Israel Medical Association Journal

Large language models have revolutionized natural language processing. The emergence phenomenon is observed in these models and has the potential to revolutionize data processing and management. In this review, we discuss the concept of emergence in artificial intelligence, give detailed examples, and elaborate on the risks and limitations of large language models. The review exposes physicians to large language models, their advantages, and the inherent opportunities. We also describe the limitations and dangers, as these models are expected to impact medicine soon.

Background: Pulmonary aspiration is a potentially lethal perioperative complication that can be precipitated by gastric insufflation. Face mask ventilation (FMV), a ubiquitous anesthetic procedure, can cause gastric insufflation. FMV with an inspiratory pressure of 15 cm H₂O provides the best balance between adequate pulmonary ventilation and a low probability of gastric insufflation. There is no data about the effects of FMV > 120 seconds.

Objectives: To investigate the effect of prolonged FMV on gastric insufflation.

Methods: We conducted a prospective observational study at a tertiary medical center with female patients who underwent oocyte retrieval surgery under general anesthesia FMV. Pre- and postoperative gastric ultrasound examinations measured the gastric antral cross-sectional area to detect gastric insufflation. Pressure-controlled FMV with an inspiratory pressure of 15 cm H₂O was continued from the anesthesia induction until the end of the surgery.

Results: The study comprised 49 patients. Baseline preoperative gastric ultrasound demonstrated optimal and good image quality. All supine measurements were feasible. The median duration of FMV was 13 minutes (interquartile range 9–18). In the postoperative period, gastric insufflation was detected in only 2 of 49 patients (4.1%). There was no association between the duration of FMV and delta gastric antral cross-sectional area (β -0.01; 95% confidence interval -0.04 to 0.01, P = 0.31).

Conclusions: Pressure-controlled FMV with an inspiratory pressure of 15 cm H₂O carries a low incidence of gastric insufflations, not only as a bridge to a definitive airway but as an alternative ventilation method for relatively short procedures in selective populations.

Background: The management of complicated appendicitis is inconclusive. Guidelines have not been established for the use of personalized antibiotic treatment.

Objectives: To investigate specific risk factors to consider during the initial first-choice antibiotic therapy in children with complicated appendicitis.

Methods: This study included all pediatric patients younger than 18 years of age who underwent a laparoscopic appendectomy during 2012–2022 at a single tertiary medical center.

Results: In total, 300 pediatric patients underwent laparoscopic appendectomy due to complicated appendicitis. The patients were treated with ceftriaxone + metronidazole (CM). For 57 (19%) patients, the empirical treatment was changed to tazobactam/piperacillin (TP) due to resistant bacteria or clinical deterioration. The presence of generalized peritonitis during surgery and C-reactive protein (CRP) levels above 20 mg/L at admission were identified as risk factors for changing the antibiotic regimen from CM to TP.

Conclusions: Generalized peritonitis and CRP > 20 gr/L were highly correlated with changing the antibiotic regimen to TP. For such patients, initial treatment with TP may result in clinical improvement and shorter hospitalization. 

Background: Presentation of intoxicated patients to hospitals is frequent, varied, and increasing. Medical toxicology expertise could lead to important changes in diagnosis and treatment, especially in patients presenting with altered mental status.

Objectives: To describe and analyze clinical scenarios during a 1-year period after the establishment of a medical toxicology consultation service (MTCS).

Methods: Cases of 10 patients with altered mental status at presentation were evaluated. Medical toxicology consultation suggested major and significant changes in diagnosis and management.

Results: Of 973 toxicology consultations performed during the study period, bedside consultation was provided for 413 (42%) patients. Of these 413, 88 (21%) presented with some level of altered mental status. We described 10 patients in whom medical toxicology consultation brought about major and significant changes in diagnosis and management.

Conclusions: Benefits may be derived from medical toxicology consultations, especially in patients with altered mental status. Medical toxicology specialists are well positioned to provide high value and expedited patient care.

Background: Meibomian gland dysfunction (MGD) causes significant patient morbidity as well as economic burden.

Objectives: To evaluate a novel eyelid warming and a neuro-stimulating device that delivers heat via low-level infrared radiation to the eyelids of patients with MGD.

Methods: In this prospective interventional study, patients with MGD were recruited at a single medical center. The main outcome measures included changes in tear break-up time (TBUT), Schirmer’s test, and Ocular Surface Disease Index (OSDI), overall satisfaction, and corneal signs of dry eye. Patients were instructed to use the device twice daily for 5 minutes on each eye for a total of 14 days. Follow-up assessments were performed after the 2-week treatment.

