INTRODUCTION:This issue of Harefuah presents scientific contributions from the clinical and research teams of Meir Medical Center, Clalit Health Services. Established in 1956, the center has evolved into a leading tertiary academic institution, providing advanced care to nearly one million residents. In recent years, Meir Medical Center has expanded significantly, with increasing clinical complexity, the development of centers of excellence, and a growing emphasis on innovation, including data-driven and artificial intelligence-based initiatives aimed at improving quality and patient safety. As an academic medical center affiliated with Tel Aviv University, it plays a central role in medical education and multidisciplinary research. The articles in this issue reflect a broad spectrum of clinical and scientific activity, highlighting the center's ongoing commitment to excellence, innovation, and advancing patient care.
BACKGROUND:Many mechanically ventilated intensive care unit (ICU) patients receive continuous infusion of intravenous opiates for pain relief and sedation. Upon cessation of these infusions to wean the patient from mechanical ventilation, withdrawal symptoms may ensue. For prevention, long-acting opiates, such as oral methadone or transdermal fentanyl, may be used. OBJECTIVES:To compare the number and intensity of agitation episodes, admission times, ventilation days, and the need for physical restraint between patients who received methadone vs transdermal fentanyl. METHODS:This retrospective study involves data retrieval from the computerized systems of patients who were admitted to the ICU at Meir Medical Center in Kfar Saba, Israel, between 2020 and 2022, and received either enteral methadone (49 patients) or a fentanyl patch (50 patients). RESULTS:No statistically significant differences were found between the groups in the number and intensity of agitation episodes, admission times, ventilation days, and physical restraint. A statistically significant difference was found in the need for agitation rescue drugs, which was higher in the methadone group. CONCLUSIONS:No drug had an advantage in most of the parameters measured, excluding the higher need for agitation rescue drugs in the methadone group. DISCUSSION:Data regarding fentanyl patches in ICU patients are scarce. Here, methadone did not have an advantage over fentanyl patch in admission or ventilation times and agitation prevention. Choice of therapy should therefore rely on other considerations, including ideal drug route and adverse effects. Methadone and fentanyl patch are equivalent in terms of agitation prevention, except for a higher need for agitation rescue drugs in the methadone group.
INTRODUCTION:Attention deficit hyperactivity disorder (ADHD) is a common neurodevelopmental disorder of unknown etiology, but it is likely related to an impairment in the brain's dopaminergic activity. Physical exercise has been suggested as a complementary treatment for ADHD due to its close and bidirectional relationship with the dopaminergic system. However, findings regarding the effectiveness of physical activity in improving ADHD symptoms remain inconsistent. In children with ADHD, we found that in response to physical exertion, the catecholamine response - particularly dopamine - as well as the secretion of growth hormone, is blunted compared to children without ADHD. Treatment with methylphenidate slightly mitigates the suppression of dopamine and growth hormone secretion in response to physical exertion, thereby providing at least a partial explanation for why stimulant medication in children with ADHD allows normal growth. The possible use of catecholamine and growth hormone responses to physical exertion for the diagnosis and treatment of children with ADHD requires further research.
BACKGROUND:There is evidence of a reduction in fertility rates of approximately 10% following cesarean delivery (CD) compared with vaginal delivery. However, it is challenging to determine whether this decline is directly linked to the procedure itself or if it stems from voluntary infertility. To examine the direct impact of CD on the intrauterine environment, the in vitro fertilization (IVF) outcomes in women with secondary infertility were studied. OBJECTIVES:To evaluate the impact of delivery mode on IVF treatment outcomes - specifically cumulative live birth rate and cumulative implantation rate-in women newly diagnosed with secondary infertility. METHODS:A retrospective study was conducted comprising women with a new diagnosis of secondary infertility who sought IVF treatment at Meir Medical Center between 2011 and 2021. Demographic data, previous delivery details, and current treatment characteristics and outcomes were collected. The study population was divided into two groups based on the delivery mode in the previous pregnancy: the vaginal delivery group and the CD group. RESULTS:The study included 232 women, 169 in the vaginal delivery group and 63 in the CD group. The CD group had a higher percentage of patients with tubal factor infertility (28.6% vs. 15.4%, p=0.02) and reduced endometrial thickness, although this difference was statistically nonsignificant (9.71 ± 2.20 vs. 10.28 ± 2.26 mm, p=0.08). No differences were observed between the groups in other demographic characteristics, infertility characteristics, treatment parameters, or treatment results. No differences were found in the cumulative live birth rate (22.2% vs. 19.1%, p=0.53) or cumulative implantation rate. Multivariate regression analysis did not find an association between CD and adverse IVF treatment outcomes. CONCLUSIONS:This study did not find an association between a history of CD and poorer IVF treatment outcomes among women with secondary infertility. However, due to the limited sample size and the retrospective nature of the study, these findings cannot be generalized to the overall population.
