Summer 2023

Original Articles

Risk Factors for A Negative Birth Experience Using The BSS-R Questionnaire

Neta Hochman BSc, Alex Galper MSc, Varda Stanger PhD, Gabriel Levin MD, Karin Herzog MSc, Tal Cahan MD, Shiran Bookstein Peretz MD and Raanan Meyer MD 15-21
Background: Women’s birth satisfaction is an important indicator of maternity care quality and has implications for the health and well-being of women and their newborns.
Objectives: To evaluate the risk factors for a negative birth experience by questionnaire answered by women during the first week postpartum.
Methods: A cross-sectional study including women who gave birth at a single tertiary hospital, between 2/2021-1/2022. Birth satisfaction was measured using the BSS-R questionnaire. Maternal, pregnancy, delivery and neonatal characteristics were collected. Negative birth experience was defined as BSS-R score lower than the median. Multivariable regression analysis was used to examine association between birth characteristics and negative birth experience.
Results: 1,495 women answered the questionnaire and were included in the analysis; 779 women comprised the positive birth experience group and 716 women comprised the negative birth experience group. Number of previous deliveries, proportion of spontaneous onset of labor and vaginal delivery were lower in the negative birth experience group, while labor length was longer. In multivariable regression analysis, number of prior de-liveries [aOR (95%CI) 0.73 (0.58-0.91), p=0.005] was associated with lower risk of negative birth experience, while cesarean delivery (CD) was associated with increased negative birth experience risk [aOR (95%CI) 4.35 (1.20-16.67), p=0.025].
Conclusions: Lower parity and CD were associated with negative birth experiences. Further studies are needed to evaluate potential interventions to mitigate the effects of these factors.

Long Term Visual Function and Other Clinical Characteristics in Patients with Achromatopsia

Yuval Margherita Eshel BSc, Ora Avez M. Optom and Claudia Yahalom MD 22-26
Background: Achromatopsia is an autosomal recessive cone dysfunction syndrome, characterized by absence of color discrimination, low visual acuity, photophobia, and nystagmus. Achromatopsia constitutes as one of the major causes of visual impairment in children, with a prevalence of 1:30,000 worldwide.
Objectives: To characterizes the clinical characteristics of achromatopsia, the main genes causing the disease in the Israeli population and the clinical course of the disease, with an emphasis on visual function stability with age.
Methods: A retrospective study based on medical charts of patients with achromatopsia. Patients were divided into two groups according to their age at last follow-up: older and younger than 10 years. A subset of patients with long-term follow-up were analyzed separately, with patients being described in both age groups.
Results: Seventy-six patients were included in the study. Vari- ants in the CNGA3 gene were the most common (identified in 75% of patients who underwent genetic testing, p<< 0.0001). Clinical characteristics included photophobia (97.3%), nystagmus (93.8%), hypermetropia (69.1%) and strabismus (43.5%). Mean best corrected visual acuity (BCVA) was 0.94. In the large cohort there was no correlation of age with visual acuity (p= 0.392). In the separate subset cohort with long follow-up there was improvement in visual acuity with age (p< 0.0001). There was no correlation between the gene causing the disease and the clinical phenotype, specifically photophobia (p= 1.000), nystagmus (p= 0.442), strabismus (p= 0.377), type of refractive error (p= 1.000), and visual acuity (p= 0.276).
Conclusions: CNGA3 is the main gene associated with achromatopsia in our population (around 75%), which is in contrast to the distribution worldwide (~ 25%). Most achromats suffer from photophobia and nystagmus, and the main refractive error is hypermetropia. Achromatopsia’s natural course is stationary and non-progressive, and there may even be a slight improvement in visual acuity with time.

The Risk and Predictors of Malignancies in Ankylosing Spondylitis Patients in Israel. A Retrospective Electronic Databased Study.

