Ofer Merin - Academia.edu (original) (raw)
Papers by Ofer Merin
Challenges in Implementing International Standards for the Field Hospital Emergency Department in a Disaster Zone: The Israeli Experience
The Journal of Emergency Medicine
Untreated Mitral Regurgitation Does Not Affect Survival of Elderly Patients Undergoing TAVI
The Journal of heart valve disease, 2016
The study aim was to examine the impact of concomitant significant mitral regurgitation (MR) in p... more The study aim was to examine the impact of concomitant significant mitral regurgitation (MR) in patients undergoing transcatheter aortic valve implantation (TAVI). TAVI has become an acceptable mode of treatment for high-surgical risk patients with aortic stenosis (AS) requiring valve replacement. A significant number of patients have concomitant MR which cannot be addressed by TAVI alone, and therefore may not be considered candidates for this procedure. A comparison was conducted of results obtained from patients undergoing TAVI with or without MR. Between 2008 and 2013, a total of 164 patients (mean age 81 ± 8 years) underwent TAVI at the authors' institution. Of these patients, 87 (53%) had MR of moderate or greater degree. The groups were similar with respect to age, gender, presence of congestive heart failure, left ventricular function and co-morbid conditions. The logistic EuroSCORE was higher in the MR group (p = 0.02). Procedural (30-day) mortality was 12% (n = 19) and...
The Annals of thoracic surgery, 2018
The neutrophil-lymphocyte ratio (NLR) is a recognized marker of inflammation associated with poor... more The neutrophil-lymphocyte ratio (NLR) is a recognized marker of inflammation associated with poor outcomes in various clinical situations. We analyzed the prognostic significance of preoperative elevated NLR in patients undergoing cardiac surgery. We performed a retrospective review of 3,027 consecutive patients undergoing cardiac surgery. Receiver-operating-characteristic was used to determine the cutoff value for elevated NLR. Multivariate regression was used to determine the predictive value of preoperative NLR on clinical outcomes. Cox proportional hazards functions were used to determine predictors of late events. Late survival data to 16 years was obtained from the Ministry of Interior. The cutoff value for elevated NLR was 2.6. Patients with elevated NLR were older (p < 0.0001), had a higher incidence of cardiac comorbidity (p < 0.0001), and higher European System for Cardiac Operative Risk Evaluation score (p < 0.0001). An elevated NLR emerged as an independent pred...
Hyponatremia Predicts Poor Outcomes in Patients With Chronic Kidney Disease Undergoing Heart Operation
The Annals of thoracic surgery, 2018
Preoperative hyponatremia adversely affects outcomes of cardiothoracic operation. However, in pat... more Preoperative hyponatremia adversely affects outcomes of cardiothoracic operation. However, in patients with chronic kidney disease, the association of sodium levels on postoperative events has never been evaluated. We investigated the impact of preoperative hyponatremia on outcomes after cardiac operation in patients with non-dialysis-dependent chronic kidney disease. Primary end points were operative mortality and acute kidney injury that required dialysis. Secondary end points were major infection and long-term survival. The study is observational and includes all patients with stage III to IV chronic kidney disease (non-dialysis) undergoing cardiac operation between February 2000 and January 2016. Patients were stratified into two groups by preoperative sodium levels: sodium less than 135 mEq/L and sodium of 135 mEq/L or more. There were 1,008 patients (mean estimated glomerular filtration rate [GFR]: 43 ± 14 mL • min • 1.73 m) with 92 patients (9%) in the low-sodium group. Patie...
Outcomes of transcatheter aortic valve implantation compared with surgical aortic valve replacement in geriatric patients with chronic kidney disease
Clinical nephrology, 2018
Transcatheter aortic valve implantation (TAVI) is a less invasive treatment modality for patients... more Transcatheter aortic valve implantation (TAVI) is a less invasive treatment modality for patients with severe aortic valve stenosis (AS) who are at a higher risk if they have surgery. Preoperative chronic kidney disease (CKD) influences outcomes of cardiac surgery and is associated with a higher mortality and more complicated hospital course. The aims of our study were to evaluate the comparative outcomes of TAVI versus surgical aortic valve replacement (SAVR) in geriatric patients with preoperative CKD. We prospectively collected data on patients > 75 years of age who underwent either SAVR or TAVI at Shaare Zedek Medical Center, Jerusalem, Israel. The outcomes studied were postoperative acute kidney injury (AKI), in-hospital and long-term mortality, and major neurologic and infectious morbidity. A total of 318 patients were analyzed, of those, 199 and 119 underwent SAVR and TAVI, respectively. In patients with CKD, there was no statistically significant difference in postoperati...
