Background: The International Association for the Study of Pain (IASP) has defined three mechanisms for chronic pain: nociceptive, neuropathic, and nociplastic. Accurate differentiation between these mechanisms is essential for treatment selection but remains challenging due to symptom overlap and reliance on clinical judgment. Patient-reported questionnaires may support diagnosis, though their diagnostic accuracy relative to physician assessment has not been fully established. Objectives: This study aimed to investigate the prevalence and overlap of chronic pain mechanisms in a tertiary pain clinic population and to compare physician-assigned diagnoses with results from patient-reported questionnaires. Methods: This cross-sectional study recruited 89 adult patients with chronic pain from the Rambam Institute for Pain Medicine at Rambam Health Care Campus in Haifa, Israel. Each participant underwent a comprehensive physician evaluation based on the criteria of the International Classification of Diseases and Related Health Problems, 11th revision, and completed the Central Sensitization Inventory (CSI), PainDETECT, and 2016 American College of Rheumatology (ACR) Fibromyalgia Diagnostic Criteria surveys. Diagnostic agreement, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using physician diagnosis as the reference standard. Results: Physician diagnoses identified neuropathic pain in 51 patients (57.3%), nociceptive pain in 38 (42.7%), and nociplastic pain in 25 (28.1%), with substantial diagnostic overlap (32.6% with ≥2 mechanisms). The CSI demonstrated high sensitivity (92.0%) but low specificity (45.3%) for nociplastic pain. PainDETECT showed moderate accuracy for neuropathic pain (sensitivity 68.6%, specificity 52.6%) and higher specificity for nociceptive pain (86.3%). The 2016 ACR Fibromyalgia criteria provided a more balanced diagnostic profile (sensitivity 88.0%, specificity 68.8%). Conclusions: Questionnaire-based measures are useful for screening chronic pain mechanisms but demonstrate variable accuracy when compared to physician diagnoses, particularly in the context of overlapping pain phenotypes. Refinement of diagnostic thresholds, combined assessment strategies, and updated questionnaires may improve differentiation of pain subtypes and enhance clinical decision-making.
There has been an international resurgence in antisemitism in healthcare education and practice since October 7, 2023, prominently affecting the United States (US), United Kingdom (UK), Canada, and Australia. In the US, federal investigations by the US Department of Justice, and the Congressional Subcommittee on Education and the Workforce were initiated into antisemitic harassment and hostile learning environments in medical schools. Healthcare organizations in the UK also came under investigation, and the US Congress opened an investigation into alleged antisemitism within a national psychological association. Quantitative and descriptive studies of the prevalence and characteristics of this phenomenon within medical, psychology, and social work education and practice are scant. We conducted a narrative review given the under-recognized nature of antisemitism in this context and the limited literature on this international, inter-professional issue. We searched PubMed using a search string to capture peer-reviewed descriptive and quantitative studies of antisemitism in medicine, psychology, social work, nursing, pharmacy, physician assistant, dentistry, physical, and occupational therapy education and practice. We searched 17 ProQuest databases for media and other online or written materials and conducted a hand search for additional relevant publications. We identified studies showing a high prevalence of antisemitism particularly in medical education, psychology, and social work, where >50% of subjects experienced antisemitism since October 7, 2023. Fewer than 2% of institutions had incorporated education about antisemitism into anti-discrimination training. Our review revealed that antisemitism as a form of bigotry, hatred, and discrimination has been inadequately addressed, now taking on urgency given its reach including an anti-Israel bias “mutation” and the need to assure unbiased healthcare. Actionable recommendations to counter antisemitism in healthcare derived from the publications to date are presented.
To the Editor, I read with great interest the narrative review by Savel (2025) examining formal education in leader-ship and management for practicing clinicians, particularly those working in critical care settings. While the review clearly describes the educational opportunities available, several broader conceptual issues may merit further discussion.
