Rambam Medical Center Research Articles

Clinical parameters that predict a premature LH rise in patients undergoing ovarian stimulation for IVF

Background: Normal reproductive function requires adequate regulation of follicle stimulating hormone (FSH) and luteinizing hormone (LH) secretion. During ovarian stimulation for in-vitro fertilization (IVF), some patients will demonstrate an early rise in LH despite being treated with a gonadotropin releasing-hormone (GnRH) antagonist, sometimes necessitating cycle cancellation. Previous studies have demonstrated a possible link between a premature LH rise with ovarian response to gonadotropins. We sought to determine what clinical parameters can predict this premature LH rise and their relative contribution. Methods: A retrospective study of 382 patients who underwent IVF treatment at Rambam Medical Center. The patients were stratified into age groups. A model predicting premature LH rise based on clinical and demographic parameters was developed using both multiple linear regression and a machine-learning-based algorithm. Results: LH rise was defined as the difference between pre-trigger and basal LH levels. The clinical parameters that significantly predicted an LH rise were patient age, BMI, LH levels at stimulation outset, LH levels on day of antagonist administration, and total number of stimulation days. Importantly, when analyzing the data of specific age groups, the model’s prediction was strongest in young patients (age 25–30 years, R 2 = 0.88, p < .001) and weakest in older patients (age > 41 years, R 2 = 0.23, p = .003). Conclusions: Using both multiple linear regression and a machine-learning-based algorithm of patient data from IVF cycles, we were able to predict patients at risk for premature LH rise and/or LH surge. Utilizing this model may help prevent IVF cycle cancellation and better timing of ovulation triggering.

Paediatric Mycosis Fungoides: Clinical Variants, Treatment Modalities and Response to Therapy.

Mycosis fungoides is a rare cutaneous lymphoma in the paediatric population. The aim of this study was to examine the epidemiological, clinical, and histological characteristics, as well as the treatment modalities and response to therapy of paediatric patients with mycosis fungoides. This retrospective cohort study reviewed the records of 37 paediatric patients treated at Rambam Medical Center, Israel, between 2013 and 2021. Extracted data included epidemiology, clinical presentation, histological reports, infiltrate clonality status, treatment modalities and response to therapy. The mean follow-up period was 60 months. All patients were diagnosed with stage IA or IB disease. Folliculotropic mycosis fungoides was the most prevalent variant (49%). Most patients were treated with phototherapy (90%), with a response rate of 85%, and a complete response rate of 55% after the first course. There were no significant differences in response to phototherapy between the folliculotropic or other variants (p = 0.072). Similarly, delayed diagnosis, atopic diathesis, clonality, phototherapy type or number of treatments, were not associated with response to therapy, while protracted phototherapy was associated with prolonged remission. In conclusion, mycosis fungoides in the paediatric population is an indolent disease with a favourable prognosis and potentially prolonged response to phototherapy.

Correlations between high sensitive troponin I and acute myocarditis extent in cardiac magnetic resonance imaging.

To assess the correlation between high sensitive troponin I (HsTnI) levels and myocardial damage on cardiac magnetic resonance (CMR) represented by late gadolinium enhancement (LGE) percentage in patients diagnosed with myocarditis. Retrospective analysis of consecutive patients who underwent CMR following a suspected diagnosis of acute myocarditis, comparing CMR findings viewed as LGE percentage and HsTnI levels. Between February 2016 and December 2021, 101 patients underwent CMR for suspected myocarditis in Rambam Medical Center. Seventy-six (75.2%) patients with a documented diagnosis of acute myocarditis in the medical records based on clinical history and lab work were included in the final analysis. The median age was 30 years [interquartile range (IQR) 22,42] and 62 patients (81.6%) were male. Thirty-four patients (44.7%) had a history of fever and 26 (34.2%) had upper respiratory tract symptoms. The median maximal HsTnI was 3935 ng/l (1165,10 380) and the median C-reactive protein (CRP) was 7.97 mg/l (2.35,19.28). The median LGE percentage was 4.65% (2.6,8.5) and ventricular ejection fraction 60% (56.00,64.75).Linear association was found between LGE (%) and maximal HsTnI (ng/l) value with r = 0.49 ( P < 0.001). After including only patients in whom the CMR was performed within 5 days of the maximal HsTnI the correlation improved to r = 0.67 ( P < 0.001). HsTnI is an indicator for myocardial damage extent resulting from inflammation in patients with acute myocarditis.