BACKGROUND:A free-floating thrombus (FFT) is defined as an elongated thrombus attached to the arterial wall with circumferential blood flow distally. This condition accounts for approximately 1.3% of all ischemic stroke cases. Potential causes include hypercoagulable states, pregnancy, inflammatory diseases, malignancies, and atherosclerosis. This study presents a case series and literature review of patients with symptomatic FFT in the carotid artery treated solely with medication. OBJECTIVES:A series of 4 patients with stroke symptoms and a free-floating thrombus in the carotid artery were treated solely with medical therapy, resulting in no ischemic stroke recurrence within 30 days and complete thrombus resolution. CONCLUSIONS:A literature review of 20 articles encompassing 349 patients with ischemic stroke symptoms and extracranial carotid FFT found that, among the 272 patients treated exclusively with medical therapy, 76 (27.9%) received antiplatelet agents, 146 (53.7%) received anticoagulants, 44 (16.2%) received a combination of both, and 6(2.2%) were treated with intravenous thrombolysis. Recurrent 30-day stroke was experienced by 22 (8.1%) patients. The European Society for Vascular Surgery (ESVS) guidelines recommend anticoagulation therapy for patients with acute stroke secondary to FFT in the carotid artery and suggest considering invasive intervention if recurrence occurs during anticoagulation therapy. The level of evidence is low, and decision-making should be based on factors such as etiology, recurrent events, time since stroke onset, infarct size, thrombus location, and findings from follow-up imaging studies. DISCUSSION:Medical treatment alone has shown promising results with low 30-day stroke rates and thrombus dissolution. The limited number of cases and the predominance of retrospective studies or case reports highlight the need for large-scale prospective studies.
INTRODUCTION:Renal trauma accounts for up to 5% of trauma cases and is common in both children and adults. In grade 4 trauma accompanied by urine leakage from the collecting system, kidney drainage may sometimes be required using a ureteral stent and a urinary catheter, which will be left in place until the leakage resolves. Urine leakage monitoring is usually performed with follow-up computed tomography (CT) scans. In this article, we present an innovative use of contrast-enhanced urosonography, which in most cases allows for the monitoring of renal urine leakage while avoiding additional CT scans that involve exposure to ionizing radiation and intravenous contrast material.
INTRODUCTION:Aortic valve stenosis is a serious condition with high morbidity and mortality if untreated. Since 2002, transcatheter aortic valve implantation (TAVI) has revolutionized treatment, offering a less invasive alternative with excellent outcomes. Increased demand necessitates expanded treatment capacity, especially due to long waiting times and associated risks. While cardiac surgery centers provide emergency support, improved technology and lower complication rates now allow TAVI in centers without on-site surgery, given proper collaboration with surgical facilities. This study evaluates the feasibility of TAVI in such settings. At Meir Medical Center, 149 patients underwent TAVI with no mortality or emergency surgeries. These findings support expanding TAVI access to non-surgical centers without compromising outcomes.
INTRODUCTION:Q fever is a zoonotic disease, which is endemic in Israel. Most patients have an acute infection, but some cases manifest as a persistent focalized infection. Risk factors for a persistent focalized infection include significant valvular diseases, and aortic aneurism or vascular grafts, immunosuppression or malignancy, pregnancy, elevated anticardiolipin IgG. Recommendations for these high-risk patients after acute Q fever vary from clinical and serological follow-up to combined prolonged antimicrobial therapy, mostly with doxycycline and hydroxychloroquine. Retrospective studies involving a few dozen patients have found this treatment to significantly reduce the rates of endocarditis in patients with significant valvular abnormalities and in reducing obstetric complications in pregnant women. There is no data regarding antimicrobial prophylaxis and vascular graft infections or in patients with aortic aneurysms or malignancy; thus, some experts recommend prophylactic antimicrobial therapy in these patients as well. This paper reviews the current literature regarding the risk factors for persistent localized infection, and the efficacy of prolonged antimicrobial therapy after acute Q fever in these populations. In conclusion, risk factors for a persistent focalized infection, along with risk factors for side effects associated with prolonged antimicrobial therapy, should be taken into consideration and discussed with the patient to help the clinician decide about antimicrobial prophylaxis after acute Q fever.
