Israel Medical Association Journal

The Lancet Commission on Medicine, Nazism and the Holocaust was published in November 2023, recognized the potential dangers for the medical profession that are echoed in this history. The tragic events on 7 October 2023 have revealed just how timely and important the Commission's publication is and have raised the question of the relevance to the Holocaust to this attack. One of the continuities from this past and which has dangerous implications for current medicine, is antisemitism. Examination of the antisemitism inherent to medical education in Nazi Germany raises the question of antisemitism in current academia. Since October 7th there has been a drastic rise in antisemitism and antisemitic actions in both the academy and in medicine. We have seen outright refusal to condemn the brutal perpetrators of the October 7th massacre and continue to observe explicit support for the perpetrators from both faculty and students. Medicine, a profession whose foundational tenet is the well being of humanity–all humanity–and that hallows moral clarity, cannot allow for antisemitic speech and actions to exist within the profession. Awareness and education on this history is crucial for the medical profession so that the tragic events of the past do not happen again.

Background: Laparoscopic right hemicolectomy is considered the gold standard surgical treatment for patients with right colon malignancies. The restoration of bowel continuity can be performed by intracorporal (ICA) or extracorporal (ECA) techniques.

Objectives: To evaluate a single-center experience in laparoscopic right colectomy, comparing patients with ICA and ECA.

Methods: This is a case-control retrospective study included all patients who underwent laparoscopic right colectomy between the years 2016–2022 at our medical center. Patients were divided according to the operative technique. The study database included demographics as well as intraoperative and postoperative parameters.

Results: Overall, 125 patients were included in the study, which included 98 patients (78.4%) from the ICA group included and 27 patients in the ECA group. Both groups were comparable in demographics and co-morbidities. No significant differences were observed between the groups in intraoperative complications, length of surgery, return to the oral diet, and length of hospital stay. The incidence of postoperative ventral hernia was significantly higher in patients from the ECA group (18.5% vs. 3.1%, P = 0.012).

Conclusions: Laparoscopic right colectomy with ICA is associated with a lower rate of postoperative ventral hernias.

Background: The management of chronic hepatitis C virus (HCV) infection in patients with concurrent severe mental illness and substance use disorder poses significant challenges to treatment initiation, adherence, and completion. Multiple barriers impede successful treatment outcomes in this population, including cognitive impairments associated with mental illness, ongoing psychoactive substance use, and inadequate social and environmental support systems.

Objectives: To implement a treatment program for HCV-infected patients during their psychiatric hospitalization. To establish a multidisciplinary task force comprising a hepatologist, psychiatric ward team (psychiatrists, nurses, social workers), and a project administrator.

Methods: We conducted a retrospective cohort study of patients hospitalized with dual diagnosis (DD) of severe mental illness and substance use disorder who tested positive for HCV antibodies. Patients underwent clinical evaluations and received treatment with direct antiviral agents during hospitalization under the supervision of the joint team. Demographic and clinical characteristics were analyzed.

Results: Between January 2018 and June 2023, 694 DD patients were hospitalized, of whom 119 tested positive for HCV antibodies (prevalence 17.1%). Twenty-seven patients (23%) completed treatment; 17 (63%) achieved confirmed sustained virologic response. Treatment discontinuation occurred primarily post-discharge from the mental health facility. Significant efforts were made to engage community caregivers to maintain continuity of care.

Conclusions: Our findings demonstrate that treating HCV in patients with concurrent severe mental illness and substance use disorder requires collaborative efforts across medical disciplines. This integrated approach during psychiatric hospitalization provides a unique opportunity for initiating and monitoring HCV treatment in this complex patient population.

Background: Functional mitral and tricuspid regurgitation (fMR and fTR, respectively) portend increased morbidity and mortality among heart failure (HF) patients.

Objectives: To characterize acute decompensated valvular HF (VHF) as a novel HF category, defined by presence of either more than moderate fTR or more than moderate fMR with left ventricular ejection fraction (LVEF) ≤ 50%.

Methods: Patients with VHF were prospectively enrolled over a 6-month period and compared to acute decompensated heart failure (ADHF) patients without significant fTR or fMR. We used a standardized diuretic protocol when indicated, and appropriate inpatient guideline-directed medical therapy was initiated.

Results: Among 322 patients admitted with ADHF, 83 (26%) met VHF criteria with mean age 66 ± 13 years, 43 (52%) males, and median LVEF of 30% (20–55). Of 61 patients in whom the diuretic protocol was initiated, 59 (97%) had an adequate response (i.e., > 100 cc/hour for at least 6 hours). VHF patients had longer length of hospitalization (8 [5–13] vs. 5 [3–8] days, P < 0.001), and higher rates of 90–day heart replacement therapy (HRT) or death (hazard ratio 2.52, 95% confidence interval (1.13–5.64); P = 0.024).

Conclusions: Over a quarter of ADHF patients can be newly categorized as VHF patients, distinguished by prolonged hospitalization and worse 90-day mortality / HRT rate. The initial response rate to a standardized diuretic protocol was high.