Working in corona-designated departments in a fortified underground hospital: Concerns about corona and predictors of job burnout.

In August 2020 during Israel's second COVID-19 wave Rambam Medical Center opened the Sammy Ofer Fortified Underground Emergency Hospital. This was declared a regional Corona center in the north of Israel, receiving the most severe Corona patients from the region. Alongside the advanced inpatient capacity and technology within the underground facility, there was a severe shortage of trained medical and paramedical staff, as well as harsh working conditions. The current study examined the implications and effects of working in an underground facility on healthcare workers, focusing on emotion regulation tendencies and profession as predictors of job burnout. Seventy-six healthcare workers, who had worked in the underground hospital for a minimum continuous period of 2 weeks during the peak of the COVID-19 pandemic, and a control group of 40 healthcare workers from northern Israel were asked to fill out an online survey administered via Qualtrics (total sample 116). The survey comprised six questionnaires: a demographic survey questionnaire; a COVID-19 concerns questionnaire; a psychological distress questionnaire (DASS, Depression Anxiety Stress Scale); trait worry (PSWQ; Penn State Worry Questionnaire); emotion regulation (ERQ, Emotion Regulation Questionnaire), and burnout (SMBM, Shirom - Melamed Burnout Measure). Independent-samples t-tests revealed no significant differences in psychological distress or burnout between Rambam Underground hospital workers and the control group. Conversely, COVID-19 concern scores were significantly different in the two groups, the Rambam hospital workers showing less concern (M = 2.9, SD = 0.73) than the control group (M = 3.47, SD = 0.76) [t (114) = -3.974, p < 0.001]. Hierarchical linear regression analysis identified the significant predictors of burnout among healthcare workers. Participants' profession (physician), psychological distress (total DASS score), and a personality trait of worry were statistically significant predictors for job burnout (p = 0.028, p < 0.001, p = 0.023, respectively). Concerns about COVID-19 marginally predicted job burnout (p = 0.09). Group (underground vs. control) and emotion regulation tendencies did not predict burnout. The two groups showed no significant differences in psychological distress nor in burnout. Being a physician, having an intrinsic trait of being overly worried and experiencing psychological distress were significant predictors for job burnout among healthcare workers, regardless of work environment (underground vs. control).

P552 Anti-TNF Treatment and Risk of Atrial Fibrillation in Inflammatory Bowel Disease Patients

Abstract Background Inflammation is thought to play a role in the development of atrial fibrillation (AF). Previous studies suggested that inflammatory bowel disease (IBD) is associated with increased risk of AF. These studies also found IBD patients receiving biologic agents were at higher risk of AF than patients not receiving them. We sought to determine the association between anti-TNF treatment and the risk of AF in IBD patients Methods In this observational cohort, we included all adult IBD patients who were registered in Rambam Medical Center, diagnosed with IBD from November 1983 to October 2021. We excluded patients who were diagnosed with AF and/or stroke prior to IBD diagnosis. Disease severity was based upon IBD treatment. Mild disease was defined as no treatment, 5-ASA, or topical steroids, while moderate-to-severe disease was defined as any immunomodulator, biologic or systemic steroid therapy. Primary outcome was AF diagnosis. We used Cox proportional hazard model to compare AF in patients receiving anti-TNF treatment to those with mild disease. We further adjusted the hazard ratio of AF development based on known AF risk factors, including age, male gender, cardiovascular disease, chronic kidney disease, pervious venous thromboembolism, hyperlipidemia, diabetes, and thyroid disease. Results Our initial cohort included 5,326 patients. After exclusion, 4,886 patients were included. Median follow-up time was 8.49 years 2,720 patients were considered as having mild IBD, while 787 patients received anti-TNF medications. During follow-up period, cumulative incidence of AF was 1.50% (n=41) and 0.89% (n=7), respectively (p=0.21). Unadjusted hazard ratio of AF occurrence in anti-TNF patients was 0.6 (95% CI; 0.27-1.3, p=0.211). After adjustment, hazard ratio of AF occurence was 1.33 (95% CI; 0.53-3.3, p=0.545). Conclusion Anti-TNF treatment was not associated with increased risk of AF among IBD patients. This provides reassurance regarding the cardiovascular safety of anti-TNFs in a real-world IBD cohort.

