Israel Medical Association Journal

Background: Systemic sclerosis (SSc) is a chronic autoimmune disease characterized by fibrosis of the skin and internal organs. Its expression can vary across ethnic groups.

Objectives: To compare clinical and serological manifestations of SSc between Jewish and Arab patients in Israel.

Methods: We conducted a retrospective single-center study included 100 patients with SSc selected from our rheumatology clinic at Meir Medical Center, comprising 50 Jewish and 50 Arab patients with available complete clinical and laboratory data. Demographic characteristics, disease features, autoantibody profiles, organ involvement, and treatment patterns were collected.

Results: Most clinical, laboratory, and treatment variables did not differ significantly between Jewish and Arab patients. Significant difference was the higher prevalence of skin telangiectasia in Jewish patients (86%) compared to Arab patients (38%) (P < 0.001) as well as Raynaud phenomenon and pulmonary hypertension. Other manifestations, including organ involvement and autoantibody prevalence, were similar across the groups.

Conclusions: This study reveals significant similarities in the clinical and serological expression of SSc between Jewish and Arab patients in Israel. The higher prevalence of telangiectasia in Jewish patients suggests a possible ethnic or environmental influence on vascular manifestations. Further research is needed to explore the potential genetic or environmental factors contributing to this difference and to assess if this impacts disease progression or treatment outcomes.

Background: Gait disturbances are common in patients undergoing hemodialysis and are associated with increased fall risk, mobility decline, and adverse health outcomes. Prior research suggests that hemodialysis may impact gait parameters such as speed, stride length, and variability; however, findings are inconsistent.

Objectives: To evaluate acute changes in gait metrics before and after hemodialysis using an artificial intelligence (AI) based video gait analysis system.

Methods: We initially enrolled 38 hemodialysis patients, two were excluded due to clothing interference with video analysis (27.8% female, 72.2% male). AI-driven gait analysis was performed immediately before and after dialysis. The system extracted spatiotemporal gait and joint range of motion. Statistical analyses included the Shapiro-Wilk test for normality, Wilcoxon signed-rank tests for non-normally distributed data, and paired t-tests for normally distributed data (P < 0.05).

Results: Gait speed (0.59 m/sec pre-dialysis) remained unchanged post-dialysis (P = 0.876), as did cycle length and time. However, step length significantly decreased post-dialysis (P = 0.001), suggesting a more conservative gait pattern. Knee flexion and extension increased slightly but did not reach statistical significance.

Conclusions: Dialysis does not acutely affect overall gait speed but significantly reduces stride length. Post-dialysis fatigue or hemodynamic shifts may alter walking patterns, highlighting the need for fall prevention strategies and physical rehabilitation interventions in dialysis care. AI-based gait analysis may provide a practical tool for monitoring mobility changes in hemodialysis patients.

Background: Gastroenterological guidelines consider pancreatic serous cystadenomas (SCAs) to have minimal malignant potential and generally do not recommend intervention or surveillance. In contrast, the American College of Radiology recommends surgical consultation for large SCAs (> 4 cm).

Objectives: To evaluate the association between initial SCA size and lesion growth during follow-up.

Methods: The final reports of all patients who underwent magnetic resonance imaging/magnetic resonance cholangiopancreatography (MRI/MRCP) at our institution between the years 2011 and 2021 were reviewed for the diagnosis of serous cystadenoma. Patients with typical microcystic serous cystadenomas who had at least two MRCP examinations were included. We collected clinical data from the patients during the follow-up period, including history, symptoms, and laboratory results. The primary and maximal cyst size diameters and additional radiological characteristics were collected.

Results: Our cohort included 35 patients (21 females, 14 males) with a median age of 68 years. The median follow-up period was 32 months. None of our patients developed malignant transformation. Nineteen lesions grew during follow-up. We found no connection between the lesion size at presentation and the enlargement during follow-up. In total, 21 patients had smaller lesions < 4 cm and 14 had larger lesions > 4 cm. There were no significant clinical or radiological differences between the smaller and larger lesions.

Conclusions: We investigated whether the current radiological recommendations for serous cystadenomas should be revised. Surgical consultation may not be needed for typical asymptomatic SCAs, regardless of the size.

Background: Patient satisfaction is a key indicator of healthcare quality, influencing treatment adherence, clinical outcomes, and hospital reputation. The relationship between length of hospital stay (LOS) and patient satisfaction in neurological inpatients remains understudied, particularly regarding sex differences and neurological diagnosis types.

