Physical enhancement of older adults using hyperbaric oxygen: a randomized controlled trial.

INTRODUCTION: Aging is associated with a progressive decline in the capacity for physical activity. The objective of the current study was to evaluate the effect of an intermittent hyperbaric oxygen therapy (HBOT) protocol on maximal physical performance and cardiac perfusion in sedentary older adults. METHODS: A randomized controlled clinical trial randomized 63 adults (> 64yrs) either to HBOT (n = 30) or control arms (n = 33) for three months. Primary endpoint included the maximal oxygen consumption (VO2Max) and VO2Max/Kg, on an E100 cycle ergometer. Secondary endpoints included cardiac perfusion, evaluated by magnetic resonance imaging and pulmonary function. The HBOT protocol comprised of 60 sessions administered on a daily basis, for 12 consecutive weeks, breathing 100% oxygen at 2 absolute atmospheres (ATA) for 90 min with 5-minute air breaks every 20 min. RESULTS: Following HBOT, improvements were observed in VO2Max/kg, with a significant increase of 1.91 ± 3.29 ml/kg/min indicated by a net effect size of 0.455 (p = 0.0034). Additionally, oxygen consumption measured at the first ventilatory threshold (VO2VT1) showed a significant increase by 160.03 ± 155.35 ml/min (p < 0.001) with a net effect size of 0.617. Furthermore, both cardiac blood flow (MBF) and cardiac blood volume (MBV) exhibited significant increases when compared to the control group. The net effect size for MBF was large at 0.797 (p = 0.008), while the net effect size for MBV was even larger at 0.896 (p = 0.009). CONCLUSION: The findings of the study indicate that HBOT has the potential to improve physical performance in aging adults. The enhancements observed encompass improvements in key factors including VO2Max, and VO2VT1. An important mechanism contributing to these improvements is the heightened cardiac perfusion induced by HBOT. TRIAL REGISTRATION: ClinicalTrials.gov Identifier NCT02790541 (registration date 06/06/2016).

Spontaneous Hemoperitoneum in Pregnancy and Endometriosis: A New Challenge in a Known Disease.

Importance: Spontaneous hemoperitoneum in pregnancy (SHiP) is a rare life-threatening event previously associated with endometriosis. Although pregnancy is thought to improve the symptoms of endometriosis, abrupt intraperitoneal bleeding can occur, jeopardizing both maternal and fetal outcomes. Objective: The aim of this study was to review the published information regarding SHiP pathophysiology, presentation, diagnosis, and management in a flowchart approach. Evidence Acquisition: A descriptive review of published articles in the English-language was carried out. Results: SHiP most commonly presents in the second half of pregnancy with a combination of abdominal pain, hypovolemia, a decline in hemoglobin level, and fetal distress. Nonspecific gastrointestinal symptoms are not uncommon. Surgical management is suitable in most scenarios and avoids complications such as recurrent bleeding and infected hematoma. Maternal outcome has improved greatly, whereas perinatal mortality remained unchanged. In addition to physical strain, SHiP was reported to have a psychosocial sequela. Conclusions and Relevance: A high index of suspicion is required when patients present with acute abdominal pain and signs of hypovolemia. Early use of sonography contributes to narrowing down the diagnosis. Health care providers should be familiar with the SHiP diagnosis because early identification is crucial when attempting to safeguard maternal and fetal outcomes. Maternal and fetal requirements are often contradictory, creating a greater challenge in decision-making and treatment. A multidisciplinary team approach should coordinate the treatment, whenever a SHiP diagnosis is suspected.

Tubal patency assessment using sequential transvaginal ultrasound and hysterosalpingo-foam sonography after methotrexate treatment for tubal pregnancy.

