Wolfson Medical Center Research Articles

Prevalence and prediction of intraoperative floppy iris syndrome in patients with pseudoexfoliation syndrome

ObjectiveTo investigate the incidence of intraoperative floppy iris syndrome (IFIS) in patients with pseudoexfoliation syndrome (PXF) and analyze preoperative ocular predicting factors. DesignA retrospective case-control study MethodsThe study included 224 eyes with PXF and 287 control eyes without PXF. One eye per patient, who underwent cataract surgery at the Wolfson Medical Center between January 2020 to December 2021, was included. Medical records of the patients were reviewed. Data collected included demographic characteristics, medical history, preoperative comprehensive ophthalmic examination, biometry, surgical procedure details, and IFIS occurrence. The association of IFIS with preoperative ocular parameters was analyzed through both univariant and multivariant analyses. ResultsPatients with PXF were older and had a higher prevalence of glaucoma (77.6 ± 6.4 years vs 74.2±7.6 years; p < 0.001, and 20.1 % vs 9.8 %, p < 0.001, respectively). Prevalence of α-blockers treatment was similar in both groups. IFIS rate among the PXF group was 12.5% (n = 28) compared to 7.3% (n = 21) in the control group (p < 0.05). When omitting patients exposed to α-blockers, the PXF group exhibited a significantly higher IFIS rate (9.9% vs 4.8%; p < 0.05). Pupil dilation diameter was significantly lower among PXF patients (5.8 ± 1.1 mm vs 6.9 ± 0.99 mm; p < 0.001). Biometric evaluation revealed significant differences in anterior segment depth (ACD) and lens thickness (LT). Multivariate analysis indicated that PXF and decreased mydriatic pupil size remained significant predictors of IFIS. ConclusionThis study establishes an association between PXF and an increased risk of IFIS during cataract surgery, independent of α-blockers treatment.

Hydrocephalus associated with a molar tooth sign: A distinct subtype of Joubert syndrome.

Hydrocephalus is rarely described in Joubert-Boltshauser syndrome (JBTS). The aim of this study was to investigate whether this association is a chance occurrence or potentially signifies a new phenotypic subtype. The databases of Wolfson Medical Center, Sourasky Medical Center, and EB's personal collection were reviewed. Records from an additional family were obtained from RG. The patients' medical records, prenatal ultrasounds, and magnetic resonance imaging were assessed. In addition, we reviewed the medical literature for the association of ventriculomegaly/hydrocephalus (VM/HC) in JBTS. Only seven cases (from five families) were found with prenatal onset of VM/HC, diagnosed during the second trimester; three pregnancies were terminated, one was stillborn and three were born, of which one died within a week, and another died at the age of 6 years. Additional central nervous system findings included dysgenesis of the corpus callosum, delayed sulcation, polymicrogyria, and pachygyria. We found 16 publications describing 54 patients with JBTS and VM/HC: only five were diagnosed at birth and three were diagnosed prenatally. Hydrocephalus is extremely rare in JBTS. The recurrence of this association, reported in several publications in multiple family members, suggests that it might represent a new phenotypic subtype of JBTS possibly associated with specific genes or variants. Further genetic studies are needed to confirm this hypothesis. WHAT THIS PAPER ADDS: The association of fetal hydrocephalus with Joubert-Boltshauser syndrome (JBTS) is very rare but not a chance association. This association represents a new phenotypic subtype of JBTS possibly linked to specific genes or variants.

Influence of the CleaRing intraocular open capsule device on refractive predictability in cataract surgery.

