obstruction has been suggested.

Objectives: To determine the rate of overdiagnosis using the GOLD criteria compared to LLN in patients aged 60 and older. To find a better threshold with a minimal rate of over- and underdiagnosis.

Methods: The study population included adults aged 60 years and older who performed pulmonary function test (PFT) at Shaare Zedek Medical Center between 2014 and 2019 with results of FEV1/FVC < 0.7.

Results: We included 430 patients aged 60 years and older, 273 males (63.5%) and 157 females (36.5%). Mean age was 72 ± 8 years. Overdiagnosis was found in 35.6% of patients (95% confidence interval 31.1–40.3%) by using the GOLD criteria compared to the LLN. Overdiagnosis was reduced to 6.4% with the 0.65 threshold. The ideal point of the FEV1/FVC ratio where overdiagnosis and underdiagnosis were at their lowest rates was 0.638.

Conclusions: Use of the GOLD criteria for airflow obstruction may be associated with an overdiagnosis of more than 35% in patients older than 60 years. Lowering the FEV1/FVC ratio to < 0.65 might be more accurate in this population.

Background: Significant mitral regurgitation (MR) is associated with less spontaneous echo contrast but its effect on the occurrence of ischemic stroke in patients with atrial fibrillation (AF) is unknown.

Objectives: To examine the association of MR grade and the risk of ischemic stroke (IS) in AF patients with heart failure (HF).

Methods: We investigated 2748 patients with known AF who were hospitalized due to acute decompensated HF. All patients underwent echocardiography during hospitalization. Patients were divided into groups based on the degree of MR (high-grade MR [3–4] vs. no/low-grade MR [0–2]). The primary endpoint was IS during long term follow-up.

Results: Mean age was 79 ± 11 years, 48% were women. After 2 years of follow-up, the cumulative incidence of IS among patients with high-grade MR was significantly lower compared to patients with no/low-grade MR (6% vs. 12%, respectively; P-value = 0.0064). Multivariate Fine and Gray analysis, adjusting for CHA₂DS₂-VASc, and accounting for the competing risk of death and valve intervention, showed the presence of high-grade MR was associated with a significant 50% (P = 0.013) reduction in the risk of IS compared with no/low-grade MR. When added to the CHA₂DS₂-VASc score, MR grade allowed more accurate prediction of IS with an overall improvement of 12% (95% confidence interval 5–17%) using net reclassification index analysis.

Conclusions: Our findings suggest an inverse correlation between MR grade and the risk of stroke among AF patients with HF. These findings may be used for improved risk assessment in this population.

Background: The benefits of corticosteroid administration for suspected premature birth (PTB) are widely accepted. Although a single course of antenatal corticosteroids is generally considered to be safe, there are concerns regarding the safety and benefit of multiple courses. Nevertheless, many women who present with symptoms of PTB do not deliver early.

Objectives: To assess how often we used corticosteroid appropriately in our clinical practice in women who presented with risk of PTB.

Methods: Clinical data were retrospectively collected on patients who were admitted to our clinic between September 2014 and August 2015 due to risk of PTB and who were treated with prenatal corticosteroids.

Results: We identified 305 patients at risk of PTB who were treated with corticosteroids; 42.3% delivered < week 34, 22.5% delivered between weeks 34 and 37, and 35.1% delivered > 37 weeks. In women who delivered after week 37, the more time that elapsed between corticosteroids administration and delivery, the lower the pH and the APGAR scores were. Only 26% of patients delivered 2–14 days after the last steroids course of treatment.

Conclusions: The rate of term deliveries at our center after receiving antenatal corticosteroids due to prior symptoms of preterm labor was 35.1%. The ratio of maternal antenatal corticosteroid administration for potential versus actual PTB at < 37 weeks of gestation was not optimal but acceptable.