INTRODUCTION:Abdominal pain frequently poses a significant diagnostic challenge because of its myriad etiologies. In this case series, we describe four patients initially presenting with abdominal pain who were subsequently diagnosed with rare hematological disorders: namely, paroxysmal nocturnal hemoglobinuria (PNH), myeloproliferative neoplasm (MPN), sickle cell Disease (SCD), and aggressive systemic mastocytosis (ASM). We discuss the unique pathophysiological mechanisms underlying the abdominal pain in these cases and emphasize the importance of considering hematological disorders in the differential diagnosis of abdominal pain.
BACKGROUND:Adults over 65 years constitute the fastest-growing segment of the Western population. Drug allergies represent a significant health concern in this age group. This study aimed to assess the safety and efficacy of drug allergy evaluation in geriatric patients. METHODS:We conducted a retrospective study of patients aged >65 years who were referred for allergy evaluation at the Allergy and Clinical Immunology Unit, Meir Medical Center. The evaluation included a detailed anamnesis, skin testing when indicated, and oral drug challenges. Patients who were successfully de-labelled were followed long-term to assess subsequent use of the culprit drug and related outcomes. RESULTS:Between 2009 and 2019, a total of 1,860 elderly patients were evaluated in our clinic, of whom 270 were referred with suspected drug allergies. Ultimately, 232 patients (86.2%) had their drug allergy ruled out. Patients confirmed as allergic were offered therapeutic options, including drug desensitization when required or alternative medications when available. The evaluation process proved safe, with no severe reactions occurring during oral challenges or drug desensitizations. Long-term follow-up data were available for 144 patients, of whom 50 (34.7%) were subsequently treated with the previously suspected culprit drug. None experienced immediate reactions or severe delayed hypersensitivity following re-exposure. CONCLUSIONS:Drug allergy de-labelling is both safe and effective in elderly patients, underscoring the importance of implementing this procedure. Greater awareness is needed regarding the value of allergy workups in geriatric populations carrying drug allergy labels.
BACKGROUND:The increased use of computed tomography (CT) scans results in increased detection of small pulmonary lesions. Navigational bronchoscopy systems that integrate technologies, such as three-dimensional (3D) imaging and radial endobronchial ultrasound (r-EBUS), have been developed to aid in sampling these lesions. These systems enhance diagnostic precision, improve biopsy success rates, and reduce complications compared to conventional invasive techniques. OBJECTIVES:To evaluate the diagnostic yield, safety, and effectiveness of the Archimedes system for navigational bronchoscopy in identifying and sampling small and peripheral lung lesions. METHODS:A retrospective analysis was conducted on 43 patients who underwent navigational bronchoscopy using the Archimedes system at Meir Medical Center. The system utilizes advanced CT imaging, 3D virtual pathway construction, and real-time fluoroscopy guidance. Data collection focused on lesion size, location, and diagnostic yield. RESULTS:The average lesion size was 15.2 ± 7.9 mm, and the overall diagnostic yield was 84.2%, with a 100% success rate for ground-glass opacity (GGO) lesions. No cases of pneumothorax were reported, and only two minor bleeding incidents occurred, requiring no further intervention. A high diagnostic yield was observed for lesions under 20 mm as well as for complex cases. CONCLUSIONS:The Archimedes system demonstrates the clinical potential of navigational bronchoscopy, particularly for small and peripheral pulmonary lesions. Its implementation results in a significant increase in diagnostic yield and enhanced procedural safety. Integrating this technology into high-volume medical centers could improve early and accurate lung cancer diagnosis while maintaining a low complication profile.
INTRODUCTION:This article presents the "Stronger Than Yourself" program, developed within the integrative medicine service of the Oncology Department of Schneider Children's Medical Center of Israel. The program was designed to improve treatment adherence among pediatric oncology patients, with particular emphasis on oral medication intake. We describe the case of a 7.5-year-old girl diagnosed with acute lymphoblastic leukemia (ALL), who persistently refused to take her prescribed medication and struggled to cooperate with the medical team. Her condition required a tailored intervention to enable continuation of essential treatment. The "Stronger Than Yourself" program combines principles of empowerment and self-control, active parental guidance, and the use of mind-body modalities, such as touch, movement, guided imagery, and mindfulness. Through an individualized integrative intervention, her emotional and behavioral barriers were reduced, resulting in significant improvement in cooperation and full regular medication adherence. Since its launch in 2017, the program has supported more than 200 children, with the vast majority achieving independent and sustained medication intake. The model has been recognized by the professional community and presented internationally. This case demonstrates the potential of a focused integrative approach to address common barriers to medication adherence in pediatric oncology, to reduce distress, and strengthen coping in children and families. Further research is warranted to consolidate the model and extend its implementation in other pediatric care settings.