The marked improvement in cataract surgery and intraocular lens (IOL) quality has led to a decline in posterior capsular opacification (PCO) incidence; however, PCO remains a common complication of cataract surgery. The CleaRing intraocular capsule open device (IOCD) decreases PCO incidence. We aimed to investigate the influence of the CleaRing IOCD on refractive predictability in cataract surgery. We conducted this prospective pilot study at the Wolfson Medical Center, Holon, Israel. Ten eyes of patients who underwent cataract surgery and insertion of an IOL after IOCD implantation into the capsular bag were included. All patients completed 12 months of follow-up, including refraction, measurement of uncorrected (UDVA) and best-corrected distance visual acuity (CDVA), slit-lamp biomicroscopy, and ultrasound biomicroscopy. All the surgeries were uneventful, with no postoperative complications. The IOL was centred in the device and bag in all cases. The mean prediction error at 1 and 12 months postoperatively was +0.28 ± 0.32 D and +0.50 ± 0.32 D, respectively. The mean UDVA was 0.17 ± 0.13 and 0.15 ± 0.11 logMAR, and the mean CDVA was 0.04 ± 0.10 and 0.04 ± 0.06 logMAR, respectively. The manifest refractive cylinders at 12 months postoperatively were compatible with corneal astigmatism. Implantation of the IOCD resulted in a slight, predicted, and stable hyperopic shift with a low standard deviation. The standard deviation of the prediction error demonstrated excellent refractive accuracy and predictability using the IOCD, which was as low as 0.32 D at the 12-month follow-up.

Resilience Trustees Program in Hospitals–A Case Study: Wolfson Hospital, Israel

Introduction:Medical and paramedical staff endure a psychological toll of burn-out as part of the heavy personal consequences of their work, with an immeasurable increase during the Covid-19 pandemic outbreak. In Israel, there is an added stress of the highly unstable political situation, including war and racial-riots with direct hits of missiles leading to mass casualty events. Members often had to stay in the hospitals for days as the roads home were blocked. Wolfson Medical Center (WMC) is a medium size, level II hospital in the center of Israel. It serves a complex population, most from low to medium socioeconomic status, and a large population of displaced persons. The responsibilities of the staff weigh heavy, leading to psychological trauma, with clear signs of anxiety, depression and suicide.Israel Trauma Coalition (ITC) is a non-profit organization collaborating with over 40 organizations to create a continuum of care in psycho-trauma, response and preparedness.Method:ITC has initiated a Resilience-Trustees program, establishing a strong and active group within the organization, with adequate representation from each department and profession. Training the team to identify a colleague in distress, to respond adequately and to refer to professional help as needed. The program has started implementation in various hospitals in Israel, including WMC.Results:The expected results of this program is a change in the organization's culture of discourse and daily interaction so as to promote resilience and mutual trust and to help cope favorably with crisis situations. The actual results will be shown through a case study of the WMC team of Resilience Trustees, in accordance with the steps of the program (resilience in the original team, then the overall staff).Conclusion:This initiative will promote awareness and acceptance of mental, personal and team difficulties, as well as reduce risks of secondary traumatization, burnout and other disorders.

Evaluation of SARS-CoV-2 in the Vaginal Secretions of Women with COVID-19: A Prospective Study.

Objective: We aimed to investigate the likelihood of vaginal colonization with Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in pregnant and non-pregnant women with Coronavrus Disease 2019 (COVID-19). Materials and Methods: Vaginal swabs were taken from women diagnosed with mild to moderately acute SARS-CoV-2 infection, at Wolfson Medical Center, Israel, from March 2020 through October 2020. COVID-19 was diagnosed by real-time polymerase chain reaction (RT-PCR) performed on nasopharyngeal swabs. Vaginal swabs were tested for the presence of SARS-CoV-2 by reverse transcription polymerase chain reaction (RT-PCR). Results: In total, 51 women diagnosed with COVID-19 were included in the study. Of the 51 women with COVID-19 enrolled in this study, 16 (31.4%) were pregnant at enrollment and 35 (68.6%) were non-pregnant. Mean age was 43.5 ± 15.3 years (range 21–74 years). Compared to the non-pregnant group, the pregnant group was characterized by a higher white blood cell and absolute neutrophil count (p = 0.02 and p = 0.027, respectively). The non-pregnant patients were more likely to have chronic diseases (p = 0.035) and to be hospitalized (p < 0.001). Only one patient (1.9%) aged 60 years tested positive for SARS-CoV-2 in vaginal secretions. Mean gestational age at the diagnosis of COVID-19 of the pregnant group was 32.3 ± 7.8 weeks. Thirteen patients delivered during the study period; all delivered at term without obstetric complications and all neonates were healthy. Conclusions: Detection of SARS-CoV-2 in the vaginal secretions of patients diagnosed with COVID-19 is rare. Vaginal colonization may occur during the viremia phase of the disease, although infectivity from vaginal colonization needs to be proven.