BACKGROUND:Sleep disturbances, particularly insomnia, are increasingly recognized as behavioral determinants of type 2 diabetes (T2DM). However, their contribution to validated diabetes risk scores beyond traditional sociodemographic and lifestyle factors remains insufficiently explored. OBJECTIVE:To examine the association between insomnia severity, sociodemographic variables, lifestyle habits, and estimated T2DM risk using three validated non-invasive risk assessment scales. METHODS:A cross-sectional study was conducted among 84,898 Spanish workers aged 18-69 years undergoing occupational health evaluations (2021-2024). Sociodemographic and behavioral data were collected through standardized questionnaires, including adherence to the Mediterranean diet (MEDAS-14), physical activity (IPAQ-SF), and smoking status. Insomnia was assessed using the Insomnia Severity Index (ISI). Diabetes risk was estimated using three validated non-invasive risk-assessment tools: the Finnish Diabetes Risk Score, the QDScore/QDiabetes, and the Trinidad Risk Assessment Questionnaire for Type 2 Diabetes Mellitus. As these instruments were developed and validated in different populations, comparisons of absolute risk categories across scales should be interpreted with caution. Multivariable logistic regression models adjusted for age, sex, social class, smoking, diet, and physical activity were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS:Severe insomnia was associated with approximately 2.1-2.6-fold higher odds of high estimated diabetes risk across all three scales in the pooled analyses, with significant trends across categories of insomnia severity (all P for trend <0.001). This association persisted across sex and activity strata. Adding ISI modestly improved model discrimination (ΔAUC ≈ +0.015; P≤0.003) and reclassification (continuous net reclassification improvement [NRI], 6.5%-8.1%). CONCLUSIONS:Insomnia severity was independently associated with higher estimated risk of T2DM beyond measured sociodemographic and lifestyle determinants. Incorporating sleep health-via brief tools such as the ISI-into diabetes risk assessment could enhance early prevention strategies in clinical and occupational settings.
While individual Jewish plastic surgeons have been recognized in the literature for their groundbreaking achievements, a comprehensive review of their collective contributions to plastic surgery is lacking. The goal of this review is to document and highlight the major advancements made by Jewish physicians whose work significantly impacted plastic and reconstructive surgery from its inception as a discipline to the present day. A comprehensive literature search was conducted to identify key developments in the history of plastic surgery, which were then narrowed to those made by Jewish practitioners. The Jewish identity of these practitioners, along with the significance of their work, was verified through historical records, newspaper archives, and peer-reviewed publications. Contributions were then organized chronologically to construct a cohesive historical narrative. Beginning in the 1800s and accelerating through the 20th century, Jewish plastic surgeons have been instrumental in shaping the field. Their innovations include advancements in the treatment of facial deformities, the development of the lumpectomy with adjunctive radiation therapy as a less invasive alternative to radical mastectomy, and the founding of key institutions such as the American Society of Plastic Surgeons and the International College of Surgeons. Additional breakthroughs include the use of albumin in burn management, foundational work in angiogenesis physiology, and numerous innovations in cosmetic surgery. The history of plastic and reconstructive surgery is a rich tapestry of discovery and evolution. Fully understanding its development is not possible without acknowledging the enduring and transformative contributions of Jewish surgeons and researchers.
Objectives: This study explored the relationship between visual perceptual skills and participation performance in 4–6-year-old children diagnosed with autism spectrum disorder (ASD). Methods: A cross-sectional design was employed for children diagnosed with ASD. Visual perceptual abilities were assessed using the Motor-Free Visual Perception Test–Fourth Edition (MVPT-4), and participation levels were measured using the Children Participation Questionnaire (CPQ). Statistical analysis was done using SPSS version 26, employing one-sample t-tests and Pearson correlation analysis. Results: A total of 48 participants were included in the study: mean age, 4.98±0.82 years; 66.7% were male; 79.2% attended regular schools. One-sample t-tests indicated significant deficits across all CPQ dimensions (P<0.001). Visual perception was negatively correlated with autism severity (r=-0.429, P=0.002) and positively correlated with participation diversity (r=0.404, P=0.004). In the activities of daily living (ADL) and instrumental ADL (IADL) occupations, visual perception was significantly associated with all CPQ elements. Conversely, play and leisure occupations showed mostly negative correlations with the CPQ occupations, while social participation and education showed mixed results. Visual perception was positively correlated with most elements but negatively associated with enjoyment (r=-0.428; P=0.002). Conclusions: Preschool children with ASD demonstrate significant participation restrictions. Visual perception emerged as a critical determinant of participation, particularly in ADL and educational contexts. Early interventions targeting visual perception skills may enhance independence and functional engagement, though interventions should also address the enjoyment and emotional experience occupations to ensure holistic participation outcomes.