INTRODUCTION:Polycythemia is defined as an elevation of age and sex - adjusted hematocrit. While Polycythemia vera (PV) is a myeloproliferative neoplasm caused by JAK2 mutations leading to an autonomous proliferation of red blood cells. Most cases of polycythemia seen in general practice represent relative polycythemia or are secondary to other causes. Secondary erythrocytosis is most often due to chronic hypoxia, the use of erythropoietin-stimulating drugs such as androgens or SGLT2 inhibitors or erythropoietin -secreting tumors. Relative polycythemia results from chronic plasma volume contraction. Rarely, hereditary erythrocytosis may be a cause of polycythemia. In this review we outline our diagnostic approach to patients with polycythemia, focusing on identifying secondary causes. We suggest that when polycythemia is isolated, secondary and hereditary causes should be considered initially. If polycythemia is accompanied by leukocytosis or thrombocytosis, the initial investigations should be testing for JAK2 mutations and serum erythropoietin levels. Polycythemia vera is characterized by headache, visual disturbances, pruritus, erythromelalgia and splenomegaly. Treatment includes phlebotomy, low-dose aspirin, and cytoreductive agents. In secondary polycythemia, there are no clear guidelines regarding the desired hematocrit and management should be individualized to treat the cause. Phlebotomy is the only modality used to lower the hematocrit when this is required. A systematic clinical approach that prioritizes the exclusion of secondary causes before genetic testing may prevent unnecessary investigations and enable focused, effective patient care.
BACKGROUND:This is a first study that assesses the clinical presentation and outcomes of different ethnic groups of the patients that are near drowning in the Dead Sea. METHODS:We performed a retrospective study of all adult patients admitted to the Soroka University Medical Center with a diagnosis of the near-drowning syndrome in the Dead Sea during the years 2004-2024. All the patients were divided into three groups: patients of Jewish origin, patients who were Israeli Arabs and Bedouins in origin and tourists from any other countries. The primary outcome was the length of the hospital stay. The secondary outcomes were in-hospital mortality and 30-day mortality. RESULTS:This study included 219 patients. The majority of patients (140, or 64%) were of Jewish origin. Arab patients were significantly younger compared to the other two groups of patients (P=0.002) and significantly healthier compared to the other two patient groups (P<0.001). Significantly more tourists were hospitalized with an impaired state of consciousness, manifesting as stupor or coma, compared to the other two groups (P<0.001). Throughout the entire hospitalization, kidney function was better in patients from the Arab group compared to the two other groups. No vital differences were found between the three groups regarding study outcomes, including in-hospital mortality, 30-day mortality, or length of hospital stay. CONCLUSIONS:This study demonstrated significant demographic and clinical heterogeneity among the three patient groups on admission. Arab patients were significantly younger and had a lower comorbidity burden. Tourists presented more frequently with a severely impaired level of consciousness. Despite these marked differences in baseline characteristics and disease severity indicators, all three groups demonstrated similar short-term outcomes, with no significant differences found in outcomes. These findings imply a robust clinical system capable of managing the diverse risk profiles of the patient population.
