Israel Medical Association Journal

Background: There are conflicting data on the significance of hyperuricemia or hyperuricosuria in urolithiasis formation and on the need for medical treatment.

Objectives: To assess the significance of hyperuricemia or hyperuricosuria in urolithiasis formation, particularly when hyperuricemia occurs with normal uricosuria.

Methods: The electronic medical records of patients treated in Haifa and the Western Galilee district of Clalit Health Services, Israel, were retrospectively screened for diagnosis of nephrolithiasis or renal or urinary tract/bladder calculi between February 2014 and April 2019. The diagnosis was confirmed by ultrasonography or computed tomography. The study group included patients with one of these diagnoses. Patients in the control group did not have these diagnoses. The inclusion criterion for all patients was the presence of both serum and urinary uric acid levels.

Results: The study group included 359 patients and the control group 267. After adjustment by logistic regression, we found no significant differences in the prevalence of hyperuricosuria in the study group (14.8%) compared to the control group (9.7%), odds ratio (OR) 1.54 (95% confidence interval [95%CI] 0.74–3.2, P = 0.245). No significant differences between the groups were observed for hyperuricemia prevalence (45.4% vs. 55.1%, respectively, OR 0.82, 95%CI 0.54–1.25, P = 0.355), nor among those without hyperuricosuria (OR 0.83, 95%CI 0.52–1.33, P = 0.438) and after propensity score matching (OR 0.93, 95%CI 0.66–1.3, P = 0.655).

Conclusions: There were no significant differences in hyperuricemia or hyperuricosuria between the two groups of patients or in hyperuricemia among participants without hyperuricosuria.

Background: Lower extremity amputation related to diabetes is a serious outcome, which can have devastating effects on the patient and family. The epidemiology of amputations has recently been used as a possible measure of the adequacy of medical prevention and treatment of diabetes and diabetic foot complications.

Objectives: To report on patients undergoing amputations at one medical center in Israel, their co-morbidities, and the outcomes.

Methods: A retrospective chart study was conducted of amputees operated between 1 September 2017 and 30 September 2018.

Results: The study population comprised 72 patients who had major amputations for diabetes and/or ischemia, mean age 72 ± 10 years, 74% males, 93% with type 2 diabetes. Mean age corrected Charlson Comorbidity Index was 8.2 ± 2.1 with 90% (65 patients) presenting with a score of 6 or higher. Before the recent deterioration, fewer than 20% of the patients exited their home routinely and 24% had an official diagnosis of dementia. There were 31 below knee amputations (BKA) and 41 above knee amputations (AKA). The 30-day, 3-month, 1-year, and 2-year mortality rates were 15.3%, 27.8%, 43.1%, and 54.2% respectively. Median survival period was 20 months. Survival after AKA was 13.4 ± 20, which was significantly less than after BKA (25.4 ± 2.7, P = 0.097).

Conclusions: Factors other than the quality of management of patients with diabetes and complications may contribute to amputation rates; thus, making speculations from international comparisons of raw amputation rates problematic. This population was less healthy than reported in most studies.

Background: Over the past several years there has been a marked increase in the number of Israel Defense Forces (IDF) soldiers having hip arthroscopy based on magnetic resonance arthrography diagnosis of hip labral tears and/or impingement.

Objectives: To detail characteristics of soldiers who underwent hip arthroscopy and assess outcomes and rate of return to duty.

Methods: A retrospective chart review was conducted of all soldiers who underwent hip arthroscopy 2018 to 2020, and soldiers referred for hip arthroscopy during 2021. Demographic, medical, and military service data were collected from the computerized patient record.

Results: Our study comprised 117 soldiers (29% combatants, 24% females) who underwent hip arthroscopy, mean age 22 ± 3 years, range 18–42; 45% had physiotherapy before surgery; 31% were diagnosed during or within 3 months of having back pain and 20% had been referred for psychological assistance (not related to the hip pain); 15.4% had serious adverse events. The mean time to return to any duty (including clerical work) was 8.0 ± 0.6 months; 56% of the soldiers never returned to service and were discharged from the military. During the one-year follow-up, only 6% returned to their full pre-symptom activity.

Conclusions: The short-term results of IDF soldiers who underwent hip arthroscopy during the study period were much inferior to those reported among athletes. The lack of specificity of the diagnostic tools (history, examination, and imaging) used to determine whether surgery for hip pain is likely to be beneficial in this population may be contributing to over-diagnosis and over-treatment.

Background: Dietary modifications and patient-tailored medical management are significant in controlling renal stone disease. Nevertheless, the literature regarding effectiveness is sparse.

Objectives: To explore the impact of dietary modifications and medical management on 24-hour urinary metabolic profiles (UMP) and renal stone status in recurrent kidney stone formers.