COVID-19 Quarantine and Sexual Function after First Vaginal Delivery

Objectives: Sexual function is an important part of quality of life at all ages. Childbirth brings many changes that may affect sexual function. During COVID-19 global pandemic, nuclear families were forced to stay home. The goal of this study was to evaluate sexual function during the COVID-19 quarantine, in postpartum couples in the first months following their first vaginal childbirth. Design: This is a single-center, prospective study of females following their first vaginal delivery and their male partners. Participants were recruited in the maternity ward after their first delivery at Rambam Medical Center. Both spouses signed a consent form for answering the sexual function questionnaires. Participants: Participants were interviewed by telephone during the last week of the first COVID-19 quarantine, according to Arizona Sexual Experience Scale (ASEX). Main outcome measures: pre- and post-quarantine sexual function according to ASEX scores. ASEX is a survey that assesses sexual drive, arousal, vaginal lubrication, the ability to reach orgasm, and satisfaction from orgasm. Responses are scored on a 1–6 Likert scale with a potential range of 5–30, where the highest scores indicate worse sexual function. Results: The participants were 38 women and 29 men. The average time from delivery to the interviews was 182.8 ± 84.7 days; 56% of the spouses were under quarantine. The median baseline total ASEX score was 13 (sexual drive 3, arousal 2.5, vaginal lubrication 2.5, ability to reach orgasm 2, orgasm satisfaction 2) for women and 11 (sexual drive 3, arousal 2, penile erection 1, ability to reach orgasm 2, orgasm satisfaction 2) for men. Sixteen percent of the women and none of the men had a baseline sexual dysfunction (ASEX score >19). Significant differences were not observed in total ASEX scores before and during the quarantine. Limitations: Sexual function at the end of the quarantine was evaluated prospectively and pre-quarantine sexual function was evaluated retrospectively, with the limitation of recall bias. Conclusions: COVID-19 quarantine did not seem to have a significant effect on female or male sexual function, three to 9 months after the first vaginal delivery. The current study is the first to describe primiparous postpartum sexual function as median ASEX score.

High Non-COVID-19 in-Hospital Deaths during the First Lockdown in Israel Compared with the Second and Third Lockdowns.

During the first lockdown in Israel, citizens were instructed to visit community clinics only for urgent cases. However, they were not informed that emergency departments (EDs) were safe. Reports from the National Ambulance Services showed a 22% increase in at-home deaths during the lockdown. Perhaps, the reason is because some critically ill patients postponed referrals and came “at the last minute”. After the first lockdown, the Ministry of Health (MOH) declared that hospital EDs were safe. The objective of the study was to examine the rates of admission from EDs to hospital wards, and non-COVID-19 in-hospital deaths during the first lockdown in Israel, compared with the second and third lockdowns. From the business intelligence software of the Rambam Medical Center in Israel, we collected data about the rates of admission to the ED, the non-COVID-19 in-hospital deaths during the three lockdowns, during the same periods in the previous three years, and the main five causes of non-COVID-19 deaths. Data comparison was done using multiple chi-square tests. ED admission numbers were significantly higher during the first lockdown than during the second (χ2 (1, n = 36,245) = 24.774, p = 0.00001) and third lockdowns (χ2 (1, n = 36,547) = 8.7808, p = 0.0030). We found a significantly higher number of non-COVID-19 in-hospital deaths vs. discharges during the first lockdown than in the second and third lockdowns (χ2 (2, n = 26,268) = 7.794, p = 0.0203) The number of deaths due to respiratory diseases was significantly higher during the first lockdown than in the second lockdown (χ2 (1, n = 572) = 8.8185, p = 0.0029) and in the third lockdown (χ2 (1, n = 624) = 9.0381, p = 0.0026), and deaths from infectious diseases were higher during the first lockdown than during both the second and third lockdowns (χ2 (1, n = 566) = 5.9479, p = 0.0147, and χ2 (1, n = 624) = 9.5978, p = 0.0019), respectively. The onset of CVA and CVD are abrupt, while respiratory and infectious diseases may have an insidious pattern; this may have led patients to postpone referrals to hospitals to the “last minute” during the first lockdown, perhaps due to fears of contracting COVID-19, and as a result of vague instructions. Citizens and policymakers must be made aware of this point during future pandemics.