Results: A total of 10 patients were included; mean age was 67 ± 16 years; six males (60%). Changes in pre- vs. post-treatment TBUT (5.0–6.11), OSDI (28.1–23.9), and Schirmer score (8.67–7.11) were not statistically significant. Over a course of 243 treatments, 131 (54%) demonstrated improvement in symptoms, 40% found no change, and 6% experienced worsening of symptoms. General satisfaction was observed overall in 80% of the patients. No adverse events were observed.

Conclusions: In this first study of a novel eyelid warming device, overall subjective satisfaction was reported in 80% of patients. Potential advantages of this user-friendly device include its ability to improve MGD and tear film stability, as well as symptomatic relief, while allowing the user to continue with normal daily functioning while undergoing treatment.

Gastric perforation secondary to foreign body ingestion is rare. While obvious signs of acute abdomen usually lead to a prompt diagnosis by emergency department (ED) staff, this can be delayed in non-responsive or mentally disabled patients. An altered pain perception has been described in schizophrenia, as part of a complex phenomenon, which is thought to be unrelated to changes in nociceptive pathways. Cognitive impairment and negative symptoms may strongly influence the patient’s expression of pain [1].

In this study, we analyzed computed tomography (CT) radiological findings from trauma treated at a single hospital in the aftermath of the terror attack in Israel on 7 October 2023. The study includes images from 34 consecutive patients, consisting of 33 males and 1 female, ranging in age from 19 to 68 years. The majority of these patients underwent both chest-abdominal-pelvic (76%) and head and neck CT scans (64.7%). Key findings highlight a high incidence of head and neck injuries (55.9%), chest trauma (44.1%), and various injuries such as soft tissue lacerations (100%), fractures particularly skull fractures at 32.4%, and brain hemorrhages (23.5%). The limitations of this study include its single-center scope and the focus on stable patients, which may bias the representation of injury types. This case series provides critical insights into the radiological impacts of large-scale terror events, emphasizing the importance of comprehensive preparedness and research in the field of mass-casualty incident response.

The ancient, Biblical, holy Ten Commandments were presented to humanity to serve as guidelines for relationships between individuals and the deity they worship as well as a benchmark for living in civilized communities, irrespective of religious affiliation. The commandments are also embedded in medical education taught to medical students and other health professions throughout the world. Thus, the Ten Commandments are embedded in the medical communications curriculum at Adelson School of Medicine, Ariel University, Ariel, Israel. Unfortunately, most of these commandments were desecrated during the violent, hostile, merciless, and ruthless attack inflicted by the Hamas terror organization on villages, rural communities, and cities in southern Israel on 7 October 2023. We define the Ten Commandments in terms of medical education and describe their desecration by Hamas terrorists before and during the Iron Swords war.

Celiac disease (CD) is an immune-based reaction to dietary gluten. CD can present with a diverse array of symptoms. Many CD patients have no symptoms at all. Thus, a great number of atypical cases of CD remain undiagnosed, leading to a risk of long-term complications. Some atypical symptoms of CD such as pregnancy complications, infertility, recurrent abortions, intrauterine growth restriction, preterm delivery, and severe preeclampsia have been investigated in undiagnosed and diagnosed pregnant women with CD. Nutrient deficiency and autoimmune pathogenic mechanisms have been hypothesized to be the explanation of these adverse pregnancy outcomes. Recently, an association between obstetric complications and anti-tissue transglutaminase antibodies titers in women with CD has been reported. While the adverse effects of CD on the reproductive system are well investigated, there are only a few reports in the literature on the effect of pregnancy and puerperium on CD. We reviewed the published literature on the adverse effects and pathophysiology of CD in reproductive disorders and the effect of pregnancy and puerperium on the manifestation of CD.

Anti-tumor necrosis factor-alpha (anti-TNFα) medications are the most frequently used biologicals to treat inflammatory bowel disease (IBD). Little is known about the ocular side effects of this drug category. We present a case series of six young patients with Crohn disease (CD) and no previous ophthalmologic manifestations who developed blepharitis after commencing treatment with anti-TNFα therapy. Six otherwise healthy patients with CD, with no history of allergies or prior ocular complaints, developed blepharitis at a median of 7.5 months after the initiation of anti-TNFα therapy. All ophthalmic findings were treated topically. The ocular symptoms of two of the patients resolved shortly after discontinuation of the anti-TNFα treatment. The other four presented with relapsing-remitting symptoms. Blepharitis is a common ocular disease in the general population and an extra-intestinal manifestation in patients with IBD. It may be an adverse effect of anti-TNFα therapy in this patient population.