Deployment of field hospitals to disaster regions: Insights from ten medical relief operations spanning three decades
American journal of disaster medicine, 2017
The Israeli Defense Force (IDF) Medical Corps developed a model of airborne field hospital. This ... more The Israeli Defense Force (IDF) Medical Corps developed a model of airborne field hospital. This model was structured to deal with disaster settings, requiring self-sufficiency, innovation and flexible operative mode in the setup of large margins of uncertainty regarding the disaster environment. The current study is aimed to critically analyze the experience, gathered in ten such missions worldwide. Interviews with physicians who actively participated in the missions from 1988 until 2015 as chief medical officers combined with literature review of principal medical and auxiliary publications in order to assess and integrate information about the assembly of these missions. A body of knowledge was accumulated over the years by the IDF Medical Corps from deploying numerous relief missions to both natural (earthquake, typhoon, and tsunami), and man-made disasters, occurring in nine countries (Armenia, Rwanda, Kosovo, Turkey, India, Haiti, Japan, Philippines, and Nepal). This study sho...
Terrorist Stabbings-Distinctive Characteristics and How to Prepare for Them
The Journal of emergency medicine, 2017
The number of terror attack incidents is on the increase worldwide. The knife is one of the weapo... more The number of terror attack incidents is on the increase worldwide. The knife is one of the weapons most commonly used among terrorists. Appropriate preparation in trauma units for coping with the increasing numbers of terrorist-inflicted stabbings is different from the preparation suitable for civilian stabbings. Therapeutic and logistic guidelines need to be adjusted to accommodate those differences. Characterize the unique injuries related to terrorist stabbing, and suggest preparedness actions. Retrospective data on all terrorist-inflicted stabbing incidents between September 2015 and May 2016 were retrieved from the database of the national Israeli emergency medical services and from the Israeli Defense Forces Medical Corps records. There were a total of 414 civilian victims (34 fatalities) of terror incidents. Of these, 161 involved stabbings during 106 separate incidents. There was more than 1 stab wound per patient in approximately 60% of cases, and more than 1 victim in app...
Morbidity among the Israeli Defense Force response team during Nepal, post-earthquake mission, 2015
Journal of travel medicine, 2017
On 25 April 2015, a 7.8-magnitude earthquake struck Nepal. Soon after, the Israel Defense Force (... more On 25 April 2015, a 7.8-magnitude earthquake struck Nepal. Soon after, the Israel Defense Force (IDF) dispatched a rapid-response team and opened a tertiary field hospital in Kathmandu. There is limited data regarding the spectrum of diseases among rescue teams to disease-stricken areas. The aim of this study was to assess the morbidity among the field-hospital staff during the mission. The rescue team was deployed for a 2-week mission in Kathmandu. Pre-travel vaccinations were given prior to departure. The field-hospital was self-equipped including food and drinking water supply with a self-serving kitchen, yet had a shortage of running water. A Public Healthcare and Infectious-Diseases team was present and active during the entire mission. A survey assessing the morbidities and risk-factors throughout the mission was performed at the last day. One hundred thirty-seven (69%) team members completed the questionnaire. Medical complaints were recorded in 87 of them (64%). The most com...
Mobile in Situ Simulation as a Tool for Evaluation and Improvement of Trauma Treatment in the Emergency Department
Journal of surgical education, Jan 3, 2015
Medical simulation is an increasingly recognized tool for teaching, coaching, training, and exami... more Medical simulation is an increasingly recognized tool for teaching, coaching, training, and examining practitioners in the medical field. For many years, simulation has been used to improve trauma care and teamwork. Despite technological advances in trauma simulators, including better means of mobilization and control, most reported simulation-based trauma training has been conducted inside simulation centers, and the practice of mobile simulation in hospitals' trauma rooms has not been investigated fully. The emergency department personnel from a second-level trauma center in Israel were evaluated. Divided into randomly formed trauma teams, they were reviewed twice using in situ mobile simulation training at the hospital's trauma bay. In all, 4 simulations were held before and 4 simulations were held after a structured learning intervention. The intervention included a 1-day simulation-based training conducted at the Israel Center for Medical Simulation (MSR), which include...
