Israel Medical Association Journal

Spinal stenosis is a progressive degenerative condition characterized by the narrowing of the spinal canal, leading to compression of the spinal cord and nerve roots [1]. While commonly associated with aging, it can also develop following traumatic injuries that induce structural damage and chronic inflammation and contribute to canal narrowing [1]. Although spinal stenosis is primarily linked to neurogenic claudication, emerging evidence suggests that it may also impact respiratory function, particularly when it involves the cervical and thoracic spine [2].

We evaluated a 77-year-old male with a longstanding history of spinal stenosis and exertional dyspnea. We explored the potential connection between his symptoms and underlying spinal pathology, particularly in the absence of cardiopulmonary disease.

Background: The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems globally, affecting chronic disease management like osteoporosis and the prevention of fragility hip fractures. We hypothesized that it led to suboptimal prevention of secondary femoral neck fractures, reduced treatment frequency, and delayed treatment initiation.

Objectives: To evaluate the treatment initiation rate for secondary prevention of femoral neck fractures, comparing pre-COVID-19, COVID-19, and post-COVID periods, considering patient demographics.

Methods: This retrospective diagnostic cohort study used automated electronic medical records database from Clalit Health Services. Data regarding patients with hip fractures from January 2017 through September 2021 were extracted from the database. Treatment for osteoporosis included one of the following treatments: alendronate, risedronate, zoledronate, abaloparatide, denosumab, romosozumab, and teriparatide. The primary outcome variable in the study is the time taken to initiate appropriate therapy for the secondary prevention of femoral neck fractures.

Results: Treatment frequency decreased over time, with rates declining from 40.4% in 2019 to 33.5% in 2021 (P-value < 0.05). However, the percentage of prompt care management (within 3 months) increased between 2020 and 2021 (47.3%–62.5%) and between 2019 and 2021 (48.7%–62.5%), P < 0.05.

Conclusions: The COVID-19 pandemic reduced the rate of appropriate treatment initiation following hip fractures. However, adherence to timely treatment within 3 months of the fracture has improved. The findings highlight the effectiveness of the health system response in managing crises and ensuring the timely delivery of critical treatment.

Background: After the Nazi regime seized power, the only place where Jewish medical students were allowed to conduct their practicum in Germany were the Jewish hospitals.

Objectives: To identify the Jewish students who, during summer 1933 and later, conducted their practicum and wrote their medical dissertations in the Jewish hospitals, and to identify their tutors.

Methods: We examined the dissertations at the medical faculty of Berlin that were conducted from the summer of 1933 until the autumn 1937, identifying the students who did their practicum at Jewish hospitals and stood for the MD examination.

Results: In total, 29 Jewish students finished their medical practicum and wrote their dissertations either in the Jewish hospitals of Berlin or in other Jewish hospitals outside the capital city after April 1933. Only five of those studies were presented to the MD examination signed by their Jewish tutors. The remaining 24 works were submitted and signed by an Aryan professor. In 10 of those last studies, the names of the Jewish tutors could be uncovered.

Conclusions: The Jewish hospitals of Berlin continued their academic activity even after being ejected from Berlin hospital's medical faculty body in April 1933. At that time most of the studies dealt with surgery and gynecology. In most cases the studies were submitted for the MD examination by proxy and signed by an Aryan professor.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are established treatments for peritoneal metastasis from colorectal cancer (PM-CRC). The peritoneal carcinomatosis index (PCI) measures disease burden.

Objectives: To evaluate the effect of PCI on short- and long-term outcomes of patients with PM-CRC who underwent CRS-HIPEC.

Methods: We retrospectively analyzed 120 PM-CRC patients who underwent CRS-HIPEC, categorizing them into four PCI groups (PCI ≤ 3, PCI 4–6, PCI 7–11, PCI >11). We evaluated perioperative outcomes and long-term survival.

Results: Higher PCI scores were associated with increased surgical complexity, longer operative times, more organ resections, and higher blood transfusion requirements. Complete cytoreduction was achieved in 100% of the PCI ≤ 3 group, but only in 70.8% of the PCI > 11 group (P = 0.001). Postoperative outcomes showed a trend toward less major morbidity in low PCI patients (16.7% vs. 28%) and significantly shorter hospital stays (10–13 days vs. 19 days, P = 0.006). The 90-day mortality rate was 0% in the PCI ≤ 3 group compared to 11.5% in the PCI > 11 group. Long-term outcomes revealed significantly better disease-free survival (DFS) and overall survival (OS) for the PCI ≤ 3 group (DFS: 22 months vs. 4–6 months; OS: 79.6 months vs. 21–40 months, P < 0.001).

Conclusions: Patients with low PCI scores experience reduced morbidity and improved long-term survival, supporting the use of CRS-HIPEC in this subgroup. Further research is needed to enhance treatment strategies for patients with high PCI scores.

Background: Transcatheter aortic valve implantation (TAVI) has become the preferred therapeutic method for elderly patients presenting with severe symptomatic aortic stenosis (AS). Most TAVI procedures are performed in patients between 75–85 years of age. A few publications exist on TAVI in patients over 90 years, yet the outcome and complication rates are inconsistent.

