Israel Medical Association Journal

Background: Pediatric urinary tract infections (UTIs) are a significant health concern, with rising antibiotic resistance complicating treatment decisions. We investigated pathogen distribution, antibiotic susceptibility patterns, and the cost-effectiveness of treatment options among hospitalized children at a tertiary medical center in Israel.

Objectives: To assess antibiotic susceptibility patterns of UTI pathogens in hospitalized children and evaluate cost-effective alternatives to gentamicin.

Methods: A retrospective analysis of 1649 pediatric UTI cases (January 2010–May 2022) at Galilee Medical Center examined patient demographics, urine culture results, and antibiotic susceptibility. A cost-effectiveness analysis was performed using incremental cost-effectiveness ratios (ICERs), based on susceptibility rates from the study and antibiotic costs from the Israel Ministry of Health, with gentamicin as the comparator.

Results: Escherichia coli was the most common pathogen (63.7%). High susceptibility rates were observed for carbapenems and amikacin (> 99%), with lower rates for gentamicin (91.7%) and ceftriaxone (87.6%). Treatment costs ranged from US$2.54 (trimethoprim/sulfamethoxazole) to US$307.80 (ertapenem). Fosfomycin demonstrated higher susceptibility than gentamicin (94.2% vs 91.7%) and lower cost (US$3.77 vs US$8.05), dominating gentamicin in cost-effectiveness analysis. Piperacillin/tazobactam and ceftriaxone were dominated by gentamicin in terms of cost-effectiveness.

Conclusions: E. coli was the predominant pathogen in pediatric UTIs among hospitalized children. Carbapenems and amikacin showed high susceptibility but were costly. Fosfomycin demonstrated high susceptibility, favorable cost-effectiveness, and the advantage of oral administration, making it a promising option for empiric treatment. Empiric antibiotic selection should integrate susceptibility patterns, clinical context, and economic considerations.

Background: The correlation between epidural analgesia and successful Trial of Labor After Cesarean delivery (TOLAC) remains controversial.

Objectives: To explore this correlation considering the indication for previous cesarean section (CS).

Methods: We accessed an electronic database of an obstetrics department at a university tertiary medical center. All patients admitted for a TOLAC at term with a live singleton fetus with cephalic presentation between January 2015 and December 2021 were included. The primary outcome was the mode of delivery, based on the previous CS indication. Univariate and multivariate analyses were performed to identify the effect of epidural analgesia on TOLAC success.

Results: Overall, 1522 candidates for TOLAC were included, with previous CS due to arrest of descent in 261 cases (17.1%). Epidural analgesia was administered in 1098 deliveries (72.1%), and 282 women (18.5%) underwent a repeat CS. Women in the epidural group were younger, had higher body mass index, lower parity, and more frequent induction of labor. Prior vaginal birth after cesarean was more common in the non-epidural group. Univariate analysis showed a higher rate of epidural analgesia in repeat CS cases. However, in multivariable logistic regression, epidural analgesia was not significantly associated with the risk of repeat CS, both among women whose prior CS was for arrest of descent and among those with other indications.

Conclusions: The employment of epidural analgesia seems to have no observable influence on successful outcomes of TOLAC, regardless of the indication for the preceding CS. These findings imply that epidural anesthesia in TOLAC is safe.

Background: Out-of-hospital cardiac arrest (OHCA) poses a considerable health burden and offers poor prognosis. Information about OHCA in Israel is scarce.

Objectives: To present a pilot registry of prehospital and in-hospital characteristics of patients with OHCA.

Methods: A descriptive study was conducted of consecutive adult patients with OHCA treated in the field by Magen David Adom (MDA) paramedics and treated at the Sheba Medical Center.

Results: The study included 99 patients with OHCA who were brought by MDA to the Sheba Medical Center. The median age was 79 years (IQR 67–89(, 61% were male. In total, 69% of the events occurred at home, 16% at nursing facilities, 10% on streets, and 2% in public buildings. Most events (80%) were witnessed. Bystander-basic life support (BLS) was administered to 28%, 45% received BLS from an emergency medical service first responder. Automated external defibrillation was used in 40% of cases. In our cohort, 51 patients (51%) survived initial treatment in the emergency department (ED) and were hospitalized. Electrocardiography at arrival demonstrated ST-elevation in 22% of cases. Coronary angiography was performed in 19% (n=19) of patients, and 12% (n=12) underwent percutaneous intervention. Eventually, 26 patients (26%) survived to discharge with a Cerebral performance categories were as follows: 13% (n=13) with good cerebral performance, 10% (n=10) with moderate disability, and 3% (n=3) with severe disability or unconscious.

