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.
