08.02.2023

Summer 2022

Original Articles

Management Options for Adolescents with Abnormal Uterine Bleeding

Noa Keidar BMedSc, Noam Smorgick MD and Marianna Rachmiel MD 6-14
Background: Abnormal uterine bleeding is a common complaint among adolescents. There are no evidence-based guidelines for the treatment of this condition among adolescents. Current management is based on adult treatment.
Objectives: A) To characterize the demographic, clinical, imaging, and laboratory characteristics of adolescents referred for management of menstrual irregularities. B) To describe management protocols according to the diagnosis.
Methods: This study is a descriptive, observational, retrospective study, based on information from medical records of patients aged 10-18 years, referred to the integrated-adolescents-gynecology-endocrinology clinic at the Shamir (Assaf Harofeh) medical center (SHMC) in Israel, with the complaint of abnormal uterine bleeding from January 2007 to December 2020.
Results: One hundred and twenty-three patients had abnormal cycles. Cause for referral included heavy bleeding in 47.1%, oligomenorrhea in 33.1%, primary amenorrhea in 12.4%, and secondary amenorrhea in 7.4%. After work-up, 54(43.9%) were diagnosed with polycystic ovary syndrome (PCOS), 34(27.6%) with heavy menstrual bleeding (HMB), 7(5.7%) with primary ovarian failure, and 7(5.7%) with hypothalamic pituitary insufficiency. Menstrual irregularities resolved over time in 21(17.1%) patients, diagnosed as immature hypothalamic pituitary ovarian axis (IMMATURITY). Patients diagnosed with PCOS were older, presented with fewer cycles, had higher body mass index (BMI), and a higher degree of hirsutism. They received more medical interventions, mainly cyclic progesterone (CyP) and oral contraceptive pills (OCP), and required a switch from CyP to OCP in 29.6%. Patients with HMB had significantly lower hemoglobin, less findings on imaging, and were mainly treated with Tranexamic acid.
Conclusions: Adolescents with menstrual irregularities may be distinguished according to their age, family history, clinical and laboratory characteristics. Their initial management should depend on age, hemoglobin levels, and cause, and may include either CyP or OCP, with the option of oral Tranexamic acid in cases of HMB.

Risk Factors for Re-Hospitalization of the Geriatric Population

Dor Yizhaki MD, Lilach Didi-Shema PhD, Tsvi Sheleg MD, Orly Yakir MA, Boris Svirsky MD, Edward Kaykov MD 16-20
Background: Re-hospitalization is defined as a return to hospitalization within 30 days. Decreasing the rate of re-hospitalization of the elderly has become an important objective due to the effect on both the patient’s quality of life and the high cost of medical care. Re-hospitalization is often unavoidable but can certainly be reduced by identifying patients at risk, using a risk scale, and adjusting preventive intervention accordingly.
Objectives: To build a risk scale that predicts the patient’s chances of re-hospitalization.
Methods: We conducted a retrospective study of electronic medical data from four months in 2018, one from each season of the year – January, April, July, and October. The data was gathered from seven internal medicine departments in Galilee Medical Center.
Results: A total of 380 patients were included, 240 were hospitalized within 30 days and 140 were not. Several independent variables were found to be statistically significant between the groups. A regression model showed a significant statistical difference between age categories (65-84/85+), with the older group at 2.298 times higher risk to return to the hospital (Odds ratio [OR] P=0.021). Non-Jewish patients were 5.883 times more likely to return to the hospital (OR, P<0.001). We also found that patients who lived at home with family members, lived in an institution, and lived at home with a caregiver, were likely to return to the hospital by 5.787 (OR, P<0.001), 4.012 (OR, p=0.008), and 5.185 (OR, p=0.007) times, respectively.
Conclusions: Our study revealed that a risk scale can be creat- ed based on our findings.

The Effect of Radiotherapy and Radiation for Malignancies on Cardiac Surgery Outcomes

