Israel Medical Association Journal

Background: Ascites is a product of fluid accumulation within the peritoneal cavity. Underlying etiologies include cirrhosis, congestive heart failure (CHF), nephrotic syndrome, and malignancies. Patients with cirrhotic ascites are at increased risk for infections, especially spontaneous bacterial peritonitis (SBP), which is associated with high rates of morbidity and mortality. Ascites is diagnosed both clinically and sonographically. SBP is diagnosed via abdominal paracentesis, a relatively safe and effective procedure. However, abdominal paracentesis carries risks such as bleeding, bowel perforation, and infection.

Objectives: To identify new inflammatory markers as alternative or replacement methods for accurately evaluating patients before and after abdominal paracentesis and how these new inflammatory markers can be evaluated from a simple, inexpensive, and routinely performed blood sample.

Methods: A total of 106 patients admitted with ascites were classified into three groups based on the underlying etiology of their condition: malignant ascites (30 patients), ascites secondary to CHF (30 patients), and ascites secondary to cirrhosis (46 patients). Levels of neutrophil-lymphocyte ratio (NLR), mean platelet volume, and C-reactive protein among the study groups were examined through blood samples and subsequently compared

Results: NLR values within malignant ascites and CHF ascites were significantly higher than cirrhotic ascites (P = 0.002). In addition, among risk factors for developing ascites, significant correlations were found among the three groups in hypertension (P < 0.001), diabetes mellitus (P = 0.003), hyperlipidemia (P = 0.002), CHF (P < 0.001), and ischemic heart disease (P < 0.001) variables.

Conclusions: NLR may be a prognostic tool in patient evaluation of ascites.

Minocycline is a tetracycline antibiotic prescribed to treat various infections, acne vulgaris, and rosacea. In addition to its antibiotic activity, it possesses anti-inflammatory properties, including reducing the production of proinflammatory cytokines, suppressing neutrophil chemotaxis, activating superoxide dismutase, and inhibiting phagocytosis. Among its side effects are hypersensitivity syndrome reactions, drug-induced lupus, and polyarteritis nodosa (PAN) [1].

Pediatrics stands at the forefront of medical innovation, from neonatal care to the management of complex acute and chronic conditions. The field continues to evolve, driven by pioneering research. Advances in genetics, technology, and personalized medicine are transforming pediatric care, addressing the diverse needs of children globally, and offering new opportunities to enhance health outcomes and quality of life.

Background: Acute bronchiolitis, primarily caused by respiratory syncytial virus (RSV), is the leading cause of hospitalization in young children. Despite international guidelines supporting clinical diagnosis, laboratory evaluations are often conducted with limited validity.

Objectives: To evaluate the association between C-reactive protein (CRP) serum levels on admission and disease severity in children hospitalized due to RSV bronchiolitis.

Methods: This retrospective cohort study included children (0–24 months old) who were hospitalized due to RSV bronchiolitis (2018–2022), CRP levels taken at admission.

Results: We included 1874 children (mean age of 6.7 months, 59% males); median CRP level 1.92 mg/dl. Children with elevated CRP (> 1.92 mg/dl) were significantly older (5.1 vs. 3.8 months, P < 0.001) and had higher rates of pneumonia (9.4% vs. 4.3%, P < 0.001), urinary tract infection (UTI), (2.2% vs. 0.2%, P < 0.001), acute otitis media (AOM) (1.7% vs. 0.2%, P < 0.001), admissions to the pediatric intensive care unit (PICU) (7.4% vs. 3.7%, P < 0.001), antibiotic treatment (49.8% vs. 37.2%, P < 0.001), and longer hospitalizations (3.83 vs. 3.31 days, P < 0.001). Multivariable analysis predicted increased risk for UTI, PICU admission, pneumonia, and longer hospitalization (relative risk 11.6, 2.25, 1.98, 1.44, respectively, P < 0.001). CRP thresholds of 3.51, 1.9, and 2.81 mg/dl for PICU admission, UTI, and pneumonia, were calculated using Youden's index with AUC 0.72, 0.62, and 0.61, respectively.

Conclusions: Elevated CRP levels at admission are associated with increased disease severity and higher complication rates in children hospitalized with RSV bronchiolitis.

A full-term 1-month-old female was brought to our pediatric emergency department (ED) due to 3 days of increasing respiratory distress. She was born at term to healthy, consanguineous (2nd degree) Bedouin parents after a pregnancy that lacked adequate monitoring. At birth, a physical examination revealed an imperforate anus and a recto-vestibular fistula, left hydronephrosis, large patent ductus arteriosus (PDA), and an atrial septal defect (ASD). The diagnosis of VACTER association was made. Importantly, she had no respiratory difficulties, nor hemivertebra or tethered cord.

