Israel Medical Association Journal

Similar to ageism, which is defined as discrimination against older people due to negative and inaccurate stereotypes [1], geriatrism, a new concept in medical field, reflects a negative attitude and bias toward the study of geriatrics, especially observed among students specializing in therapeutic fields such as nursing, physiotherapy, occupational therapy, speech therapy, psychology, and medicine. However, it implies a reluctance of all professionals in the therapeutic fields, including young medical doctors, to specialize in treating individuals aged 65 years and older.

Background: Syncope is responsible for approximately 1–3% of all emergency department (ED) visits and up to 6% of all hospital admissions in the United States. Although often of no long-term consequence, syncope can be the first presentation of a range of serious conditions such as strokes, tumors, or subarachnoid hemorrhages. Head computed tomography (CT) scanning is therefore commonly ordered in the ED for patients presenting with syncope to rule out any of these conditions, which may present without other associated physical or neurological findings on initial examination. However, the diagnostic yield of head CTs in patients presenting with syncope is unclear.

Objectives: To determine the diagnostic yield of head CT in the ED in patients with syncope.

Methods: We conducted an observational analytical retrospective cross-sectional study on 360 patients diagnosed with syncope who underwent a head CT to determine the diagnostic yield of syncope to determine whether head CT is necessary for every patient presenting with syncope to the ED.

Results: The total of new CT findings was 11.4%. Percentages varied between men (12.8%) and women (9.7%), P = 0.353. There were no significant differences between sexes regarding the findings in head CT, yet the incidence increased, especially among elderly males.

Conclusions: Age had a more significant impact on diagnostic yield of syncope than head CT. The use of a head CT scan as a routine diagnosis tool in patients with syncope is unjustifiable unless there is an indication based on medical history or physical examination.

A 69-year-old woman with a 30-year history of rheumatoid arthritis (RA) on leflunomide presented with dizziness and weakness. Vital signs, cardiopulmonary auscultation, and laboratory studies were normal. The serological status of her RA was unknown. She exhibited ulnar deviation and swan-necking of the hands but no nodular skin lesions. She was an active smoker. Chest radiography revealed an opacity in the right lung. Computed tomography (CT) showed multiple pulmonary nodules and a dominant thick-walled cavitary mass in the periphery of the right lower lobe [Figure 1A]. Due to concern for a malignancy or infection, she underwent a bronchoscopy with a biopsy of the mass, which was non-diagnostic. A subsequent transthoracic needle biopsy demonstrated a central zone of necrosis surrounded by a cuff of palisading epithelioid histiocytes with the presence of occasional giant cells [Figure 1B]. There was no malignancy, and stains for micro-organisms were negative. In this clinical context, biopsy results were consistent with a pulmonary rheumatoid nodule (PRN).

Background: Advancements in artificial intelligence (AI) and natural language processing (NLP) have led to the development of language models such as ChatGPT. These models have the potential to transform healthcare and medical research. However, understanding their applications and limitations is essential.

Objectives: To present a view of ChatGPT research and to critically assess ChatGPT's role in medical writing and clinical environments.

Methods: We performed a literature review via the PubMed search engine from 20 November 2022, to 23 April 2023. The search terms included ChatGPT, OpenAI, and large language models. We included studies that focused on ChatGPT, explored its use or implications in medicine, and were original research articles. The selected studies were analyzed considering study design, NLP tasks, main findings, and limitations.

Results: Our study included 27 articles that examined ChatGPT's performance in various tasks and medical fields. These studies covered knowledge assessment, writing, and analysis tasks. While ChatGPT was found to be useful in tasks such as generating research ideas, aiding clinical reasoning, and streamlining workflows, limitations were also identified. These limitations included inaccuracies, inconsistencies, fictitious information, and limited knowledge, highlighting the need for further improvements.

Conclusions: The review underscores ChatGPT's potential in various medical applications. Yet, it also points to limitations that require careful human oversight and responsible use to improve patient care, education, and decision-making.