Noy Horesh, Polina Kagan DMD MSc, Howard Amital MD MHA, Avishai M. Tsur MD MHA , Abdulla Watad MD, Arnon D Cohen MD-PhD and Niv Ben-Shabat MD MPH. 27-33
Background: Previous studies found ambiguous associations between ankylosing spondylitis (AS) and the risk of cancer.
Objectives: To assess the risk of overall and site-specific malignancies for AS patients in Israel, while examining the role of co-morbidities and immunomodulatory therapy.
Methods: We conducted a retrospective electronic data-based study of Clalit health services patients diagnosed with AS between 2002-2018, with no history of cancer prior to enrollment, with 5:1 ratio matched-controls by age, gender, and place of residence. Odds ratio (OR) for site-specific malignancies, com- paring AS patients and controls, were calculated using logistic regressions. Predictors for malignancies within the AS cohort were evaluated in the same manner.
Results: 5,825 AS patients and 28,356 matched controls were included in the study. AS was associated with higher rate of malignancy than controls (OR=1.4, 95%CI 1.24-1.6), specifically for solid malignancies (OR=1.5, 95% CI 1.3-1.7), central nervous system (OR=3.72, 95% CI 1.29-10.7), kidney (OR=2.06, 95% CI 1.12-3.8), and cancer of unknown primary (OR=3.06, 95% CI 2.35-3.98). Old- er age at diagnosis of AS (OR=1.31, 95% CI 1.25-2.36), diabetes mellitus (DM) (OR=1.52, 95% CI 1.18-1.97), inflammatory bowel disease (IBD) (OR=2.61, 95% CI 1.75-3.89) and treatment with sulfasalazine and methotrexate (OR=2.17, 95% CI 1.65-2.83) were associated with a higher rate of solid malignancies within AS patients, while non-steroidal anti-inflammatory drugs (NSAIDs) treatment alone had a protective effect for solid malignancies (OR=0.78, 95% CI 0.61-0.99). No significant association was found between anti-tumor necrosis factor (TNF) therapy and risk for solid or hematologic malignancies within the AS group.
Conclusions: AS is associated with an increased risk for overall and site-specific malignancies. Older age, DM, IBD and treatment with DMARDs were found as independent predictors for cancer among AS patients.

Invasive Versus Non-Interventional Care in Malignant Gastric Outlet Obstruction: An 8-year Tertiary Center Experience

Ronny Maman, Yuri Goldes MD, Roi Anteby MD, Yaniv Zager MD, Chaya Shwaartz MD, Matan Cohen MD MPH, Dror Maymon MD, Eilon Shcolnik BS, Ido Nachmany MD and Nir Horesh MD 34-40
Background: Gastric outlet obstruction (GOO) poses therapeutic challenges, especially in the setting of malignant GOO. There is a paucity of data on palliative invasive intervention versus observation alone in terminal patients.
Objectives: This study was undertaken to determine the benefit of interventional treatment for GOO and to detail the etiological spectrum of GOO.
Methods: A tertiary center retrospective review of patients who were diagnosed with GOO between the years 2010-2018. Obstructive symptoms were graded according to GOO score (GOOS). Outcomes evaluated included treatment complications, mortality, and restoration of oral intake after intervention.
Results: Data was obtained from 65 patients diagnosed with GOO, with a median follow-up of 12 weeks (interquartile range 69). In 18 patients (28%) GOO was secondary to benign etiologies, most commonly peptic ulcer disease (n=6). Forty-seven (70%) patients had malignant GOO, most commonly due to pancreatic adenocarcinoma (n=16). Complications after intervention (surgery or endoscopic treatment) were higher in the malignant group compared to the benign group (76% vs. 10%, p<0.001). One-third of the complications in patients with malignant GOO were major (Clavien Dindo ≥ III). Almost half of the patients with malignant GOO that underwent invasive palliative care failed to tolerate soft solids after intervention (42% post-procedural GOOS≤1).
Conclusions: Palliative invasive intervention in our cohort carried a significant risk for complications and high rates of failure in achieving full oral intake. The potentially limited benefit and risk of complications should be weighed and communicated to patients when deciding on invasive palliative treatment.

Comparison of Laparoscopic Uterosacral Hysteropexy to Vaginal Sacrospinous Hysteropexy for Treatment of Uterovaginal Prolapse

