Israel Medical Association Journal

Twenty-five years ago, we, the undersigned together with the chairman of the Israel Medical Association at the time, Prof. Yoram Blachar, and the Secretary General of the Israel Medical Association, Adv. Leah Wapner, joined forces to found an Israeli medical journal in English. The purpose of this journal was to present to the world Israeli clinical medicine and medical research. That journal is none other than the Israel Medical Association Journal (IMAJ), and in 2023 its 300th issue was published. In 2024 we keep going, taking pride in the fact that every one of those past 300 issues has been published and dispatched on time, without delay, regardless of any circumstances.

9 November 2023: Just one month after the tragic events of 7 October 2023, 240 individuals are still held hostage, ensnared by Hamas. Their medical plight is shrouded in silence. In the heart of Tel Aviv, a sea of health professionals gathers before the International Committee of the Red Cross (ICRC) offices pleading for decisive action. Among the medical pleas for help is the haunting image of a young soldier in dire need of his inhaler [Figure 1]. Ron needs it to live. I, a pediatric pulmonologist intimately familiar with respiratory distress, captured that moment.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused significant global turmoil, including changes in social and societal conduct such as lockdowns, social isolation, and extensive regulations. These changes can be major sources of stress. The first wave of the pandemic (April–May 2020) was a time of global uncertainty. We evaluated symptom severity among 29 Israeli children and adolescents with obsessive-compulsive disorder (OCD). Our previous study found that most of these participants did not experience an exacerbation of symptoms.

Objective: To re-evaluate the OCD symptoms of 18 participants from the original group of 29 children and adolescents during three time points: before the pandemic, during the first wave, and 2 years later.

Methods: Obsessive-compulsive symptoms (OCS) were assessed using the Clinical Global Impression Scale (CGI), a functional questionnaire, and the Obsessive-Compulsive Inventory-child version (OCI-CV).

Results: OCS in patients did not change significantly during the three time points. Participants reported minimal changes in their general functioning 2 years after the outbreak of COVID-19 and showed minimal change in OCI-CV scale scores.

Conclusions: Our results indicated clinical stability of OCD symptoms among most of the participants.

Background: Pregnant women are at higher risk for severe coronavirus disease 2019 (COVID-19). Since the release of the BNT162b2 messenger RNA vaccine (Pfizer/BioNTech), there has been accumulated data about the three vaccine doses. However, information regarding obstetric and neonatal outcomes of pregnant women vaccinated with the third (booster) vaccine is limited and primarily retrospective.

Objectives: To evaluate the obstetric and early neonatal outcomes of pregnant women vaccinated during pregnancy with the COVID-19 booster vaccine compared to pregnant women vaccinated only by the first two doses.

Methods: We conducted a cross-sectional study of pregnant women who received the BNT162b2 vaccine during pregnancy. Obstetric and neonatal outcomes were compared between pregnant women who received only the first two doses of the vaccine to those who also received the booster dose.

Results: Overall, 139 pregnant women were vaccinated during pregnancy with the first two doses of the vaccine and 84 with the third dose. The third dose group received the vaccine earlier during their pregnancy compared to the two doses group (21² vs. 31⁵ weeks, respectively, P < 0.001). No differences in obstetric and early neonatal outcomes between the groups were found except for lower rates of urgent cesarean delivery in the third dose group (adjusted odds ratio 0.21; 95% confidence interval 0.048–0.926, P = 0.039).

Conclusions: Compared to the first two doses of the BNT162b2 vaccine given in pregnancy, the booster vaccination is safe and not associated with an increased rate of adverse obstetric and early neonatal outcomes.

Background: There are conflicting data on the significance of hyperuricemia or hyperuricosuria in urolithiasis formation and on the need for medical treatment.

Objectives: To assess the significance of hyperuricemia or hyperuricosuria in urolithiasis formation, particularly when hyperuricemia occurs with normal uricosuria.

Methods: The electronic medical records of patients treated in Haifa and the Western Galilee district of Clalit Health Services, Israel, were retrospectively screened for diagnosis of nephrolithiasis or renal or urinary tract/bladder calculi between February 2014 and April 2019. The diagnosis was confirmed by ultrasonography or computed tomography. The study group included patients with one of these diagnoses. Patients in the control group did not have these diagnoses. The inclusion criterion for all patients was the presence of both serum and urinary uric acid levels.