RESEARCH QUESTION: What is the efficacy of sequential two-dimensional transvaginal ultrasound (2D-US) and hysterosalpingo-foam sonography (HyFoSy) after methotrexate (MTX) treatment for tubal pregnancy among patients who desire a future pregnancy? DESIGN: A prospective trial conducted between May 2019 and November 2020. Patients who had a suspected tubal ectopic pregnancy diagnosed by ultrasound and treated by MTX were included. These patients underwent sequential transvaginal 2D-US assessment of the pelvic organs and a complementary HyFoSy for tubal patency. The primary outcome was tubal obstruction in the affected side. RESULTS: A total of 360 women underwent sequential transvaginal 2D-US assessment of the pelvic organs and a complementary HyFoSy for tubal patency. Of these, 40 (11.1%) women fulfilling the inclusion criteria were enrolled. In six out of 40 (15%), hydrosalpinx of the affected tube was found during the initial transvaginal ultrasound examination and were excluded from further investigation. In the remaining 34 (85%) patients, HyFoSy was carried out. Tubal block was found in 10 out of 34 (29.4%) patients. Of these, eight out of 34 (23.5%) and two out of 34 (5.9%) had a proximal block of the affected tube and bilateral proximal obstruction, respectively. Hysterosalpingography confirmed the tubal obstruction in all the affected cases. No procedure-related complications were documented. CONCLUSIONS: Forty per cent of women who were treated by MTX for tubal pregnancy were diagnosed with tubal obstruction. We recommend that sequential transvaginal ultrasound and HyFoSy become part of routine follow-up for these women, thus offering them timely referral to the appropriate specialist.

Clinical relevance of bilateral pleural effusion in patients with acute pulmonary embolism.

BACKGROUND: The clinical relevance of bilateral pleural effusion (BPE) in patients with acute pulmonary embolism (PE) is unclear. AIMS: To describe characteristics of patients with acute PE that present with BPE. METHODS: Patients with acute PE were retrospectively analysed and divided into three groups: without pleural effusion, unilateral pleural effusion and bilateral effusion. Clinical, laboratory and radiological characteristics were compared between the three groups. RESULTS: The study population (n = 343) consisted of unilateral effusion group (n = 83), BPE group (n = 94) and without effusion group (n = 166). Several variables were noted in higher proportion (%), in the BPE group in comparison to both the unilateral effusion and without effusion groups: heart failure (17.0 vs 7.2 vs 6.7, P = 0.017), hypoalbuminaemia (59.3 vs 39.5 vs 25.6, P ˂ 0.001), PE occurrence in-hospital setting (51 vs 25.6 vs 15.1, P ˂ 0.001), major operation (31 vs 19.2 vs 15.2, P = 0.01) and mechanical ventilation (13.0 vs 4.9 vs 4.2, P = 0.019). Norton scale scores were found to be lower among patients with BPE in comparison to both patients with unilateral and without pleural effusion (15.55 vs 16.92 vs 17.36, P = 0.006). After adjusting confounding variables, patients with BPE have lower probability for in-hospital survival in comparison to both patients with unilateral pleural effusion (odds ratio = 0.30, 95% confidence interval 0.12-0.79), and patients without pleural effusion (odds ratio = 0.26, 95% confidence interval 0.11-0.61). CONCLUSIONS: BPE in patients with acute PE may have significant clinical implications. It may signify serious underlying comorbidities which contribute to higher in-hospital mortality in comparison to both patients with unilateral pleural effusion and patients without pleural effusion.

Correction: Hyperbaric oxygen can induce angiogenesis and recover erectile function.

This has been corrected in both the PDF and HTML versions of the Article.

Hyperbaric oxygen can induce angiogenesis and recover erectile function.

Erectile dysfunction (ED) is caused by microvascular or macrovascular insufficiency in the majority of patients. Recent studies have shown that hyperbaric oxygen therapy (HBOT) can induce angiogenesis in different body organs. The effect of HBOT on the non-surgery-related ED has not been investigated yet. The aim of the current study was to evaluate the effects of HBOT on sexual function and penile vascular bed in non-surgical ED patients. A prospective analysis of patients suffering from chronic ED treated with 40 daily HBOT sessions. Clinical efficacy was assessed using the International Index of Erectile Function questionnaire (IIEF) and a global efficacy question (GEQ). The effect on the penile vascular bed was evaluated by perfusion MRI. Thirty men (mean age of 59.2 ± 1.4) suffering from ED for 4.2 ± 0.6 years completed the protocol. HBOT significantly improved all IIEF domains by 15-88% (p < 0.01). Erectile function improved by 88% (p < 0.0001) and 80% of the patients reported positive outcome according to the GEQ. Angiogenesis was indicated by perfusion MRI that showed a significant increase by 153.3 ± 43.2% of K-trans values in the corpous cavernous (p < 0.0001). HBOT can induce penile angiogenesis and improve erectile function in men suffering from EcD. HBOT reverses the basic common pathophysiology, atherosclerosis and decreased penile perfusion, responsible for most cases of ED.

