This issue of Harefuah is dedicated to the field of Allergy and Immunology (A/I). Many aspects in the field have undergone complete transformation in recent years, and here we highlight "hot topics" at the forefront of the field. These topics are not only relevant to those practicing A/I, but are often encountered by other physician in their respective fields. A classic example is penicillin allergy. The approach to penicillin allergy has changed beyond recognition, from extensive evaluation including allergy tests, to a quick de-labeling approach in most patients. In the case of food allergy, the implications extend far beyond clinical work and impact public policy. Several articles in this issue address recent developments in the field of food allergy, clarifying misconceptions and presenting up to date recommendations regarding both primary prevention and treatment. The development of new drugs in recent years has led to breakthroughs in the understanding and management of many diseases in A/I, as presented in the papers discussing mast cell activation syndrome (MCAS), eosinophilic diseases (with emphasis on hypereosinophilic syndrome and eosinophilic granulomatosis with polyangiitis), and hereditary angioedema. New classifications, based on better understanding of their pathophysiology, together with the development of novel drugs, have completely transformed the course and prognosis of these diseases. Finally, the issue includes several articles providing new insights into immunodeficiency disorders. The field of primary immunodeficiency which is now termed "Inborn Errors of Immunity (IEI)", has evolved dramatically in recent years. This includes the realization that IEI do not necessarily present as recurrent infections, but rather can present with a variety of clinical manifestations including autoimmunity, atopy, and even malignancy. In fact, IEI are now identified in diseases previously not perceived as immunodeficiencies. We hope that this issue will provide better understanding of the field of A/I, and assists every physician who encounters these diseases within their practice.
Nothing better reflects the times in which we live-amid missile barrages, air-raid sirens, sheltering in protected rooms, and yet continuing our daily routines and work-than the annual meeting of the editorial boards of the medical journals IMAJ and HaRefuah.
Nothing better reflects the times in which we live-amid missile barrages, air-raid sirens, sheltering in protected rooms, and yet continuing our daily routines and work-than the annual meeting of the editorial boards of the medical journals IMAJ and HaRefuah.
The subspecialty of pediatric otolaryngology has evolved over recent decades into an independent field, recognizing that diseases of the airway, ear, nose, and throat in children have unique anatomical and developmental characteristics. From pioneering centers around the world in the 1960s and 1970s to the establishment of the Israeli Society of Pediatric Otolaryngology, a rich and active discipline has developed in Israel, integrating clinical, research, and educational innovation. This special issue of Harefuah presents a collection of studies, reviews, and case reports from ENT departments across Israel, reflecting the spirit of innovation and progress in the country's medical centers. The articles cover a wide range of topics, including rare and complex infections, congenital pathologies of the neck and airway, advanced endoscopic surgeries, creative approaches to hearing rehabilitation, and multidisciplinary management recommendations for children following tracheostomy.
This is a first study that assesses the clinical presentation and outcomes of different ethnic groups of the patients that are near drowning in the Dead Sea. We performed a retrospective study of all adult patients admitted to the Soroka University Medical Center with a diagnosis of the near-drowning syndrome in the Dead Sea during the years 2004-2024. All the patients were divided into three groups: patients of Jewish origin, patients who were Israeli Arabs and Bedouins in origin and tourists from any other countries. The primary outcome was the length of the hospital stay. The secondary outcomes were in-hospital mortality and 30-day mortality. This study included 219 patients. The majority of patients (140, or 64%) were of Jewish origin. Arab patients were significantly younger compared to the other two groups of patients (P=0.002) and significantly healthier compared to the other two patient groups (P<0.001). Significantly more tourists were hospitalized with an impaired state of consciousness, manifesting as stupor or coma, compared to the other two groups (P<0.001). Throughout the entire hospitalization, kidney function was better in patients from the Arab group compared to the two other groups. No vital differences were found between the three groups regarding study outcomes, including in-hospital mortality, 30-day mortality, or length of hospital stay. This study demonstrated significant demographic and clinical heterogeneity among the three patient groups on admission. Arab patients were significantly younger and had a lower comorbidity burden. Tourists presented more frequently with a severely impaired level of consciousness. Despite these marked differences in baseline characteristics and disease severity indicators, all three groups demonstrated similar short-term outcomes, with no significant differences found in outcomes. These findings imply a robust clinical system capable of managing the diverse risk profiles of the patient population.
