In the last hundred years, the science of fracture repair has significantly changed. Management has moved from a simple metabolic and hormonal concept of bone regeneration to an inflammatory concept and now to a more complicated immunological description. Fracture repair has been considered age-dependent and related to diabetes, nutrition, hormone connection, autoimmune diseases, rheumatic arthritis, and nicotine. Recently a new branch of medicine, osteoimmunology, which deals with the mechanism of fracture repair, has been introduced.

Background: Local anesthetics are used in various sites and mechanisms to maximize perioperative analgesia and reduce opioid use and side effects. Pain management in the bariatric setting is challenging and the efficacy of local anesthetics intraoperatively is under current evaluation.

Objectives: To determine the safety and efficacy of a new intra-abdominal anesthetic technique performed during laparoscopic bariatric operations: visceral block.

Methods: During this prospective randomized double-blinded pilot study, 16 patients undergoing bariatric surgery were treated with the injection of ropivacaine to the anterior esophagogastric junction fat, and 15 were injected with saline as control.

Results: The procedure was shown to be safe, and no adverse events nor side effects were encountered. A non-statistically significant trend toward the use of a non-opioid analgesia was documented during the first postoperative hours.

Conclusions: Visceral block is a safe and feasible intraoperative procedure. A trend toward its efficacy warrants future larger scale studies.

Long-term sperm preservation plays a pivotal role in providing a lifeline for individuals grappling with medical and fertility challenges; thus, enabling them to pursue their aspirations of parenthood. While the significance of frozen sperm is unquestionable, it is vital to address the persistently low utilization and disposal rates of stored samples over time and resulting in an unintended accumulation of unclaimed doses. This accumulation not only carries significant medical, legal, and financial burdens for the institutions responsible, such as sperm banks, but also raises complex ethical considerations, particularly concerning potential biological paternity. These multifaceted considerations are particularly relevant within Israel's publicly funded healthcare system, accentuating the need for clearly defined preservation criteria in cases where an immediate clinical necessity is not readily apparent. We highlight the important clinical, ethical, and economic aspects of preserving the potential for biological paternity and efficiently managing the resources and responsibilities associated with long-term sperm preservation.

Background: Pseudomonas aeruginosa (PSA) is an infectious pathogen associated with acute appendicitis; however, it is not consistently addressed by empirical antibiotic therapy, despite potential complications.

Objectives: To investigate the incidence, predictors, and outcomes of PSA-associated acute appendicitis in children.

Methods: We conducted a retrospective analysis involving pediatric patients who underwent acute appendicitis surgery and had positive peritoneal cultures. Clinical, microbiological, and intraoperative data were extracted from medical records.

Results: Among 2523 children with acute appendicitis, 798 (31.6%) underwent peritoneal cultures, revealing 338 positive cases (42.3%), with PSA detected in 77 cases (22.8%). Children with PSA were three times more likely to exhibit high intraoperative grading ≥ 3 (93.4% vs. 76.8%, 95% confidence interval [95%CI] 1.2–8.3, P = 0.023) and nearly four times more likely to have polymicrobial cultures (88.3% vs. 62.1%, 95%CI 1.8–8.0, P < 0.001) than those without PSA in peritoneal cultures. Duration of symptoms did not predict PSA isolation (P = 0.827). Patients with PSA had longer median hospital stays (8 days, interquartile range [IQR] 7–10) than those with other pathogens (7 days, IQR 5–9) (P = 0.004). Antibiotic treatment duration, intensive care unit admission rates, readmission, and mortality were similar between the two groups (P = 0.893, 0.197, 0.760, and 0.761, respectively).

Conclusions: PSA is a common pathogen in children diagnosed with acute appendicitis and positive peritoneal cultures. The likelihood of isolating PSA increases with high-grade intraoperative assessment and in the presence of multiple pathogens in peritoneal cultures, suggests antipseudomonal treatment.

Background: Immunoglobulin G4-related disease (IgG4-RD) is a chronic, immune-mediated condition characterized by fibro-inflammatory lesions with lymphoplasmacytic infiltration. Diagnosis traditionally relies on histopathological findings, including the presence of IgG4+ plasma cells. However, due to challenges in biopsy accessibility, additional measures are needed to facilitate diagnosis.