Meni Shemesh BSc, Eilon Ram MD, Leonid Sternik MD 21-24
Background: The most common approach in cardiac operations is mid-sternotomy. In some groups of patients, this approach is challenging due to adhesions secondary to a previous operation. Patients undergoing re-operative cardiac surgery are, at least based on our experience, clinically more complex than patients undergoing a primary operation. There is very little data in the current literature regarding the effect of prior chest radiation on the outcomes of cardiac surgery.
Objectives: The objective of this paper is to examine the effect of chest radiation, classified by the type of radiotherapy treatment, on the outcomes of cardiac surgery.
Methods: We performed a retrospective study on a cohort of patients who underwent radiation therapy prior to cardiac surgery. Preoperative, operative and post-operative data were collected from the cardiac surgery departmental database. We classified the cohort by the type of radiotherapy treatment that the patient underwent. As a secondary analysis and as a control group, we examined the data of patients with malignancies that do not require radiation to the chest and/or patients with cancer who underwent treatment that does not include radiation.
Results: The age of a patient admitted for surgery following past chest radiation therapy gets younger as the type of radiation is more extensive, as the time from radiation to surgery increases as the type of radiation increases in its severity. The total operative time and cardiopulmonary bypass times were shorter in the Tangential radiation group. The ventilation time was longer in the Extensive radiation group. The tangential group had a lower total bleeding amount and received less red packed cells and platelets transfusion post-surgery. The total intensive care unit stay and hospital stay were longer in extensive group patients. At follow-up, there were no significant differences in the functional capacity as defined by the NYHA (New- York heart association) functional class score. Furthermore, no difference was observed in late mortality between the groups.
Conclusions: Our research showed that previous cancer radiotherapy and its extent affects various factors pre-operation and post-operation. These finding should be taken into consideration and presented to the patient before prescribing treatment for malignancies and before treating its consequences.

Review Articles

Sleeping Beauties – a Kleine Levin Syndrome review: Current research and what the future holds

Yogev Cohen BSc, Ida Birman BSc 26-31
Background: Kleine Levin Syndrome [KLS] is a rare, relapsing-remitting disease of unknown etiology. The syndrome is characterized by recurrent episodes of intensive sleep, and hypersomnia that could last several weeks or even longer. The condition is usually first manifested during adolescence, mostly in males. KLS episodes, besides intensive sleep, are associated with cognitive impairment, derealization, and other behavioral changes. Usually, between episodes, patients have normal sleep, cognitive function, and mood. Episodes may be triggered by many causes, including infections, but most have no known trigger. KLS is diagnosed clinically, although results of functional brain imaging often are abnormal, both during and between episodes.
Objectives: Our objective is to review the latest research on this rare syndrome and present the upcoming challenges in the KLS field.
Methods: We reviewed articles that involve the research of KLS using the MeSH [Medical Subject Headings] search. Since KLS is rare, and little has been discovered throughout the years, our focus was research and data collected between 1936, from Levin’s first manuscript, and 2021.
Results: Our review focused on the latest publications in KLS research. These reports shed new light on the genomic and autoimmunity aspect of the syndrome.
Conclusions: Current KLS research focuses on functional brain imaging, genetics, and possible autoimmunity and genetic aspects. Research of KLS will soon mainly focus on redundant repeat on genetics, neuroimaging advancements, and a better understanding of the KLS mechanism. Many challenges lie ahead of the researchers, as KLS is rare – so the funding is scarce, and there are few patients. Nevertheless, new data regarding the different mechanisms gives hope to many researchers and patients around the world.

3,4-methylenedioxymethamphetamine (MDMA)-Assisted Psychotherapy for the Treatment of Post-traumatic Stress Disorder

David Mazor MD 32-38
Background: Recent evidence suggests that MDMA-assisted Psychotherapy for the treatment of post-traumatic stress disorder (PTSD) might help treatment-resistant patients. Treatment-resis- tant PTSD patients do not have many therapeutic options since the currently used medications are of limited help. MDMA is an empathogen-entactogen drug that affects various processes of fear extinction, emotional processing, and memory reconsolidation.
Objectives: To review the currently used treatments for PTSD and the evidence of the effect of MDMA-Assisted Psychotherapy on PTSD patients.
Methods: Reviewing the most recent results of MDMA-assisted therapy clinical trials and the non-MDMA pharmacotherapy available for PTSD.
Results: In the first randomized controlled trial (RCT), MDMA-assisted psychotherapy was compared to placebo. After two sessions the Clinician-Administered PTSD scale for DSM (CAPS) score for the MDMA group was 25.5 (-53.7), compared to 59.1 (-20.5) for the placebo group. In the MDMA group, 83.3% no longer met the diagnostic criteria for PTSD compared to 25% in the placebo group. In six phase-2 RCTs of MDMA-assisted psychotherapy, the MDMA group had a reduction of -30.4 on CAPS-IV score, [t (95) = -4.5, P < 0.0001] compared to -10.5 in the placebo group. 54.2% no longer met PTSD diagnostic criteria in the MDMA group compared to 22.6% in the placebo group after two experimental sessions. After the third session, the results showed a significant reduction in the CAPS-IV scores, with -45.4 for the MDMA group. In the first phase-3 RCT, the MDMA-assisted therapy group showed a greater CAPS-5 score reduction (-24.4) compared to the placebo group (-13.9) after three sessions. MDMA was found to be safe, well-tolerated, and with high efficacy in the treatment of severe PTSD, as well as the dissociative type of PTSD, compared to placebo. At the end point of the primary phase-3 study, 67% of the participants in the MDMA group compared to 32% of the participants in the placebo group no longer met the diagnostic criteria for PTSD.
Conclusions: MDMA-Assisted Psychotherapy is a potential candidate for being a first-line treatment for PTSD, upon approval from the FDA, with greater efficacy, length of remission, safety, and side effect profile compared to placebo.