Intramyocardial dissecting hematoma: Two case reports and a meta-analysis of the literature.

Until recently, diagnosis of intramyocardial dissecting hematoma (IDH) was performed during necropsy or at surgery. During the recent years, echocardiography has permitted clinical suspicion, which usually needed confirmation with magnetic resonance imaging (MRI). In this study, we tried to define clinical and imaging features of IDH and predictors of mortality. We searched the literature for proven cases of IDH and analyzed them together with 2 of our cases. A total of 40 cases of IDH (2 our original and 38 literature cases) were included. Mean age was 60. In 32 cases, IDH was a complication of myocardial infarction (MI), in 66% anterior, a mean time from symptoms to diagnosis was 9 days. Thirty-eight % underwent surgery. In-hospital mortality was 23%. Multivariate analysis showed that the strongest independent predictor of mortality (42%) was EF < 35%; in patients with age >60, mortality risk was 44%; and in the presence of MI or late diagnosis (>24 hours since symptoms started), mortality risk was 50%. In summary, IDH is a diagnostic challenge. A high level of suspicion is needed for prompt diagnosis. Management of these patients is based on individual clinical and imaging parameters. Low EF, age > 60, and late diagnosis, all are predictors of in-hospital mortality.

Speckle tracking imaging in inflammatory heart diseases.

Accurate diagnosis of acute myocarditis is important for the prognosis and risk stratification of these patients. Cardiac magnetic resonance (CMR) has become a major modality for diagnosis of myocarditis, but not widely available. In this study, we tried to evaluate regional and global longitudinal strain by speckle tracking echocardiography in patients with acute inflammatory myocardial diseases in correlation with CMR. Patients with suspected acute myocarditis were recruited prospectively. Clinical diagnosis was established based on clinical, electrocardiographic, laboratory and conventional echocardiographic data. All patients underwent CMR and repeat echocardiographic examination within 24 h of CMR. Echocardiographic examinations were analyzed offline with speckle tracking imaging software. Thirty-two patients with acute perimyocarditis and myopericarditis were included. Mean age was 29 ± 8, 30 males. All patients presented with chest pain and an abnormal electrocardiogram, in 28 ST elevation was found. Troponin was elevated in 30 and was 0.7 ± 0.5 ng/ml. Creatine kinase was 487 ± 319 U. LVEF was 56 ± 5%. Wall motion abnormalities were present in postero-lateral (53%), and inferior wall (21%). Delayed enhancement on CMR was found in 29 patients. Echocardiographic EF based on speckle tracking imaging correlated with CMR calculated EF. There was a positive correlation between the amplitude of regional strain and delayed enhancement, r = 0.52. Sensitivity and specificity of regional strain for prediction of delayed enhancement was 85 and 73% respectively. Speckle tracking imaging can help in the diagnosis of acute myocarditis when CMR is not readily available. Speckle tracking imaging based EF correlates with CMR calculated LVEF and with global strain.

Low-Level Laser Therapy to the Bone Marrow Reduces Scarring and Improves Heart Function Post-Acute Myocardial Infarction in the Pig.