Conclusions: Among those admitted after surviving ED resuscitation, half survived to discharge. Most of those who survived hospitalization and were discharged with good neurological performance were young males.

Background: Locally advanced gastric adenocarcinomas are treated with neoadjuvant chemotherapy, surgery, and adjuvant chemotherapy. Since 2019 the standard of care for perioperative chemotherapy has been FLOT protocol. Concerns regarding the use of FLOT in elderly patients ≥ 65 years of age emerged due to the relatively high toxicity of this protocol.

Objectives: To evaluate the toxicity profile of FLOT and clinical outcome in elderly patients.

Methods: We conducted a retrospective analysis of patients with locally advanced gastric adenocarcinomas treated with FLOT between 2017–2023 at the Sheba Medical Center. The cohort was stratified by age (≥ or < 65 years). The primary outcome was overall survival (OS). Secondary outcomes were treatment-related toxicity. Kaplan-Meier analysis and Cox proportional hazard regression model were used to analyze the effect of exposure variables on OS.

Results: The study cohort included 91 patients. The median age was 60 years (IQR 50–67); 32 patients were included in the ≥ 65 years group, and 59 patients were included in the < 65 years group. Median follow-up was 40 months (IQR 17–58). Patients ≥ 65 years old received fewer cycles of FLOT compared to those < 65 years old (4.5 vs. 7 cycles, respectively, P = 0.03). Despite the difference in treatment intensity and cumulative chemotherapy dose, there was no difference in median OS between patients ≥ 65 years old compared with those < 65 years old (P = 0.68).

Conclusions: Elderly patients with locally advanced gastric adenocarcinomas received fewer cycles of perioperative FLOT without compromising clinical outcomes.

Ventriculoperitoneal shunt (VPS) placement is a standard treatment for pediatric hydrocephalus. However, infection remains a significant complication, occurring in 5–27% of cases, with coagulase-negative staphylococci (CONS) and Staphylococcus aureus being the most common pathogens [1]. Current guidelines recommend empirical antibiotic treatment and surgical removal of the infected shunt [2]. While shunt removal and replacement are recommended for managing shunt infections, these procedures subject the child to the risks associated with multiple surgeries. However, recent approaches have suggested that in certain cases antibiotics alone may suffice, thus avoiding the risks of surgery [3].

We describe two children with VPS infections caused by CONS who were successfully treated with vancomycin and rifampicin alone, without the need for shunt removal.

The Lancet Commission on Medicine, Nazism and the Holocaust was published in November 2023, recognized the potential dangers for the medical profession that are echoed in this history. The tragic events on 7 October 2023 have revealed just how timely and important the Commission's publication is and have raised the question of the relevance to the Holocaust to this attack. One of the continuities from this past and which has dangerous implications for current medicine, is antisemitism. Examination of the antisemitism inherent to medical education in Nazi Germany raises the question of antisemitism in current academia. Since October 7th there has been a drastic rise in antisemitism and antisemitic actions in both the academy and in medicine. We have seen outright refusal to condemn the brutal perpetrators of the October 7th massacre and continue to observe explicit support for the perpetrators from both faculty and students. Medicine, a profession whose foundational tenet is the well being of humanity–all humanity–and that hallows moral clarity, cannot allow for antisemitic speech and actions to exist within the profession. Awareness and education on this history is crucial for the medical profession so that the tragic events of the past do not happen again.

Background: The management of chronic hepatitis C virus (HCV) infection in patients with concurrent severe mental illness and substance use disorder poses significant challenges to treatment initiation, adherence, and completion. Multiple barriers impede successful treatment outcomes in this population, including cognitive impairments associated with mental illness, ongoing psychoactive substance use, and inadequate social and environmental support systems.

