Israel Medical Association Journal

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

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: 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.

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.

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: 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.

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: 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: Primary achalasia is a rare disorder but a significant cause of esophageal motor dysfunction. The pathophysiology of achalasia is still unknown, although an autoimmune etiology is suspected.

Objectives: To examine the presence of autoantibodies against autonomic nervous system receptors among primary achalasia patients.

Methods: In this observational cross-sectional study, we measure the levels of serum autoantibodies targeting G protein-coupled receptors of the autonomic nervous system, including adrenergic, muscarinic, endothelin, and angiotensin receptors. The study included 40 primary achalasia patients and 40 healthy controls without known history of achalasia, autoimmune diseases, or symptoms of an esophageal motility disorder.

Results: A statistically significant low level of autoantibodies against the M2 muscarinic receptor was observed in the serum of primary achalasia patients compared with the control group (P < 0.009). When exploring the two common achalasia types, a statistically significant low level of autoantibodies against type M1, M2, and M5 muscarinic receptors was observed among type 2 achalasia patients compared to patients with type 1 achalasia.

Conclusions: The finding of reduced levels of autoantibodies targeting the M2 muscarinic receptor in the serum of primary achalasia patients provides a valuable insight into the underlying pathogenesis of the disease.

Research into the genetic basis of homosexuality and broader sexual diversity has progressed from early 20th-century sexology to modern genomics. Von Krafft-Ebing and Hirschfeld first suggested heritable influences, and Kallmann’s twin studies in the 1950s introduced a systematic framework to separate genetic from environmental contributions to sexual orientation. Twin and related designs subsequently reported heritability estimates of 31–74% in males and 27–76% in females. Despite periodic critiques, the equal-environment assumption has remained broadly methodologically robust. Genome-wide association studies (GWAS) marked a major advance. Although early studies were limited by sample size, recent large-scale GWAS have identified significant single-nucleotide polymorphism associations with same-sex sexual behavior, reinforcing a complex, polygenic architecture. Polygenic scores (PGS) or polygenic risk scores (PRS) now offer quantitative estimates of individual genetic predisposition and may help build integrative models of human sexual behavior when combined with environmental and developmental data. Future work should harmonize phenotype definitions across identity, attraction, and behavior; aggregate measures to reduce noise; and adopt systems-level, multi-omics approaches that move beyond reductionism. Interdisciplinary collaboration across genetics, neuroscience, psychology, and social sciences is essential, in addition to greater attention to understudied domains (female homosexuality, sexual fluidity, bisexuality, pansexuality/polysexuality, asexuality, and transgender/trans-sexuality). Community-based participatory research can improve inclusivity and real-world relevance. Overall, the field has moved beyond a single gay gene toward models integrating genetic, epigenetic, and environmental influences, with sexogenomics together with GWAS, PGS/PRS and system biology providing a unifying framework that also engages ethical and societal dimensions.

Spinal stenosis is a progressive degenerative condition characterized by the narrowing of the spinal canal, leading to compression of the spinal cord and nerve roots [1]. While commonly associated with aging, it can also develop following traumatic injuries that induce structural damage and chronic inflammation and contribute to canal narrowing [1]. Although spinal stenosis is primarily linked to neurogenic claudication, emerging evidence suggests that it may also impact respiratory function, particularly when it involves the cervical and thoracic spine [2].

We evaluated a 77-year-old male with a longstanding history of spinal stenosis and exertional dyspnea. We explored the potential connection between his symptoms and underlying spinal pathology, particularly in the absence of cardiopulmonary disease.

Background: The coronavirus disease 2019 (COVID-19) pandemic has disrupted healthcare systems globally, affecting chronic disease management like osteoporosis and the prevention of fragility hip fractures. We hypothesized that it led to suboptimal prevention of secondary femoral neck fractures, reduced treatment frequency, and delayed treatment initiation.

Objectives: To evaluate the treatment initiation rate for secondary prevention of femoral neck fractures, comparing pre-COVID-19, COVID-19, and post-COVID periods, considering patient demographics.

