Israel Medical Association Journal

Background: Adolescent suicide attempts have well-established risk factors. The increased number of cases at Laniado Hospital's pediatric department over the past decade prompted our evaluation of the relative importance of these factors.

Objectives: To characterize adolescents presenting after suicide attempts and to use these features to develop a neural network for early identification of at-risk youth.

Methods: We conducted a retrospective study of suicide attempts among adolescents (11–18 years) admitted to Laniado Hospital's pediatric department (2015–2021). The study included 82 patients with a matched control group (n=82). We analyzed epidemiological, medical, and psychosocial characteristics, identifying statistically significant factors associated with suicide attempts. We then built a predictive model using neural networks.

Results: Significant risk factors for suicide attempts included living outside original home (odds ratio [OR] 6.71, P = 0.0002), female gender (OR 12.67, P = 0.0502), unmarried parents (OR=98.51, P < 0.0001), advanced age (95% confidence interval [95%CI] 0.477–1.583, P = 0.0001), higher hemoglobin (95%CI 0.689–1.81, P = 6.30 × 10^-6), higher mean corpuscular volume (MCV) (95%CI 3.61–8.07, P = 0.014), and prior psychiatric diagnosis (OR 71.82, P < 0.0001). Non-Ashkenazi background was more common but not significant (P = 0.074). Our neural network model achieved 99.85% predictive accuracy.

Conclusions: Psychiatric history, unmarried parents, female gender, and living outside the home were the strongest risk factors for adolescent suicide attempts. We observed higher hemoglobin levels and MCV among affected individuals. Our neural network showed high accuracy (99.85%) in distinguishing between adolescents with suicide attempts from matched controls.

Background: Trichosporon asahii is an opportunistic fungal pathogen increasingly recognized in immunocompromised patients, including children. Although rare, T. asahii fungemia carries significant morbidity and mortality, particularly in those with hematologic malignancies or prolonged immunosuppression.

Objectives: This case series aimed to describe the clinical characteristics, risk factors, microbiological profiles, and treatment outcomes of pediatric patients diagnosed with T. asahii fungemia over a 13-year period at a tertiary care children’s hospital.

Methods: A retrospective review was conducted of all cases of T. asahii fungemia diagnosed between 2010 and 2023 in patients under 18 years of age. Data collected included patient demographics, underlying conditions, immunosuppressive status, presence of central venous catheters (CVCs), neutrophil counts, antifungal susceptibility profiles, treatments administered, and clinical outcomes.

Results: Most cases occurred in immunocompromised patients, mainly those with neutropenia and a CVC. Half of the patients died. T. asahii isolates were generally susceptible to voriconazole and other azoles but showed partial resistance to amphotericin B. Clinical improvement was mainly associated with early antifungal treatment (particularly voriconazole) and supportive measures, including immunosuppression reduction, neutrophil recovery, and CVC removal.

Conclusions: Voriconazole appears to be a reasonable empiric treatment option for pediatric T. asahii fungemia, a condition associated with a very poor prognosis. Successful management may also require early recognition of risk factors and interventions aimed at reversing immunosuppression and eliminating potential sources of infection such as CVCs.

Background: Continuous-flow left ventricular assist devices (CF-LVADs) have yielded improved outcomes compared with pulsatile-flow devices; however, significant rates of gastrointestinal bleeding (GIB) have been observed. The HeartMate 3 left ventricular assist device (HM3-LVAD) (Abbott, Inc., Chicago, IL, USA) includes new features, such as an artificial pulse, which may decrease GIB prevalence compared to the HeartMate 2 left ventricular assist device (HM2-LVAD).

Objectives: To evaluate the incidence, predictors, and clinical outcomes of GIB in patients supported by the HM3-LVAD.

Methods: From 2016 until 2024, 180 patients with chronic heart failure underwent HM3-LVAD implantation. Records were reviewed to determine the post-implant GIB prevalence, location of the bleeding, and associated morbidity and mortality. Univariate and multivariate analyses were conducted to identify independent predictors of GIB.