Objectives: To identify all patients with AS who underwent TAVI between 2019 and 2020, specifically those age > 90 years at the time of the TAVI.

Methods: We reviewed the Maccabi Healthcare Services database for all severe/critical AS patients who underwent TAVI between 2019 and 2020, specifically those age > 90 years at the time of TAVI. These patients were compared to all patients aged 80–89 years who underwent TAVI during the same time. Follow-up ended on 31 December 2022. We compared mortality and complications rates in nonagenarians vs. those 80–89 years and evaluated the change in left ventricular ejection fraction before and after the procedure.

Results: We identified 36 nonagenarians who underwent TAVI during the study period, mean age 92.3 years, male:female ratio 15:21. During a mean follow-up period of 3 years, 44% of nonagenarians died, 26% of the control patients died (P < 0.01).

Conclusions: TAVI in nonagenarians is feasible. Total mortality during follow-up was significantly higher in nonagenarians. Overall complication rates were also higher in nonagenarians, mostly due to vascular complications. Left ventricular dysfunction appeared to improve after TAVI, even in nonagenarians.

Background: Carbohydrate counting (CC), a recommended method for managing insulin bolus in patients with Type 1 diabetes mellitus (T1DM), depends on patient cognitive ability and motivation, and often does not account for ethnic foods. We have developed a simplified, accessible, patient-specific carbohydrate counting tool (SCC) to serve our very diverse population.

Objective: To retrospectively evaluate the long-term efficacy of the SCC with an emphasis on patients with moderate to poor glycemic control.

Method: The SCC tool is tailored to each patient’s insulin:carbohydrate ratio (I:C), insulin sensitivity (IS), and dietary pattern. It includes two tables written in the patient's preferred language. The first lists the units of insulin needed to correct pre-meal blood glucose to target glucose. The second contains a list of food items derived from participant's personal eating habits, carbohydrate content, and the number of insulin units needed.

At a median follow-up period of 6 months, we examined the change in hemoglobin A1c (HbA1c) in 212 patients with T1DM who utilized the SCC.

Results: At follow-up, HbA1c in the study population decreased by 1.07% (22.43 mmol/mol) (95% confidence interval 0.8–1.3, P < 0.001). The variables sex and diabetes duration were nearly statistically significant in relation to the change in HbA1c levels (P = 0.059, P = 0.056).

Conclusions: While not influenced by age, sex, ethnicity, socioeconomic status, education, insulin delivery method, duration of diabetes, or residence, the SCC tool is designed to help adult patients with T1DM with moderate to poor glycemic control.

Background: Studies have shown that approximately half of the female population may experience some degree of pelvic organ prolapse (POP) during their lifetime, although only 3–6% report symptomatic prolapse.

Objectives: To evaluate the clinical and adverse outcomes associated with transvaginal repair using partially absorbable lightweight polypropylene Seratom PA MR MN® mini mesh for enhanced apical support in the treatment of advanced POP.

Methods: A retrospective study was conducted on 114 patients who underwent transvaginal repair with the Seratom partially absorbable lightweight polypropylene mini mesh between August 2013 and January 2016. Data collected included demographic, surgical, adverse symptoms, and anatomical characteristics assessed via the modified Pelvic Organ Prolapse Quantification system (POP-Q). Postoperative pain was assessed using the Visual Analog Scale.

Results: Significant improvements were observed in POP-Q measurements (P-value < 0.001). Subjective outcomes demonstrated significant pre- to 4-month postoperative reductions in urinary stress incontinence and overactive bladder (P < 0.001). No cases of mesh erosion were reported. Immediate complications included bleeding (3.5%), fever (1.7%), and urinary obstruction (0.9%). The recurrence rate was 12.3%. Patient satisfaction scores were consistently high, with an average of 95.96% at 1 month, 94.73% at 4 months, and 91.33% at the most recent follow-up.

Conclusions: Transvaginal repair with the Seratom PA MR MN® partially absorbable mini mesh demonstrated significant improvements in anatomical and subjective outcomes, with few complications, and low recurrence rates. Further studies are necessary to validate these outcomes and optimize patient selection.

Background: Flumazenil has been available since 1991 for the treatment of acute benzodiazepine overdose, yet many physicians remain reluctant to use it.

Objectives: To evaluate the frequency of flumazenil use for benzodiazepine overdose at a large, urban, tertiary care center. To assess its effectiveness and associated adverse events.

Methods: The study was conducted in an emergency department with approximately 220,000 annual visits. Medical records of patients who received a medical toxicology consultation and were treated with flumazenil between 1 January 2019, and 31 December 2023 were reviewed. Data collected included patient demographics, medical history, substances involved, presence of seizures, indications for flumazenil use, clinical response, and adverse effects.

Results: Of 263 patients evaluated for suspected benzodiazepine overdose and referred to medical toxicology, 79 received flumazenil and comprised the study cohort. Among them, 64 cases involved intentional overdose. Indications for flumazenil administration included severe overdose with impaired consciousness and ventilatory failure (37 patients) or without ventilatory failure (42 patients). Co-ingestion of tricyclic antidepressants was documented in 4 patients and other antidepressants or antipsychotics in 35. Clinical improvement, including enhanced consciousness and/or reduced need for mechanical ventilation, was observed in all 79 patients. No adverse effects, including seizures, were reported.

