Israel Medical Association Journal

Background: Tunneled hemodialysis catheters are frequently used and are a major source of catheter-related bloodstream infections (CRBSI), which result in significant morbidity.

Objectives: To examine the adverse outcomes associated with CRBSIs, including hospitalization, recurrence, 1-year mortality, and catheter outcomes in a hemodialysis setting that uses modern preventive catheter-care practices.

Methods: We conducted a retrospective cohort study of adults with jugular tunneled hemodialysis catheters who met criteria for CRBSI from 1 January 2015 to 31 December 2020 at a tertiary referral center.

Results: Of 380 hemodialysis patients, 75 experienced CRBSI events. The average rate was 1.55 CRBSIs per 100 patient months. The median time from catheter insertion to CRBSI was 179 days; and 68% required inpatient management. Gram-positive bacteria accounted for 53% of isolates, with Gram-negative organisms also being common. Recurrence occurred in 16% of cases and was independently associated with ferritin levels over 500 ng/ml (P = 0.02), albumin levels below 3.5 g/dl (P = 0.011), and uric acid levels under 2.5 mg/dl (P = 0.04). Catheters were removed in 61.3%, exchanged over a guidewire in 24%, and salvaged in 18.6%. The 1-year mortality rate was 28% and was associated with lower weight, catheter salvage, neutrophilia, hypoalbuminemia, and hypokalemia. Using chlorhexidine exit-site dressings was associated with fewer hospital admissions.

Conclusions: Among hemodialysis patients with CRBSI, recurrence and mortality might be linked to a patient's nutritional and inflammatory status. Current preventive measures might reduce hospitalization rates, but in this cohort, they were not associated with lower recurrence or mortality rate.

Chronic Q fever, caused by Coxiella burnetii, is a persistent infection that primarily affects individuals with underlying valvular or vascular abnormalities. The standard treatment regimen consists of prolonged dual therapy with doxycycline and hydroxychloroquine, typically administered for a minimum of 18 months [1]. This combination targets both the intracellular pathogen and the acidic vacuolar environment in which it resides. A key indicator of therapeutic response is the progressive decline in phase I IgG antibody titers, which is generally observed within the first few months of treatment [2].

However, in rare instances, antibody titers may remain persistently elevated despite prolonged therapy, raising concerns about treatment failure, resistance, or host-related factors. The following case highlights an unusual drug interaction that interfered with treatment efficacy, ultimately preventing complete clinical resolution.

Peripheral facial nerve palsy is an infrequent but well-recognized clinical presentation encountered by primary care and emergency department physicians. Risk factors include diabetes mellitus (DM) and hypertension, both of which are also associated with an increased risk of cerebrovascular accident, which is a critical consideration in the differential diagnosis [1]. Prompt and accurate differentiation between central and peripheral etiologies is crucial in the initial evaluation of facial palsy. Notably, approximately 5% of cases may be secondary to neoplastic processes, whether benign or malignant [1].

Small cell carcinoma of cervix (SCCC) is a rare and aggressive high-grade neuroendocrine tumor [2]. Neurologic manifestations due to brain metastases from neuroendocrine cancers of the cervix are extremely rare, with no prior reports involving the facial nerve [3].

We report a unique case in which peripheral facial nerve palsy was the initial clinical manifestation of SCCC. This case highlights the importance of maintaining a broad differential diagnosis and underscores the pivotal role of a comprehensive history and physical examination as part of a systematic and holistic approach when evaluating patients presenting with facial nerve palsy.

A 32-year-old man with Down syndrome (DS), nonverbal due to severe cognitive impairment, presented to the emergency department after sustaining a fall from standing, causing trauma to his left hip. He had no known chronic medication use. His previous medical history included hospitalizations for severe COVID-2019 in 2021 and herpes simplex virus stomatitis in 2017. Following the fall, he was unable to bear weight on the affected limb. On physical examination, his left leg was externally rotated with preserved neurovascular status. Given the mechanism of injury and clinical presentation, non-contrast computed tomography (NCCT) was obtained to assess fractures and underlying pathology [Figure 1A].