BACKGROUND:The Circassian community in Israel represents a unique, endogamous population residing in two villages in the northern region of Israel: Kfar Kama (209 meters above sea level [m.a.s.l.]) and Rihaniya (674 m.a.s.l.). OBJECTIVES:This study sought to investigate whether the small difference in altitude between these two locations (465 m) affects red blood cell (RBC) and hemoglobin (Hb) parameters in the residents. METHODS:We examined the data from 2,517 blood samples collected from adult Israeli Circassians over 2.5 years (January 2020-June 2022). To ensure independent observations, analysis was limited to each participant's most recent complete blood count (CBC). Subjects were stratified by sex, age, anemia status, and residential location. RESULTS:Our analysis revealed that a difference of about 465 meters in residential altitude significantly elevated Hb, RBC count, and hematocrit (HCT) levels in non-anemic male and female cohorts. This elevation was accompanied by a small but significant decrease in mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH). Furthermore, we found that the effect of altitude on most RBC characteristics differed in anemic individuals of both sexes, although their RBC count still increased. CONCLUSIONS:Even minor differences in residential altitude can significantly influence Hb and RBC parameters. This observation appears only in non-anemic individuals, probably reflecting physiological altitude Hb adaptation mechanisms. While further research is needed to fully elucidate the underlying mechanisms, our findings provide new data on the physiological impact of altitude on human health, particularly at low altitudes.
Background: Chronic hypoxemia in patients with COPD is associated with increased morbidity and mortality. Although arterial partial pressure of oxygen (PaO2) is widely used, it does not adequately reflect systemic oxygen transport. Arterial oxygen content (CaO2) may provide a more comprehensive assessment. Objective: This study aimed to evaluate whether or not CaO2 is a better predictor of mortality than PaO2 in patients with COPD. Methods: This retrospective observational cohort study included 147 COPD patients aged ≥45 years. Patients were categorized according to CaO2 levels (low, normal, high). Mortality at 1, 3, and 5 years was analyzed. Statistical methods included ROC curves, Kaplan–Meier survival analysis, and Cox regression models. Results: A total of 66 deaths (45.2%) occurred in the study cohort. Mortality was highest in the low CaO2 group. The CaO2 demonstrated better predictive performance than PaO2 (AUC 0.73 versus 0.53, respectively). Low CaO2 was associated with a 2.5-fold increased risk of mortality. Despite improvements in PaO2 after long-term oxygen therapy, CaO2 did not significantly change. Conclusions: The CaO2 is a more informative marker of oxygen transport and mortality risk than PaO2 in COPD patients. It should be considered a complementary parameter in clinical assessment.
Mifepristone (RU-486), the first clinically effective progesterone antagonist, was initially identified as having antiglucocorticoid activity. Although early interest focused on its role as a glucocorticoid receptor antagonist, recognition of its antiprogesterone effects led to studies of its role in pregnancy termination. This article reviews the steps leading to its use as an abortifacient, from its initial identification for this indication and draws on the author’s direct involvement in the field with reflections on his contribution to the early clinical development of mifepristone. These studies established the efficacy of mifepristone in pregnancy termination. Unfortunately, its wider therapeutic applications have received limited attention.
Introduction: Polypharmacy carries the potential for increased risk and severity of adverse reactions. Deprescribing may reduce adverse events and possibly hospitalizations, although evidence on hard outcomes such as mortality is mixed. As the medication experts responsible for the close monitoring of their patient, doctors, nurses, and pharmacists play a crucial role in the process of medication deprescribing. They are involved in the therapeutic process and contribute to the appropriate use of medications and the proper discontinuation of those that no longer benefit the patient or are harmful. This role is particularly important for vulnerable groups, such as older people, who often take chronic medication. Objective: This study aims to review the literature on polypharmacy and the importance of suspending unnecessary or harmful medications in older people, emphasizing the role of healthcare professionals in the process. Methods: A narrative review of recent publications (articles from 2023 to 2025) in Web of Science, PubMed, and Scopus databases, addressing polypharmacy and deprescribing in older adults was conducted. Conclusions: A multidisciplinary team including doctors, nurses, and pharmacists plays a pivotal role in this process by reviewing patients’ therapeutic regimens, identifying inappropriate medications, and monitoring the withdrawal process. Their intervention can support more appropriate medication use, may improve patients’ quality of life, and has the potential to reduce healthcare costs.