Conclusions: In this retrospective cohort, flumazenil was administered without serious adverse events and was associated with improved alertness and ventilation. While caution is required, particularly in mixed overdoses, flumazenil may have a role in managing benzodiazepine-induced respiratory depression when guided by toxicology consultation.

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.

Thromboangiitis obliterans, also known as Buerger’s disease, is a nonatherosclerotic inflammatory disorder that predominantly involves the small- and medium-sized arteries, veins, and nerves. This condition primarily affects the extremities. Manifestations in other anatomical locations are exceptionally rare. It is almost exclusively seen in relatively young smokers, with an incidence rate of 12.6 per 100,000 individuals in the United States [1].

Tobacco smoking is the most significant risk factor for thromboangiitis obliterans. It plays a crucial role in both the initiation and progression of the disease. Patients typically present with ischemic symptoms resulting from occlusion of the small vessels in the extremities, whereas other symptoms are infrequent [1,2].

The diagnosis is mainly clinical, requiring a history of smoking, characteristic physical findings, and vascular abnormalities observed on imaging. Biopsy is seldom necessary for diagnosis, and smoking cessation remains the sole effective intervention to prevent disease progression [1,2].

In this report, we present the clinical course and surgical management of a 57-year-old male patient with a colonic mass that was histopathologically diagnosed as thromboangiitis obliterans.

Eosinophils are mature myeloid-derived cells, defined by the presence of prominent secondary granules [1]. In peripheral blood, the normal upper limit of absolute eosinophil count (AEC) ranges from 350 to 500 cells/µL. Eosinophilia is defined as an AEC exceeding 500 cells/µL, while hypereosinophilia is characterized by an AEC greater than 1500 cells/µL confirmed on at least two separate occasions [1,2].

Hypereosinophilic syndrome (HES) is defined by the presence of hypereosinophilia accompanied by organ damage or dysfunction attributed to eosinophilic infiltration in the absence of an alternative identifiable cause [1].

Eosinophilia may arise from a broad spectrum of conditions and is generally categorized as either primary (clonal) or secondary (reactive). Primary eosinophilia typically results from myeloid malignancies, whereas secondary eosinophilia is most commonly associated with allergic disorders, helminth infections, drug hypersensitivity reactions, rheumatologic disorders, and, less frequently, paraneoplastic phenomenon [1,3].

Lactation ketoacidosis (LA) is a well-documented phenomenon in cows, known as bovine ketoacidosis. It occurs when there is a negative energy balance because of a high glucose demand for milk production. LA in humans is rare, although the first case was reported in 1982 [1] and several cases have been reported in recent years. In most cases, there is a recognizable precipitating factor, often fasting or consuming a low calorie or low carbohydrate diet. However, a case of recurrent LA with no apparent trigger has also been reported [1]. In most cases the patients were euglycemic on presentation; however, hypoglycemia had been reported [2]. In this study, we present a case of LA and hypoglycemia on presentation with an unexpected striking hyperglycemia after treatment with dextrose.

Tracheobronchial injuries (TBI) are rare but potentially fatal complications of blunt thoracic trauma. Recent literature supports conservative management in selected stable cases. In this study, we describe the case of a pediatric patient with a tracheal tear that was managed successfully without surgical intervention.

In hemodynamically stable pediatric patients, even high-grade tracheal injuries may be managed conservatively with close intensive care unit (ICU) monitoring. Early multidisciplinary evaluation is essential.

TBI following blunt trauma is an uncommon but life-threatening condition, particularly in children. Blunt trauma accounts for approximately 94% of TBIs in pediatric cases, in contrast to penetrating trauma which predominates in adults [1]. Management options are typically guided by injury classification, such as the (American Association for the Surgery of Trauma [AAST] Grade III, Cardillo Level IIIA). Non-operative treatment may be appropriate in specific stable cases even in high-grade injuries, as illustrated in former literature [2,3].

Genitourinary syndrome of menopause (GSM) has gained increasing attention in recent years, with growing literature on its pathophysiology, clinical presentation, and treatment options. A bibliometric analysis helps identify high-quality research based on citation rates and journal impact factors. In this review, our objective was to analyze the key themes and topics in GSM literature. We conducted a bibliometric analysis using the Thomson Reuters Web of Science database to identify the top 100 most-cited articles on GSM published over the past 50 years. Data were categorized into manuscript type, theme, author, country of origin, journal impact factor, and citation rate. The mean citation count per article was 67, ranging from 405 to 5. The most-cited paper, authored by the North American Menopause Society, had the highest citation rate of 45.0 citations per year. The majority of articles (n=65) were published between 2010 and 2019. Randomized controlled trials comprised the largest publication type (29%). Most articles (n=65) were published in Q1-ranked journals. Although GSM is a relatively recent concept, the most-cited articles from the past 50 years generally focus on its medical and surgical treatments, as well as its epidemiology. This bibliometric analysis is the first to evaluate the top 100 most influential publications on GSM.