Background: Antiphospholipid syndrome (APS) is a common form of acquired thrombophilia associated with a high thrombotic risk. Fabry’s disease (FD) is an X-linked lysosomal storage disease caused by mutations in the alpha-galactosidase A (GLA) gene and presents with a wide range of clinical manifestations, including a high rate of thrombosis. Previously reported, 45% of FD patients were found to have antiphospholipid autoantibodies.

Objectives: To determine the prevalence of FD in patients with APS.

Methods: We conducted a prospective study. Data were collected from 41 APS patients at our outpatient clinic at Meir Medical Center in Israel. We utilized chemical and genetic analyses to identify FD among APS patients. Dried blood spot (DBS) was used to assess GLA activity in males, and mutational analysis of the GLA gene was performed by sequencing exons and their flanking regions in women.

Results: Among 41 antiphospholipid patients, one male patient was diagnosed with FD. Gal variants were not detected in any of the tested female patients.

Conclusions: We found a low prevalence (2.4%) of FD in APS patients. Larger studies are needed to evaluate the clinical utility and cost-effectiveness of routine FD screening in this population.

Background: Cesarean section (CS) comprised almost one-third of all births. One of the complications after CS is intra-abdominal and pelvic adhesions formation.

Objectives: To investigate whether a previous CS poses an additional perioperative or postoperative risk for complications when performing a total laparoscopic hysterectomy (TLH).

Methods: We conducted a retrospective cohort study of women who had undergone a TLH between 2014 and 2020. Perioperative and postoperative complications were assessed according to the Clavien-Dindo classification system. Descriptive statistics were used to analyze the results.

Results: In total, 190 women underwent TLH during the study period, 50 (26.5%) had a previous CS (study group) and 140 (73.5%) had no history of CS. The complication rates using the Clavien-Dindo classification system were similar in both groups; however, the major complications rate was not significantly higher in the study group (CS 6% vs. no CS 1.4%, P = 0.08). Urethral injury was the most common major complication (2, 4% vs. 1, 0.7%). The duration of surgery (125 min vs. 112 min, P = 0.02), estimated blood loss (174 ml vs. 115 ml, P = 0.02), and additional postoperative endoscopic interventions (4% vs. 0%, P = 0.01) and were significantly greater in patients with a previous CS.

Conclusions: Although the need for postoperative endoscopic interventions, surgery duration, and estimated blood loss were significantly higher in patients with a previous CS, TLH remains a safe and recommended procedure for these patients. Major complications are rare and do not occur more frequently following a previous CS.

Background: Direct oral anticoagulants (DOACs) have significantly transformed anticoagulant therapy, improving effectiveness, safety, and convenience in managing thromboembolic conditions. However, concerns persist regarding drug-related problems (DRPs) associated with DOACs, necessitating the establishment of multidisciplinary antithrombotic stewardship programs to optimize the selection, dosing, and monitoring of DOACs.

Objectives: To evaluate the incidence and types of DRPs associated with DOACs, the frequency of clinical pharmacist consultations, the acceptance rates of the clinical pharmacist recommendations, and physicians' adherence to appropriate DOACs prescribing practices.

Methods: A retrospective cohort study was conducted over 4 months in the internal medicine departments at Shamir Medical Center (Assaf Harofeh), Israel. The study included patients aged 18 years and older who were prescribed DOACs (apixaban, rivaroxaban, and dabigatran). Data on patient characteristics and clinical outcomes were collected from electronic medical records. A clinical pharmacist reviewed and reassessed the appropriateness of DOAC prescribing.

Results: During the study period, 415 patients receiving DOACs were identified. Among them, 28.4% had inappropriate DOAC prescriptions leading to 128 recommended interventions. The most common DRP was underdosing (29.7%) followed by unjustified antiplatelet use (26.6%). Clinical pharmacists performed 85.9% of the interventions, with a physician acceptance rate of 72.7%. Patients with inappropriate DOAC prescriptions exhibited increased trends in thromboembolic events and in-hospital mortality.

Conclusions: Despite over a decade of clinical experience with DOACs, DRPs remain a significant challenge. Implementing antithrombotic stewardship programs is critical for optimizing DOACs use, reducing DRPs, and enhancing patient safety.

Methotrexate, a folate analog antimetabolite, is one of the oldest cytotoxic drugs still in use. It is active against a variety of malignancies including bladder and breast cancer, head and neck tumors, gestational choriocarcinoma, osteogenic sarcoma, lymphomas, and leukemias.

Methotrexate is given mostly intravenously (IV), usually at standard doses (milligrams). It can also be delivered in much higher doses (grams), which is known as high-dose methotrexate (HDMTX). The intrathecal (IT) route is used particularly in children with acute lymphoblastic leukemia (ALL) and in adults with meningeal carcinomatosis. The drug may be administered orally as well, mainly in non-oncological conditions such as rheumatoid arthritis and other autoimmune diseases.