We report the first successful implantation of the CARMAT Aeson® total artificial heart (TAH) in Israel, performed as a bridge to transplantation in a patient with advanced biventricular heart failure and severe right ventricular dysfunction precluding left ventricular assist device (LVAD) therapy. The CARMAT Aeson® TAH is a next generation bioprosthetic device equipped with biological valves, hemocompatible membranes, and an integrated sensor array that enables autoregulation of stroke volume to balance left and right circulation, thereby reducing thrombogenicity and improving physiological adaptation. Following implantation, the patient demonstrated rapid hemodynamic stabilization, complete weaning from inotropes, and marked functional recovery. Remarkably, during the index hospitalization he underwent successful elective inguinal hernia repair under general anesthesia, a procedure previously deemed prohibitive due to high cardiovascular risk. This patient is the first CARMAT TAH recipient to undergoing a non-cardiac surgical procedure. Perioperative interruption of anticoagulation was achieved safely without thromboembolic complications, underscoring the device’s biocompatibility and reduced thrombogenicity compared with continuous-flow VADs. The patient was discharged home on postoperative day 61 in an ambulatory state, clinically stable, and remains actively listed for heart transplantation. This case highlights the feasibility and safety of the CARMAT Aeson® TAH in patients with end-stage biventricular failure, with potential advantages over continuous-flow devices, including pulsatile physiology, autoregulation, and reduced risk of bleeding or thrombotic complications. These advantages strengthen its role as an important bridging strategy to heart transplantation.

Uremic cardiomyopathy (U-CMP), also known as chronic kidney disease cardiomyopathy (CKD-CMP), is a phenotype of non-ischemic cardiomyopathy frequently seen among patients with chronic kidney disease. Left ventricular (LV) systolic dysfunction is seen in approximately 13% of patients, and LV ejection fraction (LVEF) below 40% has been reported in 5.8% of patients [1]. Severe LV dysfunction may be considered a relative contraindication to renal transplantation. We present a case of complete recovery of ventricular function following renal transplantation in a patient with severe U-CMP.

In this study, we assessed the efficacy and outcomes of percutaneous cholecystostomy with cystic duct cannulation for biliary drainage in patients in whom conventional endoscopic retrograde cholangiopancreatography (ERCP) was either unsuccessful or contraindicated. In addition, we provide a contemporary review of this technique. We retrospectively reviewed data of 323 consecutive patients who underwent percutaneous gallbladder drainage at our institution between 2017 and 2022. Transcholecystic common bile duct (CBD) cannulation via the cystic duct was attempted in six carefully selected patients in whom ERCP was not feasible or had failed, or who were unfit for endoscopy. Four technically successful cases are described in detail. Two additional attempts were unsuccessful due to inability to traverse the cystic duct. A focused literature review examined the historical development and contemporary applications of transcholecystic biliary intervention. Transcholecystic cannulation of the common bile duct is not routinely performed at our institution. Percutaneous cholecystostomy with cystic duct cannulation is a well-established technique with over five decades of documented use. This approach provides a viable and safe alternative to biliary drainage in complex cases in which traditional methods are not feasible, particularly in high-risk patients with anatomical challenges.

A 65-year-old man had a long history of gout attacks, beginning at the age of 35 years. The disease was never well controlled. The patient did not follow diets, nor did he adhere to medication recommendations. He presented with systemic arterial hypertension, overweight (body mass index 29 kg/m²), and metabolic syndrome.

Nothing better reflects the times in which we live–amid missile barrages, air-raid sirens, sheltering in protected rooms, and yet continuing our daily routines and work–than the annual meeting of the editorial boards of the medical journals IMAJ and HaRefuah

The Holocaust represents an extreme failure of medical ethics, with physicians actively involved in crimes against humanity. Rheumatology is directly affected through eponyms that honor Nazi perpetrators and through persistent musculoskeletal consequences observed in Holocaust survivors. In this article, we critically analyzed symbolic (nomenclature) and biological (trauma-related disability) legacies of Nazism in rheumatology. Narrative reviews of PubMed/MEDLINE, Scopus, and Israel Medical Association Journal (IMAJ) as well as key historiographic analyses and clinical studies of musculoskeletal outcomes among Holocaust survivors were included. Ethical codes emerging post-Holocaust (Nuremberg Code and Declaration of Helsinki) were integrated. Renaming Reiter’s syndrome as reactive arthritis and Wegener’s granulomatosis as granulomatosis with polyangiitis represents ethical correction. Clinical evidence shows Holocaust survivors experience such as reduced functional recovery after hip fracture, lower perceived health despite similar objective measures, and greater cardiovascular burden impairing rehabilitation tolerance. Rheumatology must align nomenclature with ethical responsibility and recognize trauma-associated musculoskeletal vulnerability. Historical memory should guide clinical decisions, language, and education

It is 3:00 in the morning at an Israeli medical center. The rhythmic beeping of monitors pierces the silence as an on-call team gathers around a patient's bed. The team includes a Jewish doctor, a Muslim nurse, and a Christian physician. In these critical moments, the only language spoken is the language of medicine–a seamless blend of physiology, pharmacology, and an ancient medical oath.