Objectives: To implement a treatment program for HCV-infected patients during their psychiatric hospitalization. To establish a multidisciplinary task force comprising a hepatologist, psychiatric ward team (psychiatrists, nurses, social workers), and a project administrator.

Methods: We conducted a retrospective cohort study of patients hospitalized with dual diagnosis (DD) of severe mental illness and substance use disorder who tested positive for HCV antibodies. Patients underwent clinical evaluations and received treatment with direct antiviral agents during hospitalization under the supervision of the joint team. Demographic and clinical characteristics were analyzed.

Results: Between January 2018 and June 2023, 694 DD patients were hospitalized, of whom 119 tested positive for HCV antibodies (prevalence 17.1%). Twenty-seven patients (23%) completed treatment; 17 (63%) achieved confirmed sustained virologic response. Treatment discontinuation occurred primarily post-discharge from the mental health facility. Significant efforts were made to engage community caregivers to maintain continuity of care.

Conclusions: Our findings demonstrate that treating HCV in patients with concurrent severe mental illness and substance use disorder requires collaborative efforts across medical disciplines. This integrated approach during psychiatric hospitalization provides a unique opportunity for initiating and monitoring HCV treatment in this complex patient population.

Methotrexate, a folate analog antimetabolite, is one of the oldest cytotoxic drugs still in use. It is active against a variety of malignancies including bladder and breast cancer, head and neck tumors, gestational choriocarcinoma, osteogenic sarcoma, lymphomas, and leukemias.

Methotrexate is given mostly intravenously (IV), usually at standard doses (milligrams). It can also be delivered in much higher doses (grams), which is known as high-dose methotrexate (HDMTX). The intrathecal (IT) route is used particularly in children with acute lymphoblastic leukemia (ALL) and in adults with meningeal carcinomatosis. The drug may be administered orally as well, mainly in non-oncological conditions such as rheumatoid arthritis and other autoimmune diseases.

Immune thrombocytopenia (ITP), driven by autoantibodies targeting platelet antigens, is an acquired disorder posing considerable challenges, particularly in pregnancy, where its prevalence escalates to 1–3 per 10,000 women, a tenfold increase compared to the general population [1]. Predominantly characterized by a heightened risk of bleeding, particularly during pregnancy, the incidence of significant hemorrhagic events stands at approximately 18%, mostly non-severe [1]. Despite its rarity, thrombosis can manifest as a complication, especially when accompanied by antiphospholipid antibodies, which amplify the propensity for arterial and venous thrombotic events alongside obstetric complications and thrombocytopenia [2,3].

In this case report, we present the case of a young female with primary unexplained infertility, complicated by ITP and antiphospholipid syndrome (APS), predisposing her to increased bleeding and thrombotic risks. During a multidisciplinary consultation, the medical staff navigated the intricate landscape of fertility treatments and pregnancy options, carefully considering the delicate balance between risks and benefits to optimize patient outcomes.

A 70-year-old female with a 10-year history of dermatomyositis involving the skin, muscles, and gastrointestinal system was diagnosed based on proximal muscle weakness, typical dermatomyositis-specific rashes, elevated creatine kinase, and muscle biopsy findings consistent with dermatomyositis. Myositis-specific autoantibodies were negative.

The patient initially received treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) but experienced gastrointestinal intolerance to both methotrexate and azathioprine. Subsequently, she was managed with intravenous immunoglobulin (IVIg) for 4 years; however, due to a relapse of muscle involvement, rituximab was initiated and has been administered for the past 3 years.

Over the last year, the patient achieved remission in muscle involvement but experienced worsening dermatomyositis-specific skin manifestations, including heliotrope rash, Gottron signs, and holster sign [Figure 1A], accompanied by severe pruritus that significantly impaired her quality of life. The Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) activity score reached 17. Her skin condition remained refractory despite treatment with topical steroids and calcineurin inhibitors.

Recent publications based on newly available list of surgeries performed in Nazi concentration camps raised the question of motivation for thousands of procedures on internees incarcerated from occupied Europe. The performance of major surgeries would be suspicious in their intent, indicating, if not directly proving, their intention as an exercise for junior physicians or medical students. The concept of the Revier (infirmary) is discussed. The Revier (also known as Krankenrevier or infirmary) in Nazi concentrations camps was located next to the extermination unit. Procedures performed at the Revier were considered non-therapeutic, as the victims had a minimal chance of survival without appropriate postoperative facilities. A review of medical documents of major concentration camps (Auschwitz, Mauthausen, Gusen, Ebensee) indicates the criminal intention of the authorities. This unusual type of crime was raised in post-war trials, but no specific legal code was nominated.

