Tel Aviv Sourasky Medical Center

Purpose To evaluate the intraoperative central corneal epithelial thickness (ET) as measured by optical coherence pachymetry (OCP) in myopic eyes undergoing alcohol-assisted photorefractive keratectomy (PRK). Methods A retrospective review of patients who underwent alcohol-assisted PRK was performed. Data were abstracted on age, gender, contact lens (CL) wear, preoperative refractive errors, keratometry, topographic and ultrasonic pachymetry, and intraoperative OCP measurements before and after epithelium removal. The central ET was calculated by subtracting OCP measurement after epithelium removal from the OCP measurement prior to epithelium removal. Results The study comprised of 162 consecutive eyes from 81 patients. Mean age was 26.73 ± 6.47 years, 50.6% were males. CL was used in 92 eyes (56.8%). The mean sphere and spherical equivalent were −3.60 ± 1.84 D and −3.26 ± 1.85D, respectively. The mean intraoperative ET was 58.22 ± 17.53 µm (range, 15–121µm). Fifty-five percent of the eyes had an ET measurement above or below the range of 40-60µm. ET was significantly higher in the second operated eye compared to the first operated eye (p = 0.006), and an association was found to CL-wear (p = 0.03). There was no significant difference in thickness between genders (p = 0.62), and no correlation to patient age (p = 0.45, rp = 0.06), refractive errors (p > 0.30,rp=−0.07–0.08), nor keratometry(p > 0.80, rp=−0.01− (−0.02)). Conclusion The intraoperative assessment of ET in alcohol-assisted PRK showed a high variability of the central corneal epithelium, with a significant difference between the first and second operated eyes. This difference may have implications when the epithelium is not included in the surgical planning in surface ablation.

Purpose Non‐contrast‐enhanced time of flight (TOF) is a standard method for magnetic resonance angiography used to depict vessel morphology. TOF is commonly performed with a 3D steady‐state acquisition, employing a short repetition time to support high resolution imaging. At 7 T, TOF exhibits substantial increase in SNR and contrast, improving its clinical value. However, one of the remaining challenges, exacerbated at 7 T, is the presence of artifacts due to pulsatile blood flow, especially near major blood vessels. In this study we examine a method to significantly reduce these artifacts. Methods We recently introduced a new “local‐scrambling” approach that semi‐randomizes the acquisition order of the phase encodes, to achieve a controllable cutoff frequency above which the artifacts are drastically reduced. With this approach, artifacts resulting from fast local fluctuations such as cardiac pulsation are significantly reduced. In this study, we explore the ability of this local‐scrambling approach to reduce pulsatile blood flow artifacts in a 3D TOF acquisition. Cartesian line‐by‐line and center‐out ordering, with and without local‐scrambling, were compared in simulations and in human brain imaging at 3 and 7 T scanners. Results In the simulations the artifact intensity showed a 10‐fold reduction using local‐scrambling compared to line‐by‐line and 4‐fold compared to center‐out ordering. In vivo results show that artifacts are much more pronounced at 7 T compared to 3 T, and in both cases they are effectively reduced by local‐scrambling. Conclusion Local‐scrambling improves image quality for both line‐by‐line and center‐out ordering. This approach can easily be implemented in the scanner without any changes to the reconstruction.