OBJECTIVE: Cell therapy for myocardial repair is one of the most intensely investigated strategies for treating acute myocardial infarction (MI). The aim of the present study was to determine whether low-level laser therapy (LLLT) application to stem cells in the bone marrow (BM) could affect the infarcted porcine heart and reduce scarring following MI. METHODS: MI was induced in farm pigs by percutaneous balloon inflation in the left coronary artery for 90 min. Laser was applied to the tibia and iliac bones 30 min, and 2 and 7 days post-induction of MI. Pigs were euthanized 90 days post-MI. The extent of scarring was analyzed by histology and MRI, and heart function was analyzed by echocardiography. RESULTS: The number of c-kit+ cells (stem cells) in the circulating blood of the laser-treated (LT) pigs was 2.62- and 2.4-fold higher than in the non-laser-treated (NLT) pigs 24 and 48 h post-MI, respectively. The infarct size [% of scar tissue out of the left ventricle (LV) volume as measured from histology] in the LT pigs was 3.2 ± 0.82%, significantly lower, 68% (p < 0.05), than that (16.6 ± 3.7%) in the NLT pigs. The mean density of small blood vessels in the infarcted area was significantly higher [6.5-fold (p < 0.025)], in the LT pigs than in the NLT ones. Echocardiography (ECHO) analysis for heart function revealed the left ventricular ejection fraction in the LT pigs to be significantly higher than in the NLT ones. CONCLUSIONS: LLLT application to BM in the porcine model for MI caused a significant reduction in scarring, enhanced angiogenesis and functional improvement both in the acute and long term phase post-MI.

Anthropometric Assessment of Neck Adipose Tissue and Airway Volume Using Multidetector Computed Tomography: An Imaging Approach and Association With Overall Mortality.

Neck adiposity tissue volume (NATV) accumulation is an indicator for metabolic syndrome and cardiovascular disease (CVD). Neck circumference is a poor measure of NATV, and a quantifier for this entity has not yet been established. To evaluate volumetric quantification by multidetector computed tomography (MDCT) as a reproducible anthropometric tool to measure NATV and airway volume (AWV). A total of 519 patients, including a subset of 70 random patients who underwent head and neck CT scanning in our hospital within 1 year (2013), were studied. Included patients were all those undergoing nonenhanced CT (NECT) or CT angiography (CTA). Neck cross-sectional areas (NCSA) were measured at 2 separate levels of the neck, and 3D postprocessing tissue reconstruction was performed, and NATV and AWVs were quantified volumetrically for all patients within the year. The average NCSA at the level of the soft palate and thyroid cartilage was 22,579 and 14,500 mm, respectively. NATV when compared to the upper and lower levels of NCSA showed correlations of 0.64 and 0.79, respectively (P < 0.001). Interobserver analysis showed mean deviations of 0.46% and 0.32% for NATV and AWV, respectively. A strong correlation between NATV and body mass index (BMI) was found (r = 0.658, P < 0.001), and the top quartile of NATV:AWV patients (out of 519 patients) displayed a statistically significant mortality rate during 670 days of follow-up (d = 7.5%, P = 0.032). After adjustment for age and gender, the association between NATV:AWV and mortality was close to significant (P = 0.072). Volumetric quantification of NATV and AWV is a reproducible and prognostic anthropometric tool, as a high NATV:AWV demonstrated a significant risk factor for mortality; future research may further advance our understanding of this phenomenon.

Left ventricular function in acute inflammatory peri-myocardial diseases - new insights and long-term follow-up.

BACKGROUND: Until recently acute inflammatory peri-myocardial syndromes have been associated with global rather regional left ventricular (LV) dysfunction. Recent advances in cardiac imaging with echocardiographic techniques and magnetic resonance imaging (MRI) permit comprehensive evaluation of global and regional LV function. Our study was aimed to assess regional LV function in 100 patients with acute perimyocarditis, and correlate these findings with the clinical presentation. METHODS: We report on 100 patients with acute perimyocarditis admitted during 2008-2011, in whom LV function was assessed by semi-quantitative wall motion score analysis on conventional echo. Long-term mortality and recurrent hospitalization were also assessed. RESULTS: Wall motion score in 100 patients with acute perimyocarditis demonstrated a significant predominance of regional wall motion abnormalities in the infero-postero-lateral LV wall. These data correspond well with speckle tracking results of a subgroup of these patients published earlier. Recent MRI data show frequent late enhancement of contrast in the infero-lateral region of the LV in patients with perimyocarditis. These observations were useful in re-classification of our patients into one of the following groups: pure or predominant pericarditis, and pure or predominant myocarditis. Over a mean period of 37 months, there was no mortality. Though recurrent hospitalizations were rather frequent, no significant differences were observed among groups. CONCLUSIONS: Regional wall motion abnormalities in the infero-postero-lateral segments of the LV are frequent in patients with acute perimyocarditis. Detailed echocardiographic examination early in the course of the disease should become a major factor in the clinical differentiation among the various clinical presentations of acute inflammatory peri-myocardial syndromes. The long-term outcome of these patients appears to be benign, though recurrent hospitalizations are not infrequent.