The Israel Medical Association journal: IMAJ
The Israel Medical Association journal : IMAJ, 2004
The Evolution of Surgical Humanitarian Missions
The Role of Anesthesiology in Global Health, 2014
Axillary Lymph Node Dissection in Breast Cancer: Current Status and Controversies, Alternative Strategies and Future Perspectives
Acta Oncologica, 2000
Axillary lymph node dissection (ALND) has traditionally been considered as a standard procedure i... more Axillary lymph node dissection (ALND) has traditionally been considered as a standard procedure in the surgical management of patients with breast cancer. The goals of ALND in breast cancer surgery are: (a) to provide accurate prognostic information, (b) to maintain local control of the disease in the axilla and (c) to provide a rational basis for decisions about adjuvant therapy. Although controversial, ALND may also be associated with a small therapeutic benefit. Recently, the question of whether ALND is needed for every patient with invasive breast cancer has been the subject of ongoing debate in the literature. This is mainly due to the widespread use of adjuvant systemic therapy for patients with node-negative breast cancer and to the increasingly frequent detection of small invasive cancers by mammographic screening; the majority of these patients have negative axillae. Sentinel lymph node (SLN) biopsy is a new, promising, minimally invasive procedure, which accurately predicts nodal status with minimal morbidity, and reserves ALND for patients with positive SLN biopsies. However, this method is still investigational. Partial (levels I and II) ALND remains the gold standard in the surgical management of patients with breast cancer.
Treating terrorists and victims: a moral dilemma
Lancet, Jan 4, 2015
Glasgow Coma Scale Score in Survivors of Explosion With Possible Traumatic Brain Injury in Need of Neurosurgical Intervention
JAMA Surgery, 2016
Head injury following explosions is common. Rapid identification of patients with severe traumati... more Head injury following explosions is common. Rapid identification of patients with severe traumatic brain injury (TBI) in need of neurosurgical intervention is complicated in a situation where multiple casualties are admitted following an explosion. To evaluate whether Glasgow Coma Scale (GCS) score or the Simplified Motor Score at presentation would identify patients with severe TBI in need of neurosurgical intervention. Analysis of clinical data recorded in the Israel National Trauma Registry of 1081 patients treated following terrorist bombings in the civilian setting between 1998 and 2005. Primary analysis of the data was conducted in 2009, and analysis was completed in 2015. Proportion of patients with TBI in need of neurosurgical intervention per GCS score or Simplified Motor Score. Of 1081 patients (median age, 29 years [range, 0-90 years]; 38.9% women), 198 (18.3%) were diagnosed as having TBI (48 mild and 150 severe). Severe TBI was diagnosed in 48 of 877 patients (5%) with a GCS score of 15 and in 99 of 171 patients (58%) with GCS scores of 3 to 14 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). In 65 patients with abnormal GCS (38%), no head injury was recorded. Nine of 877 patients (1%) with a GCS score of 15 were in need of a neurosurgical operation, and fewer than 51 of the 171 patients (30%) with GCS scores of 3 to 14 had a neurosurgical operation (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). No difference was found between the proportion of patients in need of neurosurgery with GCS scores of 3 to 8 and those with GCS scores of 9 to 14 (30% vs 27%; P = .83). When the Simplified Motor Score and GCS were compared with respect to their ability to identify patients in need of neurosurgical interventions, no difference was found between the 2 scores. Following an explosion in the civilian setting, 65 patients (38%) with GCS scores of 3 to 14 did not experience severe TBI. The proportion of patients with severe TBI and severe TBI in need of a neurosurgical intervention were similar in patients presenting with GCS scores of 3 to 8 and GCS scores of 9 to 14. In this study, GCS and Simplified Motor Score did not help identify patients with severe TBI in need of a neurosurgical intervention.
Transradial catheterization: a word of caution
The Journal of Invasive Cardiology, Apr 1, 2000
The radial artery has been used as an access for transcatheter procedures as well as a source for... more The radial artery has been used as an access for transcatheter procedures as well as a source for arterial conduit during coronary bypass surgery. It has been reported that 5Eth 13% of radial arteries may be damaged during transradial catheterization. The damage can be irreversible, and may therefore prohibit the radial arteryOs subsequent utilization as a coronary conduit.