Objective Temporal bone pneumatization (TBP) is speculated to serve as a shock absorber in temporal bone fractures (TBF), directing the fracture line away from vital structures. This study correlates TBP extent with TBF patterns and preservations of vital TB structures. Study Design Retrospective cohort study. Setting Tertiary referral medical center. Methods All TBF patients referred to a single tertiary center 2017 to 2023 were evaluated. A pneumatization index score for each of their TBs was derived by counting automated‐voxel density in a 0 to 100 scale. Results were correlated to the TBF type and the violated structure(s). The ossification index was compared to previously detailed qualitative classification systems of TBP. Results One hundred and forty‐five patients were enrolled (mean age 43 ± 17 years). Kinematics were motor vehicle accidents (46%), scooter (15%), bicycle (14%), falls (13%), and assaults (8%). The mastoid ossification index we used showed a strong correlation to all qualitative classification systems (sigmoid = 0.829; labyrinthine = 0.849; carotis = 0.863, infralabyrinthine = 0.869, all P < .001). The pneumatization index strongly correlated with capsule‐violating TBFs, with a mean of 44 ± 23 for otic capsule‐sparing TBF and 61 ± 20 for otic capsule‐violating (OCV) TBF ( P < .001). The facial nerve was violated in 30 patients. Facial canal (FC) involvement was not correlated to the ossification index: it was 49 ± 23 for FC‐sparing and 44 ± 23 for FC‐violating ( P = .620). Conclusion TBP serves as a protective mechanism against OCV TBF. The more pneumatized the TB, the less likely the otic capsule will be violated in the event of a TBF with the exception of the carotid and FCs. TBP index is in strong agreement with qualitative TBP classification systems.

Neutrophils are the first line of defense against invading pathogens. Neutrophils execute and modulate immune responses by generating reactive oxygen species (ROS). Chronic Granulomatous Disease (CGD) is a primary immune deficiency disorder of phagocytes, caused by inherited mutations in the genes of the NADPH oxidase enzyme. These mutations lead to failure of ROS generation followed by recurrent bacterial and fungal infections, frequently associated with hyper-inflammatory manifestations. We report a multi-center cumulative experience in diagnosing and treating patients with CGD. From 1986 to 2021, 2,918 patients suffering from frequent infections were referred for neutrophil evaluation. Among them, 110 patients were diagnosed with CGD, 56 of Jewish ancestry, 48 of Arabic ancestry and 6 non-Jewish/non-Arabic. As opposed to other Western countries, the autosomal recessive (AR) CGD subtypes were predominant in Israel (71/110 patients). Thirty-nine patients had X-linked CGD, in most patients associated with severe infections (clinical severity score ≥3) and poor outcomes, presenting at a significantly earlier age than AR-CGD subtypes. The full spectrum of infections and hyper-inflammatory manifestations are described. Six patients had hypomorphic mutations with significantly milder phenotype, clinical severity score ≤2, and better outcomes. Hematopoietic stem cell transplantation was implemented in 39/110 patients (35.5%). Successful engraftment was achieved in 92%, with 82% long-term survival and 71% full clinical recovery. CGD is a complex disorder requiring a multi-professional team. Early identification of the genetic mutation is essential for prompt diagnosis, suitable management and prevention.

Background To evaluate real-world utilization of gonioscopy for diagnosing glaucoma among ophthalmologists with diverse subspecialties, and understand current perceptions of teaching, training, and confidence in gonioscopy. Methods A nationwide anonymous online survey was conducted among practicing ophthalmologists, querying about demographics, professional experience, practice of routine ocular examination for glaucoma and perceptions of confidence in performing them. Results 136 ophthalmologists participated in the survey, with various levels of experience from residency to over twenty years of ophthalmology practice. Glaucoma specialists comprised 23 (16.9%) of the participants. Of the non-glaucoma-specialist respondents, only 33 (29.2%) expressed being highly confident in interpreting gonioscopic findings, which correlated significantly with their self-reported inadequate level of training in gonioscopy during residency (p < 0.001) and even more so with their low frequency of implementing gonioscopy in routine examinations (p < 0.001). The commonly cited reasons for the low practice of gonioscopy were insufficient time allotted to examinations and lack of experience, knowledge or equipment. Conclusions Gonioscopy is fundamental to the detection of glaucoma. This study reveals underutilization of gonioscopy in the practice of ophthalmology and its association with lower training opportunities, calling for expedited changes in the residency’s curriculum, alongside measures to promote its use in clinical practice.

