Barzilai University Medical Center, Ashqelon

Study Objective The study examined a training program for integrative medicine (IM) providers, teaching clinical skills for treating acute stress disorder (ASD). Methods A 10‐h online training program, designed by IM and mental health professionals, was attended by a group of 32 IM providers working in supportive and palliative oncology care. Pre‐ and post‐course questionnaires assessed self‐perceived levels of IM and mental health ASD‐related skills (from 1, very low; to 7, very high). Results Most participants (25; 78%) completed pre‐ and post‐study questionnaires, which showed an increase in post‐course scores for the expectation that IM could reduce ASD‐related pain ( p = 0.004). Scores for self‐assessed skill levels increased for treating gastro‐intestinal symptoms and appetite ( p = 0.039) and for dyspnea ( p = 0.048). A borderline increase for arousal was observed ( p = 0.063), with no increase with other arousal symptom cluster symptoms. Conclusions The ASD‐focused training program for IM practitioners was associated with an increase in self‐perceived levels for related clinical skills quality of life‐related concerns, primarily pain, appetite and dyspnea. Further research is needed to better understand the implications of the findings, and to explore the implementation of the learned skills in clinical practice.

Background Considering the global shortage of nurses, leaders in the field must understand the strengths and weaknesses of various nursing specialties in order to retain professionals within the field. Occupational prestige reflects the perceived contribution of an occupation ‘to society’, and measures its desirability, benefit and values. Understanding how experienced nurses view the prestige of nursing specialties may help to explain why some specialties are more desirable than others. We conducted a cross-sectional study to examine the prestige of nursing specialties among nurses taking post-graduate in-training courses. Methods The study questionnaire examined nurses’ perceived prestige of nine nursing specialties, the perceived extent of autonomy and authority, the unique knowledge and clinical skills required for each specialty, and participants' demographic and professional characteristics. Results A total of 101 nurses (90% females, mean age 35.4 ± 9.39 years) completed the questionnaire. Intensive care (4.67 ± 0.59) and neonatal intensive care (4.57 ± 0.74) were perceived as having the highest prestige, whereas physical activity consultation (2.67 ± 0.98) and sleep consultation (2.71 ± 0.92) were perceived as having the lowest prestige. These specialties were also perceived as requiring the most and least unique knowledge and clinical skills, respectively. In contrast, authority and autonomy were ranked highest in breastfeeding consultation (4.50 ± 0.81), followed by intensive care (4.10 ± 0.87), while congestive heart failure received the lowest score (3.48 ± 0.84). Principal component analysis showed that higher prestige is attributed to acute care specialties, while chronic care specialties or ones involving consultation have lower prestige. Conclusions Nursing specialties with lower scores should be rebranded to encourage nurses to enter these fields.

Background Giant cell tumor of bone (GCTB) is a locally aggressive tumor that may affect the bones of the hand and rarely causes pulmonary metastasis. It exhibits a variable recurrence rate after surgical interventions, which presents challenges in its management. This systematic review aims to delineate recurrence rates and identify risk factors for GCTB in the hand. Methods We conducted a systematic literature search in April 2024, following PRISMA guidelines, on PubMed and TDNet for studies reporting postsurgical recurrence of GCTB in the hand. Cohort and case-control studies provided recurrence rates, whereas case reports and series were utilized to identify risk factors, compensating for the sparse data in the primary studies. We used descriptive statistics, χ ² tests, and logistic regression to analyze demographics, lesion characteristics, treatments, and outcomes. Results We reviewed 13 cohort and case-control studies involving 244 patients, finding an overall recurrence rate of 19.57%. Curettage was associated with higher recurrence rates compared with other surgical methods. After additional review of case reports, a limited range of motion in patients emerged as a significant protective factor against recurrence, suggesting potential benefits in surgical management and outcome prediction. Conclusions The significant recurrence rate associated with curettage highlights the need for alternative surgical strategies in GCTB management of the hand. The protective role of limited ROM underscores the importance of thorough preoperative assessments to optimize surgical approaches and enhance patient outcomes.

