Israel Medical Association Journal

Background: The impact of the coronavirus disease 2019 (COVID-19) pandemic on patient populations can be divided to direct consequences of the disease and indirect implications of changes imposed on the national healthcare systems. The impact of the later survival of chronic hemodialysis patients is still unknown.

Objectives: To examine the impact of quarantine on health outcomes of dialysis patients.

Methods: In a retrospective case-controlled study, we compared chronic hemodialysis patients from two separate timeframes: during a quarantine period and a parallel time without quarantine.

Results: The study included 344 hemodialysis patients. Baseline characteristics were compared between those enrolled in 2015 and those enrolled in 2020. Despite comparable clinical parameters, a statistically significant increase in the 6-month mortality rate was observed in 2020 (1.2% vs. 6.7%, P = 0.01), primarily attributed to sepsis. Notably, no deaths were attributed to COVID-19 in 2020. Interdialytic weight gain and dialysis quality remained similar between the two groups, with a mild trend toward excessive weight gain in 2020. Secondary outcomes after 6 months did not significantly differ, except for lower sodium values in 2015 compared to 2020.

Conclusions: Dialysis patients experienced disproportionate effects from the COVID-19 pandemic, even with continuous care and no direct virus-related fatalities. The findings showed unintended consequences of quarantine measures, highlighting adverse impact on both physical and mental health. Recognizing and addressing these consequences are imperative for minimizing their impact in future pandemics, emphasizing the importance of proactive measures in healthcare planning.

Background: Dermatofibrosarcoma protuberans (DFSP) is a rare, locally aggressive, soft-tissue sarcoma. The treatment is surgical and includes wide local excision (WLE) or Mohs micrographic Surgery (MMS). There is no consensus regarding the preferred type of surgery.

Objectives: To compare the outcomes of the two types of surgery (WLE and MMS).

Methods: This retrospective cohort study was based on the medical records of 59 patients with DFSP treated at Sheba Medical Center (using the WLE method) or Assuta Medical Center (using the MMS method) between 1995 and 2018. The data included demographics, clinical presentations, imaging, types of wound closures, pathological margin status, surgical defect sizes, recurrences, and follow-up.

Results: Of the 59 included patients, 18 (30.5%) underwent WLE and 41 (69.5%) underwent MMS. The mean age at diagnosis was 40.1 ± 14.4 years. The male-to-female ratio was 1.5:1. The main tumor location was the trunk (50% for WLE and 41.5% for MMS). The main type of closure for both procedures was primary closure. In 72.2% of WLE and 78.8% of MMS cases, the margins were free. The difference between the final surgical defect and the original tumor size was statistically significantly smaller in patients who underwent MMS. The median duration of follow-up was 6.6 years. There was no significant difference in the rate of recurrence.

Conclusions: MMS enables better tissue preservation and results in a minor surgical defect compared to WLE, with no difference in tumor recurrence between the two methods.

Background: One of the major causes of reversible visual impairment is a refractive error, which can be corrected through refractive surgery. Data regarding the outcomes and complications of these procedures exist; however, there is a notable gap in understanding the factors leading to patient rejection, particularly in diverse populations like Israel.

Objectives: To detect clinical risk factors of patients who intend to undergo LASIK procedure and to improve the conversion rates of LASIK procedure in this population.

Methods: The study included a retrospective analysis of patients who were rejected from having refractive surgery in two Enaim Refractive Surgery Centers: Jerusalem and Tel Aviv. Comparisons between centers were conducted using the t-test for continuous variables and Fisher's exact test for categorical data.

Results: Our study included 337 patients who were rejected from having refractive surgery, including 152 (45.1%) who were rejected permanently and 185 (54.9%) rejected temporarily. The most common reasons for permanent rejection were corneal irregularity (n=81, 53.3%), keratoconus (n=27, 17.8%), thin corneas (n=13, 8.6%), and amblyopia (n=10, 6.6%). The most common temporary reasons were unstable refraction (n=96, 51.9%), prolonged use of contact lenses (n=54, 29.2%), and corneal irregularity (n=16, 8.6%).

Conclusions: The leading permanent cause of rejection for refractive surgery was a corneal irregularity, whereas the primary temporary cause was unstable refraction. In a time of rapid technological advancements and growing demand for freedom from glasses, there is an increasing need for more informed and patient-focused refractive correction approaches.

Takotsubo cardiomyopathy (TC) is a temporary and reversible hypokinesia of the left ventricle's apical area of the heart mediating systolic abnormality. This phenomenon resembles myocardial infarction but without coronary artery disease (CAD) [1]. The prevalence is 1.0–2.5% annually. Most of the patients with TC are postmenopausal women [2]. Over-stimulation of the sympathetic system, microvascular and myocardial tissue metabolism abnormality, and coronary artery vasospasm are linked to TC [2]. The criterion of the diagnosis consists of temporary hypokinesis or akinesis in left ventricle segments with or without apical involvement, electrocardiogram (ST-segment elevation and/or T-wave inversion), or significant elevation of serum cardiac troponins and non-existence of pheochromocytoma or myocarditis [3]. The pathognomonic finding of TC during echocardiography is apical ballooning involving the left ventricle. This unique morphology was reported to present in 75% of patients [2,3]. In 25% of patients. The morphology was reported to follow a mid-ventricular ballooning pattern due to mid-LV akinesis with no disturbance of apical and basal contraction [2,3].