Results: The study group included 359 patients and the control group 267. After adjustment by logistic regression, we found no significant differences in the prevalence of hyperuricosuria in the study group (14.8%) compared to the control group (9.7%), odds ratio (OR) 1.54 (95% confidence interval [95%CI] 0.74–3.2, P = 0.245). No significant differences between the groups were observed for hyperuricemia prevalence (45.4% vs. 55.1%, respectively, OR 0.82, 95%CI 0.54–1.25, P = 0.355), nor among those without hyperuricosuria (OR 0.83, 95%CI 0.52–1.33, P = 0.438) and after propensity score matching (OR 0.93, 95%CI 0.66–1.3, P = 0.655).

Conclusions: There were no significant differences in hyperuricemia or hyperuricosuria between the two groups of patients or in hyperuricemia among participants without hyperuricosuria.

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: Laryngopharyngeal reflux (LPR) refers to the backflow of acidic stomach content into the larynx, pharynx, and upper aerodigestive tract. The diagnosis of LPR is based on the patient's history and findings of the laryngoscopy associated with LPR. Other possible manifestations consistent with LPR symptoms include laryngeal cancer, vocal fold granulomas, Reinke's space edema, and vocal polyps. In this study, we compared the characteristics of patients with LPR symptoms and incidental laryngeal findings (ILF) in the laryngoscopic evaluation to those without ILF (WILF).

Objectives: Determine the characteristics of LPR-symptomatic patients with ILF versus WILF.

Methods: In this retrospective study, we examined 160 medical charts from patients referred to the otolaryngology clinic at Galilee Medical Center for LPR evaluation 2016–2018. The reflux symptoms index (RSI), reflux finding score (RFS), and demographics of the patient were collected. All patients with a positive RSI score for LPR (RSI > 9) were included, and the profiles of patients with versus without ILF on laryngoscopy examination were compared.

Results: Of the 160 patients, 20 (12.5%) had ILF during laryngoscopy. Most had vocal cord findings such as leukoplakia (20%), polyps (15%), and nodules (20%). Hoarseness, throat clearing, swallowing difficulty, breathing difficulties, and total RSI score were significantly higher in patients with ILF.

Conclusions: Evaluation of LPR symptoms may provide otolaryngologists with a tool to identify patients with other findings on fiberoptic laryngoscopy. A laryngoscopic examination should be part of the examination of every patient with LPR to enable diagnosis of incidental findings.

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.

Paraneoplastic syndromes are reported in 8–15% of patients diagnosed with cancer [1]. They are defined as syndromes that occur due to an underlying malignancy, which has yet to be diagnosed, or at the time of the diagnosis and less frequently following the diagnosis of a malignancy. Several mechanisms are involved including autocrine and paracrine mediators, hormones, peptides, cytotoxic lymphocytes, and cytokines [1,2].

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].

Illicit drug abuse is a widespread medical problem with numerous sequelae. One of the major challenges in reaching a diagnosis is the difficulty in obtaining accurate details during the medical interview. We describe a patient who initially denied drug abuse while presenting a bizarre nasopharyngeal disease secondary to inhalation of oxycodone-acetaminophen powder.

The cause of death for Pharaoh Tutankhamun (ca. 1330–1324 BCE) is still unknown despite the advancement in modern paleopathology and the introduction of computed tomography mummy examination and modern molecular pathology, including PCR-based gene analysis. Many speculations regarding his unexpected death have been published, including crush injury, infectious diseases such as malaria, and hereditary disease. We discuss for the first time all these events that could have ultimately caused Tutankhamun's sudden death, particularly sickle cell disease, which can cause osteonecrosis and lead to walking disability, bone deformities, and fragility. Malaria-associated tropical splenomegaly, as an acquired infectious disease, and the crush injury, which represents an acute event, were verified by a left distal femur fracture that contributed to splenic rupture as a major fatal event. We highlight important issues that can provide clinicians and clinical care practitioners with a broad vision while analyzing such cases.

A dramatic portrait bust of the physician Gabriele da Fonseca (1586? to 1668) at prayer is considered by art historians to be one of the finest late works of Gian Lorenzo Bernini (1598–1680), the preeminent sculptor of 17th century Rome. This statue is of medical as well as artistic interest. First, Fonseca is shown wearing his physician’s robe, thus celebrating his successful career as a leading medical figure in Rome, holding both Papal and university appointments at the highest level. In addition, the positioning of the statue in a special chapel designed by Bernini highlights Fonseca’s role as an influential participant in the introduction of quinine into Europe as a cure for malaria. Last, an examination of the statue’s hands identifies a number of pathologies and anatomical anomalies that raise interesting questions, regrettably unanswerable given the information presently available, concerning Fonseca’s illnesses and cause of death.