Background Hereditary angioedema (HAE) is a chronic, unpredictable disease. Long‐term prophylactic treatments that offer durable efficacy, safety, and convenience are required to assist patients in achieving complete disease control, per international guidelines. We report an interim analysis of an ongoing phase 3 (VANGUARD) open‐label extension (OLE) study evaluating the long‐term safety and efficacy of garadacimab for HAE prophylaxis. Methods Adults and adolescents aged ≥12 years with HAE previously participating in phase 2 and pivotal phase 3 (VANGUARD) studies were rolled over to an OLE, alongside newly enrolled patients. Patients received garadacimab 200 mg subcutaneously, once monthly for ≥12 months. The primary endpoint was treatment‐emergent adverse events (TEAEs) in patients with C1 inhibitor deficiency/dysfunction. Results At data cut‐off (February 13, 2023; N = 161), median (interquartile range) exposure was 13.8 months (11.9–16.3). For the primary endpoint, 133/159 patients experienced ≥1 TEAE (524 events), equivalent to 0.23 events/administration and 2.84 events/patient‐year. Garadacimab‐related TEAEs (13% of patients, 52 events) were most commonly injection‐site reactions (ISRs). No deaths occurred. One patient discontinued treatment due to garadacimab‐related moderate ISR. Most TEAEs were mild/moderate; three events were serious (COVID‐19, two events; abdominal HAE attack, one event) and not garadacimab related. No abnormal bleeding, thromboembolic, severe hypersensitivity, or anaphylactic events were observed. Mean HAE attack rate decreased by 95% from the run‐in period; 60% of patients were attack‐free. Almost all patients (93%) rated their response to garadacimab as “good” or “excellent.” Conclusion Garadacimab has a favorable safety profile suitable for long‐term use and provides durable protection against HAE attacks.

The tubulointerstitial compartment comprises most of the kidney parenchyma. Inflammation in this compartment (tubulointerstitial nephritis-TIN) can be acute and resolves if the offending factor is withdrawn or may enter a chronic process leading to irreversible kidney damage. Etiologic factors differ, including different exposures, infections, and autoimmune and genetic tendency, and the initial damage can be acute, recurrent, or permanent, determining whether the acute inflammatory process will lead to complete healing or to a chronic course of inflammation leading to fibrosis. Clinical and laboratory findings of TIN are often nonspecific, which may lead to delayed diagnosis and a poorer clinical outcome. We provide a general review of TIN, with special mention of the molecular pathophysiological mechanisms of the associated kidney damage.

Purpose To compare laser-assisted in situ keratomileusis (LASIK) outcomes in patients with different corneal curvatures. Methods This is a retrospective comparative chart review. Patients included in this study underwent wavefront-optimized myopic LASIK between January 2013 and December 2022 at Care-Vision Laser Center, Tel-Aviv, Israel. Patients were divided into 3 groups based on the steepness of the cornea (steep keratometry) (flat: <42 diopters [D], normal: 42–46 D, and steep: >46 D). Case-by-case matching was performed to verify that baseline parameters (age, preoperative visual acuity, and refractive error) were similar between groups. Primary outcome measures were postoperative corrected/uncorrected distance visual acuity, efficacy index, safety index, spherical equivalence, and astigmatism. Results After matching, 300 eyes were included in each group, which were similar in baseline parameters. There were no significant postoperative differences between flat, normal, and steep corneas regarding safety index (1.01 vs. 1.02 vs. 1.01, P = 0.95), efficacy index (1.03 vs. 1.02 vs. 1.02, P = 0.94), logarithm of the minimum angle of resolution corrected distance visual acuity (0.01 vs. 0.01 vs. 0.01, P = 0.17), logarithm of the minimum angle of resolution uncorrected distance visual acuity (0.02 vs. 0.03 vs. 0.02, P = 0.65), proportion of patients with spherical equivalence within 0.50 D (73.0% vs. 73.7% vs. 69.3%, P = 0.45) or 1.00 D (93.3% vs. 94.7% vs. 91.7%, P = 0.34) of the target, and proportion of patients with astigmatism within 0.50 D (86.7% vs. 82.3% vs. 80.3%, P = 0.11) or 1.00 D (98.7% vs. 98.7% vs. 99.0%, P = 0.91) of the target. Longer term follow-up of a smaller set of patients revealed similar results. Conclusions No significant differences were found between flat, normal, and steep corneas following wavefront-optimized myopic LASIK. Thus, this procedure may be safely and effectively performed across a wide range of corneal curvatures.