P-015 Automated, efficient sorting of sperm using dielectrophoresis (DEP), utilizing the electrical properties of the tail as a biomarker of the viability, even for immotile cells

Abstract Study question Developing a simple and automated method and device that sorts semen cell by cell for eventual application to retrieving rare sperm from severely oligozoospermic samples. Summary answer Over 90% of the viable cells in a sample can be sorted out from non-viable sperm cells and other debris using this method. What is known already The varying electrical properties of different cell types can result in unique frequency dependent dielectrophoretic (DEP) behavior when they are exposed to alternating current (AC). They are either repelled or attracted depending on their properties and the field frequency. This has been applied to sorting rare cells such as circulating tumor cells from blood. We have previously shown that the head and tail of human sperm have different electrical properties. As a result, at certain frequencies of an AC electric field the tails of viable cells (even immotile ones) are attracted to electric field gradients while the heads are distanced. Study design, size, duration Semen samples from several patients at Rambam medical center were collected and cryopreserved. Later the thawed semen samples were then tested in our sorting device. At least one hundred live cells were evaluated in each sample. The percentage of live cells that were successfully sorted out of the original mixture of live sperm cells, dead sperm cells and other debris was assessed. Participants/materials, setting, methods After thawing the samples were stained using CFDA and PI for visual live/dead identification (in actual practice no staining is necessary). The device consists of a polydimethylsiloxane (PDMS) microchannel on a glass slide patterned with Indium Tin Oxide (ITO) transparent electrodes. In the device the sperm are transferred to a low conductivity buffer. A curved electrode then sorts them out of the stream of the cell mixture to an alternate exit. Main results and the role of chance We have successfully demonstrated a new biomarker of live sperm (even immotile ones). The tails of live sperm have a positive (attractive) DEP response while dead sperm react negatively and are repelled from field gradients. At the specific frequencies used the head is simultaneously distanced from the electric fields helping to prevent damage to the DNA during the sorting. We also showed that this effect could be used to sort sperm with over 90% efficiency from a sample with dead sperm and other debris. Since each cell passes the electrodes and is automatically sorted it could possibly be used for severely oligozoospermic and cryptozoospermic samples to find sperm and make more sperm available for more discriminatory sperm selection in such samples. Nowadays such samples are searched manually and the minute number of sperm present is often missed leading to a mistaken azoospermic diagnosis and possibly unnecessary surgery. The components are relatively low cost and the chips disposable allowing for wider implementation. Significant progress was also made in preventing sperm from sticking to the substrates using coatings and a vibrational motor. Additionally, a proof of concept parallelization of the electrodes to increase the throughput was also demonstrated. Limitations, reasons for caution The inherent difficulty with microfluidic technologies is low throughput. Further work is needed to effectively parallelize and optimize the system. Effective pre-processing to clean the sample may also help to increase the throughput. Wider implications of the findings This biomarker can potentially be useful in determining an immotile cell’s viability for ICSI. This technology can also be of potential use for testicular tissue samples where there are many other cell types and debris and it is difficult to find rare sperm. Advanced sperm selection can also be incorporated. Trial registration number not applicable

P-566 Clinical parameters that predict a premature LH rise in patients undergoing ovarian stimulation for IVF