The Need for Research in the Curriculum of Medical Students

Tom Fishboom and Aviv Mesika 39-44
Background: The field of medicine is rapidly changing and updating; hence a physician must be able to keep up with the changes and innovations in his specialty. In Israel, research plays an important part in the medical curriculum. Medical students and residents have to conduct research in one of the following topics: basic science, clinical research, epidemiology, or sociology. Medical students do their research during the pre-clinic period for their M.D. thesis, residents have 6 months of “basic science” during their training. By conducting research, the medical students and residents are exposed to research methodology, learn principles of performing and planning research, and develop critical thinking abilities. Those abilities will help shape the new generation of physicians and can improve the patient’s treatment. In recent years, there are some doubts about the necessity of research during medical school and residency. In this article, we review the current state of research as part of the medical curriculum in Israel and present the arguments of the proponents and opponents as described in the literature.
Objectives: The aim of this article is to shed some light on the place of research in medical training and provoke a discussion on the subject.
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RUSH it - Point of Care Ultrasound as a Cricial Diagnostic Tool: Review and Case Report

Yael Erez, Daniel Trotzky MD-MHA and Gal Pachys MD 46-52
Background: Undifferentiated shock is a common clinical enigma, where a delay in arriving at a correct diagnosis can have an enormous impact on a patient’s ultimate outcome. History and physical examination may give an incomplete picture, and the diagnostic challenge is increased in complex patients. But invasive monitoring techniques, comprehensive diagnostic testing, and imaging modalities can be time-consuming, costly, and are not always readily available to the ED clinician. Bedside ultrasound protocols have been proposed to identify the cause of shock and guide targeted therapy for patients with undifferentiated hypotension and shock.
Objectives: A literature review of an abdominal aortic emergency and the use of comprehensive bedside ultrasound imaging in rapid differentiation between types of shock and etiologies of a shock state, which can lead to more rapid and more definitive diagnosis and improvement in outcomes.
Methods: We present a case of undifferentiated shock that suggest that in the clinical evaluation of shock, the identification of the correct type of shock is crucial, and a standardized approach can assist in resuscitation, help identify etiologies of shock that are rare, yet confer high mortality; and expedite both diagnosis and treatment and maybe even save lives.
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Conclusions: When a patient presents with hypotension or shock especially if they have abdominal or back pain, the RUSH protocol should be used as the primary diagnostic tool.

Case Articles

Extraordinary Therapy for an Unusual Abnormality in a Newborn

Tamir Lotan, Raucher Sternfeld Alona MD, Yair Erell MD, Sion Sarid Rachel MD, Sagi Assa MD 53-55
Background: We present a case of a newborn with hypoxemia at birth. After the failure of various respiratory support methods and several cardiopulmonary resuscitations (CPRs), he required extracor- poreal membrane oxygenation (ECMO). He was diagnosed with a rare genetic syndrome with a significant pulmonary abnor- mality phenotype. Three weeks after his delivery, an uncom- mon treatment led to his recovery.
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Letters To The Editor

Are Overlong Shifts for Medical Residents Ethical?

Jonathan Koren 56-57
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Jordan River Village: The Importance of Accessible Summer Camps

Noga Lempel 58-59
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Why Medical Care for Asylum Seekers is Important for Medical Professionalism

Shahar Barami 60-62
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Feature Articles

From the Operating Table to Medical School: My Journey with Scoliosis and How it Affects My View

Ella Yarom 64-65
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In the Realm of Hungry Ghosts: Close Encounters with Addiction (Mate Gabor / 2007)

Guy Hadassi BMSc 66
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Epiphany

התקף חרדה

אביב חלפון 67
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