Objectives: To identify additional parameters for characterizing IgG4-RD patients.

Methods: We compared several circulating factors between a cohort of patients with IgG4-RD disease seen at our hospital between 2017 and 2023 and healthy controls.

Results: Among 16 suspected patients, 13 were confirmed to have IgG4-RD, and 3 were classified as highly likely. Comparison with controls revealed differences in white blood cell count (WBC) (Folf change (FC) 1.46, P < 0.05), plasmablasts (FC 3.76, P< 0.05), plasmablasts CD38 (FC 1.43, P < 0.05), and CD27 (FC 0.66, P = 0.054), thus highlighting potential markers for IgG4-RD diagnosis. Treatments with steroids/rituximab tend to reduce plasmablast (FC 0.6) and IgG4 (FC 0.28) levels and to increase Gal-3 levels.

Conclusions: Levels of plasmablasts are a significant diagnostic feature in IgG4-RD. Healthy individuals have a lower level of plasmablasts. Elevated Gal-3 in serum of patients with IgG4-RD suggests a role in plasmablast activation. CD38/CD27 expression by plasmablasts emerges as a potential marker. Further research on a larger cohort is needed to confirm these findings.

Background: Long-term support with a HeartMate 3 (HM3) left ventricular assist device (LVAD) has improved outcomes of patients with end-stage heart failure. However, there is a paucity of data on the outcomes of patients who underwent concomitant cardiac surgical procedure (CCSP) during HM3-LVAD implantation.

Objectives: To assess our single-center experience with patients who underwent CCSP during the implantation of an HM3-LVAD.

Methods: From December 2016 until April 2022, 131 adult patients underwent HM3-LVAD implantation. A total of 23 patients underwent CCSP during the HM3-LVAD implantation+CCSP, and 108 underwent only HM3-LVAD implantation (HM3-only).

Results: The median age was 59 ± 11 years (range 54-67), 82% (n=108) were male, and 76% (n=100) were implanted as a bridge-to-transplant. The concomitant procedures performed during the implantation included 8 aortic valve repairs/replacements, 14 tricuspid valve repairs, 4 patent foramen ovales or atrial septal defect closures, and 3 other cardiac procedures. The mean cardiopulmonary bypass time was 113 ± 58 minutes for the HM3-only group and 155 ± 47 minutes for the HM3+CCSP group (P = 0.007). The mortality rates at 30 days, 6 months, and 12 months post-implantation were 2 (9%), 5 (22%), and 6 (26%) respectively for the HM3+CCSP group, and 7 (6%), 18 (17%), and 30 (28%) for the HM3-only group (P = 0.658, 0.554, and 1.000).

Conclusions: Our experience demonstrated no significant difference in the 30-day, 6-month, and 12-month mortality rates for patients who underwent a CCSP during HM3-LVAD implantation compared to patients who did not undergo CCSP during HM3-LVAD implantation.

Background: Hidradenitis suppurativa (HS) is a chronic inflammatory skin disease involving apocrine gland-bearing regions. There is an under-representation of non-Caucasians in epidemiologic studies of HS. The characteristics of HS in Israeli Arabs have not yet been studied.

Objectives: To investigate the demographic and clinical profile of HS in the Israeli Arab population.

Methods: A retrospective analysis was conducted in two cohorts of patients with HS in Israel. The patients were derived from the database of a large health management organization (n=4191, 639 Arabs; population-based) and a major tertiary medical center (n=372, 49 Arabs). Demographic and clinical data were compared between ethnic groups.

Results: The prevalence of HS in Israeli Arabs was found to be 0.5%, fivefold higher than in Jews. Arab patients were younger (35.3 vs. 40.5 years, P < 0.001) and mostly male (52% vs. 35.7%, p < 0.001), with lower rates of co-morbidities, including smoking (40.8% vs. 55.7%, p < 0.001), hyperlipidemia, and depression as well as a higher rate of dissecting cellulitis (10.2% vs. 1.9%, p = 0.008). HS was more severe in Arabs, but of shorter duration, with mainly axillary involvement (79.6% vs. 57.9%, p = 0.004). Treatment with hormones was more common in Jews, and with biologic agents in Arabs.