Obesity is a growing global health concern, with its prevalence contributing to the rise of multiple chronic conditions, including autoimmune diseases. In this review I explore the intricate relationship between obesity and autoimmunity, focusing on how excess adiposity can affect immune responses and promote the development of autoimmune disorders. Obesity alters adipose tissue architecture, promoting chronic low-grade inflammation and triggering the release of pro-inflammatory cytokines, which contribute to immune system dysregulation. Adipose tissue is no longer seen as merely an energy store but as an active endocrine organ that interacts with the immune system. The review delves into mechanisms such as the role of adipokines, altered T cell function, and the recruitment of immune cells to inflamed adipose tissue, which together exacerbate autoimmune risk in obese individuals. Genetic and environmental factors also play a critical role in these processes, as polymorphisms and high-fat diets have been shown to influence both obesity and autoimmune susceptibility. Last, the review explores potential therapeutic strategies, such as lifestyle interventions and targeting obesity-driven inflammatory pathways, which could mitigate autoimmunity. Understanding the connection between obesity and autoimmunity offers insights into more effective interventions for patients suffering from these intertwined conditions.

Plastic and reconstructive surgery is a specialty that has an important place in the surgical field. Plastic surgeons cooperate with all surgical disciplines to solve complex multidisciplinary surgical cases. This issue of the Israel Medical Association Journal (IMAJ) covers some of the groundbreaking treatments being performed by plastic surgeons in Israel.

The articles show the wide and complex range of issues where plastic surgery is needed, including hospital-based breast reconstructions, oncologic resections, and innovative lymphedema surgery, as well as aesthetic procedures. The efforts of plastic surgeons have been especially highlighted due to the Iron Swords war, which started on 7 October 2023. Injuries included complex burns and amputations that required attention under fire. In addition, advances were achieved through cutting‑edge reconstructive microsurgical traumatic solutions. Together, these articles highlight how Israeli teams have leveraged experience in trauma, high‑volume civilian and military caseloads and innovative inspirations that have generated knowledge that may be broadly applicable to surgeons worldwide.

During these challenging times, following the October 7th terrorist attacks and the ongoing Iron Swords war, there is a greater need to strengthen the Israeli Society of Plastic and Aesthetic Surgery. Prof. Josef Haik, chair of the Israeli Society of Plastic and Aesthetic Surgery, leads this effort. In addition, it is vital to highlight Israel's contributions to the global Plastic and Aesthetic Surgery community and to encourage collaboration with the nursing division for plastic surgery and burns. Our department is involved in presenting our findings and collaborating with colleagues. In this article, we outlined five main topics: the role of plastic surgery in wartime, reconstructive plastic surgery, aesthetic plastic surgery, microsurgery, and innovation in plastic surgery.

Background: Soft-tissue defects of the lower limb pose a reconstructive challenge. Soft tissue loss with exposed bone, tendon, or cartilage often requires free flap reconstruction. Dermal substitutes are used for treatment of extensive burns to replace damaged skin and may be ideal for lower limb reconstruction in selected cases.

Objectives: To present our experience with reconstruction of lower limb wounds using Integra® Bilayer Wound Matrix (Integra LifeSciences Corp., Plainsboro, NJ, USA) and MatriDerm® (MedSkin Solutions Dr. Suwelack AG, Billerbeck, Germany).

Methods: This single center retrospective study comprised 10 patients who underwent reconstruction of extensive tissue defects of the distal lower limbs with dermal matrices and split-thickness skin grafts.

Results: All patients were successfully reconstructed and resumed normal ambulation. Six patients had complete and four partial graft takes that was treated conservatively until full wound healing. Older patients with medical co-morbidities or history of wound infection were more likely to have partial graft take. One postoperative infection was recorded in the study.

Conclusions: Dermal substitutes are easy to apply and safe, show minimal donor site morbidity, provide good functional and aesthetic outcomes, and should be used for reconstruction of complex lower limb wounds.