Exercise Hemodynamics of Aortic Prostheses: Comparison Between Stentless Bioprostheses and Mechanical Valves
Nonstented bioprostheses have been associated with lower resting gradients than stented bioprosth... more Nonstented bioprostheses have been associated with lower resting gradients than stented bioprostheses or mechanical valves. We compared the hemodynamic performance of nonstented bioprostheses and mechanical valves with normal native aortic valves at rest and exercise. Dobutamine echocardiography was used to assess gradients and effective orifice area index at rest and exercise in patients with the Toronto stentless porcine valve (TSPV; n = 13; mean implant size 25.7 mm), Medtronic Freestyle (FR; n = 11; mean implant size 23.9 mm), Sorin Bicarbon (SOR; n = 11; mean implant size 24.5 mm), St. Jude Medical (SJM; n = 10; mean implant size 21.3 mm), and normal native aortic valves (NOR; n = 10). All groups demonstrated a major rise in cardiac output at maximal dobutamine infusion. At rest and exercise, respectively, mean gradients were 5.48 +/- 1.1 mm Hg and 5.83 +/- 0.9 mm Hg for TSPV, 5.68 +/- 1.2 mm Hg and 7.50 +/- 1.7 mm Hg for FR, 10.29 +/- 1.4 mm Hg and 20.78 +/- 2.7 mm Hg for SJM, 5.26 +/- 0.8 mm Hg and 11.1 +/- 1.8 mm Hg for SOR, and 1.54 +/- 0.4 mm Hg and 2.18 +/- 0.7 mm Hg for NOR. In comparison with normal valves, both stentless groups showed no change in mean gradient at exercise, whereas both mechanical groups showed an increase in gradient at exercise (p < 0.04). Stentless valves behave similarly to normal aortic valves in that there is almost no increase in gradient at exercise. Both mechanical valve groups showed increased gradients at exercise, suggesting that these valves obstruct blood flow. Our data add further evidence that stentless valves are hemodynamically superior to mechanical valves in the aortic position.
The Annals of Thoracic Surgery, Nov 30, 2004
Background. The diagnosis of infective endocarditis is usually made on the basis of clinical and ... more Background. The diagnosis of infective endocarditis is usually made on the basis of clinical and laboratory criteria and may be confirmed by histologic examination or culture of excised valves. We tried to determine the incidence and significance of inflammatory changes in valves excised during operations for reasons other than infective endocarditis.
[Pleural effusion following coronary bypass surgery]
Harefuah, Nov 1, 2007
BACKGROUND: Pleural effusion is a common finding after coronary artery bypass surgery (CABG). We ... more BACKGROUND: Pleural effusion is a common finding after coronary artery bypass surgery (CABG). We sought to determine the incidence and patient characteristics predictive of its appearance, in addition to the effect of post-operative treatment with enoxaparin.METHODS: We retrospectively examined 893 patients undergoing CABG: 520 consecutive patients did not receive enoxaparin, and 373 patients received it. All early (up to 10 days) peri-operative chest radiograms were examined and graded by the amount of pleural effusion: (i) small--obliteration of the costophrenic angle; (ii) moderate-- < 50% of lung field; (iii) large-- > 50% of lung field. Patient characteristics as well as operative and post-operative parameters were analyzed in order to identify predictors for pleural effusion.RESULTS: Pleural effusion was small in 415 patients (46%), moderate in 346 (39%) and large in 132 (15%). Older age, female gender and congestive heart failure were found to be predictors for pleural effusion by multi-variate analysis (p <0.05). Routine use of enoxaparin was not found to be associated with pleural effusion after CABG.CONCLUSIONS: Over 50% of patients will develop a significant pleural effusion following CABG. Prophylactic treatment with enoxaparin does not increase the risk for pleural effusion.
[Surgical repair of myxomatous mitral valve]
Harefuah
Myxomatous mitral valve disease is now the most common cause of mitral regurgitation in the weste... more Myxomatous mitral valve disease is now the most common cause of mitral regurgitation in the western world. Repair of the leaking valve has become standard surgical procedure during the past 2 decades. Between 1993-1999 we performed 113 repairs of the mitral valve. In 25 patients the etiology was myxomatous degeneration (no mortality). Long-term clinical results depend on patients' functional class at surgery. Based on this fact, and the good surgical results, it is recommended to refer such patients even with severe mitral incompetence for surgery at an early stage, even if symptoms are minimal.