P1497INCIDSENCE OF CANCER IN HEMODIALYSIS-TREATED PATIENTS

Abstract Background and Aims In recent decades, there has been an increase in the incidence and prevalence of patients with end stage renal disease (ESRD) worldwide. Previous studies have shown an increased incidence of malignancies among ESRD patients, compared to age-matched controls, although it was unclear whether different etiologies of ESRD ( diabetes, hypertension, cystic disease) confer different risk ratio. Our present study intends to re-examine relationships between ESRD, classified according to the etiology of renal disease, cancer incidence and types of malignancies in hemodialysis treated patients. Method We conducted a retrospective study, analyzing hemodialysis (HD) treated patients over the age of 18 at the Wolfson Medical Center in Holon, Israel, from 2008-2017. Patients diagnosed with cancer prior to dialysis or with history of transplantation were excluded. Data on etiology of chronic kidney disease and ESRD, comorbidities and cancer diagnosis was collected from patients' files and verified using the Israeli National Cancer Registry. A single, multivariate survival analysis was conducted to examine the relationship between the various predictors and the incidence of cancer. Results The study included 333 patients, 211 (63.4%) were males, mean age 67.2±13.1 years. The median follow was 4 years (95% CI: 2-6.5). Twenty eight (8.4%), developed primary malignancy during hemodialysis, annual rate: 2.1%, Vs 0.35% age-adjusted annual rate in Israeli general population. The average age of all patients diagnosed with cancer over the study period was higher than that of patients without cancer (72.3±7.7 Vs 66.7±13.4 years. P=0.001). The most common sites of malignancy were colon (33%), bladder (16.7%), kidney (10%) and prostate (10%). Older age was the only risk factor associated with the onset of malignancy. No statistically significant relationship was found between ESRD etiology, comorbidities and occurrence of malignancy. Conclusion Among our cohort of patients on chronic hemodialysis, annual cancer incidence rate is 6 times higher than age matched controls in the Israeli general population. Older age is a risk factor associated with onset of malignancy. We did not found associations between ESRD etiology, comorbidities and cancer incidence. This study constitutes a platform for a longer period multicenter study.

Does Bariatric Surgery Affect Intraocular Pressure?

The effect of body mass index (BMI) reduction following bariatric surgery on intraocular pressure (IOP) is not well established. We evaluated association between BMI reduction and IOP measurements and other ocular and metabolic parameters 1year after bariatric surgery. A retrospective study with over 1-year follow-up on patients who underwent weight reduction bariatric surgery between January 2016 and December 2016 at Wolfson Medical Center, Israel. Patient data was extracted from outpatient's bariatric and ocular clinic records. Metabolic, ocular, and clinical parameters were assessed including BMI changes, IOP, central corneal and retinal nerve fiber layer thickness, optical coherence tomography, and biometry results. Of 22 bariatric surgery patients, 15 underwent laparoscopic sleeve gastrectomy (LSG) and 7 laparoscopic mini gastric bypass (MGB). All were followed up for over 1year after surgery. Average BMI decreased from 41.9 ± 7.3 to 25.5 ± 5.7kg/m2 at 1-year follow-up (p < 0.001). Mean IOP decreased significantly by 21% after 1year (p < 0.001). Decrease in IOP 1year after surgery was correlated with decrease in IOP at 3-month follow-up (r = 0.677, p = 0.001), preoperative IOP (r = 0.837, p < 0.001), and corneal thickness (r = 0.589, p = 0.006), with no correlation between reduction in IOP and baseline weight, BMI, or the reduction in either (p > 0.05). Central corneal thickness and retinal nerve fiber layer thickness were also significantly decreased (p = 0.038) and (p = 0.018), respectively. BMI reduction achieved by bariatric surgery was associated with significant and continued decline in IOP beyond 1year after surgery. Clinical implications highlight the importance of considering bariatric surgery in patients with ocular hypertension.