The role of diagnostic laparoscopy in detecting minimal peritoneal metastatic deposits in patients with pancreatic cancer scheduled for curative resection.

BACKGROUND: Pancreatic cancer (PC) is an aggressive disease usually diagnosed at an advanced stage. Modern computed tomography can define the subgroup of operable patients. However, minimal peritoneal deposits can be undetected even by modern computed tomography protocols. AIM: To diagnose those patients who are not operable because of a peritoneal spread using diagnostic laparoscopy (DL), thus avoiding unnecessary laparotomies. METHODS: A retrospective study was conducted on 52 consecutive patients with PC scheduled for curative pancreatic surgery. RESULTS: Out of 52 patients who underwent DL, peritoneal spread was diagnosed in 5 patients and these patients were denied surgery. Laparoscopy did not detect 2 other patients with peritoneal spread. CONCLUSIONS: Although the added value of DL in patients with PC is small (around 10% in our series), considering the minimal morbidity and costs attributed to this procedure, we believe that it should be adopted as a routine approach.

Renal oncocytoma--are there sufficient grounds to consider surveillance following prenephrectomy histologic diagnosis.

INTRODUCTION: Oncocytoma is a benign neoplasm of the kidney and comprises about 12% of all renal masses. A definitive preoperative diagnosis of oncocytoma is currently technically not feasible and its practical implication is controversial. OBJECTIVES: To analyze the current status of preoperative diagnostic tools for oncocytoma, study the different occurrences of oncocytoma-renal cell carcinoma (RCC) coexistence, including the phenomenon of true hybrid tumors, and investigate the rare reports on the natural history of unresected oncocytoma. MATERIALS AND METHODS: A PubMed search was performed using the following key word: oncocytoma, renal cell carcinoma, natural history, electron microscopy, and cytogenetics. Medline articles and abstracts prior to August 2009 were reviewed. RESULTS AND CONCLUSIONS: At the moment, preoperative renal mass biopsy is the only way for prenephrectomy histologic diagnosis of oncocytoma. However, it is expected that some of these biopsies, although suggestive for oncocytoma, will suspect chromophobe RCC. In all the English literature, the number of true ipsilateral synchronous hybrid oncocytoma-RCC tumors is extremely low in comparison with the "pure" oncocytomas being resected worldwide. There is almost no data on the natural history of oncocytoma.

Severe influenza A (H1N1): the course of imaging findings.

BACKGROUND: An outbreak of respiratory illness caused by a novel swine-origin influenza virus (influenza A/H1N1 2009) that began in Mexico was declared a global pandemic by the World Health Organization in June 2009. The pandemic affected many countries, including Israel. OBJECTIVES: To compare the course of chest radiographic and computed tomography findings in patients who survived and those who died following admission to the intensive care unit (ICU) or intubation due to severe laboratory-confirmed swine-origin influenza A/H1N1 2009. METHODS: We retrospectively reviewed the patient records (267 radiographs, 8 CTs) of 22 patients (10 males, 12 females) aged 3.5-66 years (median 34) with confirmed influenza A/ H1N1 2009, admitted to the ICU and/or intubated in five major Israeli medical centers during the period July-November 2009. We recorded demographic, clinical, and imaging findings--including pattern of opacification, extent, laterality, distribution, zone of findings, and presence/absence of nodular opacities--at initial radiography and during the course of disease, and compared the findings of survivors and non-survivors. Statistical significance was calculated using the Wilcoxon (continuous variables) and Fisher exact tests. RESULTS: The most common findings on the initial chest radiography were airspace opacities, which were multifocal in 17 patients (77%) and bilateral in 16 (73%), and located in the lower or lower and middle lung zones in 19 patients (86%). Large airspace nodules with indistinct margins were seen in 8 patients (36%). Twelve patients survived, 10 died. Patients who died had multiple background illnesses and were significantly older than survivors (P = 0.006). Radiologic findings for the two groups were not significantly different. CONCLUSION: Airspace opacities, often with nodular appearance, were the most common findings among patients with severe influenza A/H1N1 2009. The course of radiologic findings was similar in patients with severe influenza A/ H1N1 2009 who survived and those who died.