Results: GIB occurred in 25 patients (14%) with a duration of support ranging from 1 to 1821 days. Sources of GIB included the small bowel and rectum in eight patients each, large bowel in one, and stomach in two. No clear source was identified in 11 patients. Recurrent GIB occurred in 16 patients (64%). There were no deaths attributable to GIB. None of the historical or demographic parameters were found to be independent predictors of GIB.

Conclusions: GIB is a frequent source of morbidity for patients on HM3-LVAD support but does not significantly impact survival. As the implantation of CF-LVADs with non-pulsatile flow gains popularity for both bridge-to-transplant and destination therapy, a better understanding of the pathophysiology of GIB in these patients will reduce the prevalence of this complication.

Background: Acute myocarditis (AM) is an inflammatory cardiac condition with heterogeneous clinical manifestations that often overlap with other acute cardiac syndromes, making diagnosis challenging.

Objectives: To characterize the prevalence, clinical profile, and outcomes of AM patients with respiratory viral pathogen detection on nasopharyngeal swabs at admission.

Methods: We retrospectively analyzed all patients admitted to the Sheba Medical Center with confirmed AM between January 2005 and December 2020. Diagnosis was based on compatible presentation, elevated cardiac biomarkers, and supportive imaging findings. Nasopharyngeal swab results, when performed, were reviewed for respiratory viral detection.

Results: Among 425 identified AM cases, 146 (34%) underwent swab testing; 11 (8%) tested positive for respiratory viral pathogens, most commonly influenza A (n=5) and adenovirus (n=3). With one exception, all positive cases occurred during winter or early spring (10/77, 13%). Compared with swab-negative patients, swab-positive individuals were older (47 ± 22 vs. 35 ± 14 years, P = 0.03), more frequently female (45% vs. 14%, P = 0.007), and more often presented with dyspnea (55% vs. 25%, P = 0.036) but less commonly with ST-segment elevation (27% vs. 70%, P = 0.003). No differences were observed in inflammatory markers, imaging findings, or hospital stay.

Conclusions: Respiratory viral detection in AM is uncommon and predominantly seasonal. Nasopharyngeal swabbing is a simple, non-invasive tool that may help identify treatable viral pathogens and guide patient management. These data provide a pre-COVID-19 reference for future studies investigating the impact of viral infection on myocardial injury.

Background: Large language models (LLMs) are rapidly advancing, with the potential to improve healthcare. While LLM performance on medical licensing exams were studied extensively, their performance in rheumatology exams requires specific evaluation.

Objective: To assess Chat Generative Pre-Trained Transformer (ChatGPT) performance on 200 validated Israeli rheumatology board exam questions.

Methods: ChatGPT performance was evaluated using 200 multiple-choice questions from the 2023 and 2024 Israeli official rheumatology board examinations. Three gpt-4-turbo based variants were assessed: base model (Model 1), few-shot chain of thought (CoT) model (Model 2), and knowledge-augmented prompting model incorporating rheumatology guidelines (Model 3). Model 1 was assessed using both the original Hebrew and a validated English translated version, while Models 2 and 3 were assessed using the English version only.

Results: Overall, Model 3 achieved the highest numerical accuracy (81%), followed by Model 1 (English, 77%), Model 2 (75%), and Model 1 (Hebrew, 74.5%); however, these differences were not statistically significant. Performance varied markedly by question type. For text-only questions (n=177), accuracies ranged from 78.5% to 83.1%, with Model 3 showing the highest point estimate (83.1%). In contrast, all models demonstrated substantially lower performance on questions that included images (n=23), with accuracies ranging from 34.8% to 65.2%. Model 3 yielded the highest numerical accuracy (65.2%).

Conclusions: The study highlights the potential role of LLMs in rheumatology board examinations but also emphasizes their critical limitations. Future research should focus on addressing limitations, especially image interpretation and management of complex cases to enable efficient application of LLMs in rheumatology.