Aims Haemodynamic monitoring using implantable pressure sensors reduces the risk of heart failure (HF) hospitalizations. Patient self‐management (PSM) of haemodynamics in HF has the potential to personalize treatment, increase adherence, and reduce the risk of worsening HF, while lowering clinicians' burden. Methods and results The VECTOR‐HF I and IIa studies are prospective, single‐arm, open‐label clinical trials assessing safety, usability and performance of left atrial pressure (LAP)‐guided HF management using PSM in New York Heart Association class II and III HF patients. Physician‐prescribed LAP thresholds trigger patient self‐adjustment of diuretics. Primary endpoints include the ability to perform LAP measurements and transmit data to the healthcare provider (HCP) interface and the patient guidance application, and safety outcomes. This is an interim analysis of 13 patients using the PSM approach. Over 12 months, no procedure‐ or device‐related major adverse cardiovascular or neurological events were observed, and there were no failures to obtain measurements from the sensor and transmit the data to the HCP interface and the patient guidance application. Patient adherence was 91.4%. Using PSM, annualized HF hospitalization rate significantly decreased compared to a similar period prior to PSM utilization (0 admissions vs. 0.69 admissions over 11.84 months, p = 0.004). At 6 months, 6‐min walk test distance and the Kansas City Cardiomyopathy Questionnaire overall summary score demonstrated significant improvement. Conclusions Interim findings suggest that PSM using a LAP monitoring system is feasible and safe. PSM is associated with high patient adherence, potentially improving HF patients' functional status, quality of life, and limiting HF hospitalizations.

Background SPEAK OUT! has been shown to enhance various aspects of voice such as intensity, prosody, voice quality and perception of voice. However, their impacts on expiration and communication effectiveness have not yet been evaluated. This study aimed to evaluate the effectiveness of the Hybrid SPEAK OUT! method on aerodynamic measurements and patient‐reported outcome measures (PROMs) in individuals with Parkinson's disease (PD). Methods This study included 157 participants with PD who underwent an intensive 8‐week multidisciplinary treatment program. The Hybrid SPEAK OUT! method consisted of three sessions per week, including two group sessions and one individual treatment session. Voice‐related aerodynamic measures included maximum phonation time (MPT), vocal cord function using the S/Z ratio, and expiratory flow measures including peak expiratory flow (PEF) and peak cough flow (PCF). Two PROMs were included: the Hebrew version of the voice handicap index‐10 and communication effectiveness questionnaire. Results The results of 111 participants were analysed. MPT duration increased, PEF and PCF increased, and better scores were found in PROMs. Conclusion These findings would appear to support the effectiveness of the Hybrid SPEAK OUT! methods improving function, activity and participation in individuals with PD. However, further research is needed. WHAT THIS PAPER ADDS What is already known on the subject Prior research has demonstrated the effectiveness of behavioral therapies, including the SPEAK OUT! program, in managing speech symptoms in individuals with Parkinson's disease (PD). These therapies have shown improvements in voice intensity, fundamental frequency, voice quality, and voice perception. However, the impact on aerodynamic measures, expiratory flow, and patient‐reported outcome measures has not been extensively studied. What this paper adds to existing knowledge This study adds to the existing knowledge by demonstrating that a Hybrid SPEAK OUT! approach, can lead to improvements in aerodynamic measures, including maximum phonation time (MPT), expiratory and cough peak flow. In terms of motor learning, we found that two non‐speech exhalation‐related tasks that were not directly trained improved following the intensive speech training protocol. Furthermore, it shows positive changes in patient‐reported outcome measures, with reduced voice‐related disability and improved communication efficiency. What are the potential or actual clinical implications of this work? The findings of this study have important clinical implications for the management of speech symptoms in individuals with PD. The Hybrid SPEAK OUT! program, which combines group and individual sessions, can effectively improve voice, aerodynamic measurements and patient‐reported outcome measures (PROMs), ultimately enhancing the overall quality of life for patients. These findings support the effectiveness of the Hybrid SPEAK OUT! methods for improving function, activity, and participation in individuals with PD.