Serotonin (5-hydroxytryptamin, 5-HT) is a vital monoamine neurotransmitter that modulates various physiological processes. Selective serotonin reuptake inhibitors (SSRIs) are commonly used for the management of depressive disorders. Prolonged administration of SSRIs may lead to reduced platelet aggregability due to the depletion of serotonin stores within platelets. However, the association between chronic SSRI use and the risk of postoperative bleeding remains a topic of debate, with no standardized guidelines for managing this risk in the field of plastic surgery. This literature review and case report highlights the importance of considering chronic SSRI use as a potential risk factor for postoperative bleeding in plastic surgery patients. Standardized guidelines for handling postoperative bleeding risk in patients using SSRIs are crucial for ensuring optimal surgical outcomes and patient safety.

Background: High prevalence of hepatitis C (HCV) among people with severe mental illness (SMI) is attributed mostly to current or past intravenous (IV) drug use. However, such history may disappear from patient files over time, especially in chronic SMI with prolonged psychiatric admissions.

Objectives: To explore HCV and SMI cross-morbidity (HCV/SMI) in a hospitalized population.

Methods: In this observational, retrospective, historical computerized study we examined prevalence, characteristics, and outcomes of patients with HCV/SMI compared to HCV alone in patients admitted to an Israeli hospital 1 January 2005 to 31 December 2020.

Results: Of 1638 eligible HCV patients, 219 (13.4%) were HCV/SMI. Significantly more native Israelis showed HCV/SMI than HCV alone (36.1% vs. 18.1%, P = 0.013) and history of IV drug use (60.3% vs. 32.4%, P < 0.001). Among Israeli natives, more Jews were SMI/HCV compared to HCV only (67.1% vs. 45%, P < 0.01). Among non-native Israelis, immigration age was lower in SMI/HCV compared to HCV only (27.97 vs. 37.23 years, P < 0.001). No differences were found in mortality or cirrhosis, although HCV/SMI patients experienced earlier mortality compared to HCV alone (61.42 ± 14.3 vs. 72.8 ± 14.6 years, P < 0.001). Cirrhosis among HCV/SMI patients was a risk factor for early mortality (hazard ratio 5.528, 95% confidence interval 3.721–8.213).

Conclusions: HCV/SMI is related to early mortality, particularly with cirrhosis. There is significantly high SMI prevalence in hospitalized HCV patients, representing a unique at-risk population. Identification during hospitalization and medical recommendations at discharge may fill the gaps.

Background: BRCA1/BRCA2 female pathogenic sequence variant (PSV) carriers in Israel are offered semiannual cancer antigen 125 (CA125) serum level determination and transvaginal ultrasound until performing risk reducing salpingo-oophorectomy (RRSO), even with the lack of proven efficacy of these procedures in providing adequate early detection of ovarian cancer.

Objectives: To report the results of longitudinal CA125 measurements in BRCA1/BRCA2 carriers as a tool for ovarian cancer detection in a single medical center in Israel.

Methods: Asymptomatic BRCA1/BRCA2 PSV carriers attending the Meirav High Risk Clinic at Sheba Medical Center for more than 3 years were eligible. Data on specific PSV, risk reducing surgeries, and cancer diagnoses were obtained from participant records. We used chi-square and Wilcoxon-Rank tests for statistical analyses.

Results: Overall, 739 (399 BRCA1, 336 BRCA2, 4 BRCA1 + BRCA2) PSV carriers were included. Mean age at the start of follow-up was 38.96 ± 11.13 years, mean follow-up time was 7.93 ± 2.34 years, (5860.80 women/years). Most participants (490/739 [66.3%]) had stable CA125 levels (± 5 U/µl). Of participants, 61 had CA125 levels > 35 U/µl at least twice (n=42) or at least doubling of marker levels to a minimum of 20 U/µl (n=19), results that have led to further cancer defining investigations. Of these, 14 and 4 were diagnosed with breast and ovarian cancer, respectively.

Conclusions: Longitudinally stable CA125 levels were noted in most BRCA1/BRCA2 PSV carriers and elevated levels were a poor marker for ovarian cancer development.