Blunt pancreatic trauma in children.

PURPOSE: To report our experience with blunt pancreatic trauma in pediatric patients and evaluate several various management strategies. METHODS: Ten children admitted over the last 10 years with pancreatic blunt trauma were included in the present series. RESULTS: The average time from injury to hospital admission was 2.4 days. All injuries resulted from accidents: bicycle handlebar injuries (5), being kicked by a horse (2), falls from a height (2), and injury sustained during closure of an electric gate (1). Additional systemic and abdominal injuries were recorded in 7 patients. The amylase levels at the time of patient admission were normal in 3 patients, mildly raised in 4 patients, and elevated in 3 patients. Abdominal computed tomography was performed in 10 patients, ultrasonography in 5, and endoscopic retrograde cholangiopancreatography (ERCP) in 4. Pancreatic injuries comprised 4 grade I, 3 grade II, and 3 grade III injuries. Grade I and II injuries were successfully managed by conservative treatment. The 3 children with grade III trauma and pancreatic ductal injury in the neck (1), body (1), and tail (1) of the gland were surgically treated, having an uneventful postoperative stay of 8-14 days and no complications during the 1-year follow-up period. CONCLUSION: The present study supports early ERCP as an essential part of the initial patient evaluation when pancreatic transection is highly suspected.

Use of adult criteria for slice imaging may limit unnecessary radiation exposure in children presenting with hematuria and blunt abdominal trauma.

OBJECTIVE: To examine whether it would be safe to use adult criteria for imaging in pediatric blunt renal trauma and hematuria. MATERIAL AND METHODS: From 1999 to 2007, 46 consecutive children were admitted for renal trauma and hematuria. All had abdominal computed tomography (CT) scan. Patients were divided into 2 groups: microhematuria and macrohematuria. Outcomes analyzed were presence of renal injury per CT, grade of renal injury, and indication for and details of surgical intervention. RESULTS: Twenty-seven patients (59%) had microhematuria. Nineteen (41%) had macrohematuria. On abdominal CT scan, no injury was found in 18 patients with microhematuria (67%) and 3 (16%) with macrohematuria. Two microhematuria patients required surgical intervention. In both cases, no actual renal intervention was performed during surgery. Three macrohematuria patients required surgical intervention; all had renal relevant procedures. The performance of the macro-microhematuria distinction in the prediction of renal injury on CT scan is relatively poor: sensitivity 59%, specificity 14%, positive predictive value (PPV) 84%, and negative predictive value (NPV) 62%, whereas the performance of macrohematuria criteria in the prediction of renal-relevant injury is sensitivity 100%, specificity 61%, PPV 18%, and NPV 93%. CONCLUSIONS: The yield of abdominal CT in pediatric renal trauma is low in patients presenting with microhematuria. Our data suggest that it may be possible that adult criteria for renal imaging are sufficient for children with abdominal blunt trauma and microhematuria. Adopting such strategy will result in substantial reduction in exposure to radiation, supposedly without increasing the patient's risk.

Continuous positive airway pressure improves sleep apnea associated fatty liver.

Treatment of sleep apnea can improve liver enzyme abnormalities in patients with nonalcoholic fatty liver disease. However, the effect of continuous positive airway pressure therapy for sleep apnea on liver fat accumulation was not assessed. Liver biopsy is the "gold standard" for determining and quantifying liver fat accumulation; however, obtaining two separate liver biopsies is challenging. We examined, using a newly described computerized tomography method to quantify liver fat accumulation, whether treatment of sleep apnea improves liver steatosis. In a prospective cohort study, patients diagnosed with obstructive sleep apnea, at Assaf Harofeh Medical Center's sleep laboratory, were identified. Patients completed a questionnaire and underwent blood tests for liver enzymes and lipid profile, and computed tomography scans to determine the liver attenuation index. Patients with liver attenuation index or=30%) were treated with continuous positive airway pressure for 2-3 years. Subsequently, patients underwent repeat blood tests and tomography scans. Of 47 patients who were analyzed, 16 had a low liver attenuation index (