Jonia Amer Alshiek MD, MSc, Roni Neuman, Keren Kogan Houri MD, Ilan Bruchim MD and Benjamin Feiner 41-46
Background: Pelvic organ prolapse (POP) affects approximately 38-41% of women. Surgical approaches to POP repair involve suspension of pelvic walls to ligaments with or without hysterectomy. A growing body of evidence suggests that uterine-preserving procedures are safe and effective. Vaginal sacrospinous hysteropexy (SSF-H) and laparoscopic uterosacral hysteropexy (USLS-H) are uterine-preserving procedures that have comparable outcomes to vaginal hysterectomy with repair.
Objectives: Evaluate the efficacy and safety of SSF-H versus USLS-H.
Methods: Multicenter, retrospective study of women who underwent uterine-preserving repair by SSF-H and USLS-H at Hillel Yaffe and Herzliya Medical Centers, Israel in 2017-2021. We collected data from medical charts and conducted two follow-ups including questionnaires (PFDI, PISQ) and clinical assessment (anatomic evaluation using POP-Q).
Results: 110 patients were included (26.4% USLS-H, 73.6% SSF-H). Patients in the USLS-H group were significantly younger than in the SSF-H group (52.6±10.6 vs. 59.6±12.0 years). BMI was lower in USLS-H patients (27.6±4.6 vs 31.4±5.0) and this group had fewer comorbidities (15% vs 47.5%). Regarding intraoperative outcomes, all measures were comparable except blood loss, which was greater after SSF-H (220 vs 179 ml). After a median interval of 22 months post-surgery, POP-Q C point was improved by 4 cm following USLS-H as compared to 2 cm after SSF-H. In the posterior compartment, POP-Q Bp point was improved by 3 cm following SSF-H and by 2 cm following USLS-H. Total POPQ stage in both groups improved by 1-2 stages. There was no difference regarding urinary stress, urge, fecal or gas incontinence, pain, and sexual functioning between study groups.
Conclusions: SSF-H and USLS-H are both safe and effective uterine-preserving POP repair techniques. Appropriate patient selection should take each patient’s medical and surgical history into account.

High-Fidelity Central Venous Catheter Simulation Increases Learning Effectiveness Among Nurses

Niv Atsmony BSc, Esther Leah Nof BSc, Ronnie Tepper MD 47-52
Background: Central line-associated bloodstream infection (CLABSI) is the most widespread and severe complication of central venous catheterization (CVC) and is one of the most significant challenges healthcare systems face today. Clalit Health Services (CHS) acted to reduce CLABSI incidence by providing simulation-based CVC training.
Objectives: The study compared the effectiveness of three learning methods used in CVC maintenance training for nurses: high-fidelity simulation training, low-fidelity simulation training, and reading guidelines only.
Methods: The study used a pre/post-questionnaire design. A total of 1,026 nurses from varying specialties and levels of CVC maintenance mastery received a questionnaire consisting of five questions, four of which tested knowledge about skills that were demonstrated in a high-fidelity simulation setting.
Results: High-fidelity simulation improved learning effectiveness more than low-fidelity simulation and reading guidelines only.
Conclusions: This study should improve the effectiveness of medical simulation for CVC training as it shows that high-fidelity simulation training is the most effective method for imparting knowledge and so enhancing patient safety in CVC maintenance procedures.

Review Articles

Polio: It Ain't Over Till It's Over Challenges in Polio Eradication: Lessons Learned and Novel Approaches

Hodaya Goldman and Oren Kobiler MD PhD 59-65
Background: Poliomyelitis is an infectious disease caused by the poliovirus (PV). There are three wild poliovirus serotypes: WPV1, WPV2 and WPV3. The virus is transmitted through oral-oral or fecal-oral routes and can cause irreversible paralysis, poliomyelitis or even death. There are two types of vaccines against polio, developed in the 1950s: the inactivated poliovirus vaccine (IPV) and the oral polio vaccine (OPV). The Global Polio Eradication Initiative (GPEI) was established in 1988 and the number of reported poliomyelitis cases worldwide has decreased significantly. WPV2 was declared eradicated in 2015 and WPV3 was declared eradicated in 2019.
Objectives: The objective of this paper is to summarize the current state of poliovirus eradication efforts and identify possible future directions to achieve the goal of global eradication.
Methods: A literature review of recent information on the current global and local poliovirus outbreaks and eradication efforts.
Results: While wild-type poliovirus is almost eradicated, vaccine-derived poliovirus (VDPV) is currently spreading in many countries such as the USA, England, and Israel with a genetic link between the strains causing the infection. The appearance of VDPV led to a declaration of a public health emergency of international concern by the WHO. It is suggested that low vaccine coverage has caused the return of polio outbreaks worldwide.
Conclusions: Silent circulation of poliovirus in high-income countries requires reevaluation of the strategy to eradicate the virus, as it complicates critical surveillance. Development of genetically stable vaccines and the gradual cessation of OPV must be achieved to eradicate poliovirus.