Conclusions: The findings suggest a different phenotype of HS in Arabs, warranting further study.

Background: Pyogenic flexor tenosynovitis (PFT) is a common and severe hand infection. Patients who present early can be treated with intravenous antibiotics.

Objectives: To determine whether PFT caused by animal bites and treated with antibiotics leads to a different outcome than other disease etiologies due to the extensive soft tissue insult and different bacterial flora.

Methods: We conducted a retrospective cohort study of 43 consecutive patients who presented with PFT between 2013 and 2020. The 10 patients who presented with PFT following an animal bite were compared to those who presented with PFT caused by any other etiology.

Results: Patients who were bitten pursued medical attention sooner: 1.9 ± 1.4 days compared with 5.3 ± 4.7 days (P = 0.001). Despite the quicker presentation, patients from the study group received similar antibiotic types and duration as controls. All patients were initially treated with intravenous antibiotics under surveillance of a hand surgeon. One patient (10%) from the study group and four controls (12%) were treated surgically (P = 1). Average follow-up was 17 ± 16 days. At the end of follow-up, one (10%) patient from the study group and three (9%) controls sustained mild range of motion limitation and one (3%) patient from the control group had moderate limitations (P = 0.855).

Conclusions: Intravenous antibiotic treatment, combined with an intensive hand surgeon follow-up, is a viable option for the treatment of PFT caused by animal bites.

Intranasal corticosteroids (INCS) are frequently prescribed for allergic rhinitis but can also be used for other indications, such as sinusitis and nasal congestion. INCS are considered effective in controlling nasal symptoms with a similar safety profile among the different INCS formulations. In this review, we presented all available INCS formulations marketed in Israel while emphasizing the differences among them with a practical approach for medical providers in selecting a specific INCS agent. We conducted a literature review using PubMed, Medline, and Google Scholar to identify articles related to INCS, triamcinolone acetonide, fluticasone propionate, and fluticasone furoate. Currently, five brands of INCS are available in Israel. While they all have similar efficacy in treating nasal symptoms, only fluticasone furoate consistently demonstrated a reduction in ocular symptoms compared to placebo. Other differences included sensory attributes, recommended regimens, approved age for use, and cost. When selecting INCS agent, a personalized approach is advised. Factors such as age, co-morbidities, concurrent medications, pregnancy, and patient preferences should be considered.

The concept of starvation osteopathy is an old and an investigated one, which is well established in many ways. Studies were conducted on famine survivors during World War I, in the Ukraine in the early 1930s, throughout Europe during World War II, and in Asia and Africa soon after. However, the main topic of this article is the effect of starvation inflicted during the Holocaust.

Background: The cavum septi pellucidi (CSP) is a brain-enclosed cavity located on the midline between the two leaflets of the septum pellucidum that separates the lateral ventricles. This structure develops in the fetus from week 18 and can be seen up to week 37 in almost all cases and then begins to disappear.

Objectives: To measure and determine the normative values of the CSP volume in fetuses between 20 to 40 weeks of gestation.

Methods: The study comprised 161 consecutive pregnant women between 20 to 40 weeks of gestation with single viable fetuses. All patients had normal, disease-free pregnancies. Transvaginal or transabdominal ultrasound was used according to the fetal presentation. The fetal head was assessed in mid-sagittal sections. Once the CSP was visualized, its volume was measured using three-dimensional ultrasound with Virtual Organ Computer-aided Analysis software. The width of the CSP was also measured at the biparietal diameter (BPD) plane.

Results: Of the 161 fetuses, the CSP volume was measured in 158. In three patients the CSP was not identified. The CSP volume correlated poorly with gestational age (r=0.229) and with the BPD (r=0.295). The mean CSP volume was 0.508 ± 0.372 ml (range: 0.03-1.78 ml). The simple measurement of the CSP width correlated better with gestational age (r=0.535) and the BPD (r=0.484).

Conclusions: The CSP volume had a poor correlation with gestational age; however, the volume did not exceed 2 ml regardless of gestational age. This information can be used to assess pathologies involving the CSP.

 

Background: Hypothermia, as a sign of serious bacterial infection (SBI) in children and infants older than 90 days is poorly characterized, especially in the post-pneumococcal vaccine era.