The Impact of Gestational Weight Gain on Subclinical Atherosclerosis, Placental Circulation and Neonatal Complications

Objective: Vascular atherosclerotic changes, mediated by environmental and genetic factors, develop years before an event. Detection of vascular damage, using ultrasonographic measurement of carotid IMT, is predictive of future cardiovascular events. The present study was designed to investigate the impact of gestational weight gain (GWG) on early atherosclerotic changes during late pregnancy, using intima media thickness (IMT), as well as placental vascular circulation and inflammatory lesions and pregnancy outcome. Design and methods: 59 women who gave birth at Wolfson Medical Center during 2018 were divided into two groups according weight gain during pregnancy: Group 1 included 32 women with pregnancy weight gain within recommended range, Group 2 included 27 wonen with exessive weight gain during pregnancy. IMT was measured by High-resolution B-mode ultrasound (Sonosite Titan/Sonosite, Inc., Bothell, Washington, USA). Placental histology was performed for vascular circulation, as well as inflammatory lesions of maternal and fetal origin. Metabolic measures such as fasting glucoe, lipids, hs-CRP, HOMA-IR were determined. Maternal and neonatal outcome parameters were collected. Results: Weight gain during the pregnancy was significantly higher in Group 1, compared to Group 2 (17.5+/-6.2 vs 6.8+/-5.7, p<0.0001), whereas pre-gestational BMI did not differ significantly between groups (p=0.059). IMT levels differed between groups and was significantly higher in group 1 compared to Group 2 (0.7+/-0.1 vs 0.6+/-0/1, p=0.028). In regression analisys, pregnancy weight gain remained a significant independent predictor of IMT. Rate of macrosomia was significantly higher in Group 1 than in Group 2 (p=0.014). Maternal vascular supply (MVS) abnormalities of the placental bed did not differ significantly between groups (p=0.297). Among placental lesions related to fetal vascular malperfusion, villous changes consistent with fetal thrombo-occlusive disease (FTOD) were significantly higher in Group 1 than in group 2 (p=0.034). Conclusion: In the present study, excessive weight gain during pregnancy was significantly and independently associated with an increased IMT. Among placental vascular lesions, villous changes consistent with fetal thrombo-occlusive disease (FTOD) were significantly higher women with excessive weight gain during pregnancy.

High-Intensity Statins Are Associated With Increased Incidence of Hypoglycemia During Hospitalization of Individuals Not Critically Ill

BackgroundSerum cholesterol is inversely associated with incident hypoglycemia among patients admitted to internal medicine wards. We examined the association between statin use and incidence of hypoglycemia among patients who were not critically ill. MethodsIn this retrospective study, we included all patients discharged between January 1, 2010, to December 31, 2013 from internal medicine units at the Wolfson Medical Center. Excluded were patients with hepatocellular or cholestatic liver disease upon admission. Patients were allocated to 4 groups, according to diabetes mellitus status (yes or no) and serum albumin <3.5 g/dL (yes or no) on admission. Regression analysis was used to examine the association of incident hypoglycemia during hospitalization and statin treatment (yes or no), and later, statin intensity. ResultsIncluded in this analysis were 31,094 patients (mean age 68.9±17.5 years, 48.4% males, 21.7% with diabetes mellitus). Logistic regression models showed that among patients with low admission serum albumin, administration of high-intensity statins was associated with increased incidence of hypoglycemic events compared to patients not treated with statins (odds ratio [OR] 1.303, 95% confidence interval [CI] 1.016-1.671, P = 0.037), whereas treatment with low-intensity statins was associated with less hypoglycemic events (odds ratio 0.590, 95% confidence interval 0.396-0.879, P = 0.010). Among patients with normal serum albumin, no association was found between incident hypoglycemia and statin intensity. These findings were significant regardless of diabetes mellitus status. ConclusionStatin treatment in general is associated with reduced incidence of hypoglycemia. However, among patients with low serum albumin upon admission, use of high-intensity statins is associated with an increased risk of hypoglycemic events regardless of diabetes mellitus status.

Insulin Treatment Is Associated With Improved Fetal Placental Vascular Circulation in Obese and Non-obese Women With Gestational Diabetes Mellitus.

