Israel Medical Association Journal

Modern armed conflicts increasingly expose civilian infrastructure, including hospitals, to direct military threats such as missile attacks. Hospitals provide care for some of the most vulnerable patients, including bedridden individuals and those requiring continuous monitoring that cannot be easily relocated. Protecting these patients during active hostilities presents a major operational challenge. Hospitals must maintain clinical care, prepare for potential infrastructure damage, and remain ready to receive mass casualty victims. Previous disasters and conflict-related evacuations have demonstrated the complexity and risks of relocating hospitalized patients under emergency conditions [1,2].

Background: National crises can significantly impact healthcare utilization patterns yet analyses of different types of crises are limited. While the effects of the coronavirus disease 2019 (COVID-19) pandemic on emergency department (ED) utilization have been well-documented, the healthcare impact of the Israel–Hamas war, which began 7 October 2023, remains unexplored.

Objectives: To compare ED utilization patterns for non-traumatic low back pain (LBP) during two distinct national crises.

Methods: We conducted a retrospective observational study analyzing ED visits for non-traumatic LBP at our medical center. We compared ED utilization patterns, visual analog scale (VAS) pain scores, and surgical rates during 60 days before and after two distinct dates: 7 October 2023 and 19 March 2020 (the start of the COVID-19 lockdown). Statistical analysis included independent t-tests for continuous variables and chi-square tests for categorical variables.

Results: Following 7 October, ED visits decreased by 28.6% (504 to 360). Mean VAS scores and surgery rates showed a non-significant increase from 5.5 ± 2.6 to 5.8 ± 2.4, and from 3.0% to 4.2%, respectively. During the COVID-19 lockdown, ED visits declined by 44.2%, with non-significant changes in pain scores (6.0 ± 3.0 to 5.5 ± 2.9) and surgical rates (3.5% to 2.5%).

Conclusions: Both events led to significant reductions in ED utilization for non-traumatic LBP, despite the heightened risk factors. Surgical rates remained stable, yet many symptomatic patients may have foregone adequate care. These findings underscore the need for resilient, crisis-specific emergency preparedness strategies to ensure continued access to care.

Background: Coronavirus disease 2019 (COVID-19) causes severe complications in 15% of patients, many of whom are pregnant. Most infected women continue their pregnancies until term even though severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) replicates in the decidua.

Objectives: To assess the impact of SARS-CoV-2 infection remote from delivery on obstetric outcomes.

Methods: Women diagnosed with SARS-CoV-2 infection confirmed by polymerase chain reaction at least 14 days prior to delivery were enrolled prospectively and followed monthly until delivery. Their obstetric outcomes were compared to those of women who gave birth at our center during the year preceding the pandemic. The primary endpoint was a composite of hypertensive disorders of pregnancy, oligohydramnios, and fetal distress or meconium-stained amniotic fluid during labor. Other demographic and obstetric variables were also recorded.

Results: The obstetric outcomes of 143 patients were compared to those of 3565 patients who gave birth during the year preceding the pandemic. The composite rate of placental complications was significantly higher in the study group (58 [41%] vs. 593 [17%], respectively), with an odds ratio of 3.4 (95% confidence interval 2.4–4.7). There was also an increased rate of labor induction or advancing the elective cesarean date in the study group (37 [26%] vs. 601 [17%]). No significant differences were found in the Apgar score, cord pH or gestational age at infection.

Conclusions: The risk of placental complications remains greater in pregnant women infected with SARS-CoV-2 after acute illness resolution. Those patients should be monitored closely until delivery.

Background: Electrocardiogram (ECG) may detect atrial fibrillation (AF), but the true rate of ECG performance is unknown.

Objectives: To explore the performance rate of ECG testing in patient populations at high risk for AF in a real-world cohort and to explore the incidence of newly diagnosed AF.

Methods: This retrospective observational cohort study included de-identified data of members of Maccabi Health Services older than 65 years, excluding patients with prior AF and other cardiac diseases. Patients were followed between 1 January 2016 and 30 September 2020. The number of ECGs performed in an outpatient setting for each patient was reported.

Results: In total, 211,515 patients (59.8% female) were included. The mean age was 70.3 ± 6.6 years, with a mean CHA₂DS₂-VASc score of 2.6 ± 1.0. During the study period, over half of the patients (n=112,340; 53.1%) did not undergo any ECG tests, 51,644 patients (24.4%) had one ECG, 24,914 patients (11.8%) had two, while 22,617 patients (10.7%) had more than three. Of the patients referred for an ECG, 67,433 (81.1%) underwent ECG testing within 2 months following the referral. The median time from ECG referral to ECG testing was 5 days.

