Israel Medical Association Journal

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.

Background: Listening to patients and obtaining a thorough history are fundamental in clinical practice. Some pregnant women, particularly in late or preterm gestation, report regular, painful uterine contractions that may not correspond to true labor. In some cases, patients admitted to feigning contractions using the Valsalva maneuver to gain secondary benefits. Misdiagnosing such cases may lead to unnecessary interventions, including iatrogenic prematurity.

Objectives: To explore the phenomenon of pseudo-uterine contractions and assess whether maternal heart rate (HR) can help differentiate them from true contractions.

Methods: We performed a prospective case-crossover study, which included 30 pregnant women in their third trimester who presented to Rambam Health Care Campus. Participants underwent 20 minutes of standard external monitoring followed by 10 minutes of repeated Valsalva maneuvers (every 2 minutes). Maternal and fetal HRs were recorded and compared during baseline, pseudo-, and true contractions.

Results: During pseudo-contractions, maternal HR decreased by approximately 10 bpm (P < 0.001), while fetal HR increased by 8 bpm (P < 0.001). In contrast, true contractions resulted in a maternal HR increase of 15 bpm (P < 0.001) and a fetal HR rise of 12 bpm (P < 0.001).

Conclusions: Maternal HR patterns differ significantly between true and false contractions. A decline in maternal HR during contractions may indicate Valsalva-induced pseudo-contractions, while an increase suggests true labor. This simple observation could aid in preventing unnecessary interventions in suspected cases.

Background: Neurofilament light chain (NfL) is an established biomarker for detecting axonal injury in various neurological disorders. The Quanterix Single Molecule Array (Simoa) is the current standard; however, automated immunoassays, such as the Siemens Atellica and Centaur, may serve as alternatives.

Objectives: To compare NfL measurements obtained with the Centaur system to those from the Simoa-SR-X. To assess their agreement and applicability in clinical practice, research, and animal studies.

Methods: NfL levels were measured in 27 human serum, 8 plasma, and 16 cerebrospinal fluid (CSF) samples, and 9 murine serum samples, by Centaur and Simoa systems. NfL levels in concomitantly drawn serum and plasma were compared in 8 humans. The agreement between platforms was evaluated.

Results: NfL levels measured by Centaur and Simoa systems demonstrated a strong correlation in serum (Spearman r=0.97, P < 0.0001) and plasma (Pearson R²=0.95, P < 0.0001). Centaur measurements were higher (P = 0.01) than Simoa. Most importantly, system-specific Z-scores corrected these differences. Serum and plasma levels measured by the Centaur system correlated strongly (R²=0.98, P < 0.0001) and showed similar results. CSF levels measured by the Centaur system were lower (52% bias) than those measured by Simoa, with poor correlation at concentrations within the normal range (R²=0.32, P = 0.11). Mouse serum results showed a strong correlation between systems (R²=0.86, P < 0.001) with similar values.

Conclusions: The Centaur system offers an alternative to Simoa for measuring NfL in human serum, plasma, and murine serum. System-specific age-adjusted Z-scores are essential for interpretation. CSF evaluation requires further assessment.

Background: Transgender and gender diverse (TGD) adolescents often experience higher rates of psychiatric co-morbidities, autism spectrum disorder (ASD), and autistic traits. A few studies have described TGD adolescents who were referred to psychiatric clinics. To the best of our knowledge, no study has yet compared clinical characteristics of autistic vs. nonautistic TGD adolescents.

Objectives: To describe the demographic and clinical characteristics of TGD adolescents referred to a tertiary child and adolescent psychiatric clinic, and to compare the characteristics of autistic and nonautistic TGD adolescents.

Methods: We conducted a retrospective study of 28 TDG adolescents who were consecutively referred for psychiatric evaluation in a child and adolescent psychiatric clinic at a tertiary children's hospital between December 2020 and February 2023. Data were collected from electronic medical files.

Results: Of the sample, 67.9% first questioned their gender identity after the onset of secondary sex characteristics (pubertal onset) and 35.7% were identified as gifted. The gifted group had a higher rate of pubertal onset compared to the nongifted group. Our cohort exhibited a higher rate of ASD (39.3%) than the general population. Autistic compared to nonautistic TGD adolescents had a higher rate of giftedness and a lower rate of social transition.