In recent years, we have been experiencing a technological revolution, which signifies an ethical and societal transformation. Artificial intelligence (AI) based technologies have gradually permeated all aspects of life and solidified their position. Within this context, the emergence of these technologies offers new opportunities in the medical field, including palliative care, which is aimed at alleviating suffering and improving the quality of life for terminally ill patients and their families. In Israel, the Dying Patient Act of 2005 (the law), which promotes values such as the sanctity of life and individual autonomy, allows terminally ill patients to determine their preferred treatment, and withhold life-saving treatment under certain circumstances. The law represents a significant step toward improving care for terminally ill patients, reducing pain and suffering, and respecting the patient's wishes and worldviews in their final days. However, the practical implementation of the law has encountered numerous challenges, ranging from lack of familiarity among doctors and healthcare professionals and the requirement to determining life expectancy to fulfilling the law's purpose. These challenges are associated with ethical, cultural, and religious perspectives. In this article, we describe how AI-based technologies hold immense potential in applying the law and providing palliative care based on their predictive capabilities, prognostic accuracy, and optimization of treatment as well as communication between patients and healthcare providers. However, as an innovative, developing, and complex technology, it is crucial not to overlook the ethical, societal, and legal challenges inherent in implementing and using AI-based technologies in the context of palliative care.

Background: Pregnant women are at higher risk for severe coronavirus disease 2019 (COVID-19). Since the release of the BNT162b2 messenger RNA vaccine (Pfizer/BioNTech), there has been accumulated data about the three vaccine doses. However, information regarding obstetric and neonatal outcomes of pregnant women vaccinated with the third (booster) vaccine is limited and primarily retrospective.

Objectives: To evaluate the obstetric and early neonatal outcomes of pregnant women vaccinated during pregnancy with the COVID-19 booster vaccine compared to pregnant women vaccinated only by the first two doses.

Methods: We conducted a cross-sectional study of pregnant women who received the BNT162b2 vaccine during pregnancy. Obstetric and neonatal outcomes were compared between pregnant women who received only the first two doses of the vaccine to those who also received the booster dose.

Results: Overall, 139 pregnant women were vaccinated during pregnancy with the first two doses of the vaccine and 84 with the third dose. The third dose group received the vaccine earlier during their pregnancy compared to the two doses group (21² vs. 31⁵ weeks, respectively, P < 0.001). No differences in obstetric and early neonatal outcomes between the groups were found except for lower rates of urgent cesarean delivery in the third dose group (adjusted odds ratio 0.21; 95% confidence interval 0.048–0.926, P = 0.039).

Conclusions: Compared to the first two doses of the BNT162b2 vaccine given in pregnancy, the booster vaccination is safe and not associated with an increased rate of adverse obstetric and early neonatal outcomes.

In this study, we analyzed computed tomography (CT) radiological findings from trauma treated at a single hospital in the aftermath of the terror attack in Israel on 7 October 2023. The study includes images from 34 consecutive patients, consisting of 33 males and 1 female, ranging in age from 19 to 68 years. The majority of these patients underwent both chest-abdominal-pelvic (76%) and head and neck CT scans (64.7%). Key findings highlight a high incidence of head and neck injuries (55.9%), chest trauma (44.1%), and various injuries such as soft tissue lacerations (100%), fractures particularly skull fractures at 32.4%, and brain hemorrhages (23.5%). The limitations of this study include its single-center scope and the focus on stable patients, which may bias the representation of injury types. This case series provides critical insights into the radiological impacts of large-scale terror events, emphasizing the importance of comprehensive preparedness and research in the field of mass-casualty incident response.

Background: Group A Streptococcus (GAS), the predominant bacterial pathogen of pharyngitis, is sometimes difficult to distinguish clinically from viral pharyngitis. Despite the high prevalence of viral pharyngitis in children, antibiotic treatment is common.

Objective: To investigate the effectiveness of an antibiotic stewardship program (ASP) on antibiotic prescription in children with GAS pharyngitis (GAS-P) at a large pediatric community clinic.

Methods: Antibiotic prescription data were collected from October 2016 to March 2017 (pre-intervention period) and from October 2017 to March 2018 (post-intervention period). The intervention was a one-day seminar for primary care pediatricians on the diagnosis and treatment of GAS-P in children according to national guidelines.

Results: The overall prevalence of testing differed between the two time periods. There was a decrease in children who did not undergo any testing (from 68% to 63%), an increase in streptococcal rapid antigen detection testing (28% to 32%), and a slight increase in throat cultures (3% to 4%) (p = 0.02). There was no change in the types of antibiotics prescribed before and after the intervention (p = 0.152).

Conclusions: The ASP resulted in a slight reduction in the percentage of children who did not undergo laboratory testing for GAS-P and a slight reduction in the percentage of children who received antibiotic treatment. The ASP did not reduce the use of broad-spectrum antibiotics and macrolides.