Background: Nasal obstruction is one of the most common symptoms encountered in the otorhinolaryngology clinic, with diverse etiology including deviated nasal septum (DNS) and sinusitis. When surgical intervention is considered, the referring surgeon must decide whether preoperative imaging is indicated.

Objective: To identify clinical and physical examination predictors associated with significant sinus findings on computed tomography (CT) imaging in patients with nasal obstruction. To define specific factors in the medical history and physical examination of patients with nasal obstruction, which are associated with positive CT findings.

Methods: We conducted a retrospective review of patients presenting with nasal obstruction. We collected demographic data, clinical and physical examination findings, CT imaging results, and surgical outcomes.

Results: A total of 242 patients were included (mean age 38.5 ± 16.8 years, 65.7% male), all of whom underwent CT imaging prior to surgery. On univariate analysis, nasal edema, ostiomeatal complex (OMC) blockage, or edema, were all associated with positive findings from the CT (defined as Lund–Mackay > 3). On multivariate analysis, OMC obstruction or edema were associated with positive CT findings.

Conclusion: A thorough patient history and detailed physical examination are essential for evaluating nasal obstruction and identifying patients who may benefit from preoperative CT imaging. Specific clinical symptoms can indicate chronic sinusitis, thus guiding surgeons to perform preoperative imaging for accurate diagnosis and targeted treatment beyond deviated nasal septum management.

Background: Prophylactic intravenous antibiotics are not routinely administered prior to direct peroral cholangiopancreatoscopy. The frequency of post-procedure bacteremia has not been well studied.

Objectives: To evaluate the risk of bacteremia following endoscopic retrograde cholangiopancreatography (ERCP) with cholangiopancreatoscopy. To assess the prevalence of other infectious complications and the effect of real-life practices regarding prophylactic antibiotic administration.

Methods: We conducted a retrospective analysis on consecutive patients (2016–2022) who underwent cholangiopancreatoscopy using the single-operator SpyGlass System (Boston Scientific Corporation, USA). Prophylactic antibiotic treatment was administered based on clinical discretion. Demographic and clinical data, including procedure indication, procedure reports, blood culture results, pre- and post-procedure antibiotic treatment, hospital length, mortality, and infectious and non-infectious complications, were collected.

Results: Our single-center cohort included 75 patients who underwent ERCP with direct cholangiopancreatoscopy. We involved 63 patients in the analysis. In 17/63 patients (27%), post-procedural blood cultures were drawn based on clinical suspicion of infection. Positive cultures were found in 4/17 (23.5%) of all cultures and 4/63 (6.3%) of the entire cohort; 2/63 (3.2%) had clinically significant bacteremia. Antibiotic prophylaxis was administered to 35 patients (55.6%), with no evidence of significant reduction in bacteremia, cholangitis, hospitalization length, or mortality rates when compared to patients who did not receive prophylactic antibiotics (P > 0.05). Post-procedural cholangitis was observed in 5/63 patients (7.9%). There were no cases of acute cholecystitis or liver abscess.

Conclusions: The prevalence of bacteremia and cholangitis following ERCP with direct cholangiopancreatoscopy was 6.3% and 7.9%, respectively. Prophylactic antibiotics did not reduce post-procedural infectious adverse events.

Background: Idiopathic pulmonary fibrosis (IPF) is a progressive, fatal lung disease leading to end-stage lung disease (ESLD). Single lung transplantation (SLT) is the primary treatment option for IPF; however, the native lung continues to influence post-transplant outcomes.

Objective: To determine whether the native lung continues to deteriorate under post-transplantation immunosuppression treatment by assessing chest computed tomography (CT) and perfusion scans.

Methods: We conducted a single-center retrospective analysis of patients who underwent SLT for IPF between 2016 and 2023. Serial chest CT scans assessed native lung changes. CT signs of fibrosis were scored for severity according to published criteria for defining pulmonary fibrosis disease progression. Lung volumes and perfusion were calculated.