Methods: We reviewed our prospective registry database of patients treated for nephrolithiasis. Data included age, sex, 24-hour UMP, and stone burden before treatment. Under individual treatment, patients were followed at 6–8 month intervals with repeat 24-hour UMP and radiographic images. Nephrolithiasis-related events (e.g., surgery, renal colic) were also recorded. We included patients with established long-term follow-up prior to the initiation of designated treatment, comparing individual nephrolithiasis status before and after treatment initiation.

Results: Inclusion criteria were met by 44 patients. Median age at treatment start was 60.5 (50.2–70.2) years. Male:Female ratio was 3.9:1. Median follow-up was 10 (6–25) years and 5 (3–6) years before and after initiation of medical and dietary treatment, respectively. Metabolic abnormalities detected included: hypocitraturia (95.5%), low urine volume (56.8%), hypercalciuria (45.5%), hyperoxaluria (40.9%), and hyperuricosuria (13.6%). Repeat 24-hour UMP under appropriate diet and medical treatment revealed a progressive increase in citrate levels compared to baseline and significantly decreased calcium levels (P = 0.001 and 0.03, respectively). A significant decrease was observed in stone burden (P = 0.001) and overall nephrolithiasis-related events.

Conclusions: Dietary modifications and medical management significantly aid in correcting urinary metabolic abnormalities. Consequently, reduced nehprolithiasis-related events and better stone burden control is expected.

Cardiac patients of all ages were managed in the past by internists who specialized in cardiology. During the past 50 years, the medical field has witnessed great strides in the management of congenital heart disease, and thus pediatric cardiology has become a subspecialty in many countries. This review article focuses on the advances in fetal cardiac interventions (FCI) since its inception by our group in 1975. Three major modes of FCI have evolved during the past 42 years: pharmacologic, closed FCI, and open FCI. All treatments require a careful approach by the heart team and are reserved for severe fetal cardiac conditions. They call for prenatal intervention in view of the severity and progressive nature of the diseases that are associated with high fetal morbidity and mortality if left untreated. The well-established pharmacologic FCI approach includes several new and effective agents with recommendations often varying between class I and class IIa and IIb. The advances in prenatal echocardiographic imaging and color flow Doppler has given an impetus to the development of the other FCI modes; however, the need for uterine incision and fetal cardiac bypass in the open technique have limited its advance. Long-term outcomes are still unknown and definite conclusions as to the efficacy and safety of FCI need further investigation, including multicenter trials with long-term data. 

Background: Children and adolescents are commonly referred to an orthopedic surgeon to assess knee malalignment.

Objectives: To assess the prevalence of genu varum and valgum among adolescents, and to identify correlates of these conditions.

Methods: A medical database of 47,588 candidates for military service presenting to the northern recruitment center during an 11 year period was analyzed to identify clinical knee alignment. Based on the standing skin surface intercondylar distance (ICD) or intermalleolar distance (IMD), the prevalence rates of genu varum (ICD ≥ 3 cm) and genu valgum (IMD ≥ 4 cm) were calculated. The association of gender, body mass index (BMI), and place of residence to knee alignment was studied.

Results: The rates of genu varum and valgum were 11.4% (5427) and 5.6% (2639), respectively. Genu varum was significantly more prevalent among males than females (16.2% vs. 4.4%, P < 0.001). It was also more prevalent among underweight subjects and less prevalent among overweight and obese subjects (P < 0.001). Genu valgum was significantly more prevalent among females than males (9.4% vs. 2.9%) and in overweight and obese subjects compared to those with normal BMI, while less prevalent in underweight subjects (P < 0.001). Multivariate analysis revealed that genu varum was independently positively associated with male gender, underweight, and living in a rural area. Genu valgum was independently positively associated with female gender, overweight, and obesity.

Conclusions: This study establishes a modern benchmark for the cutoff and prevalence of genu varum and valgum as well as associations with gender and BMI.

Background: Medical evaluation of a suspected meniscus injury begins with a history-taking and physical examination. Suspected meniscus injuries not responding to treatment are usually sent for imaging to confirm the diagnosis before arthroscopy. Tc-MDP bone single photon emission computed tomography (SPECT) scan has been suggested as an alternative to magnetic resonance imaging (MRI) in evaluating suspected knee meniscus tears.

Objectives: To examine the accuracy of knee SPECT as a tool to identify meniscus tears versus that of MRI as compared to the gold standard of arthroscopy.

Methods: The Israel Defense Forces database for 2005 through 2009 was searched according to the key words knee MRI, knee SPECT and knee arthroscopy. We identified 330 subjects who had undergone both a single knee SPECT and a single knee MRI prior to knee surgery. The medical files of 193 of the 330 subjects were randomly selected for review. A comparison was made between the preoperative SPECT and MRI studies and the arthroscopic finding. The sensitivity, specificity and accuracy were calculated.