Conclusions: TGD adolescents referred for psychiatric evaluation display distinct features, including high rates of ASD, giftedness, and pubertal onset. Autistic compared to nonautistic TGD are more likely to be gifted and less likely to have undergone social transition.

Background: Diverticulitis is a common cause of acute abdominal conditions, often requiring urgent or elective surgical intervention. Both psoas muscle area (PMA) and bone mineral density (BMD) have been linked to postoperative outcomes, but their role in diverticulitis remains unclear.

Objectives: To evaluate the relationship between PMA, BMD, and their combined effect on surgical outcomes in patients undergoing colectomy for diverticulitis.

Methods: In this retrospective, single-center study, we analyzed patients who underwent colectomy for diverticulitis. PMA and BMD were measured using preoperative computerized tomography. Statistical analysis assessed the association between postoperative outcomes and PMA, BMD, and their combined product (PMA × BMD).

Results: The cohort included 66 patients; median age 68.5 years (range 34–94); 41 (62.12%) females. Of the cases, 42 (63.63%) were urgent. Postoperative complications occurred in 38 patients (57.58%). Patients who developed major postoperative complications had lower PMA (1116.74 ± 716.31 mm² vs. 1948.01 ± 0.01 mm², P = 0.02). The area under the curve (AUC) for major postoperative complications was 0.94 for BMD. The AUC for postoperative ileus was 0.73, 0.69, and 0.76 for PMA, BMD, and PMA × BMD, respectively. The AUC for 30-day mortality was 0.66, 0.7, and 0.73. The AUC for ostomy reversal was 0.71, 0.71, and 0.76.

Conclusions: PMA and BMD were associated with postoperative complications after colectomy for diverticulitis. Their combined assessment may improve predictive accuracy. Current evidence regarding the impact of body composition on surgical outcomes in diverticulitis remains limited and inconsistent. Further research is warranted.

Background: Gangrenous appendicitis falls to the midpoint of the continuum between uncomplicated and complicated appendicitis. We present an eight-year single-center retrospective review of uncomplicated, complicated and gangrenous appendicitis.

Objectives: To analyze the presentation of gangrenous appendicitis in our population.

Methods: We reviewed the presentation, as well as the laboratory, surgical, and pathological findings for complicated, uncomplicated, and gangrenous appendicitis. Logistic regression analysis was conducted to identify predictors of gangrenous and of complicated appendicitis.

Results: During the study period, 865 children had uncomplicated appendicitis and 134 had complicated appendicitis. Younger age, duration of illness as well as vomiting, diarrhea, and fever were more common in complicated than uncomplicated appendicitis. White blood cell count, neutrophil count and C-reactive protein were higher in complicated appendicitis. Logistic regression showed that vomiting and presence of fever occurred more frequently in children with non-perforated gangrenous appendicitis than with other uncomplicated appendicitis. Laboratory results for non-perforated gangrenous appendicitis were comparable to those of complicated appendicitis, as was usage of radiography and computed tomography.

Conclusion: Gangrenous appendicitis shares similar historical elements with complicated appendicitis and has a similar laboratory. These children, like those with complicated appendicitis, may not be optimal candidates for non-operative management.

Background: Mass honeybee envenomation (MHE) is a rare occurrence, with possible life-threatening or fatal consequences.

Objectives: To present the first description of multiple simultaneous casualties in a single incident of MHE.

Methods: Nine young men were simultaneously attacked by a large honeybee swarm. All patients were hemodynamically stable on arrival to Sheba Medical Center. One had fiberoptic evidence of laryngeal edema. Eight (89%) of the patients had leukocytosis and laboratory evidence of rhabdomyolysis. Eight patients were hospitalized in an internal medicine ward. The patient who had the most (over 300) stings removed presented with severe rhabdomyolysis and acute renal failure (ARF) and was admitted to the intensive care unit.

Results: Most patients had a benign clinical course and were discharged within 2 days. One patient developed severe rhabdomyolysis and was treated with fluids and urine alkalinization with significant improvement. The clinical course of another patient was complicated by ARF consistent with acute tubular necrosis. His creatinine peaked at 3.04 mg/dl and improved over several days until his discharge.

Conclusions: In our case series, we demonstrated the spectrum of clinical presentations associated with MHE and highlighted the importance of stings load as a prognostic factor, which may dictate early therapeutic intervention.