We investigated teachers’ perspectives about what opportunities for learning and teaching could be created using WhatsApp as a social network to help students prepare for the final secondary-school Bagrut (matriculation) exam in mathematics. Launched by the Ministry of Education and the Center for Educational Technology three months before the Bagrut examination, the “WhatsApp Bagroup” project was initiated to serve as an additional environment for learning mathematics. The formation of these WhatsApp groups was meant to provide an online review project during which teachers integrated blended learning, and students presented problems with which they were having difficulties. During this initiative, we applied a quantitative and qualitative research model to analyze the teachers’ points of view about what learning and teaching opportunities were created. The study used a mixed method, sequential explanatory procedure to acquire a complete understanding of the factors that constitute teachers’ perceptions of learning and teaching via the Bagroup project. Quantitative and qualitative data were collected using three tools: a questionnaire with Likert-type statements and open questions, informal semi-structured interviews, and observations of four Bagroup study groups conducted during the three-month period. Factor analysis revealed three categories regarding the Bagroup environment: factors that contribute to learner’s emotional needs, factors that promote learning, and factors that inhibit learning. The findings may have implications for distance and remote learning and teaching opportunities.

In patients with lower‐risk myelodysplastic syndromes/neoplasms (MDS), response to first‐line therapy is limited and transient. The MATTERHORN randomized, double‐blind, phase 3 trial evaluated roxadustat versus placebo for patients with transfusion‐dependent, lower‐risk MDS. Eligible patients had very low‐, low‐, or intermediate‐risk MDS with or without prior erythropoiesis‐stimulating agent treatment, and a transfusion burden of 1–4 packed red blood cell (pRBC) units every 8 weeks (Q8W). Patients were randomized (3:2) to oral roxadustat (2.5 mg/kg) or placebo, both three times weekly, with best supportive care. Primary efficacy endpoint was transfusion independence (TI) for ≥56 days within 28 weeks (TI responders). MATTERHORN was terminated due to interim analysis outcomes not meeting statistical significance. In total, 272 patients were screened, and 140 patients were enrolled (82, roxadustat, and 58, placebo). At final analysis, 38/80 (47.5%) patients and 19/57 (33.3%) in the roxadustat and placebo arms, respectively, were TI responders (p = .217). A greater percentage of patients in the roxadustat arm with a transfusion burden of ≥2 pRBC units Q4W were TI responders (36.1%; 13/36) compared with the placebo arm (11.5%; 3/26; p‐nominal = .047). The seven on‐study deaths (4, roxadustat, and 3, placebo) were considered unrelated to treatment. Three roxadustat patients progressed to acute myeloid leukemia. Despite MATTERHORN not meeting its primary endpoint, a numerically higher TI rate was achieved with roxadustat treatment compared with placebo. Further analyses are needed to confirm the MDS patient subgroups deriving clinical benefit from this novel treatment.