Lung involvement in children with congenital cytomegalovirus infection has been scarcely described. We describe three new cases of persistent pulmonary hypertension in children with congenital cytomegalovirus and review the other seven cases reported in the literature since 1988. All children had a symptomatic infection, including severe central nervous system or visceral findings. Morbidity and mortality were high. Persistent pulmonary hypertension may be a rare complication in severely symptomatic congenital cytomegalovirus infants. It is important to screen for congenital cytomegalovirus in cases of idiopathic refractory persistent pulmonary hypertension. Intensive treatment should be undertaken to treat this potentially rare lung involvement in combination with antiviral treatment.

Endometriosis is a chronic gynecological disorder affecting millions of women worldwide, causing chronic pelvic pain, dyspareunia, dysmenorrhea, and infertility, and severely impacting their quality of life. Treatment primarily involves hormonal therapies and surgical excision, but high recurrence rates and the economic burden are substantial. With these challenges, significant discussion surrounds the potential role of dietary patterns in managing endometriosis, making it necessary to bridge this critical gap. This review investigates the current scientific evidence on the dietary patterns (eg, Mediterranean, vegetarian, anti-inflammatory, low-fermentable oligosaccharides, disaccharides, monosaccharides, and polyols [low-FODMAP], and Western-style diets) associated with endometriosis and provides a concise, yet thorough, overview on the subject. In addition, antioxidants, microbiota, and artificial intelligence (AI) and their potential roles were also evaluated as future directions. An electronic-based search was performed in MEDLINE, Embase, Cochrane Library, CINAHL, ClinicalTrials.gov, Scopus, and Web of Science. The current data on the topic indicate that a diet based on the Mediterranean and anti-inflammatory diet pattern, rich in dietary fiber, omega-3 fatty acids, plant-based protein, and vitamins and minerals, has a positive influence on endometriosis, yielding a promising improvement in patient symptoms. Preclinical investigations and clinical trials indicate that dietary antioxidants and gut microbiota modulation present potential new approaches in managing endometriosis. Also, AI may offer a promising avenue to explore how dietary components interact with endometriosis. Ultimately, considering genetic and lifestyle factors, a healthy, balanced, personalized approach to diet may offer valuable insights on the role of diet as a means of symptom improvement, facilitating the utilization of nutrition for the management of endometriosis.

Lumbar puncture opening pressure (LPOP) exceeding 250mmH2O is key in diagnosing idiopathic intracranial hypertension (IIH), per revised Friedman’s criteria. Some patients do not meet LPOP criteria (with or without papilledema), despite having IIH-related symptoms and neuroimaging findings. This study aimed to investigate the radiological findings and clinical symptoms in patients suspected of having IIH without meeting the LPOP criteria. We retrospectively evaluated cerebral venous sinus stenosis using the conduit Farb score (CFS) and other radiological findings suggestive of IIH by computed tomography venography and magnetic resonance venography in females ≥ 18 years-old with chronic headaches, suspected IIH, and LPOP < 250 mm. Eighty-eight women (56 with LPOP < 200 mm H2O and 32 with LPOP ranging between 200 and 250mmH2O) were included. Among patients with LPOP 200–250mmH2O, 40% (12) exhibited three or more radiological findings supporting IIH, compared to 17% (8) in the LPOP < 200 mmH2O group (p = 0.048). Cerebral venous stenosis (CFS ≤ 5) was observed in 80% (24) of those with LPOP 200–250 mmH2O, contrasting with 40% (19) of those with LPOP < 200 mmH2O (p < 0.001). Cerebral venous stenosis was significantly more common in patients with LPOP 200–250 mmH2O than < 200 mmH2O, suggesting that they may benefit from IIH treatment.