Conclusions: Most patients older than 65 years had no ECG tests within a 5-year period. However, when referred to an ECG test, most patients complied within a median of 5 days.

Background: Differences in socioeconomic status and ethnicity are linked to disparities in health outcomes, which can affect how consistently patients treat abnormal screening results and cause minority groups to be diagnosed at more advanced stages of disease.

Objective: To compare epidemiological and clinical parameters between Jewish and Arab women who were diagnosed with cervical cancer at Ziv Medical Center during a 10-year period.

Methods: We conducted a retrospective study of consecutive women diagnosed with cervical cancer at a single institution between 2014 and 2024.

Results: Overall, 83 women diagnosed with cervical cancer in the last 10 years at Ziv Medical Center were included in the study: 53 Jewish (64.6%), 30 Arab (36.2%). The groups were similar in mean age at diagnosis, body mass index, smoking status, Pap history performance prior to the diagnosis, menopause status at diagnosis, stage at diagnosis, and treatment. Arab women had higher parity (< 0.001). According to the results of our study, the percentage of cervical cancer patients undergoing Pap screening, prior to diagnosis from the Arab and Jewish sectors, were 16.7% and 17%, respectively, compared to the national screening rate of 54%. Most of the women were diagnosed at an advanced stage (≥ IIB): 83.3% and 69.8%, respectively, compared to 25% in developed countries.

Conclusions: Jewish and Arab women diagnosed with cervical cancer in northern Israel do not differ in epidemiological and clinical parameters, including age at diagnosis and stage. These findings may be attributed to the low performance rate of Pap screening tests in both groups.

Background: Postoperative atrial fibrillation (POAF) is well recognized after cardiac surgery; however, its incidence and clinical course following non-cardiac surgery (NCS) remain unclear.

Objectives: To evaluate the association between POAF after NCS, patient co-morbidities, and type of surgery.

Methods: In this retrospective cohort study, patients who underwent NCS at a private hospital network between 2016 and 2023 were included. Patients with a history of atrial fibrillation (AF) were excluded. Patients who developed POAF within 24-48 hours were compared with those who did not. To address baseline differences, propensity score matching (1:10) and inverse probability weighting combined with Firth’s penalized logistic regression were applied. Odds ratios with 95% confidence intervals were calculated.

Results: POAF developed in 174 patients within 24–48 hours postoperatively, compared with 391,329 controls. Older age, ischemic heart disease, diabetes, and prior stroke were associated with increased odds of POAF, although significance diminished after multivariable adjustment. Weighted regression confirmed these findings with narrower confidence intervals. Higher POAF risk was observed after laparoscopic pancreatectomy, hepatectomy, rectopexy, synovectomy, and gastrectomy. Total knee replacement was the most common procedure among POAF cases, representing 22% of cases and a fourfold increased risk.

Conclusions: Advanced age and cardiovascular co-morbidities were associated with increased POAF risk after NCS, although attenuated after adjustment. Consistent findings across statistical models support the robustness of the results. Targeted monitoring in high-risk patients may improve postoperative outcomes.

Background: Co-infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV) affects approximately 2.2 million people globally and is associated with accelerated liver disease progression, increased morbidity, and reduced quality of life (QoL). While direct-acting antivirals (DAAs) have revolutionized HCV treatment with high cure rates, evidence of their long-term impact on liver-related QoL and associated metabolic or immunologic shifts in HIV/HCV co-infected populations remains limited.

Objectives: To evaluate the effect of achieving sustained virologic response (SVR) with DAAs on long-term QoL in HIV/HCV co-infected patients and to examine associated changes in CD4 count, kidney function, and glucose levels.

Methods: This retrospective observational study was conducted at the Rambam Health Care Campus, between 2015 and 2019. We collected demographic, clinical, and laboratory data from all patients with HIV/HCV co-infection. QoL was evaluated for at least 6 months after the end of treatment. Metabolic variables were collected before and after treatment to test the effects of treatment.

Results: All 70 patients in the cohort achieved SVR. Successful treatment with DAAs resulted in a significant decrease in liver enzymes and globulin levels, and a substantial increase in CD4. A significant improvement in QoL after treatment was noticed in both sexes, regardless of liver fibrosis stage. FIB-4 calculations 6 months and 1 year after the end of therapy showed improved fibrosis levels after SVR.

Conclusions: The use of DAAs in HCV/HIV co-infected patients has improved the long-term QoL, metabolic factors, and fibrosis stage.

Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma-cell disorder, and skin changes (POEMS syndrome) is a rare multisystem paraneoplastic disorder driven by a plasma-cell dyscrasia and cytokine overproduction. It is often misdiagnosed as chronic inflammatory demyelinating polyneuropathy (CIDP) due to overlapping neuropathy [1]. Although thrombocytosis is typical, immune thrombocytopenia is a rare and underrecognized presentation. We describe a patient with longstanding immune thrombocytopenic purpura (ITP) that evolved to POEMS, developed sinusoidal obstruction syndrome (SOS) after an autologous stem-cell transplantation (ASCT), and remained cytopenic due to hypersplenism, highlighting diagnostic and therapeutic challenges.

A persistently irregular wide complex tachycardia is usually related to atrial fibrillation with aberrant conduction but it rarely has a ventricular origin. We present a case of irregular ventricular tachycardia (VT) associated with reversible cardiomyopathy.

Achilles tendinitis commonly occurs in runners due to overuse of the tendon. Sometimes it may be caused by inflammatory diseases like rheumatoid arthritis and psoriasis or by medications such as steroids and fluoroquinolones. It has never been mentioned in association with gait disturbances caused by abnormal foot pronation and standing due to radicular neuropathy. We reported a case of Achilles tendinitis that developed in a patient with spinal stenosis, radicular injury, and accompanying drop foot.

Surgical aortic valve replacement (SAVR) is the treatment of choice for patients with severe aortic stenosis (sAS). Balloon aortic valvuloplasty (BAV) was developed 40 years ago, and it was an alternative to conventional SAVR in elderly and frail patients for whom there were no other effective therapeutic options [1].

Transcatheter aortic valve intervention (TAVI) has expanded its indications during the last 20 years, from prohibitively high surgical risk of mortality to intermediate risk patients [2].

We reported a case of BAV that was used as a bridge to TAVI in an elderly patient with sAS, congestive heart failure (CHF), and ischemic hepatitis (IH).

Freshwater injuries often pose diagnostic challenges due to occult entry wounds and the risk of infection from environmental pathogens. We report a rare case of an embedded live-derived (biologic) foreign body, Theodoxus jordani, in the hand after rafting trauma on the Jordan River, emphasizing early imaging, prompt extraction, and environment-appropriate antimicrobial coverage.

Polycythemia vera (PV) is a chronic, Philadelphia chromosome-negative myeloproliferative neoplasm primarily driven by the Janus kinase 2 (JAK2) V617F mutation. PV leads to clonal erythrocytosis and is frequently accompanied in laboratory blood tests with leukocytosis and thrombocytosis. The diagnostic approach to PV is based on increased red cell volume and the presence of a JAK2 mutation [1]. PV should not be defined solely by hemoglobin or hematocrit values. In a large study of the genomic landscape of myeloproliferative neoplasms, approximately 65% of patients with PV had at least one additional mutation in addition to the driver mutation, most commonly in TET2, DNMT3A, and ASXL1 genes [2].

In this review article, we evaluated experimental evidence supporting the pathogenic role of autoantibodies in rheumatic diseases and selected non-rheumatic autoimmune disorders. We conducted a narrative mechanistic review focusing on experimental studies, which employed passive transfer of patient-derived immunoglobulins or active immunization with defined autoantigens capable of reproducing disease-relevant phenotypes in vivo or ex vivo. Strong experimental evidence supports direct pathogenicity for several rheumatologic autoantibodies, including anti-citrullinated protein antibodies (ACPA), anti-myeloperoxidase (MPO) ANCA, anti-β2-glycoprotein I, anti-Ro/SSA, and anti-ribosomal P antibodies. These autoantibodies induce tissue-specific injury through mechanisms involving complement activation, Fcγ receptor engagement, inflammatory amplification, and antigen accessibility. Representative non-rheumatic autoimmune models, including pemphigus vulgaris, neuromyelitis optica spectrum disorder, and myasthenia gravis, further reinforce the generalizability of antibody-mediated tissue injury across autoimmune medicine. Passive transfer and active immunization studies provide compelling evidence that selected autoantibodies are not merely biomarkers, but active mediators of tissue injury under permissive biological conditions. These findings support the development of targeted therapies directed against pathogenic antibodies, complement pathways, and Fc-mediated effector mechanisms across rheumatic and autoimmune diseases.

Patient Safety and Risk Management in Medicine: From Theory to Practice by Yaron Niv and Yossi Tal, published in 2023 by Springer Nature, is a comprehensive and timely resource dedicated to the theory and practical aspects of patient safety and risk management and focusing on the systemic approach to minimizing harm in healthcare settings.

In 1999, the U.S. Institute of Medicine (IOM) declared that rather than assigning blame for medical errors, professional investigations should be conducted to identify what caused them and how to prevent similar events from occurring in the future. The focus was on systemic factors. It is estimated that in the United States alone, there are between 250,000 and 400,000 preventable deaths annually due to medical errors, costing over US$15 billion per year.