INTRODUCTION:Throughout the 9-months of pregnancy, a woman with gestational diabetes (GDM) is expected to celebrate holidays, which makes coping with diabetes difficult and alters routine glucose control. AIMS:We hypothesized that delivery in the first week following a holiday, might be associated with altered glucose homeostasis, causing more neonatal hypoglycemia. METHODS:A retrospective study was conducted in a tertiary center between the years 2007-2023. Eligible patients were women with a term singleton pregnancy, diagnosed with GDM. Women were allocated into two groups based on the date of their delivery in relation to holidays, in the first week following a holiday (group 1) and at times unrelated to holidays (group 2). The primary outcome was the incidence of neonatal hypoglycemia, defined as a glucose level of less than 40 mg/dL (2.2 mmol/L) within 24 hours of birth. RESULTS:We analyzed 332 cases of GDM and 3,179 GDM control cases. Diet-controlled GDM represented most of our cohort (85%), and the mean blood glucose was tightly kept around 100 mg/dl throughout the labor. Baseline maternal and neonatal demographics were comparable between the groups. The incidence of neonatal hypoglycemia did not differ between the two groups, reaching 3.3% in the study group and 4.9% in the control group (p=0.19). The mean neonatal blood glucose at the nursery was also comparable between the groups, 63 ± 10.1 versus 63.2 ± 10.9 (p=0.95), respectively. GDM patients in group 1 had a higher rate of third- or fourth-degree perineal lacerations than group 2 (1.8% vs. 0.8%, p=0.04). CONCLUSIONS:Our findings reassure us that major holidays, when occurring within a week of delivery, do not adversely impact neonatal outcomes in women with GDM. DISCUSSION:Management of gestational diabetes during holiday periods may be challenging; however, delivery close to holidays does not increase the risk of neonatal hypoglycemia. Delivery during holiday periods does not increase the risk of neonatal hypoglycemia in women with gestational diabetes.
INTRODUCTION:Metabolic bariatric surgery induces significant anatomical and physiological changes in the gastrointestinal tract that may substantially affect the pharmacokinetics of orally administered drugs. These changes include, among others, reduced gastric volume, increased gastric pH, bypass of absorption segments in the small intestine, alterations in drug metabolism, as well as rapid weight loss and changes in body composition. Many neuropsychiatric medications are characterized by a narrow therapeutic window; therefore, the effects of metabolic bariatric surgery may lead either to reduced drug absorption and therapeutic failure or, conversely, to increased drug levels with a risk of toxicity. Interindividual variability is considerable, making it difficult to predict pharmacokinetic responses in individual patients. This review presents the impact of metabolic bariatric surgery on commonly used neuropsychiatric medications, aiming to promote safe and optimal pharmacotherapy in this population. The article includes a literature review, recommendations for therapeutic drug monitoring, and guidance for clinical and laboratory follow-up. Given the complexity of this issue, a proactive approach is recommended, including assessment of drug levels prior to surgery and close monitoring in the early postoperative period until clinical and laboratory stability is achieved, followed by periodic monitoring based on drug characteristics, patient factors, and the specific surgical procedure performed. A multidisciplinary approach involving a neurologist and/or psychiatrist, along with a clinical pharmacist, is essential to optimize neuropsychiatric treatment in patients undergoing metabolic bariatric surgery.
INTRODUCTION:Oculoplastics is a subspecialty of ophthalmology that focuses on a wide range of disorders affecting the orbit, lacrimal system, and eyelids. In this review, we examine orbital fractures with a focus on mechanisms of injury, clinical and radiologic evaluation, and surgical decision-making. We outline the common fracture patterns and their functional and aesthetic implications, discuss the criteria guiding conservative versus surgical management, and review contemporary surgical approaches along with recent technological advances in orbital reconstruction.
INTRODUCTION:Missed appointments in orthopedic outpatient clinics impose a considerable burden on healthcare systems by reducing operational efficiency, wasting clinical resources, and potentially compromising patient outcomes. Although personal and demographic characteristics are known to influence non-attendance, the specific factors that predict missed appointments remain insufficiently understood. AIMS:This study aimed to identify key variables associated with no-show rates in orthopedic outpatient clinics and to evaluate the performance of a predictive model designed to improve appointment adherence. METHODS:A retrospective cohort analysis was conducted using data extracted from a hospital scheduling system, encompassing appointments from January 2015 to December 2019 and from 2022. Demographic information and attendance status were analyzed to identify trends and predictive factors linked to missed visits. RESULTS:During the years 2015-2019, 1,234,425 scheduled appointments were reviewed, with an overall no-show rate of 30.25%, while orthopedic outpatient clinics exhibited a slightly lower rate of 24.97%. Based on demographic attendance data, a predictive scoring model was developed and subsequently tested using 2022 data. The model classified 64% of appointments as "Attenders" (no-show rate 13.9%) and 36% as "Non-Attenders" (no-show rate 29.4%), showing a statistically significant difference. DISCUSSION:: These results highlight the potential of predictive analytics to enhance appointment scheduling and optimize healthcare resource allocation in orthopedic settings. By identifying high-risk patients in advance, healthcare providers can implement targeted interventions to reduce non-attendance. Incorporating real-time data into predictive algorithms may further strengthen clinical decision-making and improve continuity and quality of patient care.