Potential Therapeutic Benefits of Vagal Nerve Stimulation in Transplantation and Acute Organ Rejection

Shaun Edalati BA, J Sam Meyer MSc, Dan Aravot MD, and Yaron D. Barac MD PhD 66-70
Background: Despite advances in induction and aggressive maintenance of immunosuppression, more than a third of organ transplant recipients experience acute rejection after transplantation. High levels of proinflammatory cytokines are associated with allograft rejection. Serum levels of the intracellular cytokines IFNg and TNFa produced by CD4+ and CD8+ T-cells in acute rejection patients have been shown to be increased. New noninvasive strategies can supplement immunosuppression therapy to control the innate inflammatory responses and other injuries associated with organ rejection.
Objectives: This review assesses and discusses the influence of both invasive and noninvasive vagal nerve stimulation as a prophylactic treatment for transplant patients and also as supportive treatment in patients with organ transplantation rejection.
Methods: A literature review was conducted to evaluate the mechanisms, current clinical purposes, and potential therapeutic effects of invasive and noninvasive vagal nerve stimulation.
Results: The FDA has previously approved the use of vagal nerve stimulation treatment for various conditions including epilepsy, depression, migraines, and obesity. Studies have shown that vagal nerve stimulation has anti-inflammatory effects. Further studies should be conducted to broaden the awareness of the therapeutic benefit of vagal nerve stimulation in diseases including those associated with organ transplants and rejection.
Conclusions: Considering the rise in organ demand and the decline in organ supply, it is imperative to ensure transplanted organs retain function for as long as possible with the fewest number of rejections and complications. Using vagal nerve stimulation to treat organ recipients and donors could yield promising results that will lead to extended patient survival and fewer complications associated with rejection management. Although further studies are required, the noninvasive nature of vagal nerve stimulation may hasten its implementation in organ rejection management.

Case Articles

Takayasu Arteritis and LMCA Occlusion – Rare Diagnosis In Young Female Patients: Case Report

Aviv Solomon 71-74
Background: I present my experience with a case of left main coronary artery (LMCA) occlusion in a young female with Takayasu arteritis. As an ambulance paramedic, I provide my perspective on pre-hospital care before moving on to in-hospital treatment and the patient's outcome. The case begins with a young, apparently healthy woman in a local clinic in Israel and concludes with a diagnosis of Takayasu arteritis in the cardiac intensive care unit. This case report's main goal is to discuss Takayasu arteritis and highlight how crucial it is not to disregard chest pain as a primary symptom, particularly in young female adults. Regardless of how uncommon some cases of Takayasu arteritis may be, such symptoms should not be dismissed without careful evaluation.

Torsion of the Testicular Appendage

Tatyana Pylyavets 75-76
Background: Torsion of the testicular appendage is a urological case often requiring surgical correction. It is more common among young boys; however, it can occur in men of any age. In this case presentation, the patient was a 40-year-old man who complained of right scrotal pain and was diagnosed with torsion of the appendix testis, which was then followed by a scrotal examination and removal of the appendage. This case presentation aims to raise awareness and describe a relatively rare clinical process with a familiar clinical presentation.

Feature Articles

Reporting Systematic Reviews and Meta-analyses According to PRISMA - A Practical Guide

Yotam Portnoy and JIMS editorial board members 6-14
Background: A systematic review is a type of research study that systematically searches, evaluates, and analyzes the findings of all relevant studies on a specific research question. Systematic reviews and meta-analyses are considered the highest level of evidence in evidence-based practice because they provide a comprehensive and unbiased overview of the current evidence on a particular topic. The gold standard for writing and collecting the data for a systematic review and meta-analysis is according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRIS- MA) statement. PRISMA consists of a 27-item checklist and a flow diagram that helps authors report the critical elements of a systematic review in a transparent and standardized manner. Most medical students, however, lack experience in preparing and writing a systematic review and may find the process challenging. Here, we summarize the workflow process of PRISMA in a few accessible and practical steps.

The Future of Transplantation Medicine: No More Waiting Lists

Maor Tzuberi 77-78

The Importance of Early Screening and Intervention of Postpartum Depression and its Impact on the Later Developing Condition

Or Rosentveig 79-80

A Practical Method for Initiating Medical Innovation Processes as a Medical Student Using the Biodesign Method

Orr Erlich 81-82



אביב חלפון 84