Introduction: Convolutional Neural Network (CNN) systems in healthcare are influenced by unbalanced datasets and varying sizes. This article delves into the impact of dataset size, class imbalance, and their interplay on CNN systems, focusing on the size of the training set versus imbalance—a unique perspective compared to the prevailing literature. Furthermore, it addresses scenarios with more than two classification groups, often overlooked but prevalent in practical settings. Methods: Initially, a CNN was developed to classify lung diseases using X-ray images, distinguishing between healthy individuals and COVID-19 patients. Later, the model was expanded to include pneumonia patients. To evaluate performance, numerous experiments were conducted with varied data sizes and imbalance ratios for both binary and ternary classifications, measuring various indices to validate the model’s efficacy. Results: The study revealed that increasing dataset size positively impacts CNN performance, but this improvement saturates beyond a certain size. A novel finding is that the data balance ratio influences performance more significantly than dataset size. The behavior of three-class classification mirrored that of binary classification, underscoring the importance of balanced datasets for accurate classification. Conclusions: This study emphasizes the fact that achieving balanced representation in datasets is crucial for optimal CNN performance in healthcare, challenging the conventional focus on dataset size. Balanced datasets improve classification accuracy, both in two-class and three-class scenarios, highlighting the need for data-balancing techniques to improve model reliability and effectiveness. Motivation: Our study is motivated by a scenario with 100 patient samples, offering two options: a balanced dataset with 200 samples and an unbalanced dataset with 500 samples (400 healthy individuals). We aim to provide insights into the optimal choice based on the interplay between dataset size and imbalance, enriching the discourse for stakeholders interested in achieving optimal model performance. Limitations: Recognizing a single model’s generalizability limitations, we assert that further studies on diverse datasets are needed.

Background: An unannounced balance loss during walking, i.e., balance perturbation, is a stressful event that changes the activity of the Sympathetic Nervous System (SNS). We examined SNS response to unannounced balance perturbation during walking, simulating real-life conditions of balance loss. Research question: Do laboratory-induced unannounced balance losses during walking cause a sympathetic response, and if so - does it habituate after a series of perturbations? Methods: 34 young adults underwent a series of six successive unannounced balance perturbations while walking on a treadmill. Sympathetic activity was monitored continuously using Electrodermal Activity and compared before and immediately after each unannounced perturbation. Results: All perturbations elicited a significant increase in Electrodermal Activity (p<0.001), indicating a phasic increase in the sympathetic drive. The relative phasic increase of Electrodermal Activity caused by the first perturbation was significantly higher than the last perturbation (p<0.05). Three types of Electrodermal Activity behavior were observed: Steady level tonic SNS activity, increased SNS activity, and decreased SNS activity. Significance: Balance loss during walking triggers phasic SNS response, this response habituates after a series of unannounced balance perturbations. In addition, three distinct patterns of tonic sympathetic activity may imply variations in the ability of the SNS response to habituate across individuals.