In recent years, artificial intelligence (AI) has brought about a dramatic transformation in obstetrics, gynecology, and fertility medicine. AI, including methods such as machine learning, deep learning, and large language models (LLMs), is reshaping the way clinical data are collected, analyzed, and applied. Image processing, particularly through deep learning applications, significantly enhances the detection of fetal anomalies in prenatal ultrasound, the classification of embryo quality in fertility treatments, and the early identification of gynecological pathologies. The integration of artificial intelligence systems with clinical expertise improves diagnostic accuracy, especially in the fields of medical imaging and pathology, while reducing the rate of false positive findings in imaging and pathology tests. However, artificial intelligence serves only as an assistive tool and does not replace medical judgment or established diagnostic standards. In parallel, machine learning models enable the prediction of pregnancy complications, the success of oncological treatments in gynecology and more. A major advantage of these models is their interpretability, which increases their potential for clinical adoption. LLMs contribute to the analysis of medical records, research summarization, and clinical decision support, although their use in other languages, such as Hebrew, remains limited. Augmented reality technologies offer new possibilities for enhancing patient experiences by reducing pain and anxiety during medical procedures. Despite the significant potential, challenges remain, including issues of data privacy and security, model reliability, and the need for appropriate regulatory frameworks. Israel, with its advanced yet heavily burdened healthcare system and high birth rates, is uniquely positioned to lead research and innovation in this field. Studying the capabilities and limitations of these tools will allow for their controlled and safe integration, promoting personalized medicine and optimizing public healthcare resource utilization. The aim of this study is to review advancements in implantation of AI tools in gynecology.
Myasthenia gravis (MG) is an autoimmune disease impairing neuromuscular ‎transmission due to antibodies against acetylcholine receptors. Preeclampsia is a ‎pregnancy-specific hypertensive disorder that can lead to seizures and cerebral ‎complications, typically prevented with IV magnesium sulfate.‎ In MG patients, magnesium is contraindicated as it inhibits acetylcholine release, ‎worsening muscle weakness and risking respiratory failure.‎ We present a pregnant MG patient with additional preeclampsia risk factors: nulliparity, ‎age, epilepsy, gestational diabetes and chronic hypertension. Due to limited literature, a tailored protocol ‎was created including instructions to:‎ avoid magnesium; use levetiracetam or diazepam for seizures;‎ control blood pressure with hydralazine; add labetalol if needed; Cesarean only for obstetric reasons and to ensure team awareness and minimize stress.‎ This case emphasizes the need for individualized care in high-risk pregnancies with MG.
Background: Artificial intelligence (AI) chatbots are increasingly used for health-related dialogue and psychoeducation. Their highly realistic, opaque, and human-like interactions may affect mental health, particularly in vulnerable users. Objective: To synthesize (through August 2025) the clinical benefits and risks of AI chatbots in psychiatric contexts, emphasizing risk mechanisms (reality/simulation blurring, anthropomorphism, and sycophancy or agreement bias) and practical implications. Methods: A PubMed search was conducted, complemented by technical/regulatory sources; we included reviews, primary studies, case reports, and policy documents, all filtered for clinical relevance and recency. Findings: Benefits include automated speech analysis for early psychosis detection and psychoeducational support. Reported risks included: reinforcement of delusions in users prone to psychosis, reassurance loops in obsessive-compulsive disorder (OCD) and health-anxiety escalation, information overload, inconsistent responses and delayed care in depression and inconsistent crisis detection for suicidality. Sycophancy is described as a key mediator that blindly affirms user statements. Regulators classify health-intended systems as "high-risk" in the EU and provide person-centered care planning (PCCP) pathways in the US. In Israel, privacy and ethics guidelines are being formulated. Conclusions: Safe use requires clear disclosure, human oversight, usage limits, and emergency pathways; avoid anthropomorphic framing; measure and mitigate sycophancy. Chatbots can be adjuncts but not substitutes for clinical assessment and treatment by a human professional.