Challenges in Implementing International Standards for the Field Hospital Emergency Department in a Disaster Zone: The Israeli Experience
The Journal of Emergency Medicine
Untreated Mitral Regurgitation Does Not Affect Survival of Elderly Patients Undergoing TAVI
The Journal of heart valve disease, 2016
The study aim was to examine the impact of concomitant significant mitral regurgitation (MR) in p... more The study aim was to examine the impact of concomitant significant mitral regurgitation (MR) in patients undergoing transcatheter aortic valve implantation (TAVI). TAVI has become an acceptable mode of treatment for high-surgical risk patients with aortic stenosis (AS) requiring valve replacement. A significant number of patients have concomitant MR which cannot be addressed by TAVI alone, and therefore may not be considered candidates for this procedure. A comparison was conducted of results obtained from patients undergoing TAVI with or without MR. Between 2008 and 2013, a total of 164 patients (mean age 81 ± 8 years) underwent TAVI at the authors' institution. Of these patients, 87 (53%) had MR of moderate or greater degree. The groups were similar with respect to age, gender, presence of congestive heart failure, left ventricular function and co-morbid conditions. The logistic EuroSCORE was higher in the MR group (p = 0.02). Procedural (30-day) mortality was 12% (n = 19) and...
The Annals of thoracic surgery, 2018
The neutrophil-lymphocyte ratio (NLR) is a recognized marker of inflammation associated with poor... more The neutrophil-lymphocyte ratio (NLR) is a recognized marker of inflammation associated with poor outcomes in various clinical situations. We analyzed the prognostic significance of preoperative elevated NLR in patients undergoing cardiac surgery. We performed a retrospective review of 3,027 consecutive patients undergoing cardiac surgery. Receiver-operating-characteristic was used to determine the cutoff value for elevated NLR. Multivariate regression was used to determine the predictive value of preoperative NLR on clinical outcomes. Cox proportional hazards functions were used to determine predictors of late events. Late survival data to 16 years was obtained from the Ministry of Interior. The cutoff value for elevated NLR was 2.6. Patients with elevated NLR were older (p < 0.0001), had a higher incidence of cardiac comorbidity (p < 0.0001), and higher European System for Cardiac Operative Risk Evaluation score (p < 0.0001). An elevated NLR emerged as an independent pred...
Hyponatremia Predicts Poor Outcomes in Patients With Chronic Kidney Disease Undergoing Heart Operation
The Annals of thoracic surgery, 2018
Preoperative hyponatremia adversely affects outcomes of cardiothoracic operation. However, in pat... more Preoperative hyponatremia adversely affects outcomes of cardiothoracic operation. However, in patients with chronic kidney disease, the association of sodium levels on postoperative events has never been evaluated. We investigated the impact of preoperative hyponatremia on outcomes after cardiac operation in patients with non-dialysis-dependent chronic kidney disease. Primary end points were operative mortality and acute kidney injury that required dialysis. Secondary end points were major infection and long-term survival. The study is observational and includes all patients with stage III to IV chronic kidney disease (non-dialysis) undergoing cardiac operation between February 2000 and January 2016. Patients were stratified into two groups by preoperative sodium levels: sodium less than 135 mEq/L and sodium of 135 mEq/L or more. There were 1,008 patients (mean estimated glomerular filtration rate [GFR]: 43 ± 14 mL • min • 1.73 m) with 92 patients (9%) in the low-sodium group. Patie...
Outcomes of transcatheter aortic valve implantation compared with surgical aortic valve replacement in geriatric patients with chronic kidney disease
Clinical nephrology, 2018
Transcatheter aortic valve implantation (TAVI) is a less invasive treatment modality for patients... more Transcatheter aortic valve implantation (TAVI) is a less invasive treatment modality for patients with severe aortic valve stenosis (AS) who are at a higher risk if they have surgery. Preoperative chronic kidney disease (CKD) influences outcomes of cardiac surgery and is associated with a higher mortality and more complicated hospital course. The aims of our study were to evaluate the comparative outcomes of TAVI versus surgical aortic valve replacement (SAVR) in geriatric patients with preoperative CKD. We prospectively collected data on patients > 75 years of age who underwent either SAVR or TAVI at Shaare Zedek Medical Center, Jerusalem, Israel. The outcomes studied were postoperative acute kidney injury (AKI), in-hospital and long-term mortality, and major neurologic and infectious morbidity. A total of 318 patients were analyzed, of those, 199 and 119 underwent SAVR and TAVI, respectively. In patients with CKD, there was no statistically significant difference in postoperati...