Estimates of the spectrum and frequency of pathogenic variants in Parkinson’s disease (PD) in different populations are currently limited and biased. Furthermore, although therapeutic modification of several genetic targets has reached the clinical trial stage, a major obstacle in conducting these trials is that PD patients are largely unaware of their genetic status and, therefore, cannot be recruited. Expanding the number of investigated PD-related genes and including genes related to disorders with overlapping clinical features in large, well-phenotyped PD patient groups is a prerequisite for capturing the full variant spectrum underlying PD and for stratifying and prioritizing patients for gene-targeted clinical trials. The Rostock Parkinson’s disease (ROPAD) study is an observational clinical study aiming to determine the frequency and spectrum of genetic variants contributing to PD in a large international cohort. We investigated variants in 50 genes with either an established relevance for PD or possible phenotypic overlap in a group of 12 580 PD patients from 16 countries [62.3% male; 92.0% White; 27.0% positive family history (FH+), median age at onset (AAO) 59 years] using a next-generation sequencing panel. Altogether, in 1864 (14.8%) ROPAD participants (58.1% male; 91.0% White, 35.5% FH+, median AAO 55 years), a PD-relevant genetic test (PDGT) was positive based on GBA1 risk variants (10.4%) or pathogenic/likely pathogenic variants in LRRK2 (2.9%), PRKN (0.9%), SNCA (0.2%) or PINK1 (0.1%) or a combination of two genetic findings in two genes (∼0.2%). Of note, the adjusted positive PDGT fraction, i.e. the fraction of positive PDGTs per country weighted by the fraction of the population of the world that they represent, was 14.5%. Positive PDGTs were identified in 19.9% of patients with an AAO ≤ 50 years, in 19.5% of patients with FH+ and in 26.9% with an AAO ≤ 50 years and FH+. In comparison to the idiopathic PD group (6846 patients with benign variants), the positive PDGT group had a significantly lower AAO (4 years, P = 9 × 10⁻³⁴). The probability of a positive PDGT decreased by 3% with every additional AAO year (P = 1 × 10⁻³⁵). Female patients were 22% more likely to have a positive PDGT (P = 3 × 10⁻⁴), and for individuals with FH+ this likelihood was 55% higher (P = 1 × 10⁻¹⁴). About 0.8% of the ROPAD participants had positive genetic testing findings in parkinsonism-, dystonia/dyskinesia- or dementia-related genes. In the emerging era of gene-targeted PD clinical trials, our finding that ∼15% of patients harbour potentially actionable genetic variants offers an important prospect to affected individuals and their families and underlines the need for genetic testing in PD patients. Thus, the insights from the ROPAD study allow for data-driven, differential genetic counselling across the spectrum of different AAOs and family histories and promote a possible policy change in the application of genetic testing as a routine part of patient evaluation and care in PD.

Introduction Orthogeriatric patients with femur fractures, despite their multiple comorbidities and associated healthcare costs, have a promising new approach. This approach suggests that most patients should be hospitalized in the geriatric department, with daily orthopedic follow-up. The potential for lower mortality rates through orthogeriatric co-management and dual care is a reason for hope in our field. Methods This study is retrospective and involved 285 patients with proximal hip fractures. Two treatment models were compared: hospitalization in orthopedic and geriatric departments with different treatment protocols. The study analyzed demographic data and postoperative outcomes. It also included an analysis of 26 patients who received conservative treatment. Results Our study revealed significant differences between patients hospitalized in the orthopedic and geriatric departments. Geriatric department patients, who were significantly older and had higher comorbidities, experienced extended hospitalization and higher mortality rates during hospitalization, at 30 days, and at one-year follow-up (p<0.05). Notably, a significantly higher proportion of geriatric patients were discharged to home rehabilitation at the end of hospitalization compared to orthopedic patients (17.5% vs. 7.4%; p<0.01). Among non-operated patients, the mortality rate was 57.7% compared to 16.5% in patients who underwent surgery during the one-year follow-up. Discussion Our study suggests that elderly patients with hip fractures may benefit from management in the geriatric department. Despite experiencing significantly longer hospital stays, these patients have a higher likelihood of being discharged home compared to those managed in the orthopedic department. These findings have important implications for the care of orthogeriatric patients and may help guide future treatment strategies.