When Fecal Impaction Becomes Life-Threatening.
People suffering from advanced dementia commonly develop eating difficulties. The recommendation is for careful hand feeding, but this is not always feasible. Research has tried to evaluate the efficacy of enteral tube feeding and has failed to show a benefit, but the research is problematic with heavy bias. To compare the outcomes of oral vs enteral feeding for patients with advanced dementia, in the last year of life. A retrospective chart analysis of patients with advanced dementia who died in the internal medical and geriatric departments in 2022 in Shaare Zedek Medical Center. The study group included patients with Percutaneous Endoscopic Gastrostomy (PEG) feeding and the control group, patients with oral feeding. We compared demographics, comorbidity, admissions, hospital days, aspiration pneumonia, pressure sores, and albumin levels. A total of 199 patients with advanced dementia in the last year of their life were included in the study. Thirty-five patients were fed via PEG prior to their last admission and 164 were fed orally. The number of admissions and days of admission were significantly higher in the study group vs. controls (4 Vs. 2, p<0.001 and 27 vs. 15, p=0.01, respectively). There was no difference in prevalence of pressure sores or their severity between the groups. When assessing the length of admission as an independent factor, patients with longer admissions (>17days) were more likely to receive PEG feeding, had more respiratory diagnoses, longer admissions and more pressure ulcers. The study showed that patients with PEG feeding had more and longer admissions than those with oral feeding. Those fed via PEG did not have a greater risk of pneumonia, aspiration or pressure sores. Patients with advanced dementia who had prolonged admissions (more than 17 days) were more likely to be fed via PEG and had a higher incidence of pneumonia, aspiration and pressure sores.
A fourth branchial cleft remnant is relatively rare and often misdiagnosed, primarily presenting as a sinus with an opening in the pyriform sinus, known as pyriform sinus fistula. Confirmation of the diagnosis is achieved through either a barium swallow test, or direct rigid laryngoscopy. We present our experience in diagnosing this anomaly. The series comprised 6 children, 4 boys and 2 girls 1-13 years of age, all with left cervical infection. Five patients presented with a primary episode of cervical infection, while in one case, it was a second infection. Diagnosis was confirmed in all cases by direct visualization of the tract opening in the left pyriform sinus. Treatment involved endoscopic cauterization of the fistula by diathermy for all patients. One child experienced a recurrent infection post-diathermic treatment and had a second successful cauterization. We retrospectively reviewed six children referred to our medical center between the years 2020 and 2023, due to cervical infection who had a final diagnosis of fourth branchial cleft sinus. A fourth branchial arch anomaly is a relatively rare diagnosis that may mimic thyroiditis. Diagnosing this anomaly can be challenging and requires direct visualization of the fistulae in the pyriform sinus. Familiarity with this diagnosis is essential for enabling efficient and prompt diagnosis and treatment.
This article presents three yeshiva students who developed anorexia due to a desire for religious asceticism and spiritual elevation, leading them to a life-threatening condition that required hospitalization. These young men do not fit the classical description of anorexia nervosa, as they did not initially seek to change their body shape. The article reviews historical instances of self-starvation: fasting before religious revelations, fasting as a form of atonement, prayer, and drawing closer to God, fasting as a means of detaching from the material and physical world, fasting to escape feminine burdens and marriage, and later, fasting as a sign of demonic possession or, finally, as a recognized symptom of illness. Contemporary sacred anorexia can remain elusive, making awareness of this subgroup essential for healthcare providers. Cultural sensitivity and the involvement of community leaders can facilitate treatment.
Emerging Trends in Pediatric rheumatology: Key Insights from the PReS 2025 European Congress - Helsinki, Finland, September 2025.