The Talmud describes several illnesses attributed to Rabbi Judah ha-Nasi, one of the foremost leaders of the Jewish people after the destruction of the Second Temple, and the compiler of the canonical Mishnah. Among these conditions, Tzafedina of the oral cavity is mentioned, characterized by severe and persistent pain lasting for seven years. Although many modern scholars tend to identify this condition with scurvy, the Talmudic accounts of Rabbi Judah's diet and lifestyle do not support a state of nutritional deficiency. Moreover, scurvy is not typically associated with oral pain. Instead, it is more plausible that the term Tzafedina functioned as an umbrella designation for a spectrum of oral disorders, potentially involving the teeth or gingiva. When applied to Rabbi Judah ha-Nasi, the Talmudic narrative appears to emphasize the psychological and symbolic dimensions of suffering. Thus, in addition to the possibility of organic oral pathologies with psychosomatic components that may manifest in the gingiva, the account may also correspond to chronic oral pain syndromes recognized in contemporary oral medicine.
The evolving landscape of metastatic prostate cancer (mPCa) necessitates a redefinition of the urologist's role, extending beyond diagnosis to active participation in therapeutic and surgical management. This review outlines evidence-based approaches to biopsy and surgical interventions across the disease spectrum. Prostate biopsy remains fundamental for diagnosis, treatment stratification, and molecular profiling, with targeted and metastatic lesion sampling improving precision oncology. For symptom relief, surgical management of bladder outlet obstruction through transurethral resection of the prostate and holmium laser enucleation of the prostate remains essential, with emerging data suggesting possible oncologic benefits when combined with systemic therapy. GreenLight photoselective vaporization may represent an alternative option, though evidence remains limited. Cytoreductive radical prostatectomy in carefully selected patients with metastatic hormone-sensitive disease may provide improved local control and delayed progression, supported by growing biological rationale but constrained by the retrospective nature of current evidence. Collectively, these findings underscore the expanding multidisciplinary role of the urologist in mPCa care, emphasizing the need for prospective studies to validate the integration of surgical approaches within systemic treatment frameworks.
Obesity is a complex, multifactorial disease that contributes to a broad range of cardiometabolic, reproductive, and psychological disorders. Representing a major global health challenge, obesity can be addressed by lifestyle modifications such as reduced calorie intake, physical activity, adequate sleep, and stress manage¬ment to help achieve sustainable weight loss and improve metabolic health in the long term. Glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) are the two naturally produced incretin hormones in the gastrointestinal tract. Incretin analogues were initially approved for type 2 diabetes mellitus but were later found to exhibit weight-reducing properties. Liraglutide, semaglutide, and tirzepatide are the three incretin analogues approved for obesity in non-diabetic patients. This narrative review presents detailed comparisons of the three approved incretin analogues for obesity, their cost-effectiveness, and trends in the clinical setting.
To the Editor: We commend Cohen et al. for introducing a prag-matic composite—Padua score × D-dimer (PaDd)—designed to refine pulmonary embolism (PE) exclusion in adults aged ≥65 years, a population often characterized by multimorbidity, physiological heterogeneity, and atypical presentations. Their single-center retrospective cohort (2021–2023) provides a compelling, hypothesis-generating signal: combining a validated venous thromboembolism risk score with D-dimer may enhance specificity without compromising safety.
To the Editor: I read with interest the paper by Priya et al. and appreciate their study examining the mental health status among parental caregivers of children with special needs in Puducherry. The authors addressed an important and understudied population in the Indian caregiver context. Their work made several noteworthy contributions that deserve recognition.
To the Editor: We thank Thakur and Bhatia for their insightful letter, “Home-based Pulmonary Rehabilitation in COPD: Bridging Evidence and Practice for Compre-hensive Patient-centered Care,” and for their gracious recognition of our study, “From Breathless-ness to Better Living: Transforming COPD Care with Home-based Pulmonary Rehabilitation.” We appreciate their remarks, which underscore the value of our findings and enrich the discussion with constructive suggestions to further strengthen home-based pulmonary rehabilitation (PR). We share their vision for a more accessible, patient-centered, and holistic approach to chronic obstructive pulmonary disease (COPD) care and welcome this opportunity to continue the dialogue.