Objective: The present study was designed to investigate the impact of carbohydrate restriction and insulin treatment on placental maternal and fetal vascular circulation in obese and non-obese women with gestational diabetes mellitus (GDM).Design and methods: One Hundred Ninety-One women with GDM who gave birth and underwent a placental histopathological examination at Wolfson Medical Center, Israel, were included in the study: 122 women who were treated with carbohydrate/calorie restriction diet (Group 1) and 69 women who were treated with diet plus insulin (Group 2). Additionally, each group was divided into two subgroups according to pre-pregnancy BMI: non-obese and obese.Results: Maternal vascular malperfusion lesions did not differ significantly between groups. Vascular lesions related to fetal malperfusion were significantly lower in GDM women treated by insulin and diet compared to women with diet alone (p = 0.027). Among fetal malperfusion lesions, villous changes consistent with fetal thrombo-occlusive disease (FTOD) were significantly lower in women treated with diet plus insulin and lowest in GDM women with pre-pregnancy BMI < 30 kg/m2 (p = 0.009). In the logistic regression analysis, insulin treatment was significantly associated with a decreased rate of villous changes consistent with FTOD (OR 0.97, 95% CI 0.12–0.80, p = 0.03). Prevalence of gestational hypertension was higher in obese women of both treatment groups (p = 0.024).Conclusion: Combination of obesity and GDM increased rate of FTOD and prevalence of gestational hypertension. Carbohydrate restriction diet plus insulin treatment was associated with improved fetal placental vascular circulation, especially in GDM women with pre-pregnancy BMI < 30 kg/m2.

The role of substance use and adult sexual assault severity in the course of schizophrenia: An epidemiological catchment study of sexual assault victims

BackgroundChildhood trauma increases the risk of schizophrenia, yet the role of adult sexual assault in the course of schizophrenia is unknown. This study aims to examine the associations between substance use and sexual assault severity characteristics with the course of schizophrenia among adult sexual assault victims using an epidemiologic study design. MethodsSexual assault data on all individuals received from 2000 to 2010 (N = 2147) at the Center for Care of Sexual Assault Victims at Wolfson Medical Center, the largest medical center for sexual assault victims in the country, were merged with the Israel National Psychiatric Case Registry, that consisted of lifetime psychiatric hospitalizations of schizophrenia (birth to 6 years post-assault). The associations between substance use and adult sexual assault severity characteristics with hospitalizations were quantified using recurrent events Cox modeling. ResultsSchizophrenia with sexual assault survivors occurred in 117 persons. Cox modeling showed that recurrent psychiatric hospitalizations were associated with younger age, sexual assault at older age, previous diagnosis of psychosis, and drug use shortly before or during the assault. Other assault characteristics (number of assailants, means of subdual, penetration type, perpetrator violence, physical injury of the victim) and immediacy of seeking help had a null association with the course of psychiatric hospitalization. These results replicated in two sensitivity analyses. ConclusionsSubstance use among victims of sexual assault was associated with an exacerbated course of schizophrenia, pointing to a possibly modifiable risk factor that should be targeted in prevention, assessment, treatment formulation and implementation.

Documented hypoglycemia is associated with poor short and long term prognosis among patients admitted to general internal medicine departments

AimTo study the association of documented hypoglycemia with length of stay, 30-day mortality, and 1-year mortality, among patients with and without diabetes admitted to internal medicine units. MethodsThe electronic medical records of all patients hospitalized in internal medicine departments at E. Wolfson Medical Center, Holon, Israel, between 1/1/2010 and 31/12/2013, were reviewed. Data extracted included all glucose measurements (performed using an institutional blood glucose monitoring system). Patients were considered hypoglycemic if at least one hypoglycemic event was recorded. Regression analysis was used to assess the association between documented hypoglycemia and length of stay, 30-day and one-year mortality. Age, sex, reason for admission, and the Charlson comorbidity index were entered as covariates, and the most conservative model was developed. ResultsThe study population included 45,272 patients (mean age 68.9 ± 17.8 years, 49.4% males, 21.0% had diabetes mellitus). The rate of hypoglycemia in the total study population was 7.5% (16.8% among DM patients, 6.0% among patients without diabetes, p < 0.001). Patients with documented hypoglycemia had a longer length of hospital stay (9.3 ± 18.7 vs. 3.1 ± 6.4 days, p < 0.001), as well as higher risk for both 30-day (23.7% vs. 7.0%, p < 0.001) and 1-year mortality (41.6% vs. 15.3%, p < 0.001). Cox regression analysis showed that hypoglycemia significantly increased risk death at one year (HR 2.436, 95% CI 2.298–2.582, p < 0.001) independent of age, sex, the Charlson comorbidity index, DM status and reason for admission. ConclusionDocumented hypoglycemia is associated with prolonged length of hospital stay and increased risk for both 30-day and 1-year mortality, regardless of diabetes mellitus status.