Deployment of field hospitals to disaster regions: Insights from ten medical relief operations spanning three decades
American journal of disaster medicine, 2017
The Israeli Defense Force (IDF) Medical Corps developed a model of airborne field hospital. This ... more The Israeli Defense Force (IDF) Medical Corps developed a model of airborne field hospital. This model was structured to deal with disaster settings, requiring self-sufficiency, innovation and flexible operative mode in the setup of large margins of uncertainty regarding the disaster environment. The current study is aimed to critically analyze the experience, gathered in ten such missions worldwide. Interviews with physicians who actively participated in the missions from 1988 until 2015 as chief medical officers combined with literature review of principal medical and auxiliary publications in order to assess and integrate information about the assembly of these missions. A body of knowledge was accumulated over the years by the IDF Medical Corps from deploying numerous relief missions to both natural (earthquake, typhoon, and tsunami), and man-made disasters, occurring in nine countries (Armenia, Rwanda, Kosovo, Turkey, India, Haiti, Japan, Philippines, and Nepal). This study sho...
Terrorist Stabbings-Distinctive Characteristics and How to Prepare for Them
The Journal of emergency medicine, 2017
The number of terror attack incidents is on the increase worldwide. The knife is one of the weapo... more The number of terror attack incidents is on the increase worldwide. The knife is one of the weapons most commonly used among terrorists. Appropriate preparation in trauma units for coping with the increasing numbers of terrorist-inflicted stabbings is different from the preparation suitable for civilian stabbings. Therapeutic and logistic guidelines need to be adjusted to accommodate those differences. Characterize the unique injuries related to terrorist stabbing, and suggest preparedness actions. Retrospective data on all terrorist-inflicted stabbing incidents between September 2015 and May 2016 were retrieved from the database of the national Israeli emergency medical services and from the Israeli Defense Forces Medical Corps records. There were a total of 414 civilian victims (34 fatalities) of terror incidents. Of these, 161 involved stabbings during 106 separate incidents. There was more than 1 stab wound per patient in approximately 60% of cases, and more than 1 victim in app...
Morbidity among the Israeli Defense Force response team during Nepal, post-earthquake mission, 2015
Journal of travel medicine, 2017
On 25 April 2015, a 7.8-magnitude earthquake struck Nepal. Soon after, the Israel Defense Force (... more On 25 April 2015, a 7.8-magnitude earthquake struck Nepal. Soon after, the Israel Defense Force (IDF) dispatched a rapid-response team and opened a tertiary field hospital in Kathmandu. There is limited data regarding the spectrum of diseases among rescue teams to disease-stricken areas. The aim of this study was to assess the morbidity among the field-hospital staff during the mission. The rescue team was deployed for a 2-week mission in Kathmandu. Pre-travel vaccinations were given prior to departure. The field-hospital was self-equipped including food and drinking water supply with a self-serving kitchen, yet had a shortage of running water. A Public Healthcare and Infectious-Diseases team was present and active during the entire mission. A survey assessing the morbidities and risk-factors throughout the mission was performed at the last day. One hundred thirty-seven (69%) team members completed the questionnaire. Medical complaints were recorded in 87 of them (64%). The most com...
Mobile in Situ Simulation as a Tool for Evaluation and Improvement of Trauma Treatment in the Emergency Department
Journal of surgical education, Jan 3, 2015
Medical simulation is an increasingly recognized tool for teaching, coaching, training, and exami... more Medical simulation is an increasingly recognized tool for teaching, coaching, training, and examining practitioners in the medical field. For many years, simulation has been used to improve trauma care and teamwork. Despite technological advances in trauma simulators, including better means of mobilization and control, most reported simulation-based trauma training has been conducted inside simulation centers, and the practice of mobile simulation in hospitals' trauma rooms has not been investigated fully. The emergency department personnel from a second-level trauma center in Israel were evaluated. Divided into randomly formed trauma teams, they were reviewed twice using in situ mobile simulation training at the hospital's trauma bay. In all, 4 simulations were held before and 4 simulations were held after a structured learning intervention. The intervention included a 1-day simulation-based training conducted at the Israel Center for Medical Simulation (MSR), which include...