For us in Israel, this reality is natural and common. Yet, viewed through a historical lens, particularly against the backdrop of World War II when medicine itself was weaponized and conscripted into an extermination machine, this collaboration was nothing short of a monumental triumph of the human spirit. In this editorial, I invite you on a historical journey to revisit two profound narratives where physicians from diverse backgrounds transformed their clinical knowledge and authority into instruments of life and resistance.

In this study on Holocaust (Shoah) survivors, we reviewed accumulated data demonstrating an increased incidence of diabetes and cancer in the later years of survivors. We evaluated the status of high nutrition, compared to the low incidence of the same morbidities affecting the prisoners in the ghettos of World War II, while experiencing severe nutritional deficiency. The assumption of the high glucose requirement of cancer cells is discussed.

Phlycten syndrome was described as a traumatic surgical syndrome of the lower limbs, beginning as streptococcal cellulitis and progressing to necrotizing edema in individuals with starvation-induced hypoalbuminemia and electrolyte imbalance. Independently documented by three physicians during their imprisonment in Nazi concentration camps in World War II, the syndrome also developed when edematous, emaciated prisoners were flogged, causing rapid progression to gangrene and sepsis.

Background: This study provides valuable insight on the importance of antenatal follow-up, despite advances in medical capabilities.

Objectives: To provide current information on mortality rates and causes including demographic parameters.

Methods: A total of 3362 infants were admitted to the neonatal intensive care unit at Kaplan Medical Center between 2009 and 2021. Retrospective data were extracted from a computerized prospective database and further divided to two groups: 2009–2014 and 2015–2021. For sequential variables, we calculated the mean, standard deviation, and median. For categorical variables we calculated the prevalence and performed a chi-square test. The sequential variables did not show a normal distribution according to the Shapiro-Wilk test. Therefore, the A-parameter Mann-Whitney test was used. Results were considered significant when the P-value < 0.05.

Results: A decrease in the death rate was found, but when evaluating the infants who died, a decrease in full antenatal follow-up from 55.2% to 31.5% was seen (P-value = 0.06).

Conclusions: Despite advancements in medical knowledge and capabilities, an association was found between increased mortality and reduced antenatal follow-up.

Background: The rapid evolution of large language models warrants updated benchmarking in ophthalmology to determine whether newer versions offer clinically meaningful improvements over earlier models and human comparators.

Objectives: To evaluate the diagnostic accuracy of ChatGPT-4o and ChatGPT-5 in ophthalmic cases and to compare it with previously reported results of ChatGPT-3.5, residents, and specialists.

Methods: This retrospective cohort study was conducted in one academic tertiary medical center. We reviewed data of patients admitted to the ophthalmology department from June 2022 to January 2023. We then created two clinical cases for each patient. The first was according to medical history alone (Hx). The second added the clinical examination (Hx and Ex). For each case, we asked for the three most likely diagnoses from ChatGPT-4o and ChatGPT-5. We then compared the accuracy rates (at least one correct diagnosis) with previous results of ChatGPT-3.5, residents, and specialists.

Results: A total of 63 cases were analyzed, first using history alone and then with examination findings. Based on history alone, GPT-5 and GPT-4o correctly identified 73% and 70% of cases, respectively, outperforming GPT-3.5 (54%, P < 0.05) and approaching the accuracy of residents (75%) and attending physicians (71%, P < 0.05). When physical examination was included, diagnostic accuracy rose to 94% for GPT-5 and 89% for GPT-4o, surpassing GPT-3.5 (68%, P < 0.05) and closely matching or exceeding human performance (residents 94%, attendings 87%).

Conclusions: ChatGPT-4o and ChatGPT-5 significantly outperformed GPT-3.5 and achieved diagnostic accuracy similar or even higher to clinicians in diagnosing ophthalmology cases.