Israel Medical Association Journal

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.

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.

Background: Apparent treatment-resistant hypertension (aTRH) is a high-risk phenotype associated with increased cardiovascular and renal morbidity. Renal denervation (RDN) has emerged as a promising intervention for patients with refractory blood pressure (BP) despite maximal medical therapy.

Objectives: To present the first Israeli prospective cohort evaluating RDN outcomes in aTRH patients.

Methods: The Tel Aviv Renal Denervation registry is a single-center, prospective cohort of 19 patients with aTRH who underwent RDN between 2021 and 2024. Baseline data included demographics, co-morbidities, medication burden, ambulatory BP monitoring (ABPM), and renal function. Outcomes were assessed at 3 and 12 months post-procedure, with repeated measures analyses used to evaluate longitudinal trends.

Results: The cohort (median age 62 years, 42% female) exhibited a high burden of co-morbidities including ischemic heart disease (37%), diabetes (26%), and chronic kidney disease (21%). Baseline ABPM showed a median 24-hour systolic BP of 152 mmHg. Following RDN, mean systolic BP decreased to 143 mmHg at 3 months and 138 mmHg at 12 months (P = 0.097), with a significant reduction in nighttime systolic BP (P = 0.033). Pill burden decreased from a median of 7 to 4 pills daily (P = 0.037). The number of antihypertensive drug classes declined from 6 to 4 (P = 0.052). Renal function remained stable throughout follow-up.

Conclusions: In this Israeli RDN cohort, patients with aTRH experienced clinically meaningful reductions in BP and medication burden, with preserved renal function and minimal complications. These findings support further expansion of national RDN registries to better guide patient selection and optimize long-term outcomes.

Ossifying fibroma (OF) of the jaws presents as a slow-growing, benign, fibro-osseous lesion that poses a risk for significant local destruction. Effective treatment of OF usually requires wide resection, which may lead to substantial morbidity. There are no alternative treatment options reported to date. Osteoclasts, a type of multinucleate giant cell that expresses receptor activator of nuclear factor-kappa B ligand (RANKL), play a major role in OF pathogenesis as well as in central giant cell granuloma (CGCG). CGCG is currently treated with denosumab, a human monoclonal antibody that inhibits bone lysis by binding to RANKL.

In this study, we assessed whether denosumab could be used to treat OF while avoiding surgery. Denosumab successfully treated an aggressive craniofacial ossifying fibroma, circumventing the need for invasive surgery.

Pleural effusion is a common finding after coronary bypass graft surgery. Rarely, patients may develop loculated effusions, which may potentially lead to cardiac chamber compression. We report a rare case of loculated right pleural effusion (LRPE) that resulted in right atrial compression, leading to cardiac tamponade physiology, which resolved completely after emergent surgical drainage of the pleural effusion. This case underscores the need for early implementation of echocardiography in the postoperative management of hemodynamically unstable patients following cardiac surgery.

Neck masses are a common yet challenging presentation in pediatric patients. They may be caused by congenital, inflammatory, neoplastic, or vascular issues. The diverse nature of these masses can make definitive diagnosis difficult for clinicians. Several classification systems exist to categorize neck masses, considering factors such as age at presentation, anatomical location, imaging characteristics, and underlying etiology [1].

These masses often reflect benign infectious, inflammatory, or congenital etiologies. However, in certain cases, lymphadenopathy or other neck masses may indicate an underlying malignancy, thereby serving as a significant source of anxiety for patients and their families.

Fibromatosis colli (FMC) is characterized by a diffuse enlargement of the sternocleidomastoid muscle (SCM), usually in infancy. FMC, initially described as SCM tumors in childhood, is detected in 0.4% of live births but is among the most frequent perinatal neck masses [2].

Polymicrobial endocarditis is a rare clinical entity associated with high rate of morbidity and mortality. We present a case of prosthetic valve endocarditis caused by Enterococcus faecalis and Proteus mirabilis, emphasizing the clinical course, microbiological findings, and potential microbial synergy contributing to disease persistence.

E. faecalis is a gram-positive, facultatively anaerobic bacterium that can cause significant morbidity and mortality. It commonly presents as bacteremia and endocarditis and is a major contributor to nosocomial infections. This bacterium produces biofilms on native and artificial tissues, allowing it to establish resistance to antimicrobial agents. Many infections caused by E. faecalis are polymicrobial, as its biofilm creates an environment that supports the colonization of other microorganisms, leading to mixed-species biofilms on endogenous tissues or medical devices.

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.

We read with great interest the article by Toledano and colleagues [1] about Merkel cell carcinoma (MCC). The authors describe demographic and tumor characteristics of 17 patients seen at Shaare Zedek Medical Center between 2015 and 2022.

The authors claim that “data on MCC, especially from tertiary centers in Israel, is limited,” without providing a reference to document their statement. We would like to argue the opposite.

To the reviewers of 2025, who gave of their time to constructively assess the articles sent to them.