Results: Among 57 patients (mean age 57 years; 33% female), 42% died during follow-up (median survival 95 months). The most common immunosuppressive regimen (54% of patients) included prednisone, calcineurin inhibitor, and mycophenolate mofetil. CT analysis demonstrated that in 41/57 (72%) patients, fibrosis signs continued to deteriorate. There was also a significant correlation decline in native lung volume and perfusion scans over time (P = 0.0003, P < 0.0001, respectively) (r = 0.82, P = 0.03).

Conclusions: Fibrotic progression in the native lung persists after SLT as demonstrated by both chest CT and nuclear perfusion scan, thus highlighting the importance of ongoing monitoring for accuracy and complications assessment, integrating it into routine surveillance, and ensuring it is consistently considered in post-transplant assessments.

A 55-year-old male with a history of Dubin-Johnson syndrome (DJS), obesity, and smoking presented to the emergency department with generalized weakness and jaundice. On admission, he was hypotensive (blood pressure 87/56 mmHg), and profound jaundice was noted. Laboratory investigations revealed severe acute kidney injury with a creatinine level of 5.53 mg/dl and blood urea nitrogen of 92 mg/dl. Liver function tests were mildly elevated, and his lipid profile was within normal limits. Total bilirubin was markedly elevated at 52.5 mg/dl, predominantly direct (40.9 mg/dl). The patient was anuric at the time of catheter insertion.

A non-contrast abdominal computed tomography scan showed normal kidney size and appearance without hydronephrosis. The liver was normal size with sharp borders. The patient was treated with intravenous fluids, inotropic support, and intravenous antibiotics. Despite these interventions, he remained anuric with worsening hyperkalemia, necessitating urgent hemodialysis.

Within 10 minutes of initiating hemodialysis, a yellowish discoloration appeared in the effluent tubing of the dialysate. Simultaneously, the dialyzer fibers, which are typically pinkish in color, began to develop a yellowish tint. By the end of the session, the dialyzer appeared distinctly yellow, likely due to bilirubin deposition [Figure 1A–1C].

Presacral tumors are rare and heterogeneous neoplasms that develop in the space between the rectum and sacrum. Their low prevalence and diverse embryologic origins often complicate diagnosis and management. We present the case of a 43-year-old woman who was initially misdiagnosed with a pilonidal abscess, later identified as a benign presacral tumor.

PATIENT DESCRIPTION

A 43-year-old woman presented with a gradually enlarging mass in the pilonidal region over the course of several months. She was referred to our colorectal clinic with a presumptive diagnosis of a pilonidal abscess made by her primary care physician. The patient was otherwise healthy, with no complaints of pain, fever, chills, or unintentional weight loss.

On physical examination, a non-tender mass was palpated over the coccygeal region. Notably, there were no midline pits or visible hair [Figure 1A]. Given the atypical presentation, a magnetic resonance imaging (MRI) was performed, which revealed a well-defined, large presacral bilobular thin-walled cystic mass, posterior to the rectum, without any post contrast ring-enhancement or intramural solid nodule [Figure 1B].

Due to the low anatomical position of the mass relative to the sacrum, a Kraske approach was selected for surgical excision. Under general anesthesia, the patient was placed in the prone jackknife position. A vertical midline incision was made 7 cm cephalad to the anal verge, over the coccyx. This position exposed a well-encapsulated, large presacral tumor [Figure 1C], which was excised en-bloc along with the tip of the coccyx [Figure 1D, Figure 1E].

The specimen was sent for pathological evaluation, which revealed a retrorectal epidermal cyst. The patient's postoperative course was uneventful, and she was discharged on postoperative day one.

Informed consent was obtained from the patient.

Sinus of Valsalva aneurysms (SVA) are uncommon cardiac anomalies. They represent only 0.1–3.5% of congenital heart defects. While rupture of an SVA can lead to acute left-to-right shunting and heart failure, its association with chromosome 22q11.2 deletion (DiGeorge syndrome) has rarely been documented.