Pre-selection of primary intubation technique is associated with a low incidence of difficult intubation in patients with a BMI of 35 kg/m2 or higher

The incidence of difficult intubation (DI) in obese patients may reach a two-digit figure. No studies have assessed the effect of primary use of special intubation devices on lowering the incidence of DI. We assessed the effect of primary selection of special intubation techniques on the incidence of DI in patients with a BMI of 35 kg/m2 or higher. Data from 546 patients with a BMI of 35 kg/m2 or higher who underwent bariatric surgery at Wolfson Medical Center from 2010 through 2014 was retrospectively extracted and analyzed for demographics, predictors of DI and intubation techniques employed. Difficult intubation was defined as the presence of at least one of the followings: laryngoscopy grade 3 or 4, need for >1 laryngoscopy or intubation attempt, need for changing the blade size, failed direct laryngoscopy (DL), difficult or failed videolaryngoscopy (VL-Glidescope), difficult or failed awake fiberoptic intubation (AFOI) and using VL or awake AFOI as rescue airway techniques. Primary intubation techniques were direct DL, VL and AFOI. We correlated the predictors of DI with the actual incidence of DI and with the choice of intubation technique employed. The overall incidence of DI was 1.6% (1.5% with DL vs. 2.2 with VL + AFOI, p = 0.61). With logistic regression analysis, age was the only significant predictor of DI. Predictors of DI that affected the selection of VL or AFOI as primary intubation tools were Mallampati class 3 or 4, limited neck movement, age, male gender, body mass index and obstructive sleep apnea syndrome. The lower incidence of DI in our study group may stem from the primary use of special intubation devices, based on the presence of predictors of DI.

Effect of short- and long-term diabetes control on in-hospital and one year mortality rates in hospitalized patients with diabetic foot

IntroductionIt remains unclear whether diabetic patients with diabetic foot complications benefit from strict glycemic control during hospitalization The present study investigates the effect of short- and long-term diabetes control on hospital outcomes including: in-hospital and one year mortality rates, length of hospital stay and the rate of repeated admissions. MethodsType 2 diabetic patients (n = 341) were hospitalized for diabetic foot complications at Wolfson Medical Center over a 5 year period (2008–2012). The adequate short-term glycemic control was defined as average glucose levels between 110 and 180 mg/dL. HbA1c values below 7% were defined as adequate long–term glycemic control. ResultsThe average glucose levels during hospitalization were 179 ± 45 mg/dL and 40% of the measurements were between 110 and 180 mg/dL. Mean admission HBA1c levels were 8.43% ± 2.26%, and 31% of the values were below 7%. The mean length of hospital stay was 24.3 ± 22.6 days, 15.0% of the patients needed surgical intervention during admission, the in-hospital mortality rate was 10.3%, and the rate of 1-year readmission was 25.1%. Adequate diabetes control during hospitalization was not significantly associated with reduced in-hospital mortality (hazard ratio, 0.454, 95% confidence interval 0.186–1.103, p = 0.081). However, adequate diabetes control during hospitalization lead to significantly decreased one year mortality (hazard ratio, 0.269, 95% confidence interval 0.707–0.101, p = 0.009). Adequate diabetes control during hospitalization did not affect the length of hospital stay or the rate of repeated admission. ConclusionsImproved glucose control during hospital admission (levels between 110 and 180 mg/dL) was associated with reduction of one year mortality.