Results: The subjects’ age was 21.3 ± 3.9. The agreement between SPECT and arthroscopy was 0.14 for the medial meniscus and 0.29 for the lateral meniscus. The agreement between MRI and arthroscopy was 0.59 for the medial meniscus and 0.69 for the lateral meniscus. SPECT scan was found to be 61% sensitive, 54% specific and 58% accurate in detecting common knee pathology, whereas MRI was found to be 95% sensitive, 67% specific and 85% accurate.

Conclusions: Knee SPECT has a lower sensitivity, specificity and accuracy than MRI in evaluating meniscal injuries and its use can result in increased unnecessary surgery.

Background: The presence of stones in the common bile duct (CBD) may cause complications such as obstructing jaundice or ascending cholangitis, and the stones should be removed.

0bjectives: To report our results with percutaneous elimination of CBD stones from the gallbladder through the papilla.

Methods: During a 4 year period, six patients (five men and one woman, mean age 71.5 years) who had CBD stones and an existing gallbladder drain underwent percutaneous stone push into the duodenum after balloon dilatation of the papilla, with a diameter equal to that of the largest stone. Access into the CBD was from the gallbladder, using an already existing percutaneous gallbladder drain (cholecystostomy tube).

Results: Each patient had one to three CBD stones measuring 7–14 mm. Successful CBD stone elimination into the duodenum was achieved in five of the six patients. The single failure occurred in a patient with choledochal diverticulum, who was operated successfully. There were no major or minor complications during or after the procedures.

Conclusions: Trans-cholecystic CBD stone elimination is a safe and feasible percutaneous technique that utilizes existing tracts, thus obviating the need to create new percutaneous access. This procedure can replace endoscopic or surgical CBD exploration.
 

Background: Previous pregnancies may influence the success of medical termination of pregnancy.

Objectives: To determine the effect of parity and gravidity on the successful termination of pregnancy using mifepristone and misoprostol.

Methods: The medical files of all patients attending a department of obstetrics and gynecology during the years 2006 and 2007 for the purpose of medical termination of pregnancy at ≤ 49 days of gestation were analyzed retrospectively. The medical history, previous pregnancies and deliveries were recorded. Mifepristone was administered orally followed by 400 mg of misoprostol 48 hours later. A second dose of misoprostol was offered 2 weeks later if uterine content thickness was more than 15 mm. Then, after 24 hours, if uterine content thickness was more than 15 mm the uterus was evacuated by dilation and curettage.

Results: Of 403 women, 349 (86.6%) aborted following the basic regime; 207 (51.4%) (group A) were primiparous while 196 (48.6%) (group B) had at least one prior pregnancy. Uterine curettage was performed in 17 patients (8.2%) in group A and in 37 (18.9%) in group B (P = 0.002). When patients with a history of a previous abortion were excluded from group B, 32 of 143 (22.4%) required curettage (P < 0.001). When patients without a history of previous cesarean section were excluded, 10 of 52 (19.2%) underwent curettage (P = 0.038).

Conclusions: Previous pregnancies negatively affect the success of medical termination of pregnancy, especially in women with a previous term pregnancy. This information is important when counseling women about the method of pregnancy termination.
 

Background: Idiopathic frozen shoulder is a self-limiting regional skeletal problem of unknown etiology. Clinically, patients first experience a phase of pain, progressing to a freezing stage when glenohumeral motion is lost, followed by a thawing phase when pain gradually subsides and most of the lost motion returns.

Objectives: To identify possible specific and non-specific risk factors for idiopathic frozen shoulder.

Methods: We compared the medical histories, drug treatment, previous hospital as well as health management organization blood tests of 126 new consecutive frozen shoulder patients from a shoulder clinic to those of an age-matched control group of 98 consecutive patients from an orthopedic foot and ankle clinic and to the regional population disease prevalence registry. Frozen shoulder was classified as idiopathic only if there was no history of trauma and no evidence of a rotator cuff tear.

Results: Among the frozen shoulder patients 29.4% had diabetes and 13.5% had thyroid disorders. The risk ratio for diabetes in the frozen shoulder group was 5.9 for males (95% confidence interval 4.1–8.4, P < 0.001) and 5.0 for females (95% CI[1] 3.3–7.5, P < 0.001). The risk ratio for thyroid disorders among females with frozen shoulder was 7.3 (95% CI 4.8–11.1, P = 0.001). No significant difference was found in the prevalence of thyroid disorders between frozen shoulder and the control group, but there was a significantly higher prevalence of diabetes in males and a trend for higher prevalence in females in the frozen shoulder group.

Conclusions: Physicians should be aware that diabetes is a specific risk factor for idiopathic frozen shoulder in both males and females and thyroid disorders are a non-specific risk factor in females only.