The Israel Medical Association journal: IMAJ
The Israel Medical Association journal : IMAJ, 2004
The Evolution of Surgical Humanitarian Missions
The Role of Anesthesiology in Global Health, 2014
Axillary Lymph Node Dissection in Breast Cancer: Current Status and Controversies, Alternative Strategies and Future Perspectives
Acta Oncologica, 2000
Axillary lymph node dissection (ALND) has traditionally been considered as a standard procedure i... more Axillary lymph node dissection (ALND) has traditionally been considered as a standard procedure in the surgical management of patients with breast cancer. The goals of ALND in breast cancer surgery are: (a) to provide accurate prognostic information, (b) to maintain local control of the disease in the axilla and (c) to provide a rational basis for decisions about adjuvant therapy. Although controversial, ALND may also be associated with a small therapeutic benefit. Recently, the question of whether ALND is needed for every patient with invasive breast cancer has been the subject of ongoing debate in the literature. This is mainly due to the widespread use of adjuvant systemic therapy for patients with node-negative breast cancer and to the increasingly frequent detection of small invasive cancers by mammographic screening; the majority of these patients have negative axillae. Sentinel lymph node (SLN) biopsy is a new, promising, minimally invasive procedure, which accurately predicts nodal status with minimal morbidity, and reserves ALND for patients with positive SLN biopsies. However, this method is still investigational. Partial (levels I and II) ALND remains the gold standard in the surgical management of patients with breast cancer.
Treating terrorists and victims: a moral dilemma
Lancet, Jan 4, 2015
Glasgow Coma Scale Score in Survivors of Explosion With Possible Traumatic Brain Injury in Need of Neurosurgical Intervention
JAMA Surgery, 2016
Head injury following explosions is common. Rapid identification of patients with severe traumati... more Head injury following explosions is common. Rapid identification of patients with severe traumatic brain injury (TBI) in need of neurosurgical intervention is complicated in a situation where multiple casualties are admitted following an explosion. To evaluate whether Glasgow Coma Scale (GCS) score or the Simplified Motor Score at presentation would identify patients with severe TBI in need of neurosurgical intervention. Analysis of clinical data recorded in the Israel National Trauma Registry of 1081 patients treated following terrorist bombings in the civilian setting between 1998 and 2005. Primary analysis of the data was conducted in 2009, and analysis was completed in 2015. Proportion of patients with TBI in need of neurosurgical intervention per GCS score or Simplified Motor Score. Of 1081 patients (median age, 29 years [range, 0-90 years]; 38.9% women), 198 (18.3%) were diagnosed as having TBI (48 mild and 150 severe). Severe TBI was diagnosed in 48 of 877 patients (5%) with a GCS score of 15 and in 99 of 171 patients (58%) with GCS scores of 3 to 14 (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). In 65 patients with abnormal GCS (38%), no head injury was recorded. Nine of 877 patients (1%) with a GCS score of 15 were in need of a neurosurgical operation, and fewer than 51 of the 171 patients (30%) with GCS scores of 3 to 14 had a neurosurgical operation (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; .001). No difference was found between the proportion of patients in need of neurosurgery with GCS scores of 3 to 8 and those with GCS scores of 9 to 14 (30% vs 27%; P = .83). When the Simplified Motor Score and GCS were compared with respect to their ability to identify patients in need of neurosurgical interventions, no difference was found between the 2 scores. Following an explosion in the civilian setting, 65 patients (38%) with GCS scores of 3 to 14 did not experience severe TBI. The proportion of patients with severe TBI and severe TBI in need of a neurosurgical intervention were similar in patients presenting with GCS scores of 3 to 8 and GCS scores of 9 to 14. In this study, GCS and Simplified Motor Score did not help identify patients with severe TBI in need of a neurosurgical intervention.
Transradial catheterization: a word of caution
The Journal of Invasive Cardiology, Apr 1, 2000
The radial artery has been used as an access for transcatheter procedures as well as a source for... more The radial artery has been used as an access for transcatheter procedures as well as a source for arterial conduit during coronary bypass surgery. It has been reported that 5Eth 13% of radial arteries may be damaged during transradial catheterization. The damage can be irreversible, and may therefore prohibit the radial arteryOs subsequent utilization as a coronary conduit.