Abstract Study question What are the clinical parameters that can predict a premature LH rise or LH surge in patients undergoing ovarian stimulation for IVF? Summary answer The parameters predicting an early LH rise are: Age, BMI, day 3 LH levels, LH on day of antagonist administration, and number of stimulation days. What is known already Normal reproductive function and fertility require precise regulation of FSH and LH secretion. In IVF stimulation cycles some patients will have an early LH rise even while being treated with a GnRH antagonist. Previous studies have shown a possible link of LH rise with ovarian response to gonadotropins. Nevertheless, little is known of which clinical parameters can predict this LH rise; an occurrence that may necessitate cycle cancellation. Early prediction of premature LH rise will enable us to foresee this unwanted hypophyseal event, and in turn may lead to early antagonist administration and/or early triggering for oocyte retrieval. Study design, size, duration A retrospective study enrolling 382 patients who underwent IVF treatment at Rambam Medical Center (2015 - 2021): age 34.1±6.7 years; BMI 25.0±5.1 kg/m²; AFC 11.2±7.1; day 3 FSH 7.2±2.9U/L; day 3 LH 6.4±4.3U/L; eggs retrieved 8.0±6.1; fertilizations 4.7±4.2. Patients were stimulated with rFSH (Gonal F)/rFSH+LH (Pergoveris)/ highly purified urinary FSH+hCG(Menopur); GnRH antagonist (Cetrotide/ Orgalutran) was administered using a flexible protocol; triggering of ovulation was performed using GnRHagonist and/or hCG, based on estradiol levels. Participants/materials, setting, methods Clinical parameters included from chart data were: age; BMI; estradiol, progesterone, LH and FSH levels at day3/ day of antagonist administration/ and last day before triggering; total stimulation days and total FSH dose. In order to establish a model to predict premature LH rise we performed multiple linear regression using ANOVA with a confidence interval of 0.95 considered significant. A machine learning based model was used to test the accuracy of our model using Python. Main results and the role of chance An LH rise was calculated as the difference between pre-trigger- and basal LH levels. For the total group of patients this LH rise was significantly predicted by patient age; BMI; LH levels at day 3 and LH at the day of antagonist administration; and total stimulation days (R = 0.742, R²=0.55, p &amp;lt; 0.001). Importantly, when analyzing the data of specific age groups, the prediction of the model was strongest in the young patients (age 25-30: R = 0.94, R²=0.88, p &amp;lt; 0.001) and weakest in the older patients (age &amp;gt; 41: R = 0.48,R²=0.23, p = 0.003). Accordingly, using a machine learning model in which a Python based algorithm is trained by analyzing 80% of the data, we were able to successfully predict the remaining 20%: mean squared error of 4.32 and 82.3 in the young- and old patient groups respectively. Interestingly, 21 patients demonstrated a “full LH surge” as defined by a more than two fold increase in LH levels. These patients were also predicted by a similar model (LH levels at day 3 and at the day of antagonist administration, BMI and total FSH dose; R = 0.89, R²=0.80, p = 0.015). Limitations, reasons for caution This is a retrospective study and its conclusions need to be validated by a prospective randomized trial. Wider implications of the findings Using machine-learning based analysis of patient data from IVF cycles, we were able to predict patients at risk for premature LH-rise and/or LH-surge. Interestingly, the prediction of this model was strongest in young patients. Utilizing this model will help prevent IVF cycle cancellation and better timing of ovulation triggering. Trial registration number NA

Literature Review and Knowledge Distribution During an Outbreak: A Methodology for Managing Infodemics.

The COVID-19 pandemic has challenged health care systems in an unprecedented way by imposing new demands on health care resources and scientific knowledge. There has also been an exceedingly fast accumulation of new information on this novel virus. As the traditional peer-review process takes time, there is currently a significant gap between the ability to generate new data and the ability to critically evaluate them. This problem of an excess of mixed-quality data, or infodemic, is echoing throughout the scientific community. The authors aimed to help their colleagues at the Rambam Medical Center, Haifa, Israel, manage the COVID-19 infodemic with a methodologic solution: establishing an in-house mechanism for continuous literature review and knowledge distribution (March-April 2020). Their methodology included the following building blocks: a dedicated literature review team, artificial intelligence-based research algorithms, brief written updates in a graphical format, large-scale webinars and online meetings, and a feedback loop. During the first month (April 2020), the project produced 21 graphical updates. After consideration of feedback from colleagues and final editing, 13 graphical updates were uploaded to the center's website; of these, 31% addressed the clinical presentation of the disease and 38% referred to specific treatments. This methodology as well as the graphical updates it generated were adopted by the Israeli Ministry of Health and distributed in a hospital preparation kit. The authors believe they have established a novel methodology that can assist in the battle against COVID-19 by making high-quality scientific data more accessible to clinicians. In the future, they expect this methodology to create a favorable uniform standard for evidence-guided health care during infodemics. Further evolution of the methodology may include evaluation of its long-term sustainability and impact on the day-to-day clinical practice and self-confidence of clinicians who treat COVID-19 patients.

Did the events following the COVID-19 outbreak influence the incidents of violence against hospital staff?