Almost three-quarters of a century ago an American surgeon named Frederick Edward Mohs, had the idea of excising skin cancers and examining the margins before the closure of the surgical wound. In this manner he thought the patient would get better treatment with the best cosmetic result.

Mohs micrographic surgery (MMS) in its present format has been used as a surgical method for treating skin cancers for the last 70 years. The method became popular with American dermatologists 54 years ago when the original Mohs technique was modified into its fresh tissue modality [2] and in the rest of the Western world and Israel more than 35 years ago. Variations of MMS started to appear and indications for surgery also expanded. At the beginning, MMS was indicated mainly for basal and squamous cell carcinomas–nonmelanoma skin cancers (NMSC). Knowledge has been collected and today the method is applicable for a variety of other skin cancers such as melanoma in situ, microcystic adnexal carcinoma, dermatofibrosarcoma protuberans (DFSP), and other adnexal and spindle cell tumors. In this issue of the Israel Medical Association Journal (IMAJ), Landov and colleagues [3] showed the value of MMS for the treatment of DFSP.

Letter 1: "Not type 2" by Moti Ravid 

Letter 2: "Hyponatremia, hyperkalemia, and acute kidney injury: clues for the diagnosis of uroperitoneum in patients with new-onset ascites" by Zvi Ackerman and Samuel N. Heyman, 

Letter 3: "Surgery in Mauthausen Concentration Camp" by George M. Weisz

Background: The massive terrorist attack on a mixed population of civilians, soldiers, and foreigners on October 7, 2023, resulted in 1200 casualties and led to many major personal identification issues. At the Israel National Center for Forensic Medicine (INCFM), addressing the mass casualty incidents required precision that included technical, ethical, and humanitarian dimensions. Many obstacles arose that were attributable to the vast number and diversity of victims and the heavy workload in the setting of a small forensic team.

Objectives: To define the various methods utilized for victim identification.

Methods: The different types of identification were visual, primary, and circumstantial. Primary methods compared unique and stable characters of the human body, including fingerprints, comparisons of dental data, X-rays, and medical databases. We implemented other methods (anthropology, genetics) and novel creative strategies (digital photography taken by random individuals using mobile phones) and computed tomography (CT) scan at another designated site other than at the INCFM.

Results: Often, visual recognition and extraction of DNA were impossible because of burnt human remains. Hence, a comparison method of antemortem and postmortem CT findings became imperative for many unidentified victims. The more complex cases included the finding of body parts of more than one individual in different body bags (comingled remains). In such situations, we matched the body parts by utilizing DNA methods. We present seven case challenges.

Conclusions: We utilized various known and novel methods for victim identification in the aftermath of the events of 7 October 2023 while addressing ethical issues in a case series.

Background: Military medicine has evolved significantly over the past 50 years, advancing from basic treatments and limited evacuations to sophisticated combat casualty care. Innovations such as hemorrhage control, early blood product administration, and telemedicine have greatly improved battlefield care. Rapid evacuation systems and skilled medical teams have reduced mortality and morbidity rates.

Objectives: To review the transformation of the Israel Defense Forces Medical Corps (IDF-MC) in combat casualty care over the past 50 years, focusing on recent applications during the Iron Swords war.

Methods: Data were collected from the personal experiences of IDF-MC doctors, IDF archives, and relevant military medical literature, with an emphasis on life-saving strategies, personnel, equipment, mental health support, and civil–military cooperation.

Results: Rapid evacuation and immediate care have improved survival rates, while increased front-line deployment of medical staff has enhanced response capabilities. Modern medical tools and techniques, such as tourniquets and blood products, have been widely adopted. Improved psychological support strategies ensure better mental health outcomes for soldiers. Enhanced coordination with civilian trauma systems optimizes care and resource allocation, leading to more efficient and effective casualty treatment.

Conclusions: The IDF-MC's advancements in rapid evacuation and front-line medical support have significantly improved combat casualty outcomes. Continued innovation and collaboration with civilian systems are essential for further progress in military medicine. Future technological advancements are anticipated to further enhance military medical care.

On 7 October 2023, the Hamas terror organization launched an unprecedented terror attack on Israel. Their forces infiltrated the country from the Gaza Strip invading nearby kibbutzim (collective farm settlements) and towns. During the attack an estimated 1200 Israelis were murdered and another 255 taken hostage, including children and older people, women and men.

Background: The Agatston coronary artery calcium (CAC) score is a decision-guiding aid for risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease.

Objectives: To explore the real-life clinical experience of CAC testing by characterizing its indications, significance of scores, and corresponding lipid-lowering treatments.

Methods: A retrospective descriptive study of patients treated at the lipids clinic at Rabin Medical Center (Beilinson Campus), who underwent CAC score evaluation between 2017 and 2022 was conducted. The data collected from electronic medical files included demographics, co-morbidities, indications for the test, CAC score levels, and the recommended therapeutic regimen.