Background: The DES-obstructive sleep apnea (DES-OSA) score uses morphological characteristics to predict the presence and severity of obstructive sleep apnea syndrome (OSAS).

Objectives: To validate DES-OSA scores on the Israeli population. To identify patients requiring treatment for OSAS. To evaluate whether additional parameters could improve the diagnostic value of DES-OSA scores.

Methods: We performed a prospective cohort study on patients attending a sleep clinic. Polysomnography results were examined independently by two physicians. DES-OSA scores were calculated. STOP and Epworth questionnaires were administered, and data on cardiovascular risk was extracted.

Results: We recruited 106 patients, median age 64 years, 58% male. DES-OSA scores were positively correlated with apnea-hypopnea index (AHI) (P < 0.001) and were significantly different between the OSAS severity groups. Interobserver agreement for calculating DES-OSA was very high between the two physicians (intraclass correlation coefficient 0.86). DES-OSA scores ≤ 5 were associated with high sensitivity and low specificity (0.90 and 0.27, respectively) for moderate to severe OSAS. In univariate analysis, only age was significantly correlated with the presence of OSAS (OR 1.26, P = 0.01). Age older than 66 years as a single point in the DES-OSA score slightly improved the sensitivity of the test.

Conclusions: DES-OSA is a valid score based solely on physical examination, which may be useful for excluding OSAS requiring therapy. DES-OSA score ≤ 5 effectively ruled out moderate to severe OSAS. Age older than 66 years as an extra point improved the sensitivity of the test.

Background: Implantable loop recorders (ILRs) are a central tool in the evaluation of unexplained syncope. These devices record and store electrocardiograms, both automatically and on patient-dependent activation. Therefore, obtaining optimal diagnostic results relies on a patient's comprehension and collaboration.

Objectives: To evaluate the effect of ethnic background and mother-tongue language on the diagnostic yield (DY) of ILRs.

Methods: Patients at two medical centers in Israel, who had ILRs as part of syncope workup were included. Inclusion criteria were age over 18 years and an ILR for at least one year (or less if the cause of syncope was detected). Patient demographics, ethnic background, and previous medical history were recorded. All findings from ILR recordings, activation mode (manual vs. automatic), and treatment decisions (none, ablation, device implantation) were collected.

Results: The study comprised 94 patients, 62 Jews (i.e., ethnic majority) and 32 non-Jews (i.e., ethnic minority). While baseline demographic characteristics, medical history, and drug therapy were similar in both groups, Jewish patients were significantly older at the time of device implantation: 64.3 ± 16.0 years of age vs. 50.6 ± 16.9, respectively; (P < 0.001). Arrhythmias recorded in both groups as well as treatment decisions and device activation mode were similar. Total follow-up time from device implantation was longer in the non-Jewish vs. the Jewish group (17.5 ± 12.2 vs. 24.0 ± 12.4 months, respectively; P < 0.017).

Conclusions: The DY of ILR implanted for unexplained syncope did not seem to be influenced by patient's mother-tongue language or ethnicity.

Background: Intrathoracic cancer can cause hyponatremia, but it is uncertain whether mild hyponatremia in the outpatient setting should be regarded as an early sign of intrathoracic cancer.

Objectives: To evaluate the risk of undiagnosed intrathoracic cancer in patients with new persistent mild hyponatremia.

Methods: We conducted a retrospective cohort study using the electronic health record database of a large healthcare organization. The hyponatremia group included patients with sodium concentration of 130–134 mmol/L twice, after a previous normal value and without previous history of cancer or diseases related to hyponatremia. A control group with normal sodium concentration was matched by sex, age, and year of testing. We measured specific intrathoracic cancer incidence during 3 years of follow-up after sodium concentration test date. A logistic regression was used to adjust for further clinical information including smoking history, symptoms, and medications.

Results: The study comprised 1539 participants with mild hyponatremia and 7624 matched controls. New intrathoracic cancer diagnosis was more common in the hyponatremia group during a 3-year follow-up; 1.49% in the hyponatremia group and 0.39% in the control group, crude odds ratio (OR) 3.84, 95% confidence interval (95%CI) 2.22–6.63. After adjustment, hyponatremia remained a significant risk factor for the diagnosis of intrathoracic cancer; adjusted OR 3.61, 95%CI 2.08–6.28.

Conclusions: New mild persistent hyponatremia might be a significant predictive marker to a yet undiagnosed intrathoracic cancer.

Acute cholecystitis is a common surgical diagnosis. If not addressed properly, it can potentially lead to sepsis, perforation of the gallbladder, and even death.