BackgroundDuring the COVID-19 outbreak, (March 1 - June 15, 2020) citizens expressed sympathy and gratitude towards medical staff through the media, while the entire hospital staff faced the same danger of infection as other citizens. This might have made hospital staff develop sympathy, understanding for the patients` and family’s needs, and a better communication.ObjectivesTo investigate if there is a relation between the mutual change in attitude between citizens and hospital staff during the first COVID-19 outbreak, and the incidence of violence cases.Materials and methodsThis is a cross sectional study conducted at Rambam Medical Center (RMC) in Israel. The data about the number of violence cases were collected from the security department, and the data about hospital wards activity were collected from the hospital Business Intelligence (BI) software.The number of violence cases in relation to the number of Emergency Department (ED) visits, admissions to hospital wards, and length of stay (LOS) were compared during the COVID-19 outbreak to the corresponding period in 2019 using the T- test. The difference in the incidence of violence between general population and people with a psychiatric or social disorder (like drug abuse and criminal background) in both periods were also compared using the Fisher exact test.ResultsDuring the first COVID-19 outbreak, there were 6 violence cases against medical staff out of 24,740 visits to the ED, vs. 21 cases out of 30,759 visits during the same periods in 2019 (P < 0.05). There were 19 violence cases in the whole hospital with 14,482 admissions in 2020 vs. 51 violence cases of 17,599 admissions in 2019 (P < 0.05). Violence against security guards in the entire hospital dropped from 20 to 11 cases, and in the set of the ED, from 13 to 4 cases in both periods respectively. A 20 % decrease in the number of visits to the ED, might have influenced the average LOS during the study period, 2020 compared to 2019 (4.4 + 0.45 vs. 5.4 + 0.36 h. (P < 0.001). The ratio of violence among general population vs. people with a psychiatric or social background revealed a non-significant change in both periods (P = 0.75 and P = 0.69) respectively.DiscussionThe COVID-19 outbreak supplied some evidence that a change in environmental conditions, trust, waiting time, personal attitude and communication might have reduced violence against hospital staff.ConclusionsExcept for violence coming from patients with psychiatric or social disorders, most other violence cases might be reduced if the environment conditions and attitudes of both citizens and staff are improved.

Role of Robotic Surgery in the Management of Benign Hepatobiliary Diseases

Background: Recently robotic surgery has emerged as one of the most promising surgical advances. Despite its worldwide acceptance in many different surgical specialties, the use of robotic assistance in the field of hepatobiliary (HBP) surgery remains relatively unexplored. Our study presents single institution´s initial experience of robotic assisted surgery for treatment of benign hepatobiliary pathologies. Methods: A retrospective analysis of a prospectively maintained database on clinical outcomes was performed for 26 consecutive patients that underwent robotic assisted surgery for benign HBP disease at Rambam Medical Center during 2013-2015. Results: There were 26 robotic assisted surgical procedures performed for benign HBP pathologies during the study period. There were 3 anatomical robotic liver resections for symptomatic hemangiomas , 9 cases of giant liver cyst, 5 robotic assisted surgery for type I choledochal cyst, 2 case of benign (iatrogenic) common bile duct (CBD) stricture, 3 cases of robotic (CBD) exploration due to large intra choledochal stones and 6 cases of cholecystectomy for cholelithiasis. The median postoperative hospital stays for all procedures were 3.5 days (range 1-6 days). General morbidity (minor) was 2%. There was no mortality in our series. Conclusions: Robotic surgery is feasible and can be safely performed in patients with different benign HBP pathologies. Further evaluation with clinical trials is required to validate it´s real benefits.

Coffee break – Epidemiologic analysis, traditions & holidays that increase burn risk of pediatric patients

BackgroundBurns are estimated to cause up to 1% of admissions to emergency department in low- and middle-income countries, and up to 220 admissions per 100 K people in high income countries. Knowing the special features in every population could help formulate prevention strategies tailored for the specific group targeted and thus help decrease the incidence of burns in the general population. Patients and MethodsWe examined all patients files admitted to the Rappaport hospital within Rambam Medical Center between the years 2012–2016. ResultsMale admissions accounted for 57% (18.1 per 100 K life years) of all admissions. Scald was the most prominent cause of burn in all the cohort subgroups, with 65% of all burns. The specific cause of scald varied in the subgroups. Burns usually happened during weekend (p < 0.001). Transition seasons, i.e. autumn and spring, were the most dangerous for our cohort (p < 0.001). ConclusionsPediatric burn patterns were found correlate to population, timing, and customs. Mapping the hazardous rituals that may cause burns in different populations, is the first step towards prevention.