The relationship between hypertensive disorders in pregnancy and placental maternal and fetal vascular circulation

We examined the impact of chronic hypertension (HTN), gestational HTN, and preeclampsia on placental maternal and fetal vascular circulation. Of the 1047 women who gave birth and underwent a placental histopathologic examination between 2007 and 2013 at Wolfson Medical Center, 140 women were included in the present study: 34 women with preeclampsia, 25 women with chronic HTN, 28 women with gestational HTN, and 53 women without hypertensive disorder, matched by age, gravidity, parity, and mode of delivery.Placental lesions related to maternal vascular malperfusion (MVM) differed significantly across groups (P < .0001) and were highest in subjects with chronic HTN and preeclampsia (72% and 65%, respectively) and lowest in women without hypertensive disorder (26%). Placental fetal vascular malperfusion rate did not differ significantly between groups (P = .767). In the logistic regression analysis, chronic HTN emerged as a significant predictor of placental MVM and increased the risk of this outcome more than sixfold (odds ratio 6.614, 95% confidence interval 2.047–21.37, P = .002). Preeclampsia emerged as a significant predictor of MVM and more than tripled the risk of this outcome (odds ratio 3.468, 95% confidence interval 1.083–11.103, P = .036). Gestational HTN was not significantly associated with increased MVM rate. We demonstrated that chronic HTN and preeclampsia were associated with an increased rate of vascular placental maternal malperfusion and emerged as significant independent predictors of this outcome.

Was the Military Operation "Protective Edge" a Risk Factor for Pregnancy Complications?

ObjectiveDuring July–August 2014, the military operation “Protective Edge” presented Israel with a threat of missile attacks. We aimed to investigate the influence of the “Protective Edge” operation on the rate of pregnancy complications among the population exposed to missile attacks, compared to the population not exposed.Study DesignThis was a retrospective study. Pregnancy outcomes were compared between women who during pregnancy were exposed to the stress of the military operation (exposed group, n=4,673) and gave birth at the Wolfson Medical Center, and women who gave birth in the previous year (unexposed group, n=4,735).ResultsRates of pregnancy complications did not differ between the groups.ConclusionExposure to environmental stress during pregnancy, for a period of almost two months, was not found to be associated with increased risk for pregnancy complications.

Elevated ferritin and circulating osteoprotegerin levels as independent predictors of hip fracture in postmenopausal women admitted for fragility fracture: time for new screening strategies?

Identification of risk factors may help us to understand the pathogenesis of osteoporotic hip fracture as well as to formulate development of better diagnostic, prevention and treatment strategies. The present study was designed to determine the impact of multiple metabolic risk factors such as markers of systemic inflammation (C-reactive protein), immune responses-acute phase reactants (ferritin), insulin resistance (HOMA-IR) and bone remodeling (osteoprotegerin), for the prediction of hip fractures in postmenopausal osteoporotic women. The study group consisted of 115 postmenopausal women divided into two groups: Group 1 consisted of 49 women hospitalized in the Orthopedic Department, Wolfson Medical Center for the diagnosis of non-traumatic hip fracture and Group 2 contained 66 postmenopausal osteoporotic women without a history of hip fracture. Metabolic parameters were determined. Circulating OPG was significantly higher in Group 1 than in Group 2 (205.2±177.1 vs 60.0=/-22.3, p<0.0001). While levels of hemoglobin (Hbg) as well as MCV and MCH did not differ between groups, circulating ferritin was significantly increased in Group 1 compared to the control Group 2 (217.9±195.1 vs 49.7±31.3, p<0.0001). In multiple linear regression analysis, which explains about 40% of the variability in CRP, 42% in OPG, and 28% in ferritin, significant by-group differences in terms of these parameters persisted even after adjustment. Elevated serum ferritin concentrations and bone remodeling marker, osteoprotegerin, are independent predictors of hip fracture in postmenopausal women hospitalized for fragility fracture.

Mending Hearts and Building Bridges: The Save a Child's Heart Foundation.