Results: The study cohort included 88 patients. The main indication was assessment of the existence of atherosclerosis in cases where there was no clear indication for lipid lowering treatment (65, 74%). In most patients, there was no evidence of atherosclerosis (CAC = 0 AU, n=30) or only mild disease (CAC=1–99 AU, n=35). As the CAC score increased, more patients were prescribed lipid lowering treatments, from very few prescriptions in those with a CAC score of 0 AU and almost 100% among those with score of ≥ 400 AU. The factors that predicted CAC > 0 AU were male sex and older age.

Conclusions: CAC scores should be used more often to determine risk assessment. Further analysis of the implications of scores between 0–400 AU is needed.

Nasopharyngeal angiofibromas represent a rare occurrence. They are characterized by vascular fibrous proliferation within the nasopharynx. While histologically benign, they exhibit a local aggressiveness, predominantly afflicting adolescent males. Despite their typically nasopharyngeal location, the exact etiology remains elusive.

Microscopically, angiofibromas manifest as a combination of vascular elements, featuring slit-like capillaries or dilated branched vessels, in addition to a stromal component comprising collagenous matrix and fibroblasts.

To the best of our knowledege, we presented the first documented example of an extra-nasopharyngeal angiofibroma in an adult male, which presented with a distinctive histologic pattern of epithelioid fibrous papule. Clinical manifestations included left-side aural fullness and gradual hearing loss over the course of 5 years. Examination revealed a mass within the left external auditory canal tethered to the posterior wall by a stalk. The audiometric assessment revealed a moderate to severe conductive hearing impairment in the left ear. Surgical excision of the mass was performed, with subsequent histopathological and immunohistochemical analysis unveiling this unforeseen diagnosis.

In this case report, we underscored the potential for angiofibromas to occur in atypical anatomical sites and highlighted the importance of recognizing their benign nature to prevent misdiagnosis as malignant tumors.

Background: Cloacal malformation represents the rarest and most complex congenital anorectal malformation in females and is characterized by the convergence of urinary, gynecological, and intestinal systems within a single common channel. Three-dimensional computed tomography reconstruction (3D CT cloacagram) has emerged as a valuable method for anatomical assessment and preoperative planning.

Objectives: To evaluate our experience with 3D CT cloacagram and assess its results.

Methods: This retrospective case series included all patients with cloacal malformation who underwent preoperative 3D CT cloacagram at a single institution during 2019–2023. Collected data included patient characteristics, timing of the 3D CT cloacagram, results of the 3D CT cloacagram, comparison with endoscopic results, surgical procedures, and postoperative outcome.

Results: Six patients with cloacal malformation were included in this study, including two with posterior cloaca. The median common channel length on 3D CT cloacagram was 24.5 mm (range 9–48 mm) and the median urethral length was 15.5 mm (range 13-24 mm). The surgical approach involved a combined abdominoperineal approach in three patients and posterior sagittal anorectal vaginal urethral plasty in one patient. Two patients were awaiting surgical reconstruction at the time of publication.

Conclusions: Our implementation of 3D cloacagram has facilitated precise measurements of both the urethra and common channel lengths, two key factors in formulating surgical strategies for cloacal reconstruction. Moreover, this technique has markedly improved our capacity for surgical planning contributing to colorectal, gynecological, and urological perspectives.

Background: Clinical toxicology is not a certified specialty in Israel, consequently there are a limited number of toxicologists and toxicology services available for consultation.

Objectives: To establish a medical toxicology consultation service focusing on bedside consultations, which had not previously been available in Israel.

Methods: This single-center, retrospective chart review of toxicology consults was conducted during the first years after the initiation of a new toxicology service.

Results: From September 2017 to December 2021, 1703 toxicology consultations were conducted. The most common exposures and reasons for consultation included psychotropic medications (427, 23%), analgesics and anti-inflammatory medications (353, 19%), household products (312, 17%), substances of abuse (240, 13%), and natural toxins (142, 8%). Bedside medical toxicology consultations were performed in 1036 cases (62%) during daytime and night shifts. The number of consultation requests increased steadily over the study period.

Conclusions: The new toxicology service led to a significant change in the institution’s approach to toxicological patients. A bedside toxicology service could help reduce the healthcare burden on national poison centers and can offer readily available, personalized, medical toxicology care.

In this case report, we elucidated the complex etiology of new-onset ascites through the unusual presentation of a 32-year-old female with abdominal swelling, oliguria, and acute renal failure. This patient's ascites was attributed to urinary bladder rupture, a rare but critical consideration in differential diagnoses. Highlighting the significance of this case, bladder rupture without recent trauma history, especially post-gynecological surgery, poses a diagnostic challenge due to its rarity and potential for severe morbidity and mortality if not promptly recognized and managed. Our patient's journey, from initial symptoms to the eventual discovery of bladder rupture, underscores the necessity of considering this diagnosis in similar clinical scenarios. The case uniquely demonstrates pseudo-renal failure, a phenomenon resulting from reversed dialysis across the peritoneal membrane, which further complicated the diagnostic process.

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.