Prognostic value of cardiac troponin levels in patients presenting with supraventricular tachycardias

BackgroundAn association between paroxysmal supraventricular tachycardias (PSVT) and elevated cardiac troponin I (cTnI) has been reported in small studies, even in the absence of significant coronary artery or structural heart disease. We sought to explore the prognostic significance of elevated cTnI among patients presenting with PSVT. MethodsThis is a retrospective single-center observational study conducted between January 2014 and Decemebr 2016. 165 patients (60% men, mean age 55 ± 17 year-old) with an acute episode of regular supraventricular tachyarrhythmia were admitted to the emergency department at Rambam Medical Center. 131 patients had at least one serum cTnI value measured. Of those, 57 had a positive result, defined as serum cTnI of more than 0.028 ng/dL. ResultsMultivariate analysis showed that heart rate > 150 beats per minute (bpm) on admission (OR = 3.9; 95% CI 1.1.6–9.5; p < 0.003) and history of coronary artery disease (CAD) (OR = 3.4; 95% CI 1.2–10.1; p = 0.026) were the only independent predictors of cTnI elevation. After mean follow-up period of 23 ± 7 months, the combined primary outcome of death, coronary intervention (PCI) or myocardial infarction (MI) occurred in 7 patients (12.3%) out of 57 patients with positive cTnI and in zero patients with negative cTn (p = 0.002). Cox proportional hazard model showed that elevated cTnI on admission was an independent predictor of adverse outcomes only in patients with known coronary artery disease (CAD) (HR = 3.3, p = 0.05). ConclusionElevated cTnI among patients presenting with PSVT appears to have prognostic significance only in patients with history of CAD. In this patient group elevated cTnI is associated with increased risk of adverse cardiac outcomes. We therefore believe serum cTnI should be measured selectively, such as in patients with symptoms of ischemic chest pain and a high pretest likelihood of having CAD.

Spontaneous cerebellar hemorrhage carries a grim prognosis in both operated and unoperated patients

Management of spontaneous cerebellar hemorrhage (SCH) has been scarcely reported, and controversies still exist regarding their surgical management. MethodsWe performed a retrospective review of the Rambam Medical Center registry. All cases with a SCH, operated or not, were reviewed. Basic patient parameters, clinical status on admission and imaging results, management and outcome measures were evaluated. Parameters were compared between the operated and unoperated groups, and assessed for their correlation to patient death within 12 months.When operated, patients underwent Suboccipital craniectomy (SOC), insertion of an external ventricular drain (EVD) or both. Results57 patients were treated for SCH in the years 2005–2017. 20 patients (35.09%) died during their original admission. 16 were discharged in non-functional status. In total, 36 patients died within 12 months of their admission. Only 21 patients (36.84%) were alive one year after their bleed.The following parameters were correlated to death in the entire cohort: older age, larger hematoma size, hydrocephalus, brainstem compression by the bleed and outcome status.The unoperated patients were younger, and had a lower Glasgow Coma Scale (GCS) on admission. Death within 12 months occurred in 69.77% of the operated patients, but only 42.86% of the unoperated patients, p = 0.10. Unfavorable outcome was found in 36% of the unoperated group and 72% of the operated group, p = 0.024. ConclusionSCH carries a grim prognosis in both operated and unoperated patients. Roughly one third of patients in our series died during their admission and another third were either vegetative or severely disabled on discharge.

Dr. Eli Sprecher

Eli Sprecher received his MD and PhD degrees from the Hebrew University of Jerusalem and specialized in dermatology at the Rambam Medical Center, Haifa. He spent a post-doctoral fellowship at Thomas Jefferson University, Philadelphia and served as attending physician at the Rambam Medical Center until 2008. During this period, he was Deputy Director for Academic affairs at the Rappaport Institute for Research at the Technion-Israel Institute of Technology, and founded as well as directed the Center for Translational Genetics at the same institution.

First reported case of thunderstorm asthma in Israel

Abstract. We report on the first recorded case of thunderstorm asthma in Israel, which occurred during an exceptionally strong eastern Mediterranean multicell thunderstorm on 25 October 2015. The storms were accompanied by intensive lightning activity, severe hail, downbursts and strong winds followed by intense rain. It was the strongest lightning-producing storm ever recorded by the Israeli Lightning Detection Network (ILDN) since it began operations in 1997. After the passage of the gust front and the ensuing increase in particle concentrations, documented by air-quality sensors, the hospital emergency room (ER) presentation records from three hospitals – two in the direct route of the storm (Meir Medical Center in Kfar Saba and Ha'Emek in Afula) and the other just west of its ground track (Rambam Medical Center in Haifa) – showed that the amount of presentation of patients with respiratory problems in the hours immediately following the storm increased compared with the average numbers in the days before. This pattern is in line with that reported by Thien et al. (2018) for the massive thunderstorm asthma epidemic in Melbourne, Australia. The increase in patient presentations to the emergency rooms persisted for an additional 48–72 h before going back to normal values, indicating that it was likely related to the multi-cell outflow. We discuss how the likelihood of incidence of such public health events associated with thunderstorms will be affected by global trends in lightning occurrence.