Save a Child's Heart addresses the challenges of heart care for children in underdeveloped countries. Save a Child's Heart has created a center of excellence for pediatric cardiac care at the Wolfson Medical Center in Israel, helped develop partner sites for evaluation and referral, and trained medical teams to return and build their own capacity for local cardiac care. Save a Child's Heart has treated more than 3600 children from 48 countries, with 50% from Iraq, Jordan, the Palestinian Authority, and Syria. In cooperation with the Palestinian Authority, Save a Child's Heart has examined more than 6000 children and treated 1750 children, trained 21 medical personnel, and conducted seminars for Palestinian medical personnel. The "Heart of the Matter Project," funded by the European Union, US Agency for International Development, the Palestinian Ministry of Health, and the Israeli Ministry of Regional Cooperation, is currently training a team at the Wolfson Medical Center from the Palestine Medical Complex in Ramallah and provides funds for Palestinian children's care in Israel. Save a Child's Heart is a model of a global humanitarian health care initiative with a single focus on heart disease in children. The "Heart of the Matter Project" is a model of health care based on regional cooperation despite local political tensions.

Decreased Dopamine Transporter Binding Ipsilateral to the Clinically More Affected Side in Parkinson's disease: Which Side to Take?

Objective: The gold standard for diagnosis of Parkinson's disease (PD) is SPECT with dopamine transporters (DaT). Reduced ligand uptake in the dorsal putamen is usually more prominent in the hemisphere contralateral to the side with more predominant clinical symptoms. However, in some cases, loss of ligand uptake is more severe on the ipsilateral side. The aim of the study was to characterize the clinical symptoms and outcome of patients with an initial diagnosis of PD and SPECT findings of reduced ligand uptake on the side ipsilateral to the motor symptoms. Methods: All SPECT studies performed at Wolfson Medical Center in 2001-2013 were reviewed for findings of an asymmetrical striatal decrease in ligand uptake. The side with the greater loss in uptake was recorded, and data on the side of disease onset were retrieved from the medical files of the corresponding patients. Patients with mismatched findings formed the study group and were further evaluated for clinical characteristics and disease course. Results: Of the 95 patients with asymmetric DaT binding on SPECT whose medical files were available for analysis, 11 met the inclusion criteria. On long-term follow-up (2-13 years), 5 had a typical course of PD. Among the remainder, one had possible diffuse Lewy body disease, one had vascular Parkinsonism, and 4 had nonprogressive disease. Conclusion: Loss of DaT binding ipsilateral to the clinically more affected side should raise suspicions of a diagnosis other than PD.

PP12.9 – 2524: Clinical spectrum of TUBB4A-related disorders: Three patients with different phenotypes and course

Objective To describe 3 patients representing the wide phenotypic spectrum of TUBB4A-related disorders. Methods The setting: Metabolic-Neurogenetic Clinic, Wolfson Medical Center, Israel. The subjects: Patient 1: An 8 year old girl with a classic clinical and radiologic picture of hypomyelination with atrophy of the basal ganglia and cerebellum (H-ABC). She presented with delayed motor development and gait instability by the end of her first year of life, followed by slowly progressive motor deterioration and extrapyramidal signs. She has mild intellectual disability and severe dysarthria. Her half-brother suffered from a similar disease and died in the second decade. Patient 2: A 3 year old girl with hypomyelination but without atrophy of the basal ganglia or cerebellum. Presented with congenital nystagmus, generalized dystonia, postnatal microcephaly and global developmental delay. Patient 3: A 9.5 year old boy with gait instability from the second year of life, followed by slowly progressive spastic paraparesis, segmental dystonia, mild intellectual disability, severe behavioral problems and regional hypomyelination with progressive cerebellar atrophy. Sequence analysis of the TUBB4A gene in the first patient's DNA and whole exome sequencing in the other 2 patients were performed. Results The first patient and her half-brother were found to carry the common D249N mutation known in H-ABC. Their mother is negative for the mutation, suggesting germline mosaicism. A novel de-novo mutation, V179L was found in the second patient and a de-novo E410K mutation was found in the third patient. Conclusions Mutations in the TUBB4A gene have been described in association with two main clinical phenotypes: childhood-onset hypomyelination with atrophy of the basal ganglia and cerebellum, and late-onset dystonia. Our cases demonstrate that the spectrum of TUBB4A-related disorders also includes: familial cases due to germline mosaicism, lack of cerebellar atrophy on neuroimaging, regional hypomyelination and a clinical phenotype consistent with complicated spastic paraparesis.