Background Gamification of behavioral intervention for tic disorders (TDs) potentially enhances compliance and offers key clinical advantages. By delivering immediate positive feedback upon tic‐suppression, games may counteract negative reinforcement, which presumably contribute to tic consolidation by relieving uncomfortable premonitory urges. Objectives We developed a gamified protocol (XTics), which leverages this potential by combining gamified tic‐triggering with immediate feedback, and evaluated its clinical value in enhancing tic suppression. Methods XTics encompasses two conditions: Immediate and Contingent Reward (ICR), where game progression is contingent upon successful tic suppression, and Delayed Reward (DR), where game events' outcomes are random. Employing a randomized crossover design, 35 participants (aged 7–15 years) underwent daily gaming sessions over a week per condition. Improvements in our primary measures, including the inter‐tic interval (ITI) and tic severity assessment by blinded evaluators (Yale Global Tic Severity‐Total Tic Score [YGTSS‐TTS], Rush), and parents (Parent Tic Questionnaire [PTQ]), were compared between ICR and DR, and assessed across conditions for the 4‐week protocol. Results No participant voluntarily left the study before completing its two‐phase protocol. As expected, ITI showed significantly larger improvement (Z = 4.19, P = 2.85 × 10–5) after ICR (1442 ± 2250%) versus DR (242 ± 493%) training, increasing at a higher pace (t(67) = 3.15, P = 0.0025). Similarly, Rush tic severity scores reduced more post‐ICR versus DR (t(47) = 3.47, P = 0.002). We observed a clinically significant reduction of 25.69 ± 23.39% in YGTSS‐TTS following a f4‐week protocol including both conditions. Parent‐reported tic severity decreased by 42.99 ± 31.69% from baseline to 3 months post‐treatment. Conclusions The combination of gamified tic‐triggering with immediate and contingent rewards demonstrates a promising approach for enhancing treatment efficacy in TDs, boosting traditional therapeutic methods. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Background Traumatic brain injury (TBI) and spinal cord injury (SCI) are diagnoses commonly encountered on the pediatric rehabilitation unit. However, there is limited evidence in the literature addressing the incidence of or rehabilitation outcomes in pediatric patients with a dual diagnosis of TBI and SCI. Objective To determine incidence and functional outcomes of the dual diagnosis population. Design Retrospective cohort study. Setting Inpatient rehabilitation unit within an academic pediatric hospital. Patients Pediatric patients admitted to a single inpatient rehabilitation unit with a diagnosis of traumatic SCI between 2006 and 2019. Fifty‐four patient records were identified and 26 met inclusion criteria. Interventions Not applicable. Main Outcome Measure Presence of concomitant TBI in patients with diagnosed SCI. Results Seven of 26 patients were given a dual diagnosis of TBI and SCI during their initial rehabilitation hospitalization. After review of charts, authors identified 12 additional patients with suspected dual diagnoses based on injury characteristics and symptoms. There were no significant differences in functional outcomes across diagnosis groups. Conclusions Incidence of dual diagnosis among pediatric patients with traumatic SCI was initially found to be 27%; the retrospective review indicated that TBI may be underdiagnosed in this patient population, and the dual diagnosis incidence may be as high as 73%. All patients had improved functional outcomes during their rehabilitation stays regardless of presence or absence of TBI.

Background Bariatric and metabolic surgery (BMS) is an effective treatment for patients with severe obesity. Patients with higher body mass index (BMI) and patients undergoing revisional surgery have a higher rate of major complications. This study purpose is to evaluate perioperative outcomes of patients with BMI ≥ 50 kg/m². Materials and Methods A retrospective analysis of patients with a BMI ≥ 50 kg/m² undergoing BMS between 2015 and 2023 was conducted. A comparative analysis was performed between patients undergoing primary versus revisional surgery. Results A total of 263 patients were included in the study. Primary procedures were performed in 220 patients (83.7%) and revisional procedures in 43 patients (16.3%). BMS included one anastomosis gastric bypass (n = 183), sleeve gastrectomy (n = 63), and other procedures (n = 17). Mean BMI was 54.6 with no difference between groups. There was no difference in baseline characteristics except the revisional group was older (44.8 ± 9.6 versus 39 ± 13 years; p = 0.006), had higher rates of gastroesophageal reflux disease (21% vs 7.3%; p = 0.005), and fatty liver disease (74% vs 55%; p = 0.02). There was perioperative mortality in three cases (1.1%) with no significant difference between groups. Leak rates were higher, and length of stay (LOS) was longer in the revisional group (4.6% vs 0.45%; p = 0.018 and 2.9 vs 3.7; p = 0.006, respectively). Conclusion Revisional BMS in patients with a BMI ≥ 50 kg/m² is associated with increased leak rates and LOS. Mortality rate is 1.1% and is insignificantly different between groups. Further prospective and large-scale studies are needed to clarify the optimal surgical approach to patients with extreme BMI including revisional surgery. Graphical Abstract