Effect and utility of targeted and immune therapy as single agent treatment for brain metastases in patients with non-small cell lung cancer.

e13581 Background: Brain metastases are estimated to occur in approximately 30% of patients with metastatic non-small cell lung cancer (NSCLC). Patients with brain metastases experience significant morbidity, often with neurological dysfunction and cognitive impairment. While brain radiation therapy was the foundation of management, it is associated with delays in systemic drug therapy and neurocognitive impairment. The use of immunotherapy or targeted therapy (TKIs) in well-selected patients may be effective in all tumor sites, including the central nervous system with a low toxicity profile.Therefore, this study aims to examine the clinical and radiological effect and efficacy of biological treatment or immunotherapy on brain metastases in patients with NSCLC and to present a new therapeutic approach. Methods: This retrospective/prospective study includes all patients referred to Oncology department- Rambam Medical Center from Oct. 2008 till Jul. 2016, and prospective for one year started from 01 Aug. 2016. The patients were diagnosed with NSCLC with brain metastases, and treated with immunotherapy or targeted therapy as single agent without radiotherapy. Treatment response was defined as symptomatic improvement and/or radiologic regression. Results: Overall, 16 patients were included. 12 patients (75%) with EGFR mutation or ALK TRANSLOCATION. 11 patients were treated with targeted therapy, and 5 were treated with immunotherapy. 7 patients (43%) had neurological symptoms and 5 of these had clinical response lasted 3 to 11 months. Of the 11 patients receiving biological therapy, 9 (82%) had a good response with tolerable treatment. Of the 5 patients treated with immunotherapy, 2 patients had a radiologic response. 6 patients with no smoking history had EGFR mutation or ALK TRANSLOCATION and received biological therapy, all of them had radiologic response, accounting for 55% of the total of patients who responded. However, only 5 out of 10 patients who are active smokers or had smoking history, had a response. This implies that all patients who did not respond to the treatment are either current or past smokers. (P = 0.09). There was no difference in response to targeted therapy or immunotherapy in patients who received brain radiation therapy in the past compared to patients who were not radiated previously. Conclusions: There is an intracranial effect of targeted therapy or immunotherapy in NSCLC patients. These treatments can delay or prevent radiation therapy to the brain and all its related neurological damage.

From Molecule to Patient and Ways to Get the Dose Precisely Right

From Molecule to Patient and Ways to Get the Dose Precisely Right

An Algorithm for Improving Hospital Performance Measures: A Department-centered Approach.

In recent years, it has become increasingly important to improve efficiency and economic balance in hospitals. The department chairperson (or Chair) contends with a production function consisting of inputs and outcomes, rife with managerial constraints. These constraints can be reduced with proper management by diverting resources and activity. Lack of a proper management algorithm at the department level is a significant impediment to improving operational efficiency in hospitals without significant additional costs. In this work we aimed to develop and implement a management algorithm in a teaching hospital department, in order to improve performances and quality of care. From September 2012 to December 2017 we developed a novel management algorithm for a surgical department and implemented it in the Head and Neck Surgery Department at Rambam Medical Center, Haifa, Israel. Changes were made to the organization structure and the concept of service provision. We defined core measures reflecting operative actions and outcomes and identified actions that could affect these measures. Based on our analysis of outcomes we constructed a management intervention process that defines operative actions leading to improved performance. The result was over 400% improvement in the department’s outcome measures including quality, activity, and service. Analysis of data from the Israeli Ministry of Health revealed that the department’s ranking in performance measures and volume improved from no. 14 of 23 departments in Israel in 2011, to no. 1 in 2013, which was sustained through 2014–2016. Improvement in efficiency also translated to economic balance and transformation from deficit to profitability. If this algorithm is implemented in the rest of the system, it is expected to improve the function of the hospital as a whole. Our results have the potential to foster the development of a new organizational culture of measurement and improvement in the hospital, and subsequently in the entire health system.