Exercise Hemodynamics of Aortic Prostheses: Comparison Between Stentless Bioprostheses and Mechanical Valves
Nonstented bioprostheses have been associated with lower resting gradients than stented bioprosth... more Nonstented bioprostheses have been associated with lower resting gradients than stented bioprostheses or mechanical valves. We compared the hemodynamic performance of nonstented bioprostheses and mechanical valves with normal native aortic valves at rest and exercise. Dobutamine echocardiography was used to assess gradients and effective orifice area index at rest and exercise in patients with the Toronto stentless porcine valve (TSPV; n = 13; mean implant size 25.7 mm), Medtronic Freestyle (FR; n = 11; mean implant size 23.9 mm), Sorin Bicarbon (SOR; n = 11; mean implant size 24.5 mm), St. Jude Medical (SJM; n = 10; mean implant size 21.3 mm), and normal native aortic valves (NOR; n = 10). All groups demonstrated a major rise in cardiac output at maximal dobutamine infusion. At rest and exercise, respectively, mean gradients were 5.48 +/- 1.1 mm Hg and 5.83 +/- 0.9 mm Hg for TSPV, 5.68 +/- 1.2 mm Hg and 7.50 +/- 1.7 mm Hg for FR, 10.29 +/- 1.4 mm Hg and 20.78 +/- 2.7 mm Hg for SJM, 5.26 +/- 0.8 mm Hg and 11.1 +/- 1.8 mm Hg for SOR, and 1.54 +/- 0.4 mm Hg and 2.18 +/- 0.7 mm Hg for NOR. In comparison with normal valves, both stentless groups showed no change in mean gradient at exercise, whereas both mechanical groups showed an increase in gradient at exercise (p < 0.04). Stentless valves behave similarly to normal aortic valves in that there is almost no increase in gradient at exercise. Both mechanical valve groups showed increased gradients at exercise, suggesting that these valves obstruct blood flow. Our data add further evidence that stentless valves are hemodynamically superior to mechanical valves in the aortic position.
The Annals of Thoracic Surgery, Nov 30, 2004
Background. The diagnosis of infective endocarditis is usually made on the basis of clinical and ... more Background. The diagnosis of infective endocarditis is usually made on the basis of clinical and laboratory criteria and may be confirmed by histologic examination or culture of excised valves. We tried to determine the incidence and significance of inflammatory changes in valves excised during operations for reasons other than infective endocarditis.
[Pleural effusion following coronary bypass surgery]
Harefuah, Nov 1, 2007
BACKGROUND: Pleural effusion is a common finding after coronary artery bypass surgery (CABG). We ... more BACKGROUND: Pleural effusion is a common finding after coronary artery bypass surgery (CABG). We sought to determine the incidence and patient characteristics predictive of its appearance, in addition to the effect of post-operative treatment with enoxaparin.METHODS: We retrospectively examined 893 patients undergoing CABG: 520 consecutive patients did not receive enoxaparin, and 373 patients received it. All early (up to 10 days) peri-operative chest radiograms were examined and graded by the amount of pleural effusion: (i) small--obliteration of the costophrenic angle; (ii) moderate-- < 50% of lung field; (iii) large-- > 50% of lung field. Patient characteristics as well as operative and post-operative parameters were analyzed in order to identify predictors for pleural effusion.RESULTS: Pleural effusion was small in 415 patients (46%), moderate in 346 (39%) and large in 132 (15%). Older age, female gender and congestive heart failure were found to be predictors for pleural effusion by multi-variate analysis (p <0.05). Routine use of enoxaparin was not found to be associated with pleural effusion after CABG.CONCLUSIONS: Over 50% of patients will develop a significant pleural effusion following CABG. Prophylactic treatment with enoxaparin does not increase the risk for pleural effusion.
[Surgical repair of myxomatous mitral valve]
Harefuah
Myxomatous mitral valve disease is now the most common cause of mitral regurgitation in the weste... more Myxomatous mitral valve disease is now the most common cause of mitral regurgitation in the western world. Repair of the leaking valve has become standard surgical procedure during the past 2 decades. Between 1993-1999 we performed 113 repairs of the mitral valve. In 25 patients the etiology was myxomatous degeneration (no mortality). Long-term clinical results depend on patients' functional class at surgery. Based on this fact, and the good surgical results, it is recommended to refer such patients even with severe mitral incompetence for surgery at an early stage, even if symptoms are minimal.