The most frequent pathogens isolated from bile cultures of patients with cholecystitis are anaerobes and Enterbacterales such as E. coli, Klebsiella species, and Streptococcus species [1].

Streptococcus gordonii belongs to the Viridians streptococci group of oral bacteria and is commonly associated with dental caries. S. gordonii has been previously reported as the causative pathogen in both endocarditis and spondylodiskitis [2]. However, it has rarely been associated with biliary infections. In this report, we presented a patient diagnosed with cholecystitis associated with S. gordonii infection.

Background: The hepatobiliary system is a sterile micro-environment. Bacterial infection in this system is most commonly associated with anaerobes as well as gram-positive and gram-negative bacteria. Biliary infections with Staphylococcus aureus are poorly characterized.

Objectives: To depict the clinical characteristics and outcome of patients with S. aureus infection of the hepatobiliary system.

Methods: Medical records of patients with bile cultures positive for S. aureus from January 2006 to November 2020 were extracted from the computerized database of a hospital in Israel.

Results: We analyzed the results of 28 cases that were found in the database. The mean age of study patients was 62.2 ± 19 years. Hypertension, dyslipidemia, chronic kidney disease, diabetes, and benign prostatic hypertrophy were the most common co-morbidities (57.1%, 32.1%, 25%, 25%, and 25%, respectively). Fourteen of the methicillin-resistant S. aureus (MRSA) bile cultures (82.3%) were a result of primary S. aureus biliary infections (no other source for S. aureus infection) and the remainder were of a secondary infection. Eight of the MRSA cultures (47.1%) were from hospital acquired infections. Increased hospital mortality in patients with S. aureus hepatobiliary infection was associated with hypertension (P = 0.04), bedridden status (P = 0.01), and nursing home residence (P = 0.003).

Conclusions: Hepatobiliary infection with S. aureus can manifest in a variety of ways. S. aureus should be especially considered in patients who are bedridden, present with hypertension, or live in nursing homes because of their association with in-hospital mortality resulting from this entity.

Overuse of healthcare services is a common phenomenon defined as: “a healthcare service that is provided under circumstances in which its potential for harm exceeds the possible benefit.” It is expressed in the gap between desired services and available ones and is accompanied by high financial and human life costs. One-fifth to one-third of patients receives unnecessary, ineffective, or potentially harmful treatments or services. One of the greatest challenges to understanding overuse is the lack of definition for appropriate use. Apart from the physical and mental damage caused by overuse or improper use of medical services, this phenomenon has many implications, such as increasing waiting times for services, creating long queues, and incurring considerable financial costs as over 10% of hospital expenses are used to correct medical errors or preventable infections. Government intervention through economic arrangements such as deductibles and pre-authorization of services by the insurer are partially effective in reducing the overuse of health services. Additional solutions include ensuring safety and quality of care as well as shared decision-making.

Background: Endobronchial ultrasound transbronchial needle aspiration (EBUS-TBNA) is a frequently used method for obtaining tissue samples for the diagnosis of various respiratory conditions, including lung cancer staging. In most cases, EBUS-TBNA is performed under moderate sedation (MS). However, in cases of respiratory compromised patients, if this procedure is performed, it is conducted under general anesthesia (GA).

Objective: To assess the diagnostic yield of EBUS-TBNA among respiratory compromised patients.

Methods: Data of consecutive patients (n=191) who underwent EBUS-TBNA at our medical center between January 2019 and December 2019 were retrospectively analyzed. Respiratory compromised patients underwent GA and patients without respiratory compromise were mostly moderately sedated (MS). Characteristics, diagnostic yield, and complication rates were compared.

Results: Diagnostic yield was similar between the two sedation modes (89% in GA group and 78% in the MS group, P = 0.11). The number of total samples obtained per procedure was significantly higher in the GA vs. the MS group (4.1 ± 2.1 vs. 2.1 ± 1.33, P < 0.01). The overall complication rate was 13% and 20.9% in the GA vs. the MS groups, respectively (P = 0.14), with the most frequent complication being minor bleeding. Interestingly, while the number of brushings, bronchoalveolar lavage, and endobronchial biopsy were similar, the percent of subjects who underwent transbronchial biopsy was significantly higher in the GA group (49% vs. 24.2%, P < 0.01).

Conclusion: EBUS-TBNA performed under GA among respiratory compromised patients is safe and has similar diagnostic yield to that of patients without a respiratory compromise