Healthcare systems are considered critical infrastructure and are therefore required to maintain continuous operation during wartime and large-scale emergencies. This reality places healthcare professionals in a complex position, as they are expected to sustain professional performance while facing personal safety threats, increased workload, and concerns for their families. This paper examines the key patterns characterizing the behavior of healthcare teams during wartime, integrating current research literature with organizational experience from the Israeli healthcare system. The literature highlights several recurring features, including a heightened sense of professional mission, increased team cohesion, and organizational adaptability. At the same time, significant emotional burdens are documented, which may lead to burnout and compassion fatigue. The article also presents an organizational case study from Assuta Medical Centers, describing measures implemented to maintain operational continuity while supporting staff during a period of armed conflict. These measures included adjustments in clinical activity, establishment of protected care environments, continuous managerial communication, and the provision of support mechanisms for employees and their families. The findings underscore the central role of organizational factors, particularly leadership, communication, and perceived organizational support, in shaping staff resilience and commitment during crisis situations. The authors conclude by proposing directions for future empirical research to systematically examine the relationship between organizational practices and healthcare workers' resilience and engagement in wartime.
Mumps infection primarily leads to parotitis in children. While complications such as orchitis and encephalitis are uncommonly reported, the development of a parotid abscess due to mumps is extremely rare. We present the first described case of parotid abscess secondary to mumps, complicated by a persistent salivary fistula. A 21-month-old unvaccinated, healthy boy presented with right-sided cheek swelling lasting 15 days. Prior treatment at home with amoxicillin-clavulanate did not yield improvement. Sonographic evaluation revealed an enlarged right parotid gland with a central hypoechoic focus and increased peripheral vascularity. Incision and drainage (I&D) were performed, and subsequent serological tests confirmed an acute mumps infection. Although the patient initially showed improvement post-drainage, he was readmitted two months later with an infected, persistent salivary fistula from the drainage site. The report emphasizes the need for careful consideration before choosing a treatment modality for mumps-induced parotid abscesses. It is yet to be determined if mumps may predispose to fistula formation. Needle aspiration might be a more viable and safer option compared to traditional I&D. The management of parotid fistula requires a conservative approach, escalating to surgical interventions only if necessary. The presence of parotid abscess, especially in unvaccinated children, should alert clinicians to the possibility of mumps as an underlying cause and requires interventional considerations accordingly.
"Patient experience" merges efficiency, safety and patient satisfaction, reflecting organizational culture and values. This includes: trust, empathy, meeting expectations for recovery, particularly in the context of a hospital and is beyond traditional "customer service". Sensitivity to vulnerable populations yielded to a targeted gender- and trauma-adapted approach. Countries with large minority populations shaped patient experience through equitable health policy. Patient experience expanded to encompass family members, recognized as being critical for care and recovery. Recently, insight has been fostered into the therapist's experience, being exposed to sensitive, embarrassing, and even traumatic situations. Thus, the term "human experience" in the health system emerged. Compassion is a cornerstone of medical professionalism, but in today's fast-paced, technology-driven environment, physicians may prioritize digital tools over personal interaction. The role of artificial intelligence is evolving, not only in decision-making but also in recognizing suffering, improving communication, and supporting decisions tailored to patient preferences and moral aspects. Simultaneously, the physician's decisiveness may be reduced. Humanity remains central to high-quality care. Early education is essential for medical students' approach and social values. Isolated hospitals' initiatives may transform into a national strategy. Health leaders increasingly recognize the importance of a collaborative effort, involving hospitals, health funds and academia, to foster a national culture of care that balances professionalism, compassion and innovation.