Placental-related fetal growth restriction, resulting from placental dysfunction, impacts 3–5% of pregnancies and is linked to elevated risk of adverse neurodevelopmental outcomes. In response, the fetus employs a mechanism known as brain-sparing, redirecting blood flow to the cerebral circuit, for adequate supply to the brain. In this study we aimed to quantitatively evaluate disparities in gyrification and brain volumes among fetal growth restriction, small for gestational age and appropriate-for gestational-age fetuses. Additionally, we compared fetal growth restriction fetuses with and without brain-sparing. The study encompassed 106 fetuses: 35 fetal growth restriction (14 with and 21 without brain-sparing), 8 small for gestational age, and 63 appropriate for gestational age. Gyrification, supratentorial, and infratentorial brain volumes were automatically computed from T2-weighted magnetic resonance images, following semi-automatic brain segmentation. Fetal growth restriction fetuses exhibited significantly reduced gyrification and brain volumes compared to appropriate for gestational age (P < 0.001). Small for gestational age fetuses displayed significantly reduced gyrification (P = 0.038) and smaller supratentorial volume (P < 0.001) compared to appropriate for gestational age. Moreover, fetal growth restriction fetuses with BS demonstrated reduced gyrification compared to those without BS (P = 0.04), with no significant differences observed in brain volumes. These findings demonstrate that brain development is affected in fetuses with fetal growth restriction, more severely than in small for gestational age, and support the concept that vasodilatation of the fetal middle cerebral artery reflects more severe hypoxemia, affecting brain development.

Background Early Barrett cancer can be curatively treated by endoscopic resection. The choice of the resection technique, however—endoscopic mucosal resection (EMR) or submucosal dissection (ESD)—largely depends on the assumed infiltration depth as judged by the endoscopist. However, the accuracy of endoscopic diagnosis of the degree of cancer infiltration is not known. Methods Three to four high‐quality images (both in overview and close‐up) from 202 of early Barrett esophagus cancer cases (82% men, mean age 66.9 years) were selected from our endoscopy database (73.3% stage T1a and 26.7% in stage T1b). Images were shown to 9 Barrett esophagus experts, with patients' clinical data (age, sex, Barrett esophagus length) and biopsy results. The experts were asked to predict infiltration depth (T1b vs. T1a), and to suggest the appropriate endoscopic resection technique (EMR or ESD, or surgery). Interobserver variability (kappa values) was also determined for these parameters. Results Overall positive (PPV) and negative predictive values (NPV) to diagnose T1b versus T1a infiltration were 40.7% (95% CI: 36.7, 44.8) and 79.8% (95% CI: 77.5, 81.9), respectively; kappa value was 0.41. Paris classification (kappa 0.51) and suggested treatment also varied between experts. In a post hoc analysis, only the correlation between lesions classified as invisible or flat according to the Paris classification (IIB; 25% of all cases) and the suggested resection technique was better: In this subgroup, EMR was recommended in >80% of cases, with a high complete (basal R0) resection rate (mean of 88.1%). Conclusions Precise endoscopic distinction between mucosal and submucosal involvement of Barrett esophagus cancer by experts as a basis for choosing the resection technique has limited predictive values and high interobserver variability. It seems that mainly invisible/flat lesions may result in good resection outcomes when treated by EMR, but this stratification strategy has to be assessed in further studies.

Purpose of Review This review explores characterizing candidates for obesity treatments including pharmacotherapy, endoscopic bariatric therapies, and metabolic bariatric surgery (MBS), focusing on established clinical parameters for diagnosing obesity beyond body mass index alone. Recent Findings Existing literature primarily provides rates for fat mass percentage (i.e., a marker for adiposity quantity), waist circumference (i.e., a marker for adiposity distribution), and C-reactive protein levels (i.e., a marker for adiposity functionality) among obesity treatment candidates. Limited data on abnormal values and sex-based differentiation exist. The literature indicates high central-tendency measures for fat mass percentage and waist circumference, while C-reactive protein levels vary. Data on the Edmonton Obesity Staging System (i.e., a marker for adiposity-related disease severity) is predominantly available for MBS candidates. Summary Future studies in obesity interventions should improve screening and diagnosis of obesity by incorporating sex-specific considerations and providing abnormal value rates for measurements to enhance understanding of patients' characteristics.