Background: In recent years, major progress has been made in treating the wet form of age-related macular degeneration (AMD) with anti-vascular endothelial growth factors, which reportedly stabilize and improve vision.

Objectives: To examine the effect of dietary supplementation, as recommended by the Age-Related Eye Disease Study 2 (AREDS2), on the number of anti-vascular endothelial growth factor injections administered to patients with wet AMD.

Methods: A retrospective study was conducted with 57 participants (27 participants in the study group and 30 in the control group) receiving injections of anti-vascular endothelial growth factors. The study group received dietary supplements for at least one year before the treatment was initiated, while the control group did not. Primary outcome was the number of injections a patient received over a 3-year period. Secondary outcomes were central macular thickness and visual acuity.

Results: The average number of injections per patient after 3 years was 21.89 ± 7.85 in the study group and 26.00 ± 5.62 in the control group (P = 0.083). Final visual acuities were 0.45 ± 0.45 and 0.8 ± 0.73 (P = 0.09), and final central macular thicknesses were 288.26 ± 55.38 and 313.12 ± 107.36 (P = 0.38) in the study and control groups, respectively.

Conclusions: The average number of injections after 3 years was lower in the study group, but this difference did not reach statistical significance. No statistically significant difference was found in final visual acuity or central macular thickness between the groups.

Background: Fetal facial clefts are among the most common congenital anomalies detected prenatally. This finding may lead to termination of pregnancy in some cases.

Objectives: To compare a cohort of fetuses with facial clefts in which the pregnancy was terminated to the cohort of cases that were born with facial clefts. To investigate risk factors for facial clefts.

Methods: We conducted a retrospective chart review of all women with prenatal and postnatal diagnosis of facial cleft that were managed in our institute. A telephone questionnaire was conducted regarding a positive family history and/or genetic predisposition for facial clefts abnormalities.

Results: The final cohort consisted of two group. One group included 54 cases of termination of pregnancy (TOP) that were performed due to cleft lip (CL) or cleft palate (CLP); 27 women answered the telephone questionnaire. The second group comprised 99 women who delivered children with facial cleft during the same period; 60 answered the questionnaire. Only seven cases were diagnosed prenatal. Among the two groups, no correlation to family history was discovered. Of note, there was one case of three consecutive fetuses with CL in one woman, without any significant genetic findings.

Conclusions: To the best of our knowledge, this is the first study to describe an anatomical malformation posing an ethical dilemma before TOP. Primary prevention with folic acid and early sonographic detection of CL/CLP with multidisciplinary consultation should be considered.

Infectious endocarditis (IE) remains challenging to treat, with substantial morbidity and mortality rates. Antibiotics are the mainstay of treatment; however, patients with large vegetations often do not respond to antibiotics. Moreover, large vegetations carry an increased risk of embolization. In such cases, guidelines recommend considering surgical treatment [1]. Surgery itself introduces potential complications and high mortality rates [2], and if performed during active infection, the technical possibilities are hindered by a catastrophic recurrence on prosthetic material. Emerging percutaneous solutions to large IE vegetations have been described in recent years to overcome the surgical limitations. Currently, several devices are available. The different debulking mechanisms are based on percutaneous mechanical, either motor or manual aspiration. While becoming more available, percutaneous treatment options are not mentioned in guidelines and data are limited. This report describes a case of percutaneous tricuspid valve (TV) vegetation aspiration using Inari Flowtriever (Inari Medical, Irvine, CA, USA). The case is followed by a review of the literature.

Patients with severe ischemic and hemorrhagic stroke may require invasive mechanical ventilation due to loss of consciousness and increased risk for aspiration pneumonia secondary to new onset dysphagia. Ventilation may also confer airway protection until the patient stabilizes [1]. Mechanically intubated stroke patients who are admitted to the intensive care unit (ICU) have a poor prognosis and a 40–80 % mortality rate [2]. Proceeding to tracheostomy is mandatory in stroke patients to ease the procedure of respiratory weaning and extubation [1]. In the stroke ICU, between 15% and 35% of the mechanically intubated patients cannot proceed to tracheostomy due to weaning and extubation failure [3].

A 52-year-old man with a history of gout presented to the emergency department with painful purulent ulcers on the left index finger. Serum C-reactive protein was elevated to 112 mg/L. Hand radiographs [Figure 1A] demonstrated almost complete osteolysis of the two distal phalanges of the involved finger (asterisk), with multiple typical gouty erosions with sclerotic margins and overhanging edges in a marginal and juxta-articular distribution (white arrows), and soft tissue tophi (black arrows). Osteomyelitis of the index finger was suspected, and the finger was amputated.