A label of "penicillin allergy" among hospitalized patients often leads to the use of second-line antibiotics. It has been demonstrated that alleged penicillin allergy is associated with prolonged hospitalization, increased risk of antimicrobial resistance, and higher mortality rates. Approximately 90% of reported penicillin allergies are inaccurate and may reflect adverse drug reactions or misinterpretation of medical history. To evaluate penicillin allergy among hospitalized patients through an educational intervention program. A prospective study implementing an intervention program aimed at removing inaccurate penicillin allergy labels in hospitalized patients in internal medicine and surgical departments. The intervention was carried out by the physicians of the department and supported by specialists in allergy and clinical immunology, infectious diseases, and clinical pharmacy. The program included educational lectures about drug allergies and clinical training in conducting penicillin drug provocation tests (DPT). A negative DPT result led to the removal of the allergy label from the patient's medical record. Between January and October 2024, a total of 26,985 patients were admitted to the internal medicine departments and the surgical division at Meir Medical Center. Of these, 2,001 patients (7.4%) had a documented penicillin allergy label. Among the labeled patients, 114 (5.7%) underwent inpatient evaluation for penicillin allergy. In the internal medicine departments, 16,791 patients were hospitalized during the study period. Of these, 1,320 (7.8%) carried a penicillin allergy label, and 54 (4.0%) underwent evaluation as part of the de-labeling intervention. In departments where the structured program was implemented, 27 of 530 patients had their allergy label removed, compared with 27 of 790 patients in departments without the intervention (5% vs. 3.4%, p = 0.1). During the same period, 10,194 patients were admitted to the surgical division. Of these, 681 patients (6.6%) had a documented penicillin allergy label, and 60 (8.8%) underwent evaluation as part of the intervention program. In departments participating in the program (gynecology, otolaryngology, and orthopedics), 38 of 200 patients underwent inpatient assessment for penicillin allergy, compared with 22 of 481 patients in departments not participating in the intervention (19% vs. 4.5%, p < 0.01). The intervention program led to a modest improvement in the rate of penicillin allergy label removal among hospitalized patients, with relatively greater success observed in surgical departments. We believe that the learning curve inherent to this process requires a prolonged implementation period. On-going application and refinement of the intervention, across both medical and surgical departments, may further reduce the prevalence of inaccurate allergy labeling.
Throughout the 9-months of pregnancy, a woman with gestational diabetes (GDM) is expected to celebrate holidays, which makes coping with diabetes difficult and alters routine glucose control. We hypothesized that delivery in the first week following a holiday, might be associated with altered glucose homeostasis, causing more neonatal hypoglycemia. A retrospective study was conducted in a tertiary center between the years 2007-2023. Eligible patients were women with a term singleton pregnancy, diagnosed with GDM. Women were allocated into two groups based on the date of their delivery in relation to holidays, in the first week following a holiday (group 1) and at times unrelated to holidays (group 2). The primary outcome was the incidence of neonatal hypoglycemia, defined as a glucose level of less than 40 mg/dL (2.2 mmol/L) within 24 hours of birth. We analyzed 332 cases of GDM and 3,179 GDM control cases. Diet-controlled GDM represented most of our cohort (85%), and the mean blood glucose was tightly kept around 100 mg/dl throughout the labor. Baseline maternal and neonatal demographics were comparable between the groups. The incidence of neonatal hypoglycemia did not differ between the two groups, reaching 3.3% in the study group and 4.9% in the control group (p=0.19). The mean neonatal blood glucose at the nursery was also comparable between the groups, 63 ± 10.1 versus 63.2 ± 10.9 (p=0.95), respectively. GDM patients in group 1 had a higher rate of third- or fourth-degree perineal lacerations than group 2 (1.8% vs. 0.8%, p=0.04). Our findings reassure us that major holidays, when occurring within a week of delivery, do not adversely impact neonatal outcomes in women with GDM. Management of gestational diabetes during holiday periods may be challenging; however, delivery close to holidays does not increase the risk of neonatal hypoglycemia. Delivery during holiday periods does not increase the risk of neonatal hypoglycemia in women with gestational diabetes.
The author is the Ministry of health counselor regarding sports medicine clinics.
Acute mastoiditis is an infectious complication of acute otitis media, potentially leading to life-threatening extracranial and intracranial sequelae. In recent years, there has been a noticeable shift in the epidemiology of causative pathogens, with an increasing incidence of less common bacteria. This article presents the case of a 1.5-year-old child diagnosed with acute mastoiditis and additional complications, who failed to respond to empirical antibiotic therapy and had persistently negative cultures. Only through the use of polymerase chain reaction (PCR) testing was the causative organism, Fusobacterium necrophorum, identified. We discuss the epidemiological and clinical features of F. necrophorum, the diagnostic challenges due to its difficult cultivation, treatment approaches, distinctive imaging findings, and the role of advanced imaging in patient follow-up. This case highlights the importance of recognizing this pathogen in culture-negative mastoiditis, the need for early consideration of PCR testing, tailored antibiotic and surgical management based on disease severity, and the necessity of radiological follow-ups.