Objectives: To understand how LOS influences satisfaction and patient experience. To evaluate care strategies and improve communication in neurological settings.

Methods: We conducted a retrospective observational study of 181 patients admitted to the neurology department at Sheba Medical Center between January 2023 and January 2025. Patient satisfaction was assessed using a standardized survey covering overall experience, communication with medical staff, and the discharge process. We used partial correlation analyses and multivariate ANOVA to explore associations of LOS, sex, diagnosis, and satisfaction.

Results: A significant negative correlation was found between LOS and patient satisfaction (r = -0.19, P = 0.012), as well as with perceptions of competency (r = -0.22, P = 0.004), physician communication, and involvement in treatment decisions. Females reported lower satisfaction than males, particularly regarding hospitalization conditions, the discharge process, and staff communication. Diagnosis-specific differences also emerged, with females diagnosed with headache consistently reporting the lowest satisfaction ratings.

Conclusions: Longer hospital stays were associated with lower patient satisfaction. Female sex and diagnosis of headaches influenced patient satisfaction the most. These findings highlight the need for improved communication and enhanced discharge planning to optimize patient satisfaction in neurological settings. Addressing these factors may contribute to more patient-centered care and better overall experiences for hospitalized neurological patients.

In June 2025, amid an escalating military conflict between Israel and Iran, hospitals across Israel were required to reassess and reinforce their emergency preparedness. Civilian populations in central Israel faced direct threats, including missile strikes on residential areas. In response, hospital leadership at Meir Medical Center, a secondary hospital in the center of Israel, issued a directive for an immediate mass casualty incident (MCI) simulation to be designed and executed within 48 hours. The objective was to test the hospital’s operational readiness under real-time wartime conditions, stress key interfaces between pediatric and adult emergency services, and identify latent system vulnerabilities.

Artificial intelligence (AI) has become the emblem of progress. We are told it learns faster, sees patterns invisible to the human eye, and will soon outthink us in every domain, from finance to philosophy, from language to life. In medicine, where decisions carry the weight of saving lives, this narrative has gained traction. Algorithms promise precision without fatigue, accuracy without bias, and reproducibility without emotion. Yet, sometimes, the data tell a quieter story.

Artificial intelligence (AI) and machine learning have moved to the forefront of scientific discourse and clinical medicine, offering improved accuracy and efficiency while raising concerns about transparency, accountability, and unintended consequences. Recent developments, particularly large-scale and generative models, have fueled these debates. However, efforts to mimic aspects of human intelligence long predate ChatGPT. These efforts include the early rule-based systems to Weizenbaum’s ELIZA program, which humorously simulated a Rogerian psychotherapist in its Doctor script [1]. For clinicians, the real test is not whether predictions become marginally more accurate on average, but whether they improve the identification of high-risk patients and meaningfully change management.

Medical education has evolved significantly since the establishment of university-based training in the 12th century, continually adapting to scientific, technological, and societal changes. In the 21st century, rapid advances in digital technologies, artificial intelligence, and the widespread availability of medical information are reshaping the competencies required of physicians. This review explores the concept of the doctor of the future and the implications for medical education and training. Future physicians will require strong cognitive abilities to interpret clinical data, utilize decision support technologies, and make informed clinical judgments while maintaining responsibility for final clinical decisions. At the same time, lifelong learning will be essential as medical knowledge and technologies rapidly evolve. Despite technological progress, core human qualities including empathy and effective communication, are essential traits that will be needed by future physicians. These skills require educational models that integrate technological competence, humanistic care, interdisciplinary teamwork, and adaptable career pathways to meet the challenges of evolving healthcare systems.

The fourth edition of Recurrent Pregnancy Loss: Causes, Controversies and Treatment summarizes the controversies and discuss the scientific basis for the various causes of recurrent pregnancy loss in depth and to clarify the various treatment modalities. The book shows a radical departure from the format of the previous three editions and succeeds profoundly in satisfying its objective. This book, first published in 2007, the second edition in 2014, and the third edition in 2020 became the foremost and most comprehensive work on recurrent pregnancy loss. In the fourth edition there are new chapters on the epigenetics of recurrent pregnancy loss, biochemical pregnancies, inflammatory placental disorders, artificial intelligence, and the role of hydroxychloroquine. This edition also discusses whether the decline in male infertility is reflected in recurrent pregnancy loss.

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.