Immune thrombocytopenia (ITP), driven by autoantibodies targeting platelet antigens, is an acquired disorder posing considerable challenges, particularly in pregnancy, where its prevalence escalates to 1–3 per 10,000 women, a tenfold increase compared to the general population [1]. Predominantly characterized by a heightened risk of bleeding, particularly during pregnancy, the incidence of significant hemorrhagic events stands at approximately 18%, mostly non-severe [1]. Despite its rarity, thrombosis can manifest as a complication, especially when accompanied by antiphospholipid antibodies, which amplify the propensity for arterial and venous thrombotic events alongside obstetric complications and thrombocytopenia [2,3].

In this case report, we present the case of a young female with primary unexplained infertility, complicated by ITP and antiphospholipid syndrome (APS), predisposing her to increased bleeding and thrombotic risks. During a multidisciplinary consultation, the medical staff navigated the intricate landscape of fertility treatments and pregnancy options, carefully considering the delicate balance between risks and benefits to optimize patient outcomes.

A 70-year-old female with a 10-year history of dermatomyositis involving the skin, muscles, and gastrointestinal system was diagnosed based on proximal muscle weakness, typical dermatomyositis-specific rashes, elevated creatine kinase, and muscle biopsy findings consistent with dermatomyositis. Myositis-specific autoantibodies were negative.

The patient initially received treatment with conventional synthetic disease-modifying antirheumatic drugs (csDMARDs) but experienced gastrointestinal intolerance to both methotrexate and azathioprine. Subsequently, she was managed with intravenous immunoglobulin (IVIg) for 4 years; however, due to a relapse of muscle involvement, rituximab was initiated and has been administered for the past 3 years.

Over the last year, the patient achieved remission in muscle involvement but experienced worsening dermatomyositis-specific skin manifestations, including heliotrope rash, Gottron signs, and holster sign [Figure 1A], accompanied by severe pruritus that significantly impaired her quality of life. The Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI) activity score reached 17. Her skin condition remained refractory despite treatment with topical steroids and calcineurin inhibitors.

Recent publications based on newly available list of surgeries performed in Nazi concentration camps raised the question of motivation for thousands of procedures on internees incarcerated from occupied Europe. The performance of major surgeries would be suspicious in their intent, indicating, if not directly proving, their intention as an exercise for junior physicians or medical students. The concept of the Revier (infirmary) is discussed. The Revier (also known as Krankenrevier or infirmary) in Nazi concentrations camps was located next to the extermination unit. Procedures performed at the Revier were considered non-therapeutic, as the victims had a minimal chance of survival without appropriate postoperative facilities. A review of medical documents of major concentration camps (Auschwitz, Mauthausen, Gusen, Ebensee) indicates the criminal intention of the authorities. This unusual type of crime was raised in post-war trials, but no specific legal code was nominated.

Obesity is a growing global health concern, with its prevalence contributing to the rise of multiple chronic conditions, including autoimmune diseases. In this review I explore the intricate relationship between obesity and autoimmunity, focusing on how excess adiposity can affect immune responses and promote the development of autoimmune disorders. Obesity alters adipose tissue architecture, promoting chronic low-grade inflammation and triggering the release of pro-inflammatory cytokines, which contribute to immune system dysregulation. Adipose tissue is no longer seen as merely an energy store but as an active endocrine organ that interacts with the immune system. The review delves into mechanisms such as the role of adipokines, altered T cell function, and the recruitment of immune cells to inflamed adipose tissue, which together exacerbate autoimmune risk in obese individuals. Genetic and environmental factors also play a critical role in these processes, as polymorphisms and high-fat diets have been shown to influence both obesity and autoimmune susceptibility. Last, the review explores potential therapeutic strategies, such as lifestyle interventions and targeting obesity-driven inflammatory pathways, which could mitigate autoimmunity. Understanding the connection between obesity and autoimmunity offers insights into more effective interventions for patients suffering from these intertwined conditions.

Chronic obstructive pulmonary disease (COPD) is a disease state characterized by persistent respiratory symptoms and airflow obstruction determined by spirometry, including emphysema, chronic bronchitis, and small airway disease. Traditional treatment settings for COPD exacerbations typically involve in-hospital care. However, hospital-at-home (HaH) programs have emerged as an innovative model to provide hospital-level care at a patient's home. I synthesized available randomized controlled trials (RCTs) and compared the outcomes of COPD management in HaH and in-hospital settings. I searched for English language medical literature studies of COPD patients in HaH programs compared to in-hospital. Searches were performed in PubMed, EMBASE, Scopus, and CENTRAL. Outcomes were compared, meta-analyses were performed, and pooled odds ratios (ORs) and 95% confidence intervals (95%CIs) were calculated. Heterogeneity was evaluated and I² statistic was used to measure the proportion of inconsistency in individual studies. Potential publication bias was also calculated. Seven controlled studies representing 19 sub-studies (data sets) were selected according to the inclusion criteria. The OR of the HaH and in-hospital comparison was 0.542, 95%CI 0.379–0.774, P = 0.001. The different clinical outcomes of HaH were better or similar to those at regular hospitals, but with higher patient preference (OR 0.316, 95%CI 0.198–0.506). Heterogeneity and inconsistency were small, with no significant publication bias. HaH may be recommended for COPD patients' hospitalization when needed according to the specific indications and patients matching HaH criteria.