Transthoracic echocardiography (TTE) revealed a continuous systolic-diastolic jet suggestive of aortic-to-right-atrial communication. TEE and contrast-enhanced computed tomography (CT) confirmed rupture of a right-coronary-cusp SVA into the right atrium. The patient underwent urgent surgical repair. Initial direct-suture closure was unsuccessful because of persistent flow and was converted to definitive pericardial-patch repair. Postoperative TTE demonstrated complete closure and preserved biventricular function. To the best of our knowledge, this case represents only the third known example of ruptured SVA in a patient with DiGeorge syndrome. It underscores the expanding cardiovascular phenotype of 22q11.2 deletion and highlights the role of multimodality imaging and timely surgical intervention.

Medical conditions affecting driving ability become more common with age, raising concerns about road safety in older adults. Many countries impose medical examinations for license renewal, but policies differ widely, and the evidence base supporting such requirements remains unclear. In Israel, the age-based re-licensing policy is currently under review. We conducted a systematic search of all 38 Organisation for Economic Co-operation and Development (OECD) countries about requirements of age-related medical examinations for driver’s license renewal (September–November 2023). Searches were performed in English and local languages. Additional data were obtained from the OECD official website and by direct correspondence with representatives. Six countries (16%) had no stated age-related policy. Among the 32 countries with defined policies, 16 (50%) set the examination threshold at ≥ 70 years, five (16%) at ≥ 50, three (9%) at ≥ 75, and two (6%) at ≥ 80. Five countries (16%) explicitly declared no age-related requirements. The United States (3%) lacked a unified federal policy, with thresholds varying by state from 63 to 85 years. The frequency of reassessment also differed widely, and none of the policies provided an evidence-based rationale. The absence of data-driven justification underscores the need for research to establish consistent, evidence-based health policies that define appropriate medical evaluation requirements for older drivers.

Celiac disease (CD) is diagnosed by demonstrating gluten-induced villous atrophy on duodenal biopsy in patients with positive serology. Duodenal histology remains the gold standard, although pediatric guidelines allow a no-biopsy approach in highly seropositive children. Video capsule endoscopy (VCE) can visualize mucosal changes typical of active CD, such as flattening of mucosal folds, fissuring, scalloping, ulcerations, throughout the small bowel, overcoming the regular endoscopy capability of reaching the proximal duodenum and missing distal and patchy lesions. In this review, I discussed whether VCE can replace duodenal biopsy for diagnosing celiac disease. I summarized diagnostic yield, sensitivity/specificity, and clinical contexts favoring VCE as well as its limitations and potential future role (including artificial intelligence enhancement). I found that video capsule endoscopy is a valuable adjunctive tool to diagnose CD, but currently it complements, rather than outright replaces, duodenal biopsy.

Thyroid gland enlargement, commonly known as goiter, appears frequently in classical and Renaissance paintings, capturing the attention of scholars across art history, endocrinology, and medical history. This condition was prevalent throughout history and became a recurring artistic motif from the Hellenistic period onward. Artists often depicted models, particularly women, with visibly enlarged thyroids during the Middle Ages and Renaissance, reflecting the high prevalence of goiter in the general population. In addition, during this period, a fuller neck was considered a sign of high social status, which significantly influenced the portrayal of women in art. As artistic styles evolved toward more faithful and less idealized representations, especially in portraits of identifiable individuals, the depiction of both diffuse and nodular goiter became increasingly pronounced. Notably, the thyroid's function was not yet understood at that time, and goiter or neck swelling had not been recognized as originating from the thyroid gland [1].

It begins with a siren, a deep, pulsating wail tearing through the night over Tel Aviv. It is 3:42 in the morning. A university student jolts awake and rushes to a reinforced room. A young couple gathers their infant and runs for the stairwell. An elderly man descends slowly toward a neighborhood shelter. They each have 90 seconds or less to get to safety. Since 7 October 2023, Israel’s Home Front Command has issued over 60,000 rocket alerts and more than 7000 UAV alerts nationwide. For much of the population, this interval, often shorter near border regions, marks the boundary between safety and danger. Beyond acute threat, these alerts impose a repeated physiological stressor that intrudes into one of the most vulnerable human states: sleep.