Methods: This retrospective diagnostic cohort study used automated electronic medical records database from Clalit Health Services. Data regarding patients with hip fractures from January 2017 through September 2021 were extracted from the database. Treatment for osteoporosis included one of the following treatments: alendronate, risedronate, zoledronate, abaloparatide, denosumab, romosozumab, and teriparatide. The primary outcome variable in the study is the time taken to initiate appropriate therapy for the secondary prevention of femoral neck fractures.

Results: Treatment frequency decreased over time, with rates declining from 40.4% in 2019 to 33.5% in 2021 (P-value < 0.05). However, the percentage of prompt care management (within 3 months) increased between 2020 and 2021 (47.3%–62.5%) and between 2019 and 2021 (48.7%–62.5%), P < 0.05.

Conclusions: The COVID-19 pandemic reduced the rate of appropriate treatment initiation following hip fractures. However, adherence to timely treatment within 3 months of the fracture has improved. The findings highlight the effectiveness of the health system response in managing crises and ensuring the timely delivery of critical treatment.

Background: Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are established treatments for peritoneal metastasis from colorectal cancer (PM-CRC). The peritoneal carcinomatosis index (PCI) measures disease burden.

Objectives: To evaluate the effect of PCI on short- and long-term outcomes of patients with PM-CRC who underwent CRS-HIPEC.

Methods: We retrospectively analyzed 120 PM-CRC patients who underwent CRS-HIPEC, categorizing them into four PCI groups (PCI ≤ 3, PCI 4–6, PCI 7–11, PCI >11). We evaluated perioperative outcomes and long-term survival.

Results: Higher PCI scores were associated with increased surgical complexity, longer operative times, more organ resections, and higher blood transfusion requirements. Complete cytoreduction was achieved in 100% of the PCI ≤ 3 group, but only in 70.8% of the PCI > 11 group (P = 0.001). Postoperative outcomes showed a trend toward less major morbidity in low PCI patients (16.7% vs. 28%) and significantly shorter hospital stays (10–13 days vs. 19 days, P = 0.006). The 90-day mortality rate was 0% in the PCI ≤ 3 group compared to 11.5% in the PCI > 11 group. Long-term outcomes revealed significantly better disease-free survival (DFS) and overall survival (OS) for the PCI ≤ 3 group (DFS: 22 months vs. 4–6 months; OS: 79.6 months vs. 21–40 months, P < 0.001).

Conclusions: Patients with low PCI scores experience reduced morbidity and improved long-term survival, supporting the use of CRS-HIPEC in this subgroup. Further research is needed to enhance treatment strategies for patients with high PCI scores.

Background: Transcatheter aortic valve implantation (TAVI) has become the preferred therapeutic method for elderly patients presenting with severe symptomatic aortic stenosis (AS). Most TAVI procedures are performed in patients between 75–85 years of age. A few publications exist on TAVI in patients over 90 years, yet the outcome and complication rates are inconsistent.

Objectives: To identify all patients with AS who underwent TAVI between 2019 and 2020, specifically those age > 90 years at the time of the TAVI.

Methods: We reviewed the Maccabi Healthcare Services database for all severe/critical AS patients who underwent TAVI between 2019 and 2020, specifically those age > 90 years at the time of TAVI. These patients were compared to all patients aged 80–89 years who underwent TAVI during the same time. Follow-up ended on 31 December 2022. We compared mortality and complications rates in nonagenarians vs. those 80–89 years and evaluated the change in left ventricular ejection fraction before and after the procedure.

Results: We identified 36 nonagenarians who underwent TAVI during the study period, mean age 92.3 years, male:female ratio 15:21. During a mean follow-up period of 3 years, 44% of nonagenarians died, 26% of the control patients died (P < 0.01).

Conclusions: TAVI in nonagenarians is feasible. Total mortality during follow-up was significantly higher in nonagenarians. Overall complication rates were also higher in nonagenarians, mostly due to vascular complications. Left ventricular dysfunction appeared to improve after TAVI, even in nonagenarians.