On admission to the ED, she presented with severe respiratory distress, tachypnea, dyspnea, and hypoxemia without evidence of upper airway obstruction or stridor. Due to impending respiratory failure, she was transferred to the pediatric intensive care unit and started on non-invasive respiratory support through a high-flow nasal cannula (HFNC), which partially relieved her work of breathing. The nasal swab for respiratory viruses was positive for enterovirus, and her urine culture grew Escherichia coli. She was transferred to the pediatric ward after clinical improvement on day 3. Echocardiography performed for evaluation of pulmonary hypertension estimated normal pressures but revealed a vascular ring anomaly. A computed tomography (CT) angiography performed confirmed the presence of an aberrant left pulmonary artery also referred to as a left pulmonary artery sling (LPAS) [Figure 1A].

Anorexia nervosa (AN) is a common psychiatric disorder primarily affecting adolescents and young adults. It is characterized by extreme restriction of food intake, distorted body image, and weight-gain anxiety. We report a case with rapid progression and severe metabolic changes in a young restrictive-type AN patient, highlighting unique aspects of this presentation and discussing pathophysiology.

An 11-year-old girl presented with a significant 29% weight loss over 4 months, leading to a body mass index (BMI) of 11.7 (< 1st BMI percentile for her sex and age). She presented with severe bradycardia and metabolic abnormalities including hypoglycemia, hypercholesterolemia, and hypothyroidism. Following diagnosis with restrictive type AN based on the DSM-5 [1] criteria and stabilization at our department, she was transferred to a specialized unit. The hypercholesterolemia our patient presented with is more typical of binge-eating/purging subtype AN, yet it was markedly elevated in this restrictive-type case.

Inborn errors of immunity (IEI), formerly known as primary immunodeficiencies (PID), comprise a diverse group of genetic disorders characterized by increased susceptibility to infections, autoimmunity, autoinflammatory conditions, allergies, and malignancies. These disorders exhibit a broad spectrum of clinical manifestations, including extra-hematopoietic manifestations, which may also present later in life. IEI diagnosis has significantly advanced, in line with the common use of next-generation sequencing-based genetic platforms, such as whole-exome and whole-genome sequencing. Treatment approaches have evolved beyond infection management to include curative therapies such as hematopoietic stem cell transplantation, gene therapy, and targeted pharmacologic treatments. In this review, we explore recent advancements in the understanding, diagnosis, and treatment of IEI, emphasizing the rapid progress in this expanding field.

It is indisputable that internal medicine is the cornerstone of medical activities, including medical education, in hospital clinical activities, and clinical and basic medical research.

The medical landscape in Israel is exceptionally demanding, far exceeding the norms of the countries that are members of the Organisation for Economic Co-operation and Development (OECD). We have fewer hospital beds per capita, a greater workload for each physician, and in the future, we will face the challenge of teaching more medical students across our current clinical fields.

The Israeli Society of Internal Medicine has made it its mission to advance internal medicine across all dimensions of the healthcare system in Israel. As such, for the third consecutive year, we are honored to present an issue of the Israel Medical Association Journal (IMAJ) dedicated to research in the different fields of internal medicine that are conducted by physicians from various departments across the country.

This year, we emphasize even more strongly that research is an integral part of our clinical practice. At a time when the basic sciences phase of residency is under threat, it is crucial to underscore its importance. In this issue of IMAJ, we have chosen to publish various studies that were conducted during the basic sciences phase of the residency in internal medicine, highlighting how this training period can be optimally utilized to advance research while simultaneously progressing and maturing through clinical training.

Background: Coronavirus disease 2019 (COVID-19) is a respiratory illness with broad spectrum of clinical manifestations ranging from asymptomatic cases to severe complications such as acute respiratory failure, multi-organ dysfunction, and death.

Objectives: To evaluate the platelet-lymphocyte ratio (PLR) as a marker of disease severity and mortality in COVID-19 patients. To explore the relationship between PLR and other inflammatory indicators, specifically C-reactive protein (CRP) and neutrophil-lymphocyte ratio (NLR).

Methods: The cohort included 400 patients (206 males, 194 females; mean age: 64.5 ± 17.1 years [range 20–100 years]) who were hospitalized between April 2020 and December 2021. Data were collected on demographic and clinical characteristics, including ward and critical care details. CRP, NLR, and PLR values were recorded on the first and last days of hospitalization. Patients were categorized based on their hospitalization outcomes.

Results: PLR statistically increased during hospitalization, from 245 ± 160 at admission to 341 ± 747 at discharge (P < 0.001). A significant association was found between PLR and both the length of hospital stay and mortality. The mean PLR in the deceased group was 445 ± 590, compared to 304 ± 795 in the survivors, P = 0.007. This finding showed a correlation between higher PLR and increased severity and mortality.

Conclusion: PLR has been identified as a relevant marker for assessing the severity of COVID-19. Elevated PLR levels are associated with cytokine storm, length of hospital stay, and mortality. The results highlight the relationship between elevated PLR and poor outcome in COVID‐19 patients, suggesting its use in monitoring disease progression and prognosis.