Background Providing emergency care during conflict poses unique challenges for frontline hospitals. Barzilai Medical Center (BUMCA) in Ashkelon, Israel is a Level I trauma center located close to the Gaza border. During the November 2023 escalation of conflict, BUMCA experienced surging numbers of civilian and military trauma patients while also coming under rocket fire. Methods We conducted a retrospective review of BUMCA operational records and 827 de-identified patient records from October 7–14, 2023. Records provided data on daily patient volumes, injury patterns, resource constraints, and impacts of rocket attacks on hospital function. Basic demographic data was obtained including age, gender, injury severity scores, and disposition. Results Of the 827 patients brought to BUMCA, most (n = 812, 98.2%) presented through the emergency department. Tragically, 99 individuals were pronounced dead on arrival. Injury severity assessments found nearly half (47%) had minor injuries such as lacerations, contusions and sprains, while 25% exhibited moderate injuries like deep lacerations and fractures. 15% sustained severe or critical injuries including severe head injuries. The largest age group consisted of adults aged 19–60 years. No pediatric patients were admitted despite proximity to residential neighborhoods. The majority of cases (61%) involved complex polytrauma affecting multiple body regions. BUMCA served as both the primary treatment facility and a triage hub, coordinating secondary transports to other trauma centers as needed. Patient volumes fluctuated unpredictably from 30 to an overwhelming 125 daily, straining emergency services. Resources faced shortages of beds, medical staff, supplies and disruptions to power from nearby missile impacts further challenging care delivery. Conclusion Despite facing surging demand, unpredictable conditions and external threats, BUMCA demonstrated resilience in maintaining emergency trauma services through an adaptive triage approach and rapid surges in capacity. Their experience provides insights for improving frontline hospital preparedness and continuity of care during conflict through advance contingency planning and surge protocols. Analysis of patient outcomes found a mortality rate of 15% given the complex, multi-region injuries sustained by many patients. This study highlights the challenges faced and strengths exhibited by medical professionals operating under hazardous conditions in minimizing loss of life. Patient and public involvement in research Given that the study analyzed patient data from a hospital treating casualties of an ongoing armed conflict, directly engaging patients or the public during the sensitive research process could have posed risks. The volatile security situation and restrictions and protections in place amidst the crisis made it not feasible or appropriate to involve them in the study’s design, methods, reporting of results, or dissemination plans. Our aim was to conduct this retrospective analysis in a way that did not endanger those affected or compromise the hospital’s emergency response operations.

Granular cell tumor (GCT), a rare Schwann cell–derived lesion, typically manifests as a benign skin or soft tissue growth. We report a case of GCT mimicking cellulitis on a woman’s foot at first presentation. Despite initial misdiagnosis, histological examination confirmed GCT, guiding successful excision and reconstruction. Our case underscores the importance of considering granular cell tumors in atypical presentations and highlights the role of histological evaluation in accurate diagnosis and management.

Non-alcoholic fatty liver disease (NAFLD) was the term first used to describe hepatic steatosis in patients with the metabolic syndrome who did not consume excess amounts of alcohol. Alcoholic liver disease (ALD) has many similarities to NAFLD in both pathogenesis and histology. This entity is now the most prevalent chronic liver disease worldwide as a consequence of the epidemic of obesity. Attempts to incorporate the importance of the metabolic syndrome in the development of steatosis resulted in the renaming of NAFLD as metabolic-associated fatty liver disease. This new term, however, has the disadvantage of the use of terms that may be perceived as derogatory. The terms fatty and non-alcoholic have negative connotations in many cultures. In addition, non-alcoholic is not usually a term applicable to pediatric cases of hepatic steatosis. Recently, an international collaborative effort, with participants from 56 countries, after a global consultation process, recommended to change the nomenclature to steatotic liver disease -including metabolic dysfunction- associated steatotic liver disease, metabolic-associated steatohepatitis and metabolic dysfunction-associated ALD. The new terminology is consistent with most of the previously published epidemiological studies and will have a major impact on research into diagnosis, prognosis and treatment.