Objectives: To assess the prevalence of SBI in children and infants presenting to the pediatric emergency department (PED) with reported or documented hypothermia.

Methods: Retrospective data analysis was conducted of all well-appearing children aged 0–16 years who presented with a diagnosis of hypothermia at two tertiary PEDs from 2010 to 2019.

Results: The study comprised 99 children, 15 (15.2%) age 0–3 months, 71 (71.7%) 3–36 months, and 13 (13.1%) > 36 months. The youngest age group had increased length of stay in the hospital (P < 0.001) and increased rates of pediatric intensive care unit admissions (P < 0.001). Empirical antibiotic coverage was initiated in 80% of the children in the 0–3 months group, 21.1% in the 3–36 months group, and 15.4% in > 36 months (P < 0.001). Only one case of SBI was recorded and no bacteremia or meningitis. Hypothermia of unknown origin was the most common diagnosis in all age groups (34%, 42%, 46%), respectively, followed by bronchiolitis (26%) and hypoglycemia (13.3%) for 0–3 month-old children, unspecified viral infection (20%) and otitis media (7%) for 3–36-month old, and unspecified viral infection (23%) and alcohol intoxication (15.2%) in > 36 months.

Conclusion: There is a low incidence of SBI in well-appearing children presenting to the PED with hypothermia and a benign course and outcome in those older than 3 months.

Background: Survivors of critical illness are at increased risk of long-term impairments, referred to as post-intensive care unit (ICU) syndrome (PICS). Post-traumatic stress disorder (PTSD) is common among ICU survivors with reported rates of up to 27%. The prevalence of PTSD among Israeli ICU survivors has not been reported to date.

Objectives: To evaluate the prevalence of new onset PTSD diagnosed in a post-ICU clinic at a tertiary center in Israel.

Methods: We conducted a retrospective, single center, cohort study. Data were collected from medical records of all patients who visited the Tel Aviv Sourasky Medical Center post-ICU clinic between October 2017 and June 2020. New onset PTSD was defined as PTSD diagnosed by a certified board psychiatrist during the post-ICU clinic visit. Data were analyzed using descriptive statistics.

Results: Overall, 39 patients (mean age 51 ± 17 years, 15/39 females [38%]) attended the post-ICU clinic during the study period. They were evaluated 82 ± 57 days after hospital discharge. After excluding 7 patients due to missing proper psychiatric analysis, 32 patients remained eligible for the primary analysis. New PTSD was diagnosed in one patient (3%).

Conclusions: We found lower incidence of PTSD in our cohort when compared to existing literature. Possible explanations include different diagnostic tools and low risk factors rate. Unique national, cultural, and/or religious perspectives might have contributed to the observed low PTSD rate. Further research in larger study populations is required to establish the prevalence of PTSD among Israeli ICU survivors.

In this special issue of Israel Medical Association Journal (IMAJ) we expose readers to the topic of artificial intelligence (AI) in medicine. AI has become a powerful tool, which enables healthcare professionals to personalize treatment based on many factors, including genetic analyses of tumors, and to consider other co-morbidities affecting a specific patient. AI gives physicians the ability to analyze huge amounts of data and to combine data from different sources. AI can be implemented make a diagnosis based on computed tomography (CT) scans and magnetic resonance imaging (MRI) scans using deep machine learning and data that are stored in the memory of mega computers. AI assists in tailoring more precise surgery to train surgeons before surgery and to support surgeons during procedures. This advancement may benefit surgical procedures by making them more accurate and faster without cutting unnecessary tissues (e.g., nerves and blood vessels); thus, patients face fewer complications, lower rates of infection, and more operation theater time. In this issue, we include three original studies that describe the use of AI in academia and eight review articles that discuss applications of AI in different specialties in medicine. One of the review articles addresses ethical issues and concerns that are raised due to the more advanced use of AI in medicine.

In the grand theater of modern medicine, artificial intelligence (AI) has swiped the lead role, with a performance so riveting it deserves an Oscar, or at least a Nobel. From the intricate labyrinths of our arteries to the profound depths of our peepers, AI is the new maestro, conducting symphonies of data with the finesse of a seasoned virtuoso [1,2].