Immunotherapy using immune checkpoint inhibitor (ICI) has been increasingly used in the oncology treatment field. Although ICIs could help suppress cancer and improve survival rates, it could also lead to certain adverse events, including immune-mediated liver injury caused by ICIs (ILICI). The manifestation of ILICI ranged greatly from asymptomatic disease to liver failure and even death. In this review article, we will discuss the pathogenesis, manifestation, and clinical approach of ILICI.
To the Editor: We thank Dr Vijayasimha and colleagues for their thoughtful analysis of our work and their proposal for prospective validation of the Padua × D-dimer (PaDd) score. Their roadmap provides a rigorous framework that addresses critical gaps in our single-center retrospective design. We welcome this opportunity to clarify key methodological considerations and invite the global research community to collaborate on next-generation studies.
This paper presents a halakhic-ethical analysis of a 2025 case involving A.S., a brain-dead pregnant woman who was maintained on somatic support to enable fetal maturation and delivery. The case raises profound questions at the intersection of Jewish law and contemporary medical practice, particularly regarding the halakhic definition of death-brain versus cardiac cessation-and the moral status of the fetus. The paper explores divergent rabbinic opinions on whether sustaining a brain-dead body for fetal viability is halakhically permissible or obligatory. Key halakhic parameters examined include the principle of pikuach nefesh (saving life), the fetus as a potential nefesh, and the permissibility of delaying burial to perform a Cesarean section. We argue that Halakhah offers nuanced and compassionate responses to unprecedented bioethical dilemmas. Moreover, the paper affirms that Jewish law is ethically responsive, evolving through dialogue with changing human circumstances while remaining rooted in balancing reverence for life with the dignity of death. It underscores the importance of interdisciplinary collaboration between halakhic authorities and medical professionals to navigate ethically complex and medically novel scenarios with both compassion and rigor. This case illustrates that the moral courage of Halakhah's heartbeat compels rabbinical scholars to navigate its boundaries with empathy, wisdom, and fidelity to tradition.
BACKGROUND:Ampullary neuroendocrine tumors (NETs) are extremely rare, representing 0.3%-1% of gastrointestinal NETs and less than 2% of periampullary cancers. Due to their rarity, there is limited data on their natural history, management, and outcomes. Current European Neuroendocrine Tumor Society guidelines (2023) recommend pancreaticoduodenectomy (PD) as the standard treatment. However, this approach is invasive and associated with high morbidity and mortality. Emerging evidence suggests that endoscopic papillectomy (EP) could be a viable alternative in selected cases. This retrospective multicenter study aimed to evaluate the feasibility and outcomes of endoscopic resection for ampullary NETs. METHODS:This retrospective case series included 14 patients who underwent EP for ampullary NETs between 2011 and 2022 across three Italian tertiary centers. Pre-procedural evaluation was performed following European Society of Gastrointestinal Endoscopy guidelines. Endoscopic papillectomy was performed under monitored sedation, using standard snares for en bloc resection. Follow-up endoscopy was conducted at a median of 3 months. Primary outcomes included complete resection (R0) and recurrence rates; secondary outcomes focused on adverse events. RESULTS:Fourteen patients (median age: 62.5 years; 50% male) were included. Median tumor size was 18 mm. In 12 out of 14 cases, ampullary NETs were diagnosed only after endoscopic resection. Post-resection histology identified 8 G1 NETs (Ki-67 1%) and 6 G2 NETs (Ki-67 5%). Complete resection was achieved in 11 cases (78.6%). Among 3 incomplete resections, 2 were managed surgically, while 1 was followed up without recurrence. Residual disease was detected in 3 patients: 2 were managed endoscopically, and 1 required surgery. No recurrences occurred during a median follow-up of 14.5 months. Adverse events occurred in 42.9% of patients, including 5 cases of bleeding and 1 case of mild pancreatitis, all resolved without major sequelae. Median hospital stay was 2.5 days. CONCLUSIONS:Our findings suggest that EP offers a promising alternative to surgery in selected patients with ampullary NETs. Endoscopic resection was associated with high rates of R0 and favorable short-term outcomes, with effective endoscopic management of residual disease and procedure-related adverse events. Consistent post-procedural surveillance remains essential to detect residual or recurrent disease. Larger prospective studies are warranted to refine patient selection criteria, optimize protocols, and establish the long-term efficacy.