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) disease pathway is heavily influenced by different inflammatory cytokines. There is ample evidence of cannabidiol (CBD) immunomodulation effects.

Objectives: To investigate the effect of CBD on patients with SARS-CoV-2 and to measure the impact on inflammatory cytokines.

Methods: A double blind, placebo-controlled study to compare the clinical outcomes and selected serum cytokine levels in patients with SARS-CoV-2 that received sublingual CBD extraction. Seven patients were randomized to the treatment arm and three to the placebo group.

Results: Clinical outcomes were better in the patient group that received sublingual CBD vs. patients receiving placebo treatment. Serum cytokine mean concentration levels showed differences between the two groups but of mixed trends.

Conclusions: Patients presenting with SARS-CoV-2 and receiving CBD sublingually had better outcomes than those receiving a placebo, although these results did not reflect in selected serum cytokines. Further study is needed.

On 9 August 1938, prisoners from Dachau concentration camp near Munich were sent to the town of Mauthausen in Austria to begin building a new camp. The site was chosen because of the nearby granite quarry and its proximity to Linz [1,2].

Mauthausen initially served as a prison camp for common criminals, prostitutes, and other categories of incorrigible law offenders. However, on 8 May 1939, it was converted to a labor camp. Later, Mauthausen KL became a Nazi concentration camp on a hill above the market town of Mauthausen, approximately 20 kilometers from Linz. It was complemented with dozens of subcamps in the surrounding areas.

The Dina Recanati School of Medicine at Reichman University offers a unique approach to preclinical medical education, combining strong scientific foundations with practical, clinical applications. This 4-year program includes two preclinical years focused on core medical knowledge and two clinical years of rotations. The curriculum emphasizes small-group learning, early clinical exposure, and a system-based block structure. Starting from the first week of the preclinical years, students will participate in biweekly clinical days, using simulations, virtual reality, and patient interactions to develop practical clinical skills. The community clinic mentorship offers real-world experience that complements the clinical program taught in class during the same week. Research is central, with students conducting supervised projects aimed at a medical doctor thesis publication. The teaching model ensures relevance by integrating clinical cases into all courses, guided by practicing physicians. Daily quizzes and block-style assessments replace traditional examination periods, promoting consistent learning. The innovative program balances clinical practice with scientific knowledge, preparing students for the challenges of modern medicine.

Background: One of the major causes of reversible visual impairment is a refractive error, which can be corrected through refractive surgery. Data regarding the outcomes and complications of these procedures exist; however, there is a notable gap in understanding the factors leading to patient rejection, particularly in diverse populations like Israel.

Objectives: To detect clinical risk factors of patients who intend to undergo LASIK procedure and to improve the conversion rates of LASIK procedure in this population.

Methods: The study included a retrospective analysis of patients who were rejected from having refractive surgery in two Enaim Refractive Surgery Centers: Jerusalem and Tel Aviv. Comparisons between centers were conducted using the t-test for continuous variables and Fisher's exact test for categorical data.

Results: Our study included 337 patients who were rejected from having refractive surgery, including 152 (45.1%) who were rejected permanently and 185 (54.9%) rejected temporarily. The most common reasons for permanent rejection were corneal irregularity (n=81, 53.3%), keratoconus (n=27, 17.8%), thin corneas (n=13, 8.6%), and amblyopia (n=10, 6.6%). The most common temporary reasons were unstable refraction (n=96, 51.9%), prolonged use of contact lenses (n=54, 29.2%), and corneal irregularity (n=16, 8.6%).

Conclusions: The leading permanent cause of rejection for refractive surgery was a corneal irregularity, whereas the primary temporary cause was unstable refraction. In a time of rapid technological advancements and growing demand for freedom from glasses, there is an increasing need for more informed and patient-focused refractive correction approaches.

Esophageal lung is a rare congenital malformation. We present a case of a full-term infant with an esophageal lung presenting as a white lung combined with VACTERL association (vertebral defects, anal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities) and dysmorphic features. A right pneumonectomy was successfully performed.

Liver transplantation (LT) remains the only definitive treatment for most types of liver failure. However, it is considered a highly technically complex surgery performed in a critically ill patient population and is, hence, associated with significant morbidity and mortality. Peroneal neuropathy with foot drop has been intermittently reported as a complication following LT, with an incidence ranging from 1.4% to 13.3% [1-4]. This debilitating condition is characterized by an inability to lift the forefoot due to paralysis or significant weakness of the dorsiflexor muscles. While it may not appear to be a serious complication, it can significantly impair gait, increase the risk of falls, and ultimately affect ambulation and the ability to perform daily activities [5].

In this case communication, we described two cases of foot drop following LT at Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel. Our research joins a growing body of evidence and raises awareness about foot drop as an underreported yet debilitating complication. It underscores the importance of increased